Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS

Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS

In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION

Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Accurate assessments of current and future fertility-including overall trends and changing population age structures across countries and regions-are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.

METHODS

To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.

FINDINGS

During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.

INTERPRETATION

Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.

FUNDING

Bill & Melinda Gates Foundation.

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Perceptions of Tobacco Price Policy among Students from Sapienza University of Rome: Can This Policy Mitigate Smoking Addiction and Its Health Impacts?

Tobacco use is one of the main risk factors for non-communicable diseases. Avoiding youth initiation and treating addiction are fundamental public health issues to ensure better health. Among tobacco control policies, increasing tobacco price is the single most effective intervention. It reduces tobacco consumption, especially among youths, while representing a government financing source. This study aimed to assess the agreement with the proposal of a one-euro increase in tobacco price earmarked to health issues among students at Sapienza University. Two convenience samples were surveyed, five years apart, on World No Tobacco Days. Smoking habits, agreement with the proposal and reasons for it were collected. Results from the 208 questionnaires (107 in 2014, 101 in 2019) showed 46.6% of agreement with the proposal (53.3% in 2014, 39.2% in 2019, p = 0.044). Main predictive factor for agreement was being a non-smoker (OR = 6.33 p < 0.001), main reason (64.8%) was it could trigger smokers to quit or reduce consumption. Several factors might have influenced this finding, including the introduction of novel tobacco products and their increased advertisement on social media. In 2024, European Union is planning to update the Tobacco Taxation Directive which could greatly contribute to the reduction of non-communicable diseases and premature deaths.

The spread in time and space of COVID-19 pandemic waves: the Italian experience from mortality data analyses

Introduction

Italy was the first European country affected by COVID-19. Thanks to governmental containment measures (9 March 2020), the spread of COVID-19 was limited. However, in this context, accurate data assessment is crucial and mortality is a more reliable indicator of the virus spread compared to the count of positive cases. This study aimed to retrospectively evaluate the impact of the pandemic in different areas of Italy using the time series analysis of official deaths and excess COVID-19 deaths.

Methods

Mortality data (23 February-30 April 2022) by Istituto Nazionale di Statistica (ISTAT) were analyzed, including four waves of COVID-19. Previous mortality data (January 2015-November 2019) were used to estimate a Poisson regression model of the pre-pandemic mortality pattern and derive the excess COVID-19 deaths as the difference between the actual deaths number and the extrapolation of the previous mortality pattern to the pandemic period, separately for Northern, Central, and Southern Italy, to compare the impact of mortality across time periods and geographical areas.

Results

Estimated excess compared with official COVID-19 mortality shows that, during the first wave, there was an underestimation of deaths. COVID-19 mortality rate almost doubled the official rate in the North (1.60‰ vs. 0.86‰) and nearly tripled it in the South (0.22‰ vs. 0.08‰). In late 2020-early 2021, official and estimated mortality curves are closer, displaying just a small gap at the start of the second wave. During the fourth wave (end of 2021-early 2022), Northern and Central Italy show reasonable agreement; the South presents a large relative underestimation of deaths (+90% increase), with a large increase in its excess deaths national quota, 9% in the first wave to 42% in the fourth.

Discussion

The results provide a measure of the COVID-19 excess deaths and an unbiased estimate of Italian mortality rates. In the first wave, the gap between official COVID-19 and excess mortality was particularly high and lockdown measures may have reduced the spread of the infection. In the fourth wave, the gap for the South increases again, probably because the healthcare system may not have coped with the prolonged pressure of the pandemic, or for a decreased compliance with the official paper-based mortality surveillance system that could be overcome in the future by digitalizing the process.

Effects of cannabis smoking on the respiratory system: A state-of-the-art review

The diminished perception of the health risks associated with the consumption of cannabis (marijuana) lead to a progressive increase in its inhalational use in many countries. Cannabis can be smoked through the use of joints, spliffs and blunts, and it can be vaporised with the use of hookah or e-cigarettes. Delta-9 tetrahydrocannabinol (THC) is the main psychoactive component of cannabis smoke but contains numerous other substances. While the recreational use of cannabis smoking has been legalised in several countries, its health consequences have been underestimated and undervalued. The purpose of this review is to critically review the impact of cannabis smoke on the respiratory system. Cannabis smoke irritates the bronchial tree and is strongly associated with symptoms of chronic bronchitis, with histological signs of airway inflammation and remodelling. Altered fungicidal and antibacterial activity of alveolar macrophages, with greater susceptibility to respiratory infections, is also reported. The association with invasive pulmonary aspergillosis in immunocompromised subjects is particularly concerning. Although cannabis has been shown to produce a rapid bronchodilator effect, its chronic use is associated with poor control of asthma by numerous studies. Cannabis smoking also represents a risk factor for the development of bullous lung disease, spontaneous pneumothorax and hypersensitivity pneumonitis. On the other hand, no association with the development of chronic obstructive pulmonary disease was found. Finally, a growing number of studies report an independent association of cannabis smoking with the development of lung cancer. In conclusion, unequivocal evidence established that cannabis smoking is harmful to the respiratory system. Cannabis smoking has a wide range of negative effects on respiratory symptoms in both healthy subjects and patients with chronic lung disease. Given that the most common and cheapest way of assumption of cannabis is by smoking, healthcare providers should be prepared to provide counselling on cannabis smoking cessation and inform the public and decision-makers.

Translation and validation of the Italian version of the incivility in nursing education-revised scale

BACKGROUND

Incivility in nursing education is present worldwide and impacts all those involved and the teacher-student relationship. The revised Incivility in Nursing Education (INE-R) is a validated and reliable instrument to measure academic incivility, but it is not available in Italian language. The aim of the study was to translate and validate the INE-R tool with an Italian sample.

METHODS

The INE-R was translated from English into Italian, culturally adapted and piloted for content and linguistic clarity. The questionnaire was administered online to Nursing Faculty (NF) and Nursing Students (NS) of Sapienza University of Rome to assess uncivil behaviors and their frequency of occurrence. The psychometric properties of the Italian version were investigated.

RESULTS

79 Italians participated, of which 63.3 % were NS. Four-factor models provided the best fit for NF and NS scales. The models explained 78.2 % (NF) and 73.2 % (NS) of the variance of the scales. The Root Mean Square Error of Approximation for both models was 0.07, indicating an acceptable fit. INE-R reliability for all 48 NF and NS incivility items was 0.962 and 0.954, respectively. Measuring the degree of incivility and establishing codes of conduct were recommended.

CONCLUSIONS

Incivility in nursing education negatively impacts the teaching-learning environment and could cause emotional or physical distress for those involved. Zero-tolerance policy regarding incivility, routine evaluation, and raising awareness among students and faculty could improve the quality of academic settings. The Italian INE-R is a valid and reliable tool that can be used to evaluate incivility in Italian nursing programs.

