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Objectives: 1. to evaluate mortality risk excess in the population residing in nursing care homes (NCHs) compared to non-NCHs before the COVID-19 outbreak; 2. to verify if the outbreak modified risk excess; 3. to estimate the COVID-19 impact; 4. to ascertain incidence-mortality relationship., Design: cohort study., Setting and Population: Mantua and Cremona provinces (Lombardy Region, Northern Italy) - included in ATS Val Padana - with COVID-19 incidence rate 7.5‰ and 16.9‰, respectively. Inhabitants aged >= 75 years as of 1st January 2018, 2019, and 2020 (three cohorts), stratified in NCH or not. The indicators calculated were: 1. rate ratio (RR) for NCH vs non-NCH, adjusted by gender, age, chronic diseases number, at least 1 hospitalisation, at least 1 Emergency room access in the previous year, for 2018, 2019, and 2020; 2. adjusted RR, 2019 and 2020 vs 2018, both sub-cohorts (i.e., NCH and non-NCH)., Main Outcome Measures: first four-month period mortality of the considered years., Results: aproximately 100,000 inhabitants by year, 7% in NCH. In the 2020 first four-month period, 4,343 deaths occurred of which 45% in NCH. RR in NCH population vs non-NCH for the year 2018 was 2.13 (95%CI 1.94-2.34); for the year 2019 was 2.70 (95%CI 2.43-3.00); for the year 2020 was 6.98 (95%CI 6,49-7,50). Adjusted RR for NCH population in 2020 vs 2018 was 2.22 (95%CI 2.05-2.42) in the whole ATS Val Padana; 1.58 (95%CI 1.40-1.77) in Mantua Province; 2.93 (2.62-3.27) in Cremona Province. Adjusted RR in non-NCH population in the year 2020 vs 2018 was 1.59 (95%CI 1.48-1.70) in the whole ATS; 1.34 (95%CI 1.23-1.46) in Mantua Province; 1.89 (95%CI 1.73-2.07) in Cremona Province., Conclusions: the NCH population experienced an excess risk mortality compared to non-NCH before the COVID-19; this excess increased during the outbreak. In 2020, in NCHs the risk was more than double compared to the 2018 risk, while in non-NCHs it rose approximately by 60%. The gap between NCHs/non-NCHs COVID-19 impact was higher in Cremona than in Mantua.

Objectives: about two months after the end of the lockdown imposed for the containment of the SARS-CoV-2 epidemic, the contagion dynamics in the Tuscany Region (Central Italy) have been assessed from the beginning of the emergency to the end of June through a compartmental model, and future medium-long term projections have been produced., Data and Methods: this study used a SIRD model in which the infection reproduction number R0 varied over time, according to a piecewise constant function. The fatality parameter and the time from contagion to infection resolution (death or recovery) were fixed to ensure parameter identifiability, and the model was calibrated on the Covid-19 deaths notified from March 9th to June 30th 2020. The uncertainty around the estimates was quantified through parametric bootstrap. Finally, the resulting model was used to produce medium-long term projections of the epidemic dynamics., Results: the date of the first infection in Tuscany was estimated as February 21st 2020. The value of R0(t) ranged from 7.78 (95%CI 7.55-7.89), at the beginning of the outbreak, to a value very close to 0 between April 27th and May 17th. Finally, R0(t) rose, reaching an average of 0.66 (0.32, 0.88) between May 18th and June 30th. At the epidemic peak, estimated at the beginning of April, the notified infected people circulating in the region were just 22% of those predicted by the model. According to the estimated SIRD, under the hypothetical scenario that R0(t) slightly exceeds 1 from the beginning of October 2020, a new wave of contagion could arise by next spring., Conclusions: the estimated trend of R0(t) is suggestive of a strong effect of the lockdown in Tuscany and of a mild increase of the contagion potentially attributable to the easing of the containment measures. Medium-long term projections unequivocally indicate that the danger of a new epidemic wave has not been averted.

Objectives: to assess the temporal variation in excess total mortality and the portion of excess explained by COVID-19 deaths by geographical area, gender, and age during the COVID-19 epidemic., Design: descriptive analysis of temporal variations of total excess deaths and COVID-19 deaths in the phase 1 and phase 2 of the epidemic in Italy., Setting and Participants: 12 Northern cities and 20 Central-Southern cities from December 2019 to June 2020: daily mortality from the National Surveillance System of Daily Mortality (SiSMG) and COVID-19 deaths from the integrated COVID-19 surveillance system., Main Outcome Measures: total mortality excess and COVID-19 deaths, defined as deaths in microbiologically confirmed cases of SARS-CoV-2, by gender and age groups., Results: the largest excess mortality was observed in the North and during the first phase of the epidemic. The portion of excess mortality explained by COVID-19 decreases with age, decreasing to 51% among the very old (>=85 years). In phase 2 (until June 2020), the impact was more contained and totally attributable to COVID-19 deaths and this suggests an effectiveness of social distancing measures., Conclusions: mortality surveillance is a sensible information basis for the monitoring of health impact of the different phases of the epidemic and supporting decision making at the local and national level on containment measures to put in place in coming months.

Objectives: to present the Longitudinal Study of Emilia-Romagna (SLER) and evaluate whether the effect of the education level on premature mortality is modified by the degree of urbanisation., Design: closed cohort study., Setting and Participants: population aged >=30 years, resident in Emilia-Romagna Region (Northern Italy) and registered in the 2011 Italian Census, followed up until death, emigration, attainment of 75th year of age, or end of 2018., Main Outcome Measures: overall and cause-specific premature mortality (malignant tumours, lung and breast tumours, diseases of the circulatory system, respiratory system and digestive system, road accidents, death of despair, alcohol-related causes)., Results: the study population consisted of 2,579,936 individuals (15,508,972 person-years and 71,213 deaths). The population was equally distributed across the three degrees of urbanisation, but the prevalence of highly educated subjects was lower in the sparsely populated areas than in cities (12.9% vs 27.7%). The higher risk of mortality among the low educated was greatest, particularly among males, in the cities (MRR 1.68; 95%CI 1.62-1.75), lowest in the intermediate density areas (MRR 1.47; 95%CI 1.40-1.55), and not negligible among women. The interaction between education level and degree of urbanisation was significant for all-cause mortality, mortality from cardiovascular diseases, malignant tumours, especially lung cancer, road accidents (only among men). Among women, there were signs of an effect modification on mortality from diseases of respiratory and digestive systems., Conclusions: this first application of the SLER revealed that the mortality gradient by education level is greater in the cities, especially among men. These results deserve to be further explored through the analysis of other health outcomes and the investigation of the main drivers of the greater socioeconomic disadvantage observed in the cities.

