Antonio Daponte

Social Inequalities and Mortality in Europe - Results from a Large Multi-National Cohort

Background Socio-economic inequalities in mortality are observed at the country level in both North America and Europe. The purpose of this work is to investigate the contribution of specific risk factors to social inequalities in cause-specific mortality using a large multi-country cohort of Europeans. Methods A total of 3,456,689 person/years follow-up of the European Prospective Investigation into Cancer and Nutrition (EPIC) was analysed. Educational level of subjects coming from 9 European countries was recorded as proxy for socio-economic status (SES). Cox proportional hazard models with a step-wise inclusion of explanatory variables were used to explore the association between SES and mortality; a Relative Index of Inequality (RII) was calculated as measure of relative inequality. Results Total mortality among men with the highest education level is reduced by 43% compared to men with the lowest (HR 0.57, 95% C.I. 0.52–0.61); among women by 29% (HR 0.71, 95% C.I. 0.64–0.78). The risk reduction was attenuated by 7% in men and 3% in women by the introduction of smoking and to a lesser extent (2% in men and 3% in women) by introducing body mass index and additional explanatory variables (alcohol consumption, leisure physical activity, fruit and vegetable intake) (3% in men and 5% in women). Social inequalities were highly statistically significant for all causes of death examined in men. In women, social inequalities were less strong, but statistically significant for all causes of death except for cancer-related mortality and injuries. Discussion In this European study, substantial social inequalities in mortality among European men and women which cannot be fully explained away by accounting for known common risk factors for chronic diseases are reported.

Air pollution and cardiovascular admissions association in Spain: results within the EMECAS project

Objective: To evaluate the short term effect of air pollution on cardiovascular admissions in 14 Spanish cities Methods: The period under study was from 1995 to 1999. Daily emergency admissions for all cardiovascular diseases (CVD) and heart diseases (HD) were obtained from hospital records, and the corresponding daily levels of particulates, SO2, NO2, CO, and ozone were recorded. The magnitude of association was estimated using Poisson generalised additive models controlling for confounding and overdispersion. For each cause, lagged effects, up to three days, of each pollutant were examined and combined estimates were obtained. For ozone the analyses were restricted to the warm period. One and two pollutant models were performed. Results: Associations were more consistent in lag 0 (concurrent day) and 1 (lag 0–1), except in the case of ozone where there was a more delayed relation (lag 2–3). For combined estimates an increase of 10 μg/m3 in the PM10 levels in lag 0–1 was associated with an increase of 0.9% (95% CI: 0.4 to 1.5%) in the number of hospital admissions for CVD, and 1.6% (0.8 to 2.3%) for HD. For ozone the corresponding estimates for lag 2–3 were 0.7% (0.3 to 1.0) for CVD, and 0.7% (0.1 to 1.2) for HD. An increase of 1 mg/m3 in CO levels was associated with an increase of 2.1% (0.7 to 3.5%) in CVD admissions, and 4.2% (1.3 to 7.1%) in HD admissions. SO2 and NO2 estimates were more sensitive in two pollutant models Conclusions: A short term association between increases in daily levels of air pollutants and the number of daily admissions for cardiovascular diseases, with specificity for heart diseases, has been described in Spanish cities.

Urinary levels of arsenic and heavy metals in children and adolescents living in the industrialised area of Ria of Huelva (SW Spain)

The Ria of Huelva (south-west Spain) is a highly polluted estuary as a consequence of long-term mining and industrial activities. Between 2003 and 2004, we conducted a biomonitoring study of exposure to arsenic and some heavy metals (cadmium, chromium, copper and nickel) in urine samples of a representative sample (n=227) of children and adolescents residing in this area, and of a reference group of 196 children and adolescents living in other less industrialised areas of Andalusia (south Spain). We also assessed the determinants of the variability in urinary metals within the population of the Ria of Huelva. There were no significant differences in the concentration of metal compounds between the two groups with the exception of Cd levels, which were significantly higher in the reference group. Levels of the five metal ions in both groups were generally within the range of values reported by other biomonitoring studies for general children population, although mean Cd levels tended to be higher as compared to other European studies. Among the population of the Ria of Huelva, the main determinants of the interindividual variation in urinary metals were age, sex, area of residence, and frequency of intake of certain food items (mainly fish and shellfish). Overall, results suggest that living in the Ria of Huelva is not increasing current levels of exposure to certain metals among children and adolescents above those found in other urban areas of Andalusia.

Area deprivation and mortality in the provincial capital cities of Andalusia and Catalonia (Spain)

Objective: To study the linkage between material deprivation and mortality from all causes, for men and women separately, in the capital cities of the provinces in Andalusia and Catalonia (Spain). Methods: A small-area ecological study was devised using the census section as the unit for analysis. 188 983 Deaths occurring in the capital cities of the Andalusian provinces and 109 478 deaths recorded in the Catalan capital cities were examined. Principal components factorial analysis was used to devise a material deprivation index comprising the percentage of manual labourers, unemployment and illiteracy. A hierarchical Bayesian model was used to study the relationship between mortality and area deprivation. Main results: In most cities, results show an increased male mortality risk in the most deprived areas in relation to the least depressed. In Andalusia, the relative risks between the highest and lowest deprivation decile ranged from 1.24 (Malaga) to 1.40 (Granada), with 95% credibility intervals showing a significant excess risk. In Catalonia, relative risks ranged between 1.08 (Girona) and 1.50 (Tarragona). No evidence was found for an excess of female mortality in most deprived areas in either of the autonomous communities. Conclusions: Within cities, gender-related differences were revealed when deprivation was correlated geographically with mortality rates. These differences were found from an ecological perspective. Further research is needed in order to validate these results from an individual approach. The idea to be analysed is to identify those factors that explain these differences at an individual level.