Thirdhand Smoke Knowledge, Beliefs and Behaviors among Parents and Families: A Systematic Review

Families play a primary role in protecting children. Thirdhand smoke (THS) is an underestimated public health issue, and health effects correlated to its exposition are emerging. The aim of this systematic review was to analyze papers focusing on knowledge, beliefs, and behaviors regarding THS among parents, families, and caregivers, published until May 2022 on MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Critical appraisal of the included studies was conducted by two independent reviewers using the Joanna Briggs Institute Critical Appraisal tool. Out of the 97 articles, 8 were included in this review (two from the USA, one from Europe, and five from Asia). Although there were no restrictions on the date of publication, all the articles were published in the last 10 years, underlining that THS is an emerging concept. They were characterized by relevant heterogeneity in the study design and assessment tools. The results showed that percentages of parents who believed that THS is harmful ranged from 42.4% to 91%, but parental awareness was not always associated with the adoption of a home- and car-smoking ban or healthy behaviors. Further research is needed to understand the resistance and problems faced by parents who are aware of THS risks but unable to improve good practices.

The Association of Tobacco Smoking, Second-hand Smoke, and Novel Tobacco Products With COVID-19 Severity and Mortality in Italy: Results From the COSMO-IT Study

BACKGROUND

Despite the robust evidence of an excess risk of coronavirus disease 2019 (COVID-19) severity and mortality in ever smokers, the debate on the role of current and ex-smokers on COVID-19 progression remains open. Limited or no data are available on the link between electronic cigarette (e-cigarette), heated tobacco product (HTP) and second-hand smoke (SHS) exposure and COVID-19 progression. To fill this knowledge gap, we undertook the COvid19 and SMOking in ITaly (COSMO-IT) study.

METHODS

A multi-centre longitudinal study was conducted in 2020-2021 in 24 Italian hospitals on a total of 1,820 laboratory-confirmed COVID-19 patients. We estimated multivariable odds ratios (OR) and 95% confidence intervals (CI) to quantify the association between smoking-related behaviours (ie, smoking status, e-cigarette and HTP use, and SHS exposure) and COVID-19 severity (composite outcome: intubation, intensive care unit admission and death) and mortality.

RESULTS

Compared to never smokers, current smokers had an increased risk of COVID-19 mortality (OR 2.17; 95% CI, 1.06-4.41). E-cigarette use was non-significantly associated to an increased risk of COVID-19 severity (OR 1.60; 95% CI, 0.96-2.67). An increased risk of mortality was observed for exposure to SHS among non-smokers (OR 1.67; 95% CI, 1.04-2.68), the risk being particularly evident for exposures of ≥6 hours/day (OR 1.99; 95% CI, 1.15-3.44).

CONCLUSION

This multicentric study from Italy shows a dismal COVID-19 progression in current smokers and, for the first time, in SHS exposed non-smokers. These data represent an additional reason to strengthen and enforce effective tobacco control measures and to support smokers in quitting.

SARS-CoV-2 Infection in San Patrignano, the Largest European Drug Rehabilitation Community

BACKGROUND

Studies on SARS-CoV-2 conducted in confined settings for prolonged times allow researchers to assess how the coronavirus spreads. San Patrignano (SP), Italy, is the largest European drug rehabilitation facility.

METHODS

Between 15 October and 31 December 2020, all SP residents were tested for SARS-CoV-2. We analyzed the relationships between individual characteristics and being SARS-CoV-2-positive. Three selected predictive models were used to calculate the number of expected hospitalizations. For each model, we summed the estimated individual risks to obtain the expected number of hospitalizations in our sample, and we tested whether the observed and expected numbers differed.

RESULTS

Of 807 residents, 529 (65.6%) were SARS-CoV-2-positive. Of these 323 (61.1%) were symptomatic. A strong relationship was found between being positive and living connections (p-value < 0.001). No statistically significant relationship was found with age, sex, smoking history, or comorbidities. Although 9 to 17 hospitalizations were expected, no hospitalizations were observed (p-value < 0.001). No one died of COVID-19.

CONCLUSIONS

The peculiar characteristics of SP residents or the SP environment might at least partially explain the null hospitalization rates. Despite the extreme uniqueness of our population and despite the protected environment and all precautions that were taken, the fact that the virus was able to circulate and infect a large portion of the population highlights the fundamental role of social interactions in the spread of the disease.

Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020

BACKGROUND

The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.

METHODS

For this analysis, we constructed burden-weighted dose-response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15-95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.

FINDINGS

The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15-39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0-0) and 0·603 (0·400-1·00) standard drinks per day, and the NDE varied between 0·002 (0-0) and 1·75 (0·698-4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0-0·403) to 1·87 (0·500-3·30) standard drinks per day and an NDE that ranged between 0·193 (0-0·900) and 6·94 (3·40-8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3-65·4) were aged 15-39 years and 76·9% (73·0-81·3) were male.

INTERPRETATION

There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.

FUNDING

Bill & Melinda Gates Foundation.

Cigarette Smoking and Human Gut Microbiota in Healthy Adults: A Systematic Review

The intestinal microbiota is a crucial regulator of human health and disease because of its interactions with the immune system. Tobacco smoke also influences the human ecosystem with implications for disease development. This systematic review aims to analyze the available evidence, until June 2021, on the relationship between traditional and/or electronic cigarette smoking and intestinal microbiota in healthy human adults. Of the 2645 articles published in PubMed, Scopus, and Web of Science, 13 were included in the review. Despite differences in design, quality, and participants’ characteristics, most of the studies reported a reduction in bacterial species diversity, and decreased variability indices in smokers’ fecal samples. At the phylum or genus level, the results are very mixed on bacterial abundance both in smokers and non-smokers with two exceptions. Prevotella spp. appears significantly increased in smokers and former smokers but not in electronic cigarette users, while Proteobacteria showed a progressive increase in Desulfovibrio with the number of pack-years of cigarette (p = 0.001) and an increase in Alphaproteobacteria (p = 0.04) in current versus never smokers. This attempt to systematically characterize the effects of tobacco smoking on the composition of gut microbiota gives new perspectives on future research in smoking cessation and on a new possible use of probiotics to contrast smoke-related dysbiosis.

Redistribution of garbage codes to underlying causes of death: a systematic analysis on Italy and a comparison with most populous Western European countries based on the Global Burden of Disease Study 2019

Background

The proportion of reported causes of death (CoDs) that are not underlying causes can be relevant even in high-income countries and seriously affect health planning. The Global Burden of Disease (GBD) study identifies these ‘garbage codes’ (GCs) and redistributes them to underlying causes using evidence-based algorithms. Planners relying on vital registration data will find discrepancies with GBD estimates. We analyse these discrepancies, through the analysis of GCs and their redistribution.

Methods

We explored the case of Italy, at national and regional level, and compared it to nine other Western European countries with similar population sizes. We analysed differences between official data and GBD 2019 estimates, for the period 1990–2017 for which we had vital registration data for most select countries.

Results

In Italy, in 2017, 33 000 deaths were attributed to unspecified type of stroke and 15 000 to unspecified type of diabetes, these making a fourth of the overall garbage. Significant heterogeneity exists on the overall proportion of GCs, type (unspecified or impossible underlying causes), and size of specific GCs among regions in Italy, and among the select countries. We found no pattern between level of garbage and relevance of specific GCs. Even locations performing below average show interesting lower levels for certain GCs if compared to better performing countries.