Objectives: to investigate the association between real estate prices, education, and mortality., Design: cohort study., Setting and Participants: residents in Rome at the 2011 Italian Census, not living in institutions, and living in the address reported in the Census survey. People aged 18-99 years were followed from 2011 to 2016 using anonymous record linkage procedures with administrative databases. The Census includes several individual information, such as gender, age, education, residential neighbourhood. Data and cause of death were collected from mortality register. Real estate prices (euros/m2) were available for each neighbourhood., Main Outcome Measures: adjusted Cox regression models (hazard ratios - HRs and 95%CIs) were used to estimate the association among individual education, real estate price in the neighbourhood, and mortality., Results: the subjects selected were 2,051,376 (54% women, 22.5% with high education level). During the follow-up, 127,352 subjects died. Taking into account gender, age, marital status, and real estate prices, education level was strongly associated with all-cause mortality; compared to highly educated the higher mortality, risk was 35% (95%CI 32%-37%) for low education level and 16% (95%CI 14%-19%) for medium education level. Taking into account the same factors and education level, each increase of 1,000 euros in price/m2 was inversely associated with mortality (HR 0.96, 95%CI 0.96-0.97)., Conclusions: there is an independent association between the two indicators and mortality in Rome. A simple indicator such as real estate prices can be used to tackle inequalities.

Background: scientific literature indicates that there are sex, and gender differences in the development, symptomatology and evolution of different diseases, in the response to drugs and in the therapeutic pathways. Even in the COVID-19 epidemic some sex/gender differences emerged., Objectives: to analyze COVID-19 epidemic data by gender and age in Italy, Germany, Spain, and Sweden, characterized by having implemented different pandemic containment policies, with the aim of observing any characteristics that can be interpreted with the lens of sex/gender differences., Materials and Methods: we used confirmed cases and deaths associated with COVID-19 for Italy, Spain, Germany, and Sweden from respective national surveillance databases. Mortality data for Italy were also analysed. The period of investigation was March-May 2020. As indicators, we used the case fatality ratio adjusted for time delay and SMR for mortality., Results: women are more vulnerable to COVID- 19 infection in the 30-60-year age group. Case fatality ratio is higher in men than women, with a ratio men/women equal to 1.7 in Italy, Spain, and Sweden and 1,4 in Germany. The ratio increases in the lower age groups. The analysis of the mortality data observed/expected in Italy in the same period with respect to 2015-2019 shows a comparable excess with SMR equal to 132 for men and 127 for women., Conclusions: COVID-19 affects both genders with some differences in the incidence, higher in women, and lethality, higher in men. These differences highlight the need to better understand the sex/gender and age interaction both for epidemiological surveillance and for a better gender-appropriateness of the ongoing prophylactic and therapeutic treatments. This would be possible if all health indicators (symptoms, past illnesses, primary and hospital-level health care, hospitalization, etc.) were provided by age and gender. Analysis of the causes of death could help to better understand the increase in mortality for both genders, in particular for women, for whom a lower lethality for COVID-19 appears from data.

Background: Data regarding pulmonary embolism (PE)-related mortality in Italy are scarce. We assessed PE-related mortality and its time trend in Italy by using the World Health Organization (WHO) Mortality Database., Methods: The vital registration data of Italy from the WHO Mortality Database were analyzed for the period between 2003 and 2015, and compared with time trends in Southern Europe. Death was defined as PE-related when classified with specific codes for PE or limb vein thrombosis listed as the primary cause of death. This coding was based on the International Classification of Diseases, tenth revision., Results: Overall, 28 647 PE-related deaths (10 178 men and 18 469 women) were recorded between 2003 and 2015. The observed age-standardized annual PE-related mortality rates were 2.5 per 100 000 men and 2.8 per 100 000 women. Moreover, PE-related mortality increased with age with a seemingly exponential distribution. Joinpoint regression analysis demonstrated a statistically significant linear decrease in age-standardized PE-related mortality of -0.21 (95% confidence interval -0.27; -0.15) and -0.22 (95% confidence interval -0.28; -0.16) deaths per 100 000 population for men and women, respectively., Conclusions: The Italian age-adjusted mortality rates appeared lower compared to overall Southern Europe, despite a similar decreasing trend over time.

Introduction: in Italy and Tuscany the resident population aged> 99 reached its all-time high in 2015. Respiratory diseases in men and ischemic heart diseases in women were the leading causes of death for Italian centenarians in 2015. The aim of this study is to describe the mortality of Tuscan centenarians by cause., Materials and Methods: population-based observational study using current health data, extracted from the Tuscan Regional Mortality Register. Main outcome measures are: proportional mortality and annual mortality trend at age >99, age-specific mortality rates (85-89; 90-94; 95-99, >99)., Results: at age >99 ischemic heart diseases, cerebrovascular diseases and respiratory diseases are among the top 5 causes of death as in the less elderly age, the relative frequency of tumors decreases and that of the ill-defined causes increases. If ill-defined and ischemic heart diseases are separated, the first cause of death is cerebrovascular diseases in males and senility in females. In the period 2002-2015 at age >99 all-cause mortality fell on average every year by -0.15% for males and -0.14% for females, mortality due to arteriosclerosis decreases -10% (males) and -12% (females) every year, due to cardiac arrest and other non-specific cardiopathies -5% (males) and -7% (females) and due to cerebrovascular diseases -3% (females). Mortality due to senility increases +6% per year in women., Conclusions: in Tuscany the first cause of death is different by gender (cerebrovascular diseases in males and senility in females) and differs from what has been observed nationally. In the 2000s, mortality from cardiovascular diseases without diagnostic significance decreased in Tuscan centenarians and that from senility increased.

