Mortality in Italian veterans deployed in Bosnia-Herzegovina and Kosovo

A systematic review and meta-analysis of mortality and kidney function in uranium-exposed individuals

BACKGROUND

Humans are exposed to uranium (U) in a variety of applications. Both animal and observational human studies support an associated U nephrotoxicity. Few statistical syntheses of the human data have been performed and these analyses are limited in the types of exposures considered.

OBJECTIVES

This study aims to evaluate the state of current evidence and to expand on existing meta-analyses by systematically evaluating kidney-associated causes of mortality in multiple U-exposed populations. This study also aims to evaluate the effect of U exposure on kidney function and biomarkers of kidney injury.

METHODS

The published and grey literature were systematically reviewed for studies that reported Standardized Mortality Ratios (SMR) for kidney cancer, chronic nephritis/nephrosis, all-cause mortality, diabetes, all circulatory/heart disease, and/or ischemic heart disease in U-exposed humans. Studies that reported kidney biomarker measures for U-exposed versus control subjects were identified separately.

RESULTS

36 studies were included. The studies were parsed into subgroups based on setting of exposure. Analysis of kidney cancer and chronic nephritis/nephrosis mortality demonstrated an SMR of 0.93 (95CI: 0.82-1.05) and 0.82 (95CI: 0.70-0.96), respectively. The other clinical outcomes evaluated also demonstrated mortality deficits in exposed relative to unexposed individuals. Subgroup analyses demonstrated similar mortality deficits. Conversely, biomarker analyses suggested better kidney function in the controls, but none of these differences reached significance.

DISCUSSION

Given that most of the included mortality studies were conducted in occupational populations, the mortality deficits observed in our analyses were likely due to the healthy-worker effect. Additionally, our analyses of kidney biomarkers were severely limited by low precision due to a low number of available studies and small study-size. Future work needs to evaluate the progression of chronic and to end-stage kidney disease in community-based populations to better assess the full impact of prolonged chronic U exposure on kidney outcomes.

Long term mortality and morbidity of Italian soldiers after deployment in Iraq as related to biomarkers assessment: Results of the SIGNUM study

INTRODUCTION

The health profile of military veterans deployed in foreign operative theatres was assessed by several international studies because of potential exposure to depleted uranium and other pollutants. Here we reported results of 15-year epidemiological surveillance assessing long-term health effects in a cohort of Italian soldiers deployed in Iraq in 2004-2005 and participating in a biomonitoring campaign to identify potential genotoxic exposure to environmental xenobiotics before and after deployment (n = 981, SIGNUM cohort).

METHODS

We evaluated mortality and hospitalization risks of the SIGNUM cohort retrospectively until 2016 and 2018 respectively. A wide cohort of military personnel never deployed abroad (n = 114,260) and the general Italian population were used as control populations in risk assessment. Causes of death and diagnoses of hospitalization were derived through deterministic record linkage with official national databases of mortality and hospital discharge. Standardized Mortality Ratio (SMR) and Standardized Hospitalization Ratio (SHR) were computed adjusting according to sex, age, area of birth, and calendar year. Differential pre-post deployment in xenobiotics concentrations and early effect biomarkers (oxidative DNA alterations and micronuclei) measured in blood serum were analysed in relation to cancer hospitalization.

RESULTS

Mortality risk due to pathologies was more than halved compared to the general population (SMR = 0.41, 95% CI 0.11-1.05) and not significantly different compared to soldiers never deployed abroad (SMR = 0.69, 95% CI 0.19-1.68). Similarly overall hospitalization risk due to pathologies was decreased with respect to the general population (SHR = 0.86, 95% CI 0.80-0.92) and comparable to the control military group (SHR = 0.99, 95% CI: 0.93-1.06). For haematological cancers a decreased hospitalization risk compared to the Italian general population was observed (SHR = 0.38, 95% CI 0-0.92). No statistically significant differences emerged in the patterns of biomarkers in association with cancer hospitalization.

CONCLUSION

The study confirms the so called 'healthy warrior' effect for the SIGNUM veterans and showed no correlation between cancer occurrence and biomonitoring markers measured on field.

War journalism: an occupational exposure

Apart from the risk of accidents, war theatres present a hazard related to numerous long-lasting toxic agents. For 10 years, a >60-year-old male journalist worked in war theatres in the Far and Near East where he was exposed to asbestos and other toxic substances (metals, silica, clays, polycyclic aromatic hydrocarbons and other organic substances) contained in dust and smoke of destroyed buildings. More than 15 years later, he developed a mucoepidermoid carcinoma of the soft palate and, subsequently, a pleural malignant mesothelioma. The safety of war journalists should focus not only on preventing the risk of being killed, but also on providing protection from toxic and carcinogenic agents. Exposure to substances released during the destruction of buildings can also pose a carcinogenic risk for survivors.