Conclusions

This systematic analysis suggests the heterogeneity in GC levels and causes, paired with a more detailed analysis of local practices, strengths and weaknesses, could be a positive element in a strategy for the reduction of GCs in Italy.

Well-being, Perceived Stress and Their Relations with Health-Relevant Behaviours Among Italian Medical Students: a Cross-Sectional Study at Sapienza University of Rome

Medical education is widely known to be demanding and stressful, with elevated levels of anxiety and depression among medical students. This study aims at examining well-being, perceived stress and quality of life in a sample of Italian first-year medical students in order to investigate the relations between these variables and individual characteristics and behaviours. An anonymous cross-sectional questionnaire was administered to a sample of 407 Italian first-year medical students. Psychological well-being, perceived stress and quality of life were assessed using standardised questionnaires PGWBI, PSS, SF-12. Data were analysed with multivariate statistical methods. Significant differences in PGWBI, PSS and SF-12 scores were found between males and females (with poorer scores for females), between smokers and non-smokers (with poorer scores for smokers) and between students who reported cannabis use in their lifetime and students who did not (with poorer scores for those who smoked cannabis). Logistic regression showed that gender (OR 0.38, 95% CI 0.24–0.61), reported cannabis use (OR 1.82, 95% CI 1.07–3.09) and regular physical exercise (OR 0.54, 95% CI 0.34–0.86) were significant predictors of distress. In summary, this study shows that female medical students and students who reported negative health behaviours and sporadic drug use reported lower psychological well-being and quality of life and higher stress, while positive health behaviours might prevent distress.

Are nutrition and physical activity associated with gut microbiota? A pilot study on a sample of healthy young adults

BACKGROUND

The literature shows that gut microbiota composition is related with health, and a lot of individual and outer factors may determine its variability. In particular, nutrition and exercise seem to influence the presence in the gut of the two major bacterial phyla of Firmicutes and Bacteroidetes.

STUDY DESIGN

An ongoing cross-sectional investigation is aimed to explore these associations in humans.

METHODS

Healthy Caucasian young adults were asked to provide a fecal sample in order to analyze their gut microbiome considering their Body Mass Index (BMI), adherence to Mediterranean diet and Physical Activity (PA) level.

RESULTS

A total of 59 participants (49.1% males, mean age 23.1 ± 3.14 years) were enrolled so far. Firmicutes (61.6±14.6) and Bacteroidetes (30.7 ± 13.3) showed the highest relative abundance in fecal samples. The Pearson's analysis showed a significant negative correlation between PA and Firmicutes (r =-0.270, p = 0.03). Linear regression confirmed a significant decrease of this phylum with the increase of PA (R2 = 0.07, p = 0.03).

CONCLUSIONS

These preliminary results suggest the association between physical activity and gut microbiota composition in healthy humans.

Direct imaging evidences of metal inorganic contaminants traced into cigarettes

Today, environmental health research on toxicological adverse effects of metal-inorganic materials diffused by cigarettes represents a new challenge for assessing new health risks directly related to the critical chemical-size features of the particles. Therefore, morpho-chemical analyses of hazardous particles become critical in response to the distinctive assumptions about the origin, evolution, and coexisting phases. Here, we report a detailed investigation through direct microscopy imaging of metal-inorganic contaminants for one traditional and two heat-not-burn commercial cigarettes of three different brands. Chemical-size studies revealed the critical presence of heavy metal-inorganic nanostructured microparticles on both paper and filter components of the cigarette, before and after smoking. The direct experimental imaging evidenced on how hazardous particles evolved in mass-size forming coexisting multi-phases of large agglomerate because of the persistence and accumulative effect of the heating puffing. The estimated porosity of the unsuitable engineered filters validated the allowed migration of micrometric pollutants independently from their intrinsic size-shape property. Furthermore, the inappropriate design of the filters made it an adverse sponge reservoir capable of collecting all possible hazardous chemical agents potentially toxic. These substantial results strongly support experimentally the tremendous effect of the smoke capable of transporting and manipulating a high amount of elusive particles, as a particles heat carrier.

Can Physical Activity Influence Human Gut Microbiota Composition Independently of Diet? A Systematic Review

Evidence suggests that physical activity (PA) influences the human gut microbiota composition, but its role is unclear because of dietary interference. The aim of this review is to clarify this issue from this new perspective in healthy individuals. Articles analyzing intestinal microbiota from fecal samples by 16S rRNA amplicon sequencing were selected by searching the electronic databases PubMed, Scopus, and Web of Science until December 2020. For each study, methodological quality was assessed, and results about microbiota biodiversity indices, phylum and genus composition, and information on PA and diet were considered. From 997 potentially relevant articles, 10 met the inclusion criteria and were analyzed. Five studies involved athletes, three were performed on active people classified on the basis of habitual PA level, and two among sedentary subjects undergoing exercise interventions. The majority of the studies reported higher variability and prevalence of the phylum Firmicutes (genera Ruminococcaceae or Fecalibacteria) in active compared to inactive individuals, especially in athletes. The assessment of diet as a possible confounder of PA/exercise effects was completed only in four studies. They reported a similar abundance of Lachnospiraceae, Paraprevotellaceae, Ruminococcaceae, and Veillonellaceae, which are involved in metabolic, protective, structural, and histological functions. Further studies are needed to confirm these findings.

The "Polonium In Vivo" Study: Polonium-210 in Bronchial Lavages of Patients with Suspected Lung Cancer

Few studies have reported on polonium-210, a decay breakdown product of radon-222 and lead-210, in human lungs and there has been no study in patients with suspected lung cancer. The main aim of this “Polonium in vivo” study was to evaluate polonium-210 radioactivity in bronchopulmonary systems of smoker, ex-smoker and never smoker patients with suspected lung cancer. Alpha-spectrometric analyses were performed on bronchial lavage (BL) fluids from two Italian hospitals in 2013–2016. Socio-demographic, smoking, occupational and spirometric characteristics, lung cancer confirmation and histologic type and radon-222 concentration in patients’ homes were collected. Seventy BL samples from never (n = 13), former (n = 35) and current smokers (n = 22) were analyzed; polonium-210 was detected in all samples from current and former smokers and in 54% of samples from never smokers (p < 0.001; median values: 1.20, 1.43 and 0.40 mBq, respectively). Polonium-210 levels were significantly higher in COPD versus no COPD patients (median value: 3.60 vs. 0.97 mBq; p = 0.007); former and current smokers, without and with COPD, had significantly increased polonium-210 levels (p = 0.012); 96% of confirmed versus 69% of non-confirmed lung cancer patients recorded detectable polonium-210 levels (p = 0.018). A polonium-210 detectable activity was measured in BL samples from all current and former smokers. Polonium-210 in the lungs could be the result of lead-210 entrapment, which, with its half-life of 22 years, could provide a continuous emission of alpha radioactivity, even many years after quitting, thus proposing a possible explanation for the onset of lung cancer, particularly in former smokers.