Objectives: This Monograph aims to provide the scientific community and the Regional Healthcare Service an up-to-date Atlas of mortality for the Campania Region (Southern Italy). The Atlas shows an overview of mortality through comparisons with national data and with intraregional macroareas. Maps presenting risk measures with municipal details are also provided., Materials and Methods: Both overall and cause-specific mortality data for the period 2006-2014 referred to people residing in Campania Region are analysed in this Atlas. Twenty-nine death causes (major causes and specific cancers) are studied; for each of them, it has been provided: • direct standardised rates (standard population EU 2013) referred to Italy, Campania Region, and the seven regional Local Health Units (LHUs); • standardised mortality ratios (SMRs), estimated on a regional basis, referred to every LHU; • years of life lost (number and rate) both on a regional and on LHU basis; • mortality rate trends for the period 2006-2014, including annual percentage changes (APCs) for Italy, Campania Region, and every LHU; • for every death cause, regional maps are provided also with municipal details for Relative Risks (RRs) and risk posterior probabilities (PPs) estimated through a Bayesian hierarchical model. Risk estimates are presented both crude and adjusted by socioeconomic deprivation index resulted from the 2011 Census of the Italian National Institute fo Statistics., Results: In Campania Region, standardised mortality ratios (per 100,000; IC95%) higher than the national average have been recorded for the following causes: all causes of death: M: 1,233.3 (IC95% 1,227.9-1,238.9) vs 1,093.8 (IC95% 1,092.5-1,095.1); F: 826.1 (IC95% 822.6-829.7) vs 722.8 (IC95% 721.9-732.6); digestive system diseases: M: 51.2 (IC95% 50.2-52.3) vs 44.2 (IC95% 44.0-44.5); F: 35.8 (IC95% 35.1-36.6) vs 29,2 (IC95% 29.0-29.4); circulatory system diseases: M: 493.1 (IC95% 489.6-496.8) vs 404.3 (IC95% 403.5-405.1); F: 388.5 (IC95% 386.1-390.9) vs 296.5 (IC95% 295.9-297.0); genitourinary system diseases: M: 27.2 (IC95% 26.4-28.1) vs 21.9- (IC95% 21.7-22.1); F: 18.2 (IC95% 17.7-18.7) vs 13.7- (IC95% 13.5-13.8); endocrine and metabolic diseases: M: 60.0 (IC95% 58.8-61.2) vs 43.8 (IC95% 43.5-44.0); F: 60.7 (IC95% 59.8-61.7) vs 36.6 (IC95% 36.4-36.8); myocardial infarction: M: 71.1 (IC95% 69.8-72.4) vs 60.9 (IC95% 60.6-61.2); F: 38.2 (IC95% 37.4-39.0) vs 30.2-(IC95% 30.0-30.4); diabetes: M: 52.6 (IC95% 51.5-53.8) vs 35.1 (IC95% 34.9-35.3); F: 53.8 (IC95% 52.9-54.7) vs 28.6 (IC95% 28.4-28.8). On the other hand, mortality rates comparable to or lower than the national average are observed for the remaining causes of death, with different differences for gender. Mortality for cancer causes in Campania Region presents rates higher than the rates observed at national level in males for the following causes: all cancers: 380.4 (IC95% 377.5-383.3) vs 356.5 (IC95% 355.8-357.2); lung cancer: 112.5 (IC95% 110.9/114.0) vs 93.0 (IC95% 92.6-93.3);larynx cancer: 7.6 (IC95% 7.2-8.0) vs 5.5 (IC95% 5.4-5.6);bladder cancer: 25.1 (IC95% 24.4-25.9) vs 17.3 (IC95% 17.1-17.4); in females for the following causes: liver cancer: 3.8 (IC95% 3.6-4.1) vs 3.3 (IC95% 3.2-3.4);bladder cancer:: 3.5 (IC95% 3.3-3.7) vs 3.0 (IC95% 2.9-3.0). In Campania Region, mortality rates comparable to or lower than the national average are observed for the remaining cancer causes both in females and in males. For almost all the death causes, the highest mortality rates are observed in the three LHUs of Naples (Naples centre, Naples 2 North, Naples 3 South); for some death causes, also the Province of Caserta presents the highest mortality rates. It is worth noting that these areas are characterised by the highest urbanisation and regional population density, and by exposures to possible environmental risks. Time trend analyses highlight that regional and national trends are similar for almost all the examined death causes. In Campania Region, males present decreasing trends for all-cause mortality; for respiratory system, circulatory system, and digestive system diseases; for all malignant cancers; for lung, prostate, and stomach cancers; for leukaemias. On the other hand, an increasing trend is shown for liver cancer. Trends for genitourinary system and nervous system diseases are almost unchanged; the same is for blood diseases and haemolymphopoietic system cancers. In females, there is a decreasing mortality trend for all causes, for circulatory system and digestive system diseases; for haemolymphopoietic system and stomach cancers; on the contrary, an increasing trend is highlighted for communicable diseases and lung and liver cancer, mirroring the national situation. Trends for respiratory system, genitourinary system, nervous system diseases; blood diseases; all malignant cancers; kidney and breast cancers; leukaemias are almost unchanged. The analysis of mortality data on municipal basis reported that the most excesses in mortality risk occur in the municipalities included in the area with the highest urban development of Naples and, partly, in the municipalities of the Caserta Province. The distribution of the excesses at municipal level is not homogeneous in Campania Region, but there are relevant intermunicipal differences related to the considered causes of death. This heterogeneity in the distribution of excess risk is a characteristic also of the area called Terra di fuochi (Land of fires), both for overall mortality and for mortality by gender., Conclusions: Mortality data are a valuable support to the analysis of the population health conditions. Excesses in general mortality and for some specific causes found in Campania Region vs Italy in 2006-2014 suggest that in this region there is a need to implement more strict intervention in terms both of primary prevention (for individuals and the environment) and of management of the whole care and clinical pathway of some pathologies, bearing in mind the burden of regional structural and economic factors on these excesses. The highest excesses in mortality in Campania Region have been found in the areas with the highest degree of urbanisation: this confirms the national data of a different distribution of diseases - and mortality - in the areas characterised by high urban development compared to rural areas. Finally, cause-specific mortality maps at municipal level, extended to the whole region, could enable to identify possible critical issues which may need epidemiological studies focused on possible local factors of environmental pressure.

Objectives: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators., Design: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration., Setting and Participants: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census., Main Outcome Measures: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs)., Results: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men., Conclusions: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

Mortality studies conducted to date in the area of Trino (Piedmont Region, northern Italy) have been limited to the years from 2000 onwards. These studies have highlighted an increased frequency of brain tumors, leukemia, mesothelioma, peritoneal, prostate, larynx and total tumors in men in the municipality of Trino while for women the increased risk was limited to melanoma. The present study has allowed us to make more robust epidemiological considerations and to analyze the historical trend in mortality in the municipality (starting from 1970) correlating it also to the social and economic changes reported. We calculated the Standard Mortality Ratio (indirect standardization) by retrieving data on observed cases from the years 1980 to 2013 from the Italian national statistics bureau (ISTAT) and the municipal archives, and using regional specific mortality rates in the Piedmont region from 1980 to 2013 for expected cases. Results show a slowly decreasing trend for brain tumors in the last 10-15 years while for leukemia, we observe a sharp increase in the same time period, affecting both men and women indistinctly.

Background: a death number increment compared to the previous years was observed in Italy for the year 2015; its causes are under study., Objectives: to verify if the mortality occurred in Palermo Province (Sicily Region, Southern Italy) for the year 2015 was greater than the one observed in the previous period (years 2009-2014) and to find which death causes it would be attributable to., Design: observed number of deaths in 2015 were compared with expected numbers calculated with the traditional analysis of direct adjusted rates, and with a 90% predictive interval estimated fitting a Generalized Additive Model (GAM), via a quasi-Poisson distribution of the observed deaths in the period 2009-2014; various measures of the environmental temperature were used as regressor. The latter method was used also to analyse causes of death., Setting and Participants: all deaths occurred in residents in Palermo Province in the years 2009-2015., Results: for each population subgroup based on sex and residence, direct adjusted rates for 2015 were lower than those observed in the previous period, but for women resident in towns outside Palermo (observed/estimated ratio: 1.04; 95%IC 1.00-1.08). GAM analysis shows mortality excesses only in men aged more than 64 years; in Palermo residents, excesses were shown in the 2nd week of December; in residents in towns of the Province excesses were shown in the 2nd and 3rd week of February and in the 1st and 2nd week of August. In the death causes analysis, mortality excesses were shown for pneumonia and bronchial pneumonia in the 1st and 2nd weeks of January; 3rd week of February; in the 1st, 2nd and 4th week of August; and in the 1st week of October. For infectious diseases, these excesses were observed in the 1st week of March., Conclusions: it is plausible that in some weeks of the year 2015 there have been a mortality excess; however, as all-year mortality is lower or equal to that of the previous periods, the Authors believe that there is an harvesting effect, that is a mortality displacement that does not affect total mortality.