Occupational Exposures and Environmental Health Hazards of Military Personnel

BACKGROUND

Military personnel are frequently exposed to environmental pollutants that can cause a variety of diseases.

METHODS

This review analyzed publications regarding epidemiological and biomonitoring studies on occupationally-exposed military personnel.

RESULTS

The exposures include sulfur mustard, organ chlorines, combustion products, fuel vapors, and ionizing and exciting radiations. Important factors to be considered are the lengths and intensities of exposures, its proximity to the sources of environmental pollutants, as well as confounding factors (cigarette smoke, diet, photo-type, healthy warrior effect, etc.). Assessment of environmental and individual exposures to pollutants is crucial, although often omitted, because soldiers have often been evaluated based on reported health problems rather than on excessive exposure to pollutants. Biomarkers of exposures and effects are tools to explore relationships between exposures and diseases in military personnel. Another observation from this review is a major problem from the lack of suitable control groups.

CONCLUSIONS

This review indicates that only studies which analyzed epidemiological and molecular biomarkers in both exposed and control groups would provide evidence-based conclusions on exposure and disease risk in military personnel.

A 5-Year Continued Follow-up of Cancer Risk and All-Cause Mortality Among Norwegian Military Peacekeepers Deployed to Kosovo During 1999-2016

INTRODUCTION

In 2012, Norwegian news media reported on cases of brain cancer among Norwegian peacekeeping troops who served in Kosovo, allegedly caused by exposure to depleted uranium fired during airstrikes before the peacekeepers arrived in 1999. A first study followed 6076 military men and women with peacekeeping service in Kosovo during 1999-2011 for cancers and deaths throughout 2011. The study did not support to the idea that peacekeeping service in Kosovo could lead to increased risk of brain cancer or other cancers. However, the average time of follow-up (10.6 years) was rather short for cancer development; therefore the aim of the present study was to evaluate cancer risk and general mortality in an updated cohort after 5 years of additional follow-up.

MATERIALS AND METHODS

The updated cohort consisted of 6,159 peacekeepers (5,884 men and 275 women) who served in Kosovo during 1999-2016 and were followed for cancer incidence and mortality from all causes combined throughout 2016. We calculated standardized incidence ratios (SIR) for cancer and standardized mortality ratios (SMR) from national population rates. Poisson regression was used to assess the effect of length of service (<1 year vs. ≥1 year) on cancer risk.

RESULTS

We observed 149 cancer cases and 75 deaths in the updated cohort. Observed cancer incidence did not exceed national rates. In men, the SIR for brain cancer was 0.73 (95% confidence interval (CI) 0.32-1.44), based on eight cases, while the risk of colon cancer was lowered (SIR = 0.14, 95% CI 0.00-0.79). The Poisson regression showed no effect of service duration on all-site cancer incidence. Mortality from all causes combined was lower than expected (SMR = 0.62, 95% CI 0.49-0.78) and in accordance with a "healthy soldier effect".

CONCLUSION

The extended follow-up did not give support to the suggestion that peacekeeping service in Kosovo could lead to increased risk of cancer.

Meta-analysis of depleted uranium levels in the Balkan region

In recent years, contradicting data has been published on the connection between the presence of depleted uranium and an increased cancer incidence among military personnel deployed in the Balkans during the 1992-1999 wars. This has led to numerous research articles investigating possible depleted uranium contamination of the afflicted regions of the Balkan Peninsula, namely Bosnia & Herzegovina, Serbia, Kosovo and Montenegro. The aim of this study was to collect data from previously published reports investigating the levels of depleted uranium in the Balkans and to present the data in the form of a meta-analysis. This would provide a clear image of the extent of depleted uranium contamination after the Balkan conflict. In addition, we tested the hypothesis that there is a correlation between the levels of depleted uranium and the assumed depleted uranium-related health effects. Our results suggest that the majority of the examined sites contain natural uranium, while the area of Kosovo appears to be most heavily afflicted by depleted uranium pollution, followed by Bosnia & Herzegovina. Furthermore, the results indicate that it is not possible to make a valid correlation between the health effects and depleted uranium-contaminated areas. We therefore suggest a structured collaborative plan of action where long-term monitoring of the residents of depleted uranium-afflicted areas would be performed. In conclusion, while the possibility of depleted uranium toxicity in post-conflict regions appears to exist, there currently exists no definitive proof of such effects, due to insufficient studies of potentially afflicted populations, in addition to the lack of a common epidemiological approach in the reviewed literature.