Exploring the association between physical activity and gut microbiota composition: a review of current evidence

The gut microbiota is implicated in digestive, metabolic and immune processes of the host. The physiological and pathophysiological functions of the intestinal microbiota depend of its composition, and several individual or external factors may be associated with the presence of some categories, phyla or species of microorganisms in the gut. In particular, two bacterial phyla - Firmicutes and Bacteroidetes - are predominant in the human gut and their relative concentrations seem to be related with age, gender, diet habits and weight status. In the last decade, several studies have tried to characterize the possible role of physical activity in determining qualitative and quantitative composition of the intestinal microbiota. This review is aimed at exploring the current evidences regarding the association between physical activity and gut microbiota composition in animal models and in the humans. Further studies are needed to clarify the mutual relationships among exercise, diet, nutritional supplements/doping agents and gut microbiota.

The Italian validation of the revised Incivility in Nursing Education survey: preliminary results

Background

Incivility in nursing education is defined as rude or disruptive behaviors that can result into psychological or physiological distress for the people involved. Therefore, academic nursing incivility may seriously impact the nursing profession. The revised Incivility in Nursing Education (INE-R) is a validated instrument to measure academic incivility, but it is not available in Italian language. The aim of the study is to translate and validate the INE-R survey instrument with an Italian sample.

Methods

The Italian version of the INE-R survey was piloted for content and general linguistic clarity. It is currently administered online to nursing faculty (NF) and nursing students (NS) of Sapienza University of Rome. The survey explores uncivil behaviors and their frequency of occurrence among NF and NS. It also collects suggestions for improving the level of academic civility.

Results

To date, 33 responders (8 NF and 25 NS) have completed the survey, of which 45,5% consider incivility in their department a moderate problem. A common NF uncivil behavior was canceling class without warning (39%), while arriving late for class was common among NS (40%). The top strategies to improve the level of civility in nursing education are the adoption of codes of conduct that define acceptable and unacceptable behaviors (39%) and the provision of training for effective communication and conflict negotiation (33%). The main consequences of incivility in nursing education are inappropriate teaching practice and poor quality education (54,5%).

Conclusions

Incivility in nursing education negatively affects teaching-learning process and can lead to emotional, or physical distress for faculty staff and students. There is therefore a need for specific policies and continuous monitoring on academic incivility to guarantee a healthy work and study environment. It is important to raise awareness among students and faculty while adopting zero-tolerance policy regarding incivility.

Key messages

Incivility in nursing education negatively affects teaching-learning process and can lead to emotional, or physical distress for the individuals involved. There is a need for specific policies and continuous monitoring on academic incivility to guarantee a healthy work environment.

The effects of physical activity on human gut microbiota composition: a systematic review

Background

Gut microbiota development and composition can be influenced by an existing dynamic balance between host physiology and lifestyle. This systematic review aims to assess the impact of physical activity on human gut microbiota.

Methods

PubMed, Scopus and Web of Science were searched until May 2019. Full-text in English were recruited if focused on gut microbiota in healthy athletes or active people, without age or gender restrictions, collected on faecal samples and analysed with genome sequencing of rRNA 16S. All types of study design were included as long as they performed a comparison with a sedentary control group. No specific time frame for the publication date was applied. Quality assessment was performed using the JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies (2017) and Cochrane Risk of Bias Tool for Randomized Controlled Trials.

Results

The analysis yielded 7/985 articles: five cross-sectional studies and two clinical trials, published from 2014 to 2019. The overall methodological assessment was of fair quality. Types of exercise included in the studies were: rugby, running, aerobic exercise, bodybuilding. More in detail, regarding the exercise load, some studies were conducted on elite professional athletes, such as rugby players, marathon runners or bodybuilders, with rigorous training, while other studies included a few weeks of aerobic and resistance training at a moderate intensity. Shannon diversity index increased in three studies. Concerning phyla, Firmicutes were increased in five studies and three studies described a significant decrease in Bacteroides.

Conclusions

This systematic review confirms the direct correlation between microbiota composition and physical activity, but further studies are needed to establish the possible presence of a causal link between the two factors.

Key messages

Exercise can play an important role as an environmental factor in determining gut microbiota composition. Further studies are needed to gain robust evidence of physical activity influence on gut microbiota variability.

Influence of tobacco and e-cig smoke on intestinal microbiota: a systematic review

Background

Intestinal microbiota (IM) plays a crucial role in maintaining human body homeostasis, yet it is highly susceptible to lifestyle changes and environmental factors, such as tobacco and e-cig smoking.

This systematic review aims to investigate the relationship between smoking and IM in healthy humans, by assessing abundance of Phyla and species' variability.

Methods

PubMed, Scopus and Web of Science were searched until April 2019. Studies assessing IM of healthy adult tobacco/e-cig smokers, collected on faecal samples and analysed with genome sequencing of rRNA 16 S, were included. Any type of study design, described in English, was considered. Quality assessment was performed with Methodological index for non-randomized studies and Joanna Briggs Institute Critical Appraisal tool for cross-sectional studies.

Results

Eight out of 1,838 studies (one controlled prospective and seven cross-sectional studies) were included. The only controlled prospective study found a significant increase in α and β-diversity, an increase in Firmicutes (p = 0.014) and a decrease in Bacteroidetes (p = 0.019) after a smoking cessation intervention. In cross- sectional studies, five out of seven studies found a statistically significant decrease in α-diversity among tobacco/e-cig smokers, while results on β-diversity were more contradictory. One out of two studies evaluating Firmicutes found a significant decrease in smokers (p = 0.047). The only study assessing Bacteroidetes found a significant increase among smokers (p = 0.015). Five studies analysed genera, three of them found a decrease in Bacteroides and two an increase in Prevotella.

Conclusions

What seems to emerge is a decreasing species’ variability in smokers, yet it is difficult to profile IM in smokers in terms of phyla’s abundance, because of few studies available and some further limitations, such as small sample sizes and lack of adjusted analysis to cope with confounding factors like gender, diet and other lifestyles.

Key messages

There is a decrease in species’ variability among smokers. Further studies are needed to assess abundance of phyla in healthy smokers, taking into account confounding factors.

Smoking and gut microbiota: a cross sectional study involving students

Background

Cigarette smoking is associated with oncological and non-oncological diseases. Tobacco smoking causes more than 7 million deaths per year worldwide. Cigarette smoking could impact not only on human tissues and organs, but also on the gut microbiota, i.e. the community of microorganisms in the gastrointestinal tract. The aim of this study is to evaluate the composition of gut microbiota among smoker and non-smoker university students.

Methods

Students from Sapienza University of Rome were asked to fill a questionnaire about smoking attitude and to provide a fecal sample. Students undergoing therapy which could affect gut microbiota were excluded. Differences in microbial composition and variability between smokers and non-smokers were assessed.

Results

A total of 107 students (43.9% males, mean age 21.96±2.52 years, 30,0% smokers) were enrolled so far. As for microbial composition, Firmicutes/Bacteroidetes ratios (F/B ratio) differed between smokers and non-smokers (5.34±16.66 vs 2.47±2.28). As for variability measures, smokers had lower Shannon index (3.43±0.26 vs 3.46±0.29). At Genus level, Prevotella was significantly more abundant in smokers (10.97±15.87 vs 4.86±10.86; p = 0.027) in comparison to non-smokers.