Background: in SENTIERI surveillance system, the health risk assessment in the contaminated sites (CSs) was carried out considering the socioeconomic deprivation index (ID-SENTIERI) at the municipal level as a confounder. Pasetto et al. discussed the use of IDs in ecological studies and proposed to examine the role of ID-SENTIERI as a confounder., Objectives: to evaluate the initial conditions necessary for the role of confounding, i.e., the verification of an association of the ID-SENTIERI with the risk of some of the diseases for which evidence of a relationship with the socioeconomic state (SES) is documented in the literature., Design: the methodological approach is to exploit ecological correlations in order to assess the relationship between ID and the occurrence of mortality or congenital malformations (CMs)., Setting and Participants: mortality and CM data from municipalities in the regions of Emilia-Romagna (Northern Italy), Tuscany (Central Italy), and Campania (Southern Italy) were used. Mortality for all causes, all tumours, and lung cancers were analysed for the period 1995-2008. For the CMs, data from the regional registries of Emilia-Romagna, Tuscany, and Campania in the periods 1995-2011, 1992-2011, 2004-2010, respectively, were used. Analyses of the relationship between mortality/CMs and ID-SENTIERI were carried out according to cause, region, gender, and demographic amplitude classes using a GAM-Poisson regression model., Results: the mortality analyses show that, for the male population of the three regions under study, the relationship between ID and mortality is increasing for each outcome for municipalities with less than 50,000 inhabitants; while results for female population differ from region to region. The results of the CMs show growing associations, considering only municipalities under 10,000 inhabitants., Conclusions: the results of the study suggest that scientific evidence of an association between SES and health should be evaluated taking into account the gender, the study area, and the demographic size of the municipalities. For ID to be used as a confounding variable, it must be associated with the outcomes for which the influence of socioeconomic factors in the reference areas has been ascertained. If there is no such association, the ID cannot be used as a confounder, as it could lead to distortions of estimates and such distortions are difficult to predict. In these cases, ad hoc IDs should be produced.

Objectives: to describe overall and amenable mortality trends over the last 30 years in the Local Health Authorities (LHAs) of Piedmont Region (Northern Italy). By comparing these trends, it is possible to analyse intraregional variability in the performance of the healthcare system., Design: descriptive study., Setting and Participants: mortality data from the Italian National Institute of Statistics (Istat) for the population between 0 and 74 years resident in Piedmont Region for the period 1980-2011., Main Outcome Measures: overall and amenable age-standardised death rates, by gender and health unit; ratio of the differences in amenable and in all-cause mortality (standardised rate difference - SRD: SRDamenable/SRDall-cause) over the observation period., Results: between 1980 and 2011, overall mortality in Piedmont has decreased from 425.8 x100,000 to 205.5 x100.000 among women, and from 891.6 x100,000 to 390.7 x100,000 among men. The rate of amenable mortality on overall mortality decreased from 40% to 32% among women, and from 33% to 21% among men. Furthermore, amenable mortality contributed to 48% of the overall mortality reduction among women and to 35% among men. Regional results show heterogeneity between health units. This heterogeneity decreased over the three decades and was higher in men than in women., Conclusion: although Piedmont is one of the Italian Regions with the highest amenable mortality rate, a considerable decrease of its contribution to the overall mortality was seen in the last three decades. This improvement was not equally among LHAs, and substantial intraregional differences are still present, probably due to different timing and way of introduction of healthcare innovations for prevention and care for amenable to healthcare diseases. The proportion of amenable mortality on overall mortality is much higher among women than men, and it probably depends on the diseases considered in the definition itself.

Introduction: the Italian National Institute of Statistics (Istat) estimated an increase in mortality in Italy of 11.3% between January and August 2015 compared to the previous year. During summer 2015, an excess in mortality, attributed to heat waves, was observed., Objectives: to estimate the excess mortality in 2015 using data from the rapid mortality surveillance system (SiSMG) operational in 32 Italian cities., Design: time series models were used to estimate the excess in mortality among the elderly (65+ years) in 2015 by season (winter and summer). Excess mortality was defined as the difference between observed daily and expected (baseline) mortality for the five previous years (2009- 2013); seasonal mortality in 2015 was compared with mortality observed in 2012, 2013, and 2014. An analysis by cause of death (cardiovascular and respiratory), gender, and age group was carried out in Rome., Results: data confirm an overall estimated excess in mortality of +11% in 2015. Seasonal analysis shows a greater excess in winter (+13%) compared to the summer period (+10%). The excess in winter deaths seems to be attributable to the peak in influenza rather than to low temperatures. Summer excess mortality was attributed to the heat waves of July and August 2015. The lower mortality registered in Italy during summer 2014 (-5.9%) may have contributed to the greater excess registered in 2015. In Rome, cause-specific analysis showed a higher excess among the very old (85+ years) mainly for cardiovascular and respiratory causes in winter. In summer, the excess was observed among both the elderly and in the adult population (35-64 years)., Conclusion: results suggest the need for a more timely use of mortality data to evaluate the impact of different risk factors. Public health measures targeted to susceptible subgroups should be enhanced (e.g., Heat Prevention Plans, flu vaccination campaigns).

Ageing is doubtless a factor characterizing population in Europe, and particularly in Emilia-Romagna, a north-east Italian region of about 4,5 million people. From 1990 to 2010 life expectancy in Emilia-Romagna has grown by about 6 years for men and 5 for women. At the same time good health life expectancy has grown even more rapidly, particularly among women. While it is expected that in 2030 the number of over-65s will have exceeded one million people, the trends in good health life expectancy is not granted. Strengthen actions aimed at increasing good health conditions promotes ageing sustainability and can feed the positive trend observed for the life expectancy in good health. The Emilia-Romagna Region takes up the demographic challenge of the coming years in the European context and promotes strategies for active and healthy ageing, working on prevention in its broadest sense and for the entire life span, with the aim of actively contribute to the achievement of the EU2020 target of an increase of two years in life expectancy in good health of European citizens.

Objective: to examine the characteristics and mortality trends for specific type of accident in immigrants resident in Tuscany and to compare them to those observed in Italians resident in the same region., Design: descriptive study using the data of the Regional Mortality Registry of Tuscany., Setting and Participants: 1997-2008 deaths for accidents by citizenship ("Italians" and "Immigrants" from Countries with strong migratory pressure or PFPM) in residents in Tuscany., Main Outcome Measures: number of deaths, proportional mortality and standardized (standard: European population) mortality 15-64 truncated rates per 100,000 for each specific accidental cause of death, by gender and population (PFPM and Italians), in 1997-2008, and confidence intervals at 95% (95%CI); trends in mortality standardized truncated rates for specific accidental cause in immigrants and Italians in 2002-2008., Results: in the period 1997-2008, 315 deaths for accidents have been registered in immigrants. The comparison between immigrants and Italians did not reveal any significant difference in mortality for road and at work accidents. Suicides are significantly higher in Italian males (rate in Italians 9.3; 95%CI 8.7-10.0 vs. rate in PFPM 4.3; 95%CI 2.4-6.2), while homicides are higher in male immigrants (rate in Italians 0.6; IC95% 0.4-0.8 vs. rate in PFPM 3.2 95%CI 1.7-4.7). Deaths from other injuries are more frequent in Italians in both genders. Trends in mortality rates indicate a reducing gap between immigrants and Italians., Conclusion: in Tuscany, mortality rates for some specific accidental causes are significantly different between immigrants and Italians, nevertheless trends of the last evaluated period seem to reveal a reducing gap suggesting a progressive integration of immigrants.

