Paolo Lauriola

Saharan dust and daily mortality in Emilia-Romagna (Italy)

Objective To investigate the association between Saharan dust outbreaks and natural, cardiovascular and respiratory mortality. Methods A case–crossover design was adopted to assess the effects of Saharan dust days (SDD) on mortality in the Emilia-Romagna region of Italy. The population under study consisted of residents in the six main towns of the central-western part of the region who died between August 2002 and December 2006. The association of Saharan dust outbreaks and PM10 concentration with mortality was estimated using conditional logistic regression, adjusted for apparent temperature, holidays, summer population decrease, flu epidemic weeks and heat wave days. The role of the interaction term between PM10 and SDD was analysed to test for effect modification induced by SDD on the PM10-mortality concentration–response function. Separate estimates were undertaken for hot and cold seasons. Results We found some evidence of increased respiratory mortality for people aged 75 or older on SDD. Respiratory mortality increased by 22.0% (95% CI 4.0% to 43.1%) on the SDD in the whole year model and by 33.9% (8.4% to 65.4%) in the hot season model. Effects substantially attenuated for natural and cardiovascular mortality with ORs of 1.042 (95% CI 0.992 to 1.095) and 1.043 (95% CI 0.969 to 1.122), respectively. Conclusions Our findings suggest an association between respiratory mortality in the elderly and Saharan dust outbreaks. We found no evidence of an effect modification of dust events on the concentration–response relationship between PM10 and daily deaths. Further work should be carried out to clarify the mechanism of action.

Emergency ambulance dispatches and apparent temperature: A time series analysis in Emilia-Romagna, Italy

INTRODUCTION Increases in mortality associated with oppressive weather have been widely investigated in several epidemiological studies. However, to properly understand the full public health significance of heat-related health effects, as well as to develop an effective surveillance system, it is also important to investigate the impact of stressful meteorological conditions on non-fatal events. The objective of our study was to evaluate the exposure-response relationship of ambulance dispatch data in association with biometeorological conditions using time series techniques similar to those used in previous studies on mortality. METHODS Daily data of emergency ambulance dispatches for people aged 35 or older in the summer periods from 2002 to 2006 were collected for the major towns in the Emilia-Romagna region. In the first stage of the analysis, the city-specific relationship between daily ambulance dispatches and increasing apparent temperature was explored using Generalized Additive Models while controlling for air pollution, seasonality, long-term trend, holidays and weekends. The relationship between ambulance dispatches and apparent temperature was approximated by linear splines. The effects of high temperatures on health were evaluated for respiratory and cardiovascular diseases as well as for all non-traumatic conditions. In the second stage of the analysis, city-specific effects were combined in fixed or random effect meta-analyses. RESULTS The percent change in the ambulance dispatches associated with every 1 °C increase in the mean apparent temperature between 25 and 30 °C was 1.45% (95% confidence interval: 0.95, 1.95) for non-traumatic diseases and 2.74% (95% CI: 1.34, 4.14) for respiratory diseases. The percent increase in risk was greater on days in which the mean apparent temperature exceeded 30 °C (8.85%, 95% CI: 7.12, 10.58 for non-traumatic diseases). In this interval of biometeorological conditions, cardiovascular diseases became positively associated with the apparent temperature. The risks increased with age. The increase in risk for the non-traumatic diseases reached 13.34% for people aged 75 or older compared to 4.75% for those aged 35-64. CONCLUSION Time series analysis techniques were adopted for the first time to investigate emergency ambulance dispatches to evaluate the risks associated with biometeorological discomfort. Our findings show a strong relationship between biometeorological conditions and ambulance dispatches.

Forecasting airborne pollen concentrations: Development of local models

Peoples sensitivity to allergies may representone of the most important health factors of thenext century to which attention must be paid inorder to reduce the incidence of social costsand improve the quality of life.Taking into consideration the earnest requestsof the medical-scientific communityEmilia-Romagna ARPA (Regional Agency for thePrevention of the Environment) moved theattention from the monitoring to a short andmedium term prediction of the concentration ofallergenic pollens in the air in order toachieve a more effective therapeutic action.Our main objectives are to improve seasonalforecasts and to interpret anomalous years.A neural network model for grass pollenforecasting has been implemented. Inputvariables were meteorological situations, i.e.,daily temperature (max., min. and average) andrainfall, in addition to combinations ofindividual variables and their thresholds. Theoutput was daily pollen concentration.The model was able to understand and predictanomalous years. We demonstrate that therelationships between pollen concentrations andmeteorological situations are independent fromsite. This means that such models canunderstand the differences in differentareas.