Conclusions

Our preliminary results seem to suggest that smoking habit affects gut microbiota. Smokers had higher Firmicutes/Bacteroidetes ratio and Prevotella Genus, while lower Shannon index. These preliminary data suggest that smoking habit may cause changes in gut microbiota pattern, but further research is needed.

Key messages

Smoking may cause changes in gut microbiota pattern. Smoking seems increases F/B ratio and Prevotella, while reduces gut microbiota variability.

Physical activity and gut microbiota: a cross-sectional study

Background

The composition of gut microbiota, and in particular the intestinal abundance of the two main bacterial phyla of Firmicutes and Bacteroidetes, are associated with human health and diseases and may be conditioned by host and environmental factors such as age, gender and diet. The role of Physical Activity (PA) in determining gut microbiota composition has not been yet completely clarified. A cross-sectional study involving undergraduates from two Italian cities is ongoing to explore this relationship.

Methods

Students were invited to provide a fecal sample and to complete the International Physical Activity Questionnaire (IPAQ) in order to define their habitual PA level (inactive, minimally active, health enhancing physical activity -HEPA- active). Demographic and anthropometric information were also collected. DNA from fecal samples was analyzed through the 16S amplicon sequencing. Microbial composition and variability of the samples were evaluated on the light of participants' PA levels.

Results

A total of 153 students (47.7% males, mean age 22.4±2.9, mean BMI 22.3±2.7) participated to the study so far. Firmicutes and Bacteroidetes were the main represented phyla. An increase in Firmicutes (58.3±16 to 61.4±13.3, p = 0.68) and a reduction in Bacteroidetes (32.6±14.8 to 30.3±11.4, p = 0.51) have been registered with the increase of PA level. A higher variability (expressed as Shannon α-index) has been detected in minimally active (3.39±0.03) and HEPA-active (3.41±0) individuals respect to inactive subjects (3.35±0.07) (p = 0.05).

Conclusions

Even if they are not significant, these preliminary results suggest a relationship between PA levels and gut microbiota composition. An active lifestyle seems to be associated with a greater microbial diversity in the gut. Further researches are needed to explain these findings.

Key messages

Physical activity seems to be associated with gut microbiota composition. A greater variability in gut microbiota was found in active people.

Covid-19 and the role of smoking: the protocol of the multicentric prospective study COSMO-IT (COvid19 and SMOking in ITaly)

The emergency caused by Covid-19 pandemic raised interest in studying lifestyles and comorbidities as important determinants of poor Covid-19 prognosis. Data on tobacco smoking, alcohol consumption and obesity are still limited, while no data are available on the role of e-cigarettes and heated tobacco products (HTP). To clarify the role of tobacco smoking and other lifestyle habits on COVID-19 severity and progression, we designed a longitudinal observational study titled COvid19 and SMOking in ITaly (COSMO-IT). About 30 Italian hospitals in North, Centre and South of Italy joined the study. Its main aims are: 1) to quantify the role of tobacco smoking and smoking cessation on the severity and progression of COVID-19 in hospitalized patients; 2) to compare smoking prevalence and severity of the disease in relation to smoking in hospitalized COVID-19 patients versus patients treated at home; 3) to quantify the association between other lifestyle factors, such as e-cigarette and HTP use, alcohol and obesity and the risk of unfavourable COVID-19 outcomes. Socio-demographic, lifestyle and medical history information will be gathered for around 3000 hospitalized and 700-1000 home-isolated, laboratory-confirmed, COVID-19 patients. Given the current absence of a vaccine against SARS-COV-2 and the lack of a specific treatment for COVID-19, prevention strategies are of extreme importance. This project, designed to highly contribute to the international scientific debate on the role of avoidable lifestyle habits on COVID-19 severity, will provide valuable epidemiological data in order to support important recommendations to prevent COVID-19 incidence, progression and mortality.

Mediterranean Diet, Physical Activity and Gut Microbiome Composition: A Cross-Sectional Study among Healthy Young Italian Adults

Background. This cross-sectional study aimed to explore the microbial composition of the gut and its possible association with the Mediterranean diet (MD) after adjusting for demographic and anthropometric characteristics in a sample of healthy young Italian adults. Methods. Gut microbiota, demographic information, and data on adherence to MD and physical activity (PA) habits were collected in a sample of 140 university students (48.6% males, mean age 22.5 ± 2.9) with a mean body mass index (BMI) of 22.4 ± 2.8 kg/m² (15.2–33.8) and a mean PA level of 3006.2 ± 2973.6 metabolic equivalent (MET)-minutes/week (148–21,090). Results. A high prevalence of Firmicutes and Bacteroidetes was found in all the fecal samples. Significant dissimilarities in the microbiota composition were found on the basis of MD adherence and PA levels (p = 0.001). At the genus level, Streptococcus and Dorea were highly abundant in overweight/obese individuals, Ruminococcus and Oscillospira in participants with lower adherence to MD, and Lachnobacterium in subjects with low levels of PA (p = 0.001). A significantly higher abundance of Paraprevotella was shown by individuals with lower BMI, lower MD adherence, and lower PA levels (p = 0.001). Conclusions. This study contributes to the characterization of the gut microbiome of healthy humans. The findings suggest the role of diet and PA in determining gut microbiota variability.

Current practices and perceived barriers to tobacco-treatment delivery among healthcare professionals from 15 European countries. The EPACTT Plus project

INTRODUCTION

The latest evidence-based Guidelines for Treating Tobacco Dependence highlight the significant role of healthcare professionals in supporting smokers interested to quit. This study aimed to identify the current practices of healthcare professionals in Europe and perceived barriers in delivering tobacco treatment to their patients who smoke.

METHODS

In the context of EPACTT-Plus, collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine) worked for the development of an accredited eLearning course on Tobacco Treatment Delivery available at http://elearning-ensp.eu/. In total, 444 healthcare professionals from the wider European region successfully completed the course from December 2018 to July 2019. Cross-sectional data were collected online on healthcare professionals’ current practices and perceived barriers in introducing tobacco-dependence treatment into their daily clinical life.

RESULTS

At registration, 41.2% of the participants reported having asked their patients if they smoked. Advise to quit smoking was offered by 47.1% of the participants, while 29.5% reported offering assistance to their patients who smoked in order to quit. From the total number of participants, 39.9% regarded the lack of patient compliance as a significant barrier. Other key barriers were lack of: interest from the patients (37.4%), healthcare professionals training (33.1%), community resources to refer patients (31.5%), and adequate time during their everyday clinical life (29.7%).

CONCLUSIONS

The identification of current practices and significant barriers is important to build evidence-based guidelines and training programs (online and/or live) that will improve the performance of healthcare professionals in offering tobacco-dependence treatment for their patients who smoke.