Objectives: This study describes up-to-date cancer incidence and survival in Italian paediatric and adolescent patients, based on data collected by the network of Italian cancer registries (AIRTUM). It updates the monograph published on the same topic in 2008. The main objective of this monograph is to present the statistics according to standard rigorous epidemiological methods and disseminate them to a wide range of readers, including the lay public. Given the deep impact of the 2008 monograph on the general public, in this update we complement descriptive statistics with additional data and commentaries on issues of importance for public health, in order to provide unambiguous criteria on how to interpret the statistics. The study is the result of the collaboration between AIRTUM and AIEOP (Italian Association of Paediatric Haematology and Oncology) with contributions from interested parties, including representatives of parent associations. The monograph is divided into three parts. The first part presents incidence rates, survival probabilities, and time trends, by sex, age, geographical area, and cancer site or type, by means of tables and graphs as in the previous monograph, to facilitate direct comparisons. Four articles summarize and comment the results. The second part uses data from AIRTUM and AIEOP to outline patient management and health care issues; it includes estimates of the number of new cases in the next decade and of young adults living after a paediatric cancer diagnosis. Health organizational aspects of treatment services for paediatric patients, based on the AIEOP database, are also discussed, along with long-term complications in cured patients. The third section describes the changes in mortality trends due to improving therapies and healthcare services, and discusses risk factors and prevention of childhood cancer, late adverse events in cured patients, and other related issues., Material and Methods: Data herein presented were provided by AIRTUM population-based cancer registries, covering 47%of the Italian population below age 20 years, in the period 2003-2008. Quality of cancer registration in Italy is elevated, with high proportions of microscopically verified diagnoses (91%in the 0-14 years age group and 96% between 15 and 19 years of age) and a very small proportion of cases collected through death certificate only (0.1%).The proportion of cases in diagnostic groups XI (other malignant epithelial neoplasms) and XII (other and unspecified neoplasms) of the International Classification for Childhood Cancer (ICCC), based on the third revision of the International Classification of Diseases for Oncology (ICD-O-3), were 7.0% in the 0-14 years age group and 26.0%in the 15-19 years age group.The ratio between mortality and incidence was 17.7% in both children and adolescents. Detailed results are presented in 24 fact sheets for the 12 major ICCC-3 diagnostic groups and 10 sub-groups of special interest; the series is completed by a sheet on all malignant tumours and one on all tumours including non-malignant neoplasms of the central nervous system. All sheets include results for three age groups (0-14, 15-19, and 0-19 years) and are followed by two commentaries on incidence in the recent period, one on trends and the other on survival. Incidence rates were age-standardized on the European population and presented per million children. Incidence rates are also presented by age group, sex, and geographical area. Incidence trends were evaluated for two periods, 1988-2008 and 1998-2008, using estimated annual percent changes, and survival estimates were calculated by age and period. Indicators and corresponding 95% confidence intervals are shown in forms of graphics and tables at the end of the monograph and online at http://www.registri-tumori.it. Geographical analyses were conducted rearranging cancer registries into four macroareas (North-West, North-East, Centre, and South and Islands). Age groups were the same used in descriptive studies on children worldwide (0, 1-4, 5-9, 10- 14 years for paediatric tumours and 15-19 years for adolescents). Incidence trend analyses included cancer registries with three or more years of registration in the 5-year period, using Poisson regression models. Observed survival was computed according to the Kaplan-Meier method. The estimate of expected cases in the next decade was based on observed incidence rates in the most recent period, extended to the Italian estimated population of children and adolescents in the periods 2011-2015 and 2016-2020. The AIEOP database (Modello 1.01) allowed us to compare the number of patients treated and followed-up in specialized centres with expected cases based on AIRTUM estimates. The AIEOP database also provided information regarding health care migration throughout Italian regions and the number of foreign (immigrated) children treated in Italian AIEOP centres., Results: In the period 2003-2008, 31 cancer registries reported 4,473 incident malignant neoplasms, 2,855 in children and 1,618 in adolescents. Cancer incidence rates were 164 cases per million in children aged 14 years or below and 269 cases per million in patients aged 15-19 years. Limited geographical variations emerged. In children (0-14 years) a significant increase in malignant cancer incidence was observed until 1997 (APC: +3.2%), followed by a plateau (APC: -1.1%not statistically significant).Until the late Nineties, a statistically significant increase was also observed in the incidence of all leukaemias in males (APC: +5.7%), lymphoid leukaemias (APC: +5.6%), representing 80% of all leukaemias, Hodgkin and non- Hodgkin lymphomas (APC: +6.3%). A significant decrease emerged for lymphoid leukaemia starting in 1995 (APC: -1.9%), while no substantial change in cancer incidence rates was observed in the last decade of observation for all malignant neoplasms and lymphomas. In addition, no variation emerged for malignant (according to the most recent classification) central nervous system (CNS) neoplasms, while an annual increase of 1.8% (significant) was observed in the period 1988-2008, when non-malignant tumours were included. Increases in cancer incidence were observed throughout the study period for neuroblastoma (APC: +1.9%) and epithelial tumours or melanoma (APC: +4.1%). In the period 1998-2008, in addition to lymphoid leukaemias, a significant decrease was observed for all malignant neoplasms, lymphomas in girls, CNS tumours (males and females), and renal tumours in girls, while no increases were observed in this age group. In adolescents (15-19 years) between 1988 and 2008, a significant increase in incidence rates was observed (APC: +2.0%) for all malignant neoplasms, all lymphomas (APC: +2.9%; in particular Hodgkin lymphoma, APC: +3.6%), thyroid cancer (APC: +6.1%), and melanoma (APC: +8.1%). Conversely, lymphoid leukaemia is the only neoplasm showing a long-term decrease in adolescents. Recent trends (1998-2008) confirm the long-term increases only for all malignant neoplasms in girls and thyroid cancer (APC: +7.9%, boys and girls), while a decrease in bone tumour incidence emerged in girls, albeit based only on 46 cases. Cancer mortality in children showed a persistent decrease for all neoplasms and even for more frequent cancer sites or types, and mortality rates for cancer were three-fold higher in the early Seventies than in 2008. In addition, five-year survival after cancer diagnosis increased in the last three decades and was still increasing in the period 2003- 2008, reaching 82% in children and 86% in adolescents. In the period 2008-2010, 4,488 children (0-14 years) were treated in one of the AIEOP clinical centres and we estimate, based on the above-presented incidence rates, that they represented 92% of all cancer cases in Italy. However, in adolescents, the proportion of patients treated in AIEOP centres was only 25%. A migration of patients living in the South of Italy to Central and Northern Italy emerged from AIEOP information. The expected number of cancer cases in children aged between 0 and 14 years of age is approximately 7,000 in the period 2016- 2020, while the corresponding figure for adolescents between 15 and 19 years of age is 4,000, with no relevant variation in comparison with the previous five-year period., Comments: The present findings update descriptive cancer epidemiology in children and adolescents in Italy based on data provided by an extensive network of general and specialized population-based cancer registries. Data obtained from cancer registries are supplemented by additional information collected by specialized clinical AIEOP centres and mortality reports collected by the National Institute of Statistics (ISTAT). Incidence rates reported in Italy were slightly higher in comparison to other developed Countries, but relatively consistent between different Italian areas. Our results also showed that the significant increase in cancer incidence observed until the end of Nineties has halted, with the exception solely of thyroid cancer in adolescents. Efficacy of therapeutic protocols has improved constantly since the Seventies, and recent findings confirm this trend in all age groups and, in particular, for rarer tumours and cancer types that have very poor prognosis. Findings derived from cross-analysis with AIEOP data suggest that it is possible to further improve the efficiency of our healthcare system, in particular for adolescents; migration can be reduced with a more rational use of hospitals throughout Italy.