Mortality and morbidity among people living close to incinerators: a cohort study based on dispersion modeling for exposure assessment

BackgroundSeveral studies have been conducted on the possible health effects for people living close to incinerators and well-conducted reviews are available. Nevertheless, several uncertainties limit the overall interpretation of the findings. We evaluated the health effects of emissions from two incinerators in a pilot cohort study.MethodsThe study area was defined as the 3.5 km radius around two incinerators located near Forlì (Italy). People who were residents in 1/1/1990, or subsequently became residents up to 31/12/2003, were enrolled in a longitudinal study (31,347 individuals). All the addresses were geocoded. Follow-up continued until 31/12/2003 by linking the mortality register, cancer registry and hospital admissions databases. Atmospheric Dispersion Model System (ADMS) software was used for exposure assessment; modelled concentration maps of heavy metals (annual average) were considered the indicators of exposure to atmospheric pollution from the incinerators, while concentration maps of nitrogen dioxide (NO2) were considered for exposure to other pollution sources. Age and area-based socioeconomic status adjusted rate ratios and 95% Confidence Intervals were estimated with Poisson regression, using the lowest exposure category to heavy metals as reference.ResultsThe mortality and morbidity experience of the whole cohort did not differ from the regional population. In the internal analysis, no association between pollution exposure from the incinerators and all-cause and cause-specific mortality outcomes was observed in men, with the exception of colon cancer. Exposure to the incinerators was associated with cancer mortality among women, in particular for all cancer sites (RR for the highest exposure level = 1.47, 95% CI: 1.09, 1.99), stomach, colon, liver and breast cancer. No clear trend was detected for cancer incidence. No association was found for hospitalizations related to major diseases. NO2 levels, as a proxy from other pollution sources (traffic in particular), did not exert an important confounding role.ConclusionsNo increased risk of mortality and morbidity was found in the entire area. The internal analysis of the cohort based on dispersion modeling found excesses of mortality for some cancer types in the highest exposure categories, especially in women. The interpretation of the findings is limited given the pilot nature of the study.

Trihalomethanes, chlorite, chlorate in drinking water and risk of congenital anomalies: A population-based case-control study in Northern Italy

BACKGROUND Epidemiological evidence of an association between disinfection by-products (DBPs) exposure via drinking water and reproductive outcomes is still inconclusive. OBJECTIVE The aim of this study was to investigate the association between trihalomethanes (THMs), chlorite and chlorate exposure and congenital anomalies. METHODS A case-control study was carried out in Emilia-Romagna Region (Italy). Data on 1917 different congenital anomalies (neural tube, cardiac, diaphragm and abdominal wall, oesophagus, cleft lip and palate, respiratory, urinary tract and chromosomal anomalies) observed in the period 2002-2005 were extracted from the Regional Malformation Registry. Four controls (newborns without anomalies) were randomly selected form the Regional Birth Register and frequency matched to cases according to pregnancy period. The network supplying water during the first trimester of pregnancy was identified on the basis of mothers address: DBPs data, technical and structural information were linked to each subject. RESULTS Overall, THMs exposure was very low (mean: 3.8±3.6 μg/l), and no risk excess was observed. Chlorite and chlorate values were fairly high (mean: 427±184 μg/l and 283±79 μg/l, respectively). Women exposed to chlorite level >700 μg/l were at higher risk of newborns with renal defects (OR: 3.30; 95% IC: 1.35-8.09), abdominal wall defects (OR: 6.88; 95% IC: 1.67-28.33) and cleft palate (OR: 4.1; 95% IC: 0.98-16.8); women exposed to chlorate level >200 μg/l were at higher risk of newborns with obstructive urinary defects (OR: 2.88; 95% IC: 1.09-7.63), cleft palate (OR: 9.60; 95% IC:1.04-88.9) and spina bifida (OR: 4.94; 95% IC:1.10-22). CONCLUSIONS This was the first study showing an excess risk of different congenital anomalies related to chlorite and chlorate exposure via drinking water: further research is needed to confirm the observed relationships in large datasets, specifically for chlorate, an unregulated DBP.