Biomonitoring of urinary metals in a population living in the vicinity of industrial sources: A comparison with the general population of Andalusia, Spain

The Ria of Huelva (south-west Spain) is one of the most polluted fluvial-estuarine systems in the world. Industrial activity delivers huge amounts of pollutants to the local environment, particularly heavy metals and arsenic. Here we aimed to determine urinary levels of As, Cd, Cr, Cu and Ni in a representative sample (n=857) of adults living in the Ria of Huelva. Levels were compared to those from a representative sample of 861 adults of the general urban population of Andalusia (southern Spain) and multiple regression models were developed to identify individual factors associated with urinary levels of these elements. Arsenic levels were significantly higher in the Ria of Huelva as compared to other Andalusian cities, whereas Cd and Ni levels were significantly lower. Despite these differences, levels in both groups were similar to the reference values reported in previous studies for general population. Age, gender, diet and lifestyle were the major factors contributing to the interindividual variation in urinary metals. In conclusion, despite living in a highly polluted area, the population of the Ria of Huelva failed to show higher urinary levels of the studied metals as compared to a reference urban population of the same region.

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities

BackgroundIntra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities.MethodsIt is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation.ResultsIn the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women.ConclusionThis study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

The public health burden of material deprivation: excess mortality in leading causes of death in Spain.

OBJECTIVE The aim of the study is to investigate the burden of deprivation-associated excess of deaths by 10 leading causes of death in each gender and two age groups. DESIGN A small-area ecological study using two indices of material deprivation drawn from 1991 census and mortality data aggregated for 1987-1995 was undertaken. SETTING 2218 small areas in Spain. Data are presented by region. MAIN OUTCOME MEASURES The 10 leading causes of death in each gender and two age groups were determined. RESULTS The deprivation-associated excess mortality in the top 10 leading causes of death was 14.4 and 11% for males and females, respectively. Excess mortality in the 9-year period studied accounted for more than 222,000 deaths. A large proportion of excess deaths was found in causes related to smoking and alcohol consumption among males and diet-related causes of death among females. The most deprived regions within the country showed the highest mortality risk. CONCLUSIONS Material deprivation appears to be manifested in high mortality rates differently by gender and region. It imposes a significant public health burden that demands urgently attention and action by health policy-makers.

Relación a corto plazo de la contaminación atmosférica y la mortalidad en 13 ciudades españolas

in the levels of the average of the concurrent and one day lag for black smoke was associated with a 0.8% (CI: 0.4-1.1) increase in mortality. The same in- crease in the concentration of SO2 was associated with a 0.5% (CI: 0.1-1.0) increase in daily deaths, and a 0.6% (CI: 0.3-0.8) increase in the case of NO2. An increase of 1 mg/m3 in the le- vels of CO was associated with an increase of 1.5% (CI: 0.5-2.6) in daily deaths. CONCLUSIONS: There is a short-term association between increases of daily levels of air pollutants and the number of daily deaths in Spanish cities.

El proyecto Emecas: protocolo del estudio multicéntrico en España de los efectos a corto plazo de la contaminación atmosférica sobre la salud

El proyecto EMECAM constato el efecto a corto plazo de la contaminacion atmosferica sobre la mortalidad en 14 ciudades espanolas entre 1990 y 1995. El Estudio Multicentrico Espanol de Contaminacion Atmosferica y Salud (EMECAS) amplia estos objetivos incorporando al analisis datos de morbilidad hospitalaria, utiliza informacion mas reciente y suma un total de 16 ciudades. Se trata de un estudio ecologico de series temporales, siendo las variables respuesta las defunciones diarias y los ingresos hospitalarios urgentes por enfermedades del aparato circulatorio y enfermedades respiratorias en los residentes de cada ciudad. Contaminantes analizados: particulas en suspension, SO2, NO2, CO y O3. Variables de control: meteorologicas, de calendario, estacionalidad y tendencia e incidencia de gripe. Analisis estadistico: estimacion de la asociacion en cada ciudad mediante la construccion de modelos de regresion de Poisson aditivos generalizados, y meta-analisis para la obtencion de estimadores conjuntos. Los niveles medios de contaminantes se situaron por debajo de los establecidos por la normativa actual para el dioxido de azufre, el monoxido de carbono y el ozono. Los valores de NO2 y PM10 se situaron alrededor de los establecidos en la normativa (40 µg/m³). Se trata del primer estudio de la relacion entre contaminacion atmosferica y morbilidad en un conjunto de ciudades espanolas. Los niveles de contaminantes estudiados son moderados para algunos contaminantes, aunque en otros, especialmente NO2 y particulas, podrian representar un problema para el cumplimiento de la normativa vigente.

Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project)

BackgroundPreventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007.MethodsWe analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used.ResultsPreventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities.ConclusionsPreventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.