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.

Objective: The limited scientific knowledge on relationship between exposure and health effects in relation to geothermal activity motivated an epidemiologic investigation in Tuscan geothermal area. The study aims to describe the health status of populations living in Tuscany municipalities where concessions for exploitation of geothermal resources were granted., Design: This is an ecological study, so it is not useful to produce evidence to sustain a judgment on the cause-effect link. The major limits of this type of study are the use of the residence at municipal level as a proxy of exposure to both environmental and socioeconomic factors and the use of aggregated data of health outcomes that can lead to the well-known ecological fallacy., Setting and Participants: Sixteen municipalities were included in the study area: eight are part of the so-called "traditional" geothermal area, defined as Northern Geothermal Area (NGA) and eight located in the Amiata Mountain defined as Southern Geothermal Area (SGA). In 2000-2006, the average resident population in the overall area was approximately 43,000 inhabitants. Thirty-one geothermal power plants were active, with a production capacity of 811 MW, 5 of them with 88 MW located in the SGA. Statistical analyses on the entire geothermal area, NGA and SGA subareas, and the sixteen municipalities were performed., Main Outcome Measures: Mortality data were obtained from Tuscany Regional Mortality Registry for the 1971-2006 period, analysing 60 causes of death, of interest for population health status or consistent with "Project SENTIERI" criteria. Hospital discharge records of residents in Tuscany Region in 2004-2006, anywhere admitted to hospital, were analyzed considering only the main diagnosis, excluding repeated admissions for the same cause. The causes taken into account are the same analysed for mortality were considered. Age-standardized mortality rates (TSDM) and the temporal trends of TSDM for four periods (1971-1979, 1980-1989, 1990-1999, 2000-2006) were computed. Age-standardized mortality/hospitalization ratios (SMR/SHR), with and without adjustment for the deprivation index based on 2001 census data, were calculated: mortality in the years 2000-2006 and hospitalization in 2004-2006. The expected number of events were computed using rates of residents in neighbouring municipalities (municipalities included in 50 km radius circle centred on the study area). Bayesian estimates of mortality/hospitalization ratios (BMR/BHR) at municipal level only and relating maps of the Bayesian risk estimators were elaborated. Congenital malformations (MC) were analysed using data from Tuscan Registry of Birth Defect in 1992-2006 period, relative to outcomes of pregnancies in women resident in the municipalities of study area, wherever the birth or termination of pregnancy occurred. The ratio between observed and expected cases (O/A), with expected defined according to regional rate, were calculated and O/A Bayesian estimates (BMR) are showed only at municipal level. The low weight and the males/females ratio at birth were analysed using data from Tuscany Birth Certificates, covering period 2001-2007, excluding births occurred in facilities outside Tuscany Region. For Low birth weight (< 2,500 grams), very low birth weight (< 1,500 grams), low birth weight in women with normal gestational age or greater than 36 weeks, gestational age less than 36 weeks, and the frequency of males, the observed/expected ratio was calculated, with the expected number defined according to regional rate., Results: ENVIRONMENTAL BACKGROUND: High levels of arsenic in drinking water distribution emerges as a critical element, so that several municipalities resorted to granting exemptions for the parameters laid down by the Legislative Decree in force (D.Lgs 31/01). However, during the final phase of the study, new blast systems activated in the SGA decreased the arsenic levels in the water supply, reaching values not requiring derogations, which, instead, are still effective in some NGA municipalities. Air quality data, from Tuscany Regional Agency for Environmental Protection-ARPAT, show that geothermal activities are able to affect air quality, especially with hydrogen sulphide in NGA, and hydrogen sulphide and mercury in SGA. A significant contribution to the presence of mercury in air is due to previous metallurgical sites. Although mercury levels are below WHO guideline values, in SGA nearby Siena, values were significantly higher than in other geothermal areas, because of power plant PC2 (turned off in July 2011) in Piancastagnaio municipality. The hydrogen sulphide concentration levels were generally lower than WHO reference values, with occasional excesses over guideline value for health protection (150 µg/m3 as average of the 24 hours). Olfactory pollution was more critic with values exceeding 7-10 µg/m3 range even in areas without geothermal plants., Results: POPULATION'S HEALTH STATUS: This study evaluated health status of resident population in geothermal areas analysing geographic and temporal distribution of mortality, hospitalization and reproductive health outcomes (congenital malformations, low birth weight, sex ratio among newborns). In both geothermal areas mortality rates steadily declined from 1971 to 2006, in males and females, in line with the regional trends. In 2000-2006 period, in the overall geothermal area a significant mortality excess was observed for all causes among males (2,312 deaths, 2,146 expected), but not among females, using as reference residents in neighbouring municipalities. The mortality excess among males was more evident for infectious diseases (25 deaths, 10 expected), especially tuberculosis (8 deaths, 2 expected), for respiratory diseases (218 deaths, 170 expected), in particular pneumoconiosis, including deaths from silicosis (51 deaths, 14 expected), and for nervous system diseases (72 deaths, 56 expected). Among females significant mortality excess for liver cirrhosis (35 deaths, 25 expected) emerged, while mortality from cardiovascular diseases and ischemic heart diseases were significantly lower than expected. In the NGA, mortality among men was lower than expected for all cancers (-15%), in particular for lung cancer (- 25%), while values significantly in excesses were observed for infectious diseases (11 observed, 4 expected) and respiratory diseases (90 observed, 73 expected), expecially pneumoconiosis (20 observed, 6 expected). Among females, significant mortality excesses for ovarian cancer (17 observed, 10 expected) and for circulatory disorders of brain (170 observed, 140 expected) resulted. In the SGA, mortality was more critical, accounting for majority of the excesses detected in overall Geothermal Area. In fact, only infectious diseases and pneumoconiosis were detected in excess in both the geothermal areas. In the SGA, excess of general mortality among males (1,431 deaths; 1,245 expected) but not among females emerged. Even for all cancers, an excess among males (505 deaths, 419 expected) was observed, in particular for cancer of stomach (53 deaths, 44 expected, not statistically significant after adjusting for DI), liver (39 deaths, 23 expected) and lung (124 deaths, 102 expected) cancer. Mortality in SGA was also in excess for respiratory diseases only among men (128 deaths, 97 expected), mostly due to silicosis (31 deaths, 8 expected), although steadily decreasing since 1971 as observed at regional level. Also tuberculosis resulted in excess in SGA (7 deaths, 1 expected). Among females acute respiratory disease mortality was significantly in excess (41 observed, 29 expected). Temporal trend showed a decline from the 70s to the 90s, with a rising trend in recent years in line with Tuscany region. It should be considered that pneumonia was the commonest cause of death of acute respiratory diseases, which allow for lower reliability of death certificate, especially among the elderly (> 64 years). Among females resident in SGA a mortality excess from digestive system diseases was observed (72 observed, 55 expected). The hospitalization in the overall Geothermal Area did not show any excess for all causes and all tumours in both genders. Statistically significant excesses for hospital admission from stomach cancer among males (49 observed, 38 expected) and females (42 observed, 28 expected), and from lymphohematopoietic tumours among females, particularly from lymphatic leukaemia (15 observed, 5 expected), were observed. As mortality analysis highlighted, also hospital admissions by geothermal areas and gender showed a worst picture in SGA than in NGA. In the latter, a significant excess of hospital admissions from all causes among females (1,357 observed, 1,284 expected) but not among males (1,193 observed, 1,141 expected) and an excess - close to statistical significance - from all tumours only among females (297 observed; 272 expected) were observed. Furthermore, statistically significant excesses of hospital admissions from digestive system diseases in both genders (M: 392 observed, 350 expected; F: 300 observed, 268 expected), from dementias (16 observed, 8 expected) and from lympho hematopoietic cancers among females, particularly from lymphatic leukaemia (9 observed, 2 expected), were observed. In the SGA, statistically significant excesses of hospital admissions for stomach cancer (M: 32 observed, 21 expected, not significant after adjusting by DI; F: 29 observed, 18 expected), for respiratory diseases (M: 408 observed, 351 expected; F: 339 observed, 277 expected) and for renal failure (M: 61 observed, 41 expected; F: 52 observed, 34 expected) were observed in both genders. (ABSTRACT TRUNCATED)