Urban Air Pollution Monitoring and Correlation Properties between Fixed-Site Stations

Abstract The rich regional air-monitoring network of the Emilia-Romagna region of Italy has been used to quantify the spatial variability of the main pollutants within urban environments and to analyze the correlations between stations. The spatial variability of the concentrations of the majority of pollutants within the city was very high, making it difficult to differentiate and characterize the urban environments and to apply legal limits with uniform criteria. On the other hand, the correlations between the fixed-site monitoring stations were high enough for their data to be retained generally very appropriately for controlling temporal trends. Starting from the high correlation level, a procedure was proposed and tested to derive pollution levels, using short-term measurements, such as passive samplers and mobile-station data. The importance of long-term statistics in urban air pollution mapping was emphasized. Treatment of missing data in time series and quality assurance were indicated as possible fields for applications for the correlation properties.

Biomonitoring of the general population living near a modern solid waste incinerator: a pilot study in Modena, Italy.

BACKGROUND AND GOALS As part of the authorization process for the solid waste incinerator (SWI) in Modena, Italy, a human biomonitoring cross-sectional pilot study was conducted to investigate the degree to which people living and working in the proximity of the plant were exposed to SWI emissions. METHODS Between May and June 2010, 65 subjects living and working within 4km of the incinerator (exposed) and 103 subjects living and working outside this area (unexposed) were enrolled in the study. Blood, serum and urinary metals (Pb, Cd, Cu, Zn, Hg, Mn, Ni), urinary benzene, toluene, xylene (BTEX), S-phenylmercapturic acid (SPMA), and urinary polycyclic aromatic hydrocarbons (PAHs) were analysed. Information about lifestyle, anthropometric characteristics, residence, and health status was collected by a self-administered questionnaire. Exposure to particulate matter (PM) emitted from the SWI was estimated using fall-out maps from a quasi-Gaussian dispersion model. A multiple linear regression analysis investigated the relationship between biomarkers and the distance of a subjects place of residence from the SWI plant or the exposure to PM. RESULTS Urinary BTEX and SPMA and blood, serum and urinary metals showed no differences between exposed and unexposed subjects. PAHs were higher in exposed than in unexposed subjects for phenanthrene, anthracene, and pyrene (median levels: 9.5 vs. 7.2ng/L, 0.8 vs. <0.5ng/L and 1.6 vs. 1.3ng/L, respectively, p<0.05). Multiple linear regression analysis showed that blood Cd and Hg and urinary Mn, fluorene, phenanthrene, anthracene and pyrene were inversely correlated to the distance of a subjects residence from the SWI. Urinary Mn, fluorene and phenanthrene were directly correlated to PM exposure. CONCLUSIONS This study, although not representative of the general population, suggests that specific biomarkers may provide information about the degree of exposure the subjects working and living in the proximity of the SWI plant may have to emissions from that facility.

Exposure to air pollution and respiratory symptoms during the first 7 years of life in an Italian birth cohort

Background Ambient air pollution has been consistently associated with exacerbation of respiratory diseases in schoolchildren, but the role of early exposure to traffic-related air pollution in the first occurrence of respiratory symptoms and asthma is not yet clear. Methods We assessed the association between indexes of exposure to traffic-related air pollution during different periods of life and respiratory outcomes in a birth cohort of 672 newborns (Rome, Italy). Direct interviews of the mother were conducted at birth and at 6, 15 months, 4 and 7 years. Exposure to traffic-related air pollution was assessed for each residential address during the follow-up period using a Land-Use Regression model (LUR) for nitrogen dioxide (NO2) and a Geographic Information System (GIS) variable of proximity to high-traffic roads (HTR) (>10 000vehicles/day). We used age-specific NO2 levels to develop indices of exposure at birth, current, and lifetime time-weighted average. The association of NO2 and traffic proximity with respiratory disorders were evaluated using logistic regression in a longitudinal approach (Generalised Estimating Equation). The exposure indexes were used as continuous and categorical variables (cut-off points based on the 75th percentile for NO2 and the 25th percentile for distance from HTRs). Results The average NO2 exposure level at birth was 37.2 μg/m3 (SD 7.2, 10–90th range 29.2–46.1). There were no statistical significant associations between the exposure indices and the respiratory outcomes in the longitudinal model. The odds ratios for a 10-µg/m3 increase in time-weighted average NO2 exposure were: asthma incidence OR=1.09; 95 CI% 0.78 to 1.52, wheezing OR=1.07; 95 CI% 0.90 to 1.28, shortness of breath with wheezing OR=1.16; 95 CI% 0.94 to 1.43, cough or phlegm apart from cold OR=1.11; 95 CI% 0.92 to 1.33, and otitis OR=1.08; 95 CI% 0.89 to 1.32. Stronger but not significant associations were found considering the 75th percentile of the NO2 distribution as a cut-off, especially for incidence of asthma and prevalence of wheeze (OR=1.41; 95 CI% 0.88 to 2.28 and OR=1.27; 95 CI% 0.95 to 1.70, respectively); the highest OR was found for wheezing (OR=2.29; 95 CI% 1.15 to 4.56) at the 7-year follow-up. No association was found with distance from HTRs. Conclusions Exposure to traffic-related air pollution is only weakly associated with respiratory symptoms in young children in the first 7 years of life.