Tobacco smoking and COVID-19 pandemic: old and new issues. A summary of the evidence from the scientific literature

INTRODUCTION

COVID-19 pandemic burst onto the international scene as a new disease not affecting patients uniformly; hence it has risen many questions yet to be clarified. The aim of this study was to outline the main issues that led tobacco smoking being discussed as a potential risk factor associated with COVID-19.

METHODS

articles from MEDLINE and pre-prints published from January to April 2020 were identified.

RESULTS

data from China showed that men had more severe outcomes of COVID-19 than women. Since smoking prevalence is very high among Chinese men in comparison to women, it was hypothesized that smoking could be a risk factor for poor prognosis. This was also supported by the higher prevalence of comorbidities, many of which are tobacco-related diseases, in patients with severe COVID-19, who were also more likely to have a smoking history. A meta-analysis confirmed these results reporting an OR=2.25 (95% CI: 1.49-3.39) for developing severe Covid-19 among patients with a smoking history. Some authors, noticing that reported smoking prevalence among hospitalized patients was substantially below smoking prevalence in the corresponding populations, speculated a protective role of nicotine. However, it is likely that low prevalence among hospitalized patients are partially due to many smokers misclassified as nonsmokers. Tobacco smoking seems to cause a dose-dependent upregulation of the angiotensin-converting- enzyme-2 (ACE2), the virus cellular entry receptor, which could explain the higher risk of severe COVID-19 in smokers.

CONCLUSIONS

There is need for further independent studies to clarify the role of smoking on COVID-19 incidence, progression and mortality.

Impact of the ENSP eLearning platform on improving knowledge, attitudes and self-efficacy for treating tobacco dependence: An assessment across 15 European countries

INTRODUCTION

In 2018, the European Network for Smoking Cessation and Prevention (ENSP) released an update to its Tobacco Treatment Guidelines for healthcare professionals, which was the scientific base for the development of an accredited eLearning curriculum to train healthcare professionals, available in 14 languages. The aim of this study was to evaluate the effectiveness of ENSP eLearning curriculum in increasing healthcare professionals' knowledge, attitudes, self-efficacy (perceived behavioral control) and intentions in delivering tobacco treatment interventions in their daily clinical routines.

METHODS

We conducted a quasi-experimental pre-post design study with 444 healthcare professionals, invited by 20 collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine), which completed the eLearning course between December 2018 and July 2019.

RESULTS

Healthcare professionals' self-reported knowledge improved after the completion of each module of the eLearning program. Increases in healthcare professionals' self-efficacy in delivering tobacco treatment interventions (p<0.001) were also documented. Significant improvements were documented in intentions to address tobacco use as a priority, document tobacco use, offer support, provide brief counselling, give written material, discuss available medication, prescribe medication, schedule dedicated appointment to develop a quit plan, and be persistent in addressing tobacco use with the patients (all p<0.001).

CONCLUSIONS

An evidence-based digital intervention can be effective in improving knowledge, attitudes, self-efficacy and intentions on future delivery of tobacco-treatment interventions.

The prevalence of musculoskeletal disorders and low back pain among Italian nurses: An observational study

BACKGROUND AND AIM OF THE WORK

Musculoskeletal disorders and low back pain have negative impact amongst Italian nurses who work in hospital. Nursing staff are known to be at risk of developing back disorders, where low back pain has a prevalence from 16% to 60% in the world. This study aims to determine the prevalence of musculoskeletal disorders and low back pain among nurses who working in a Roman hospital.

METHODS

Cross sectional study was carried out in an Italian hospital and the Nordic Musculoskeletal Questionnaire-IRSST was administered to 256 registered nurses. Logistic regression analyses were performed to understand risk factors associated with pain.

RESULTS

Nurses reported different locations of pain related to musculoskeletal disorders. The prevalence of low back pain was 90.2% during life, 80% during the last year and 44.5% during the last week. Female sex increases the risk of being affected by low back pain (OR = 2.07, 95% CI= 1.00-4.32).

CONCLUSIONS

Musculoskeletal disorders and low back pain are reported by the majority of nurses interviewed, and a higher prevalence is observed in women. Pain does not depend on the amount of years of work, nor on age or body mass index. In order to assess the prevalence of low back pain carefully, it is recommended to study a greater number of Italian nurses in different hospitals.

25-Hydroxyvitamin D serum levels and melanoma risk: a case-control study and evidence synthesis of clinical epidemiological studies

There is accumulating evidence that the vitamin D pathway may play a role in melanoma. The aim of this study was to investigate the association between 25-hydroxyvitamin D [25(OH)D] serum levels and the risk of cutaneous melanoma. A case-control study with 137 incident cases of melanoma (serum samples collected at the time of diagnosis) and 99 healthy controls (serum samples collected between October and April) was carried out and evaluated in the framework of an evidence synthesis of clinical epidemiological studies on the topic to facilitate comparisons and summarize the scientific evidence produced so far. There was a statistically significant difference in the median levels of serum vitamin D between melanoma patients and healthy controls (18.0 vs. 27.8 ng/ml, P<0.001). Among melanoma patients, 66.2%, compared with 15.2% of healthy controls, had vitamin D deficiency (≤20 ng/ml), whereas vitamin D sufficiency (≥30 ng/ml) was observed in only 7.4% of melanoma patients and in 37.4% of the healthy controls (P<0.001). A multivariate model including age, sex, and BMI showed a statistically significant inverse association between melanoma and vitamin D sufficiency versus deficiency (odds ratio=0.04; 95% confidence interval: 0.02-0.10, P<0.001). Also, vitamin D insufficiency versus deficiency was significantly inversely associated with melanoma (odds ratio=0.13; 95% confidence interval: 0.06-0.27, P<0.001). These results suggest that both deficient and insufficient serum levels of vitamin D are associated with melanoma and that a trend seems to be present with a reduced risk of melanoma when vitamin D approaches normal values.

Epidemiology of Chronic Pain in the Latium Region, Italy: A Cross-Sectional Study on the Clinical Characteristics of Patients Attending Pain Clinics

In Italy, chronic pain affects more than a quarter of the population, whereas the average European prevalence is 21%. This high prevalence might be due to the high percentage of Italian people who do not receive treatment, even after the passing of law 38/2010 (the right to access pain management in Italy), which created a regional network for the diagnosis and treatment of noncancer chronic pain. Italian epidemiologic studies on chronic pain are scanty, and this observational, multicenter, cross-sectional study is the first to investigate the clinical characteristics of patients who attended the pain management clinics in the Latium Region, Italy, for the management of their noncancer chronic pain. A total of 1,606 patients (mean age 56.8 years, standard deviation ± 11.4), 67% women, were analyzed. Severe pain was present in 54% of the sample. Women experienced pain and had it in two or more sites more often than men (57% vs. 50%, p = .02; and 55.2% vs. 45.9%, p < .001, respectively). Chronic pain was musculoskeletal (45%), mixed (34%), and neuropathic (21%). In more than 60% of the cases, chronic pain was continuous, and in 20% it had lasted for more than 48 months; long-lasting pain was often neuropathic. Low back (33.4%) and lower limbs (28.2%) were the main locations. Severe intensity of pain was statistically significantly associated with female gender (odds ratio [OR] 1.39; 95% confidence interval [CI] 1.06-1.84); with International Classification of Diseases, Ninth Revision, codes for chronic pain syndrome (OR 2.14; 95% CI 1.55-2.95); and with continuous pain (OR 2.02; 95% CI 1.54-2.66). Neuropathic pain and mixed pain were significantly associated with number of sites, and a trend seemed to be present (OR 2.11 and 3.02 for 2 and 3 + sites; 95% CI 1.59-2.79 and 2.00-4.55, respectively).