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.

Introduction: The District care activities are often presented as number of patients, interventions or home visits. A better description should render more visible the persons and their clinical problems whose outcomes should be monitored., Aim: To prospectically monitor the outcomes in a sample of home care patients followed for one year., Methods: Six hundred sixty two home care patients of two Local Health Units of Veneto Region with at least two nurses visits per month had a multidimensional assessment and were followed for one year., Results: At the end of follow-up 32% of patients had died, 3.9% had been admitted to a Nursing home; 41.9% had at least one hospital admission and for 49.7% the number of nursing visits was increased. Closeness to death and inadequate family support were independently associated to an increased risk of hospital admission, while patients with severe cognitive impairment tend to be admitted to hospital less frequently. Of the 216 bedridden patients those with inadequate family support are at higher risk for death and hospital admissions., Conclusions: Home care informative systems allow to assess and monitor the more severe patients thus producing information useful for the continuous improvement of caring processes.

Objective: To investigate survival in Italian systemic sclerosis (SSc) patients from a tertiary center, reporting death causes., Materials and Methods: We analyzed the charts of 251 SSc patients prospectively enrolled in our Rheumatology Unit from 2000 to 2008. Baseline characteristics were recorded. In 2008 the vital status and the causes of death were assessed. Overall and subgroup survival were analyzed by the Kaplan-Meier method and the log-rank test., Results: In 2008, 82% of patients were alive, 8% were known to have died and 10% were lost to follow-up. Overall 5- and 8-year survival were 94.8% and 77.1%, respectively. Patients with an age greater than the median value of the cohort (χ²=4.4; p=0.036), diffuse cutaneous SSc (χ²=3.9; p=0.048), digital ulcers (χ²=6; p=0.015), articular (χ²=5.3; p=0.021), lung (χ²=5.6; p=0.018) and heart involvement (χ²=9.3; p=0.002) had a poorer survival than patients without these features. The majority of SSc-related deaths (60%) were secondary to interstitial lung disease and heart involvement (both 33.3%); 50% of non-SSc-related deaths were due to cancer., Conclusions: Our study reports an improvement in survival of Italian SSc patients during the last decade with respect to the previous ones. Moreover, a reduction in deaths from renal involvement and an increase in deaths from interstitial lung disease were recorded in Italian SSc patients. Our data are consistent with those from recent survival studies carried out on SSc patients from other geographic areas.

Objective: the study is aimed at developing a nationwide deprivation index at municipality and census block level, based on the 2001 Census data, and meeting epidemiological needs., Setting and Participants: The study uses data drawn from the 2001 General Census of Population and Housing. From the 280 variables defined at census block level (352,605 census tracts with average number of inhabitants 169, standard deviation 225; and average area 0.6 km², sd 2.4 km²) five traits that operationally combine to represent the multidimensionality of the social and material deprivation concept have been selected; these are: low level of education, unemployment, non-home ownership, one parent family and overcrowding. The index is calculated by summing standardized indicators and it is also available as categorical by quintiles of population. The same procedure is applied to aggregate frequency data at municipality level. The correlation between mortality and deprivation has been evaluated using 2000-2004 general mortality., Results: considering national data, a strong north-south gradient in deprivation was observed. The municipality deprivation index 2001 is highly correlated to the index likewise calculated on the basis of the previous 1991 Census (r=0.91). General mortality was positively correlated to the index (in particular in population up to 64 years and in larger size municipalities)., Conclusion: the pattern described by the deprivation index was coherent with what is already known about geographic distribution of poverty and its impact on mortality. Such outcome bears out the index use for epidemiological purposes.

Objective: To evaluate the association between daily air pollutant concentration and daily data regarding mortality and hospital admissions among residents of Brindisi (Southern Italy) in the years 2003-2006., Design: The association between the time series of daily mortality (2003-2005) and hospital admissions (2003-2006) and the time series of daily pollutant concentration were analyzed using a case-crossover method and a conditional logistic regression. Bi-directional control periods were selected using a time-stratified approach. Models include mean temperature, relative humidity, influence of epidemics, summer decrease of resident population and holidays as confounders. Specific models with the following variables: cause of death or hospital admission, gender, age and season have been fitted. As hazard periods the following lags have been considered: single lag (from 0 to five) and cumulative lag (lag 0-1 for mortality and 0-3 for hospital admissions)., Main Outcome Measures: A total of 1,792 subjects deceased of all natural causes (including cardiovascular and respiratory causes) and 6,925 hospital admissions for acute conditions (cardiac, cerebrovascular and respiratory diseases) were considered. PM10, NO₂ and CO daily pollutant concentration series were examined., Results: PM10 was associated with mortality from all natural causes (10.36%; 95% CI 1.83-19.61 at lag 0-1). The risk was more pronounced for cardiovascular mortality (14.35%; 95% CI 2.11; 28.07 at lag 1). The association with hospitalization for cerebrovascular diseases was statistically significant for PM10 among females (13.4%; 95% CI 1.7; 26.4 at lag 4) and elderly over 75 years old (13.6%; 95% CI 0.4; 28.6 at lag 4). In specific population groups, increased mortality and hospital admissions have been associated with NO₂., Conclusion: This study found strong and consistent associations between outdoor air pollution (coming from both industrial emissions and urban traffic) and short-term increases in both mortality and morbidity. Precautionary measures should be taken.