Air pollution and respiratory status in asthmatic children: hints for a locally based preventive strategy. AIRE study.

Respiratory health effects of short-term exposure to ambient air pollution have been examined in 120 ‘asthma-like’ school-aged children in some areas of Emilia-Romagna (urban-industrial and rural area). They kept a daily diary, through 12 weeks, for respiratory symptoms, PEF measurements, drug consumption and daily activity. The average daily concentrations of air pollutants in the same period (TSP, NO2, CO, PM2.5) were higher in the industrial than the rural area. Asthma was diagnosed in 77% of cases, 85% of subjects took medical treatments for respiratory disease in the last year and 90% used medicine for respiratory diseases. Significantly lower variations in PEF, between morning and evening, were observed in the rural area, considering only the asthmatic or cough subsets of children. Symptom prevalence was higher in the urban-industrial area than the rural area; the most frequent symptoms were cough, phlegm and stuffed nose. The two area populations are homogeneous in individual features, family susceptibility, passive smoking exposure and atopy. The differences observed in the frequency of daily reported symptoms could be attributed to external situations like the different reported exposures to pollutants. Although most analyses revealed non-significant associations, panel analysis showed a significant statistical risk for the cough and phlegm group by an increase of 10 μg of TSP (RR 1.0017, 95% CI: 1.0002–1.0033) in the entire group. In the urban-industrial panel we observed a significant association between cough and phlegm together and PM2.5(RR 1.0044, 95% CI: 1.0011–1.0077). The results of this investigation should be used in orienting local political decisions.

Comparison of different exposure settings in a case--crossover study on air pollution and daily mortality: counterintuitive results.

Because of practical problems associated with measurement of personal exposures to air pollutants in larger populations, almost all epidemiological studies assign exposures based on fixed-site ambient air monitoring stations. In the presence of multiple monitoring stations at different locations, the selection of them may affect the observed epidemiological concentration–response (C-R) relationships. In this paper, we quantify these impacts in an observational ecologic case–crossover study of air pollution and mortality. The associations of daily concentrations of PM10, O3, and NO2 with daily all-cause non-violent mortality were investigated using conditional logistic regression to estimate percent increase in the risk of dying for an increase of 10 μg/m3 in the previous day air pollutant concentrations (lag 1). The study area covers the six main cities in the central-western part of Emilia-Romagna region (population of 1.1 million). We used four approaches to assign exposure to air pollutants for each individual considered in the study: nearest background station; city average of all stations available; average of all stations in a macro-area covering three cities and average of all six cities in the study area (50 × 150 km2). Odds ratios generally increased enlarging the spatial dimension of the exposure definition and were highest for six city-average exposure definition. The effect is especially evident for PM10, and similar for NO2, whereas for ozone, we did not find any change in the C-R estimates. Within a geographically homogeneous region, the spatial aggregation of monitoring station data leads to higher and more robust risk estimates for PM10 and NO2, even if monitor-to-monitor correlations showed a light decrease with distance. We suggest that the larger aggregation improves the representativity of the exposure estimates by decreasing exposure misclassification, which is more profound when using individual stations vs regional averages.