[Long-term exposure to air pollution and natural mortality: variations related to the use of different exposure indicators in the cohorts of BIGEPI project]

OBJECTIVES

appropriate assessment of exposure to air pollution is crucial for the estimation of adverse effects on human health, both in the short and long term. Within the BIGEPI project, different indicators of long-term exposure to air pollution, in association with mortality by cause, were tested within the Italian longitudinal metropolitan studies (LMS). This allowed an evaluation of differences in effect estimates using the different exposure indicators.

DESIGN

closed cohort.

SETTING AND PARTICIPANTS

subjects aged >=30, who took part in the 2011 census, residents in 5 cities (Turin, Bologna, Rome, Brindisi and Taranto).

MAIN OUTCOME MEASURES

at the time of enrolment, residential exposure levels to particulate matter <=10 μm (PM10), PM <=2.5 μm (PM2.5), nitrogen dioxide (NO2) and ozone (O3) for the period April-September (O3 warm season) were obtained from models at different spatial resolutions, from 1x1km to 200x200m (from the BEEP project) to 100x100m (ELAPSE project). In addition, locally developed models were used in each area (FARM photochemical model at 1x1-km for the cities of Rome, Taranto and Brindisi, Land-Use Regression (LUR) model for the city of Turin, PESCO model for Bologna). Cox proportional hazards models were applied to assess the association between exposure to air pollution (assessed using different exposure indicators) and natural mortality, adjusting for both individual and area covariates.

RESULTS

the exposure levels derived by the different models varied between pollutants, with differences between the averages ranging from 3 to 20% for PM10, from 1 to 23% for PM2.5, and from 3 to 28% for NO2; the results for O3 were more heterogeneous. A total of 267,350 deaths from natural causes were observed. There is low heterogeneity in the effect estimates calculated from different