Immunogenicity of meningococcal polysaccharide ACWY vaccine in primary immunized or revaccinated adults

Meningococcal polysaccharide (Men-Ps) vaccine immunogenicity following either primary immunization or revaccination in adults was evaluated. The study population consisted of subjects who have received tetravalent Men-Ps vaccine once (group 1) or at least twice, with a 2-6 dose range (group 2). Human leucocyte antigen (HLA)-typing was performed by polymerase chain reaction and specific immunoglobulin (Ig)G was measured by enzyme-linked immunosorbent assay. Nine months post-immunization, the percentages of individuals with levels of anti-Men-Ps IgG ≥ 2 µg/ml were comparable in both groups, with the exception of anti-Men-PsW₁₃₅ IgG, which were significantly higher in group 2. The percentage of subjects doubling IgG levels at 9 months was significantly higher in group 1. The high baseline anti-Men-Ps antibody levels negatively influenced the response to revaccination, suggesting a feedback control of specific IgG. The calculated durability of anti-Men-Ps IgG was 2·5-4·5 years, depending on the Men-Ps, following a single vaccine dose. No interference by other vaccinations nor HLA alleles association with immune response were observed. This study confirms that Men-Ps vaccine in adults is immunogenic, even when administered repeatedly, and underlines the vaccine suitability for large-scale adult immunization programmes that the higher costs of conjugate vaccines may limit in developing countries.

Are the school prevention programmes - aimed at de-normalizing smoking among youths - beneficial in the long term? An example from the Smoke Free Class Competition in Italy

Tobacco smoking by young people is of great concern because it usually leads to regular smoking, nicotine addiction and quitting difficulties. Young people "hooked" by tobacco maintain the profits of the tobacco industry by replacing smokers who quit or die. If new generations could be tobacco-free, as supported by tobacco endgame strategies, the tobacco epidemic could end within decades. Smoking prevention programmes for teens are offered by schools with the aim to prevent or delay smoking onset. Among these, the Smoke Free Class Competition (SFC) was widely implemented in Europe. Its effectiveness yielded conflicting results, but it was only evaluated at short/medium term (6 - 18 months). The aim of this study is to evaluate its effectiveness after a longer follow-up (3 to 5 years) in order to allow enough time for the maturing of the students and the internalization of the experience and its contents. Fifteen classes were randomly sampled from two Italian high schools of Bologna province that regularly offered the SFC to first year students; 382 students (174 participating in the SFC and 208 controls) were retrospectively followed-up and provided their "smoking histories". At the end of their last year of school (after 5 years from the SFC), the percentage of students who stated that they were regular smokers was lower among the SFC students than in controls: 13.5% vs 32.9% (p=0.03). From the students' "smoking histories", statistically significant protective ORs were observed for SFC students at the end of 1st and 5th year: 0.42 (95% CI 0.19-0.93) and 0.32 (95% CI 0.11-0.91) respectively. Absence of smokers in the family was also a strongly statistically significant factor associated with being a non-smoker student. These results suggest that SFC may have a positive impact on lowering the prevalence of smoking in the long term (5 years).

Sustainability of prevention practices at the workplace: safety, simplification, productivity and effectiveness

Traditional full-time employment has evolved into various types of occupational situations, and, nowadays, new work organization strategies have been developed. Previously overlooked risk factors have emerged, such as traffic accidents while commuting or during work hours, poor work organization, and detrimental lifestyles (like alcohol and substance abuse, although recent statistics seem to show a declining trend for the latter). The global scenario shows greater attention to occupational risks, but also, to the reduced degree of protection. Moreover, the elevated costs, the unacceptably high fatal accident rates in some sectors, the complexity of the prevention systems, the lack of prevention training, the inadequate controls (despite the numerous independent supervisory bodies) and the obsolescence of certain precepts, call for a prompt review of the regulatory system. This is especially needed for general simplification, streamlining certification bodies and minimizing references to other provisions in the legislation that make it difficult for Italian and foreign workers to read and understand the rules "without legal interpreters". "New" occupational diseases and occupational risk factors have also been reported in addition to pollution. There are concerns for continued economic and social destabilization, unemployment, commuting, temporary and precarious contracts. All of these contribute to the lack of wellbeing in the working population. Thus, the timing, duration, and types of prevention training should be carefully assessed, making prevention more appealing by evaluating costs and benefits with a widespread use of indicators that make appropriate actions for health promotion "visible", thus encouraging awareness. Although reducing prevention is never justified, it should still be "sustainable" economically in order to avoid waste of resources. It is also essential to have laws which are easily and consistently interpreted and to work on the ethics of employers and employees to ensure that they conform to the standards of other European countries that currently operate with greater effectiveness and lower costs.

Vatican beats Italy 1-0 in the tobacco endgame

'The Holy See cannot be cooperating with a practice that is clearly harming the health of people'. This is the reason behind Pope Francis banning the sale of tobacco products inside the Vatican in January 2018. Just outside the Holy See, in Italy, cigarette sales produce around €13 billion of fiscal revenues every year. In Italy, proposals to increase tobacco taxation are systematically rejected and new tobacco company plants have been officially inaugurated in recent years by representatives of State. The national branch of the Red Cross also shows ambivalent attitudes towards the tobacco industry, from which it has accepted significant funding in disregard of the recommendations of the International Federation of Red Cross. Against this backdrop, it is wishful thinking to imagine that tobacco sales and consumption in Italy will be substantially reduced in the near future. To counteract this situation, more than 30 Italian scientific associations/organisations launched a Manifesto, so far ignored by public authorities, indicating a set of measures whose gradual implementation at country level may lead to a tobacco endgame within the next few decades. Authors of this article would like to express their support for Pope Francis' enlightened decision and plead with politicians worldwide to follow his example, thus acting more decisively against tobacco.

Coffee, tea and caffeine intake and the risk of non-melanoma skin cancer: a review of the literature and meta-analysis

PURPOSE

Laboratory studies suggested that caffeine and other nutrients contained in coffee and tea may protect against non-melanoma skin cancer (NMSC). However, epidemiological studies conducted so far have produced conflicting results.

METHODS

We performed a literature review and meta-analysis of observational studies published until February 2016 that investigated the association between coffee and tea intake and NMSC risk. We calculated summary relative risk (SRR) and corresponding 95 % confidence intervals (95 % CI) by using random effects with maximum likelihood estimation.