The leading causes of death in the Umbria Region (Italy) between 1994-2008 were analysed and a comparison was made between data from three five-year time periods: 1994-1998, 1999-2003 and 2004-2008. Standardized rates of Years of Potential Life Lost (YPLL) at 75 years, by gender and cause of death, were also measured. Mortality data was obtained from the Umbria Registry of causes of death; diagnoses were codified according to the International Classification of Diseases 10th revision (ICD10). Mortality trends over time were analysed by using standardized mortality rates with the 2001 Umbria census data as the reference population . The joinpoint regression program was used to analyze rates calculated by the SEER (Surveillance Epidemiology and End Results) software of the National Cancer Institute (USA). Mortality for all causes, standardised by age, show a significantly decreasing trend from 1994 to 2008 in both genders. Mortality rates for cardiovascular diseases and malignant tumours show a significant constant decline in both genders. Standardised rates of YPLL at 75 years declined by 32% in males and 29% in females between the five-year period 1994-1998 and the period 2004-2008. In conclusion, a generalised decline in mortality and a shift towards older age groups is observed with a consequent decline in YPLL, allowing a positive judgment to be given regarding the efficacy of preventive, therapeutic and rehabilitation interventions implemented by the regional health care system.

Objective: to assess whether compositional (education, income index, number of family members) and contextual (area socioeconomic index) risk factors independently predict all cause and specific mortality., Design: a multilevel (hierarchic) logistic regression model was applied to the individual data of a cohort followed up from 01.01.2002 till 31.12.2007., Setting and Participants: the study evaluated 40-79 years old people resident in Palermo at 01.01.2002, for whom it was possible to match register office and census data (220,723 people, 74.8% of the same age group total population)., Main Outcomes Measures: odds ratios for specific risk factors., Results: mortality was generally lower in people with better socioeconomic conditions and living in more affluent neighbourhoods. Individual risk factors odds ratios do not vary in models with and without area related risk factor. Variance partition component and other between area and total variability ratio index show small values., Conclusion: compositional and contextual socioeconomic factors are independent predictors of mortality; area related variability is only a small fraction of total variability.

Background: in the epidemiological literature heterogeneity of short-term effects of air pollutants among different populations is widely documented. It is commonly attributed to air pollutants characteristics, modality of exposure, individual susceptibility or pollutant-temperature interaction. The case of a time trend in effect size is questionable. In the present paper we compare results of Italian studies on short-term effects of air pollutants based on data for the calendar years 1996-2005. Study objective is to evaluate time stability of risk estimates taking into account of between cities heterogeneity., Materials and Methods: daily series of deaths for natural causes and daily series of average air pollutants concentrations were obtained from the MISA and EpiAir datasets. Effect estimates were obtained by Bayesian random effect meta-analysis to cope with between city heterogeneity., Results: there was no difference in effect estimates using the case crossover or Poisson regression approach on the time period 2001-2005 and the ten Italian cities of the EpiAir study. Using the MISA dataset (time period 1996-2002) and the same statistical approach (Poisson regression with seasonality regression spline) we compared the overall effect estimates selecting different subset of italian cities. The EpiAir cities-subset showed higher risk estimates either for PM10 or NO2. Last, considering the same subset of cities we found an increase in percent variation of mortality for natural causes for 10 microg/m3 of PM10 from 0,36% (CI 95% 0.1;0.8) in the period 1996-2002 to 0.66% (0.4;0.9) in the period 2001-2005. For NO2 we found respectively a change from 0.72% (0.3;1.1) to 1.12% (0.5;1.6)., Conclusion: the results of the EpiAir study are not immediately comparable to the MISA results because the the set of cities included in the two studies is different, the statistical approach is different, and the calendar time period is different. The present analysis shows that considering the subset of cities for which we have data for both time periods and using the same statistical approach the short-term effect of air pollutants on natural mortality is increasing.

Objective: the relationship between air pollution and mortality has been well established in national and international scientific literature. This study reports the results of the EpiAir Project relative to the effect of air pollution on mortality in 10 Italian cities during 2001-2005. The association between particulate matter (PM10) and gases (nitrogen dioxide, NO2, and ozone, O3), and all natural mortality, as well as cardiac, cerebrovascular and respiratory mortality, is presented. Specific issues have been investigated, such as the latency of the air pollution-mortality effects and the identification of individual demographic characteristics and clinical conditions that result in greater susceptibility to the effects of particulate matter., Methods: the study population consisted of 276,205 subjects aged 35+ years old, resident in one of the 10 Italian cities studied, which died in the city between 2001-2005. For each subject, information was collected on cause of death, location of death, demographical variables and hospital discharge diagnoses in the previous 2-year period. The statistical analysis was adjusted for the relevant temporal and meteorological factors using the case-crossover approach. The results for ozone are limited to the warm semester (April through September). An analysis of the association between air pollution and mortality was conducted for each city, and the city-specific estimates were meta-analyzed on a second level to obtain a pooled result, and reported inter-city heterogeneity., Results: a short-term effect of PM10 on mortality has been detected for all the groups of causes considered, with latencies ranging from lag 0 for cerebrovascular mortality to lag 0-3 for respiratory mortality. The association between NO2 and mortality displays strong and similar effects for all death causes, with prolonged effects (lag 0-5) for all groups of causes. The results for O3 are similar to those found for NO2, with prolonged latency (lag 0-5) for all causes of death with the exception of cerebrovascular mortality, for which a delayed effect (lag 3-5) was identified. Individual susceptibility factors of the PM10-natural mortality association include age, as elderly subjects are especially vulnerable to the effects of particles., Conclusions: the main results of the study suggest that the air pollution originated by vehicular traffic is the most relevant environmental problem in Italian cities from a public health viewpoint.

Objective: to construct a composite municipal index of socioeconomic position (SEP) and to describe socioeconomic disparities in mortality within Sicilian elderly inhabitants (age 65+)., Design: 2001 Sicily Census data were used to develop a 5-level SEP index for the 390 municipalities of the Region. Education, occupation, housing tenure, family composition and immigration were considered in order to perform a factor analysis. We used Sicilian Mortality Registry data to compute standardized mortality rates by gender. The SEP index was used for mortality from all causes and for most common causes of death in elderly population. Rates, with 95% confidence intervals, were computed to compare mortality in each level of SEP to the highest level., Results: there were socioeconomic disparities both in overall and in cause-specific mortality. Progressively higher mortality rates with lower SEP were observed for overall mortality (ratio between extreme categories: 1.16 in men, 1.14 in women), as well for mortality from cardiovascular diseases in both genders (ratio between extreme categories: 1.12 in men, 1.09 in women), from respiratory disease in men (ratio between extreme categories: 1.20), and from endocrine glands diseases in women (ratio between extreme categories: 1.35). For deaths from cancer and from diseases of the digestive system mortalities, in both genders, we found higher risks within the lowest SEP level as compared to the highest. Cardiovascular diseases contributed the most to the socioeconomic differences in overall mortality., Conclusion: Within the Sicilian elderly population, socioeconomic position is associated with mortality. The highest mortality rates were observed in the most disadvantaged municipalities. Moreover, mortality rates were oddly distributed by gender.