RESULTS

Overall, 37,627 NMSC cases from 13 papers were available for analysis. Intake of caffeinated coffee was inversely associated with NMSC risk (SRR for those in the highest vs. lowest category of intake: 0.82, 95 % CI 0.75-0.89, I ² = 48 %), as well as intake of caffeine (SRR 0.86, 95 % CI 0.80-0.91, I ² = 48 %). In subgroup analysis, these associations were limited to the basal cell cancer (BCC) histotype. There was no association between intake of decaffeinated coffee (SRR 1.01, 95 % CI 0.85-1.21, I ² = 0) and tea (0.88, 95 % CI 0.72-1.07, I ² = 0 %) and NMSC risk. There was no evidence of publication bias affecting the results. The available evidence was not sufficient to draw conclusions on the association between green tea intake and NMSC risk.

CONCLUSIONS

Coffee intake appears to exert a moderate protective effect against BCC development, probably through the biological effect of caffeine. However, the observational nature of studies included, subject to bias and confounding, suggests taking with caution these results that should be verified in randomized clinical trials.

Exposure to polychlorinated biphenyls and hexachlorobenzene, semen quality and testicular cancer risk

PURPOSE

We carried out a case-control study to investigate the possible role of occupational and environmental exposure to endocrine disruptors in the onset of testicular cancer (TC).

METHODS

We evaluated 125 TC patients and 103 controls. Seminal fluid examination and organochlorine analysis were performed in all subjects. Cases and controls were also interviewed using a structured questionnaire to collect demographic information, residence, andrological medical history and dietary information.

RESULTS

We found that a higher level of reproductive tract birth defects was associated with a higher risk of TC. With regard to diet, cases reported a higher consumption of milk and dairy products than controls. Overall, there was a statistically significant increase in TC risk in cases with detectable values of total polychlorinated organic compounds against controls (14.4 vs. 1.0 %; p < 0.001). TC patients with detectable levels of organochlorines had lower mean semen parameters than those with undetectable levels, although this difference was not statistically significant.

CONCLUSION

The International Agency for Research on Cancer recently included dioxin-like polychlorinated biphenyls (PCBs) in Group 1 of known human carcinogens. Our study confirmed and identified various risk factors for testicular cancer: cryptorchidism, consumption of milk and dairy products, parents' occupation and serum concentration of hexachlorobenzene and PCBs and, for the first time, we showed the correlation between semen quality and the serum concentration of these pollutants.

Towards a smoke-free hospital: how the smoking status of health professionals influences their knowledge, attitude and clinical activity. Results from a hospital in central Italy

OBJECTIVES

In Italy, the prevalence of smoking among health professionals is higher than in the general population and this might hamper their role in the promotion of health. This study aimed to investigate how the smoking status of healthcare professionals might influence knowledge, attitudes and clinical practice in a hospital in central Italy in order to enforce effective tobacco control measures.

METHODS

Physicians and professionals of the hospital were asked to complete an anonymous questionnaire which yielded epidemiological and environmental information on knowledge, attitude, clinical practice and quality of the hospital environments, in relation to smoking.

RESULTS

Overall, among the employees of the hospital, the smoking prevalence was 47%, (42% among physicians and 43% among nurses); 30% admitted smoking in the hospital and three quarters of the smokers would like to quit. Some knowledge, opinions and attitudes differ statistically among the smoking categories. For example, only 35% of the smokers admitted that smoking is more dangerous to health than atmospheric and car pollution compared with 60% of the ex or never smokers (p=0.04). Fewer smokers realize that their behavior is seen as a role model by patients. A greater percentage of smokers state that patients (34%) and visitors (43%) often smoke in hospital and these percentages are significantly higher than those reported by ex or never smokers (p≤0.05). All smokers claim that they never smoke in patient rooms, infirmaries and clinics, whereas over 20% of ex or never smokers report that smoking sometimes occurs in these places (p=0.015). The mean concentration of PM 2.5 in the 25 rooms was 2.4 μg/m3 with a range from 1 to 7 μg/m3.

CONCLUSIONS

This study implies that the prevalence of smoking among health professionals may be very high, and might be twice the rate observed in the general population. Generally, smokers report less knowledge compared with ex and never-smokers and it seems that they systematically underestimate the dangers related to smoking both in their knowledge and in their behavior, and try to socially "normalize" smoking. All this and the evidence of cigarette butts in hospital rooms and clinics, notwithstanding the good quality of the air thanks to the modern ventilation system, imply that there is still a long way to go towards a smoke-free hospital.

Indoor particulate matter and secondhand smoke: simulation of an exposure scenario

BACKGROUND

To evaluate secondhand smoke (SHS) contribution on indoor Particulate Matter (PM) concentrations due to a single smoked cigarette in a real exposure scenario.

METHODS

Total Suspended Particles (TSP) and sizes ≤10 (PM(10)), ≤4 (PM(4)), ≤2.5 (PM(2.5)), and ≤1 μm (PM(1)) levels were measured before, during and after smoking in an enclosed smoke-free environment. The measurement was stopped 30 minutes after extinguishing the cigarette, to focus the monitoring just on SHS.

RESULTS

PM(1) concentrations dramatically increased during and 30 minutes after smoking (mean values: 21.1, 1544.0 and 279.0 μg/m3 before, during and after, respectively), while the other PM fractions remained almost unchanged.

CONCLUSIONS

This experiment implies that smoking even one cigarette produces important indoor air pollution which may considerably increase individual exposure to ultrafine particles, and, consequently, pose a serious threat to health.

Features and organization of Pain Centers in the Lazio Region, Italy, in 2011

BACKGROUND

Evidence on pain management highlights the importance of a multidisciplinary approach in order to achieve optimal therapeutic results. Such programs can be guaranteed by the Centers for Pain Management (CPMs), in which multidisciplinary teams are able to provide advanced and specialized activities for the assessment, diagnosis and treatment of chronic benign pain. To date, information related to healthcare supply and the organizational structure of these centers in Italy is incomplete. The aim of this paper was to provide an overview of the healthcare network of the CPMs in the Lazio region.

METHODS

A descriptive survey was conducted in all the 37 CPMs existing in the Lazio region in 2011 of which 28 participated.

RESULTS

CPMs were located either in Universities or in public or private hospital facilities. They included a clinic, a Day Hospital service, Day surgery and day-beds. CPMs were managed by anaesthesiologists who, in most instances, did not work in a multidisciplinary team. The number of other health professionals available, such as nurses, psychologists and physiotherapists, was limited. CPMs mainly provided drug therapy, Complementary Alternative Medicine (CAM) and complex interventional treatments. The median waiting time was 30 days. The clinics were not homogeneously distributed in the region with a higher concentration in Rome (56%), followed by other provinces of the Lazio region (26%) and the province of Rome (18%). Clearly, Rome was the city which offered the greatest range of healthcare services and the highest number of consultations with patients, which significantly differed from those of the other areas (χ²=19.6 p<0.01).

CONCLUSIONS

In 2011, the availability of CPMs was not equally distributed throughout the territory, and there was an over-utilization of the facilities in Rome and an under-utilization in the provincial areas. Moreover, this study showed a lack of a multi-professional approach to chronic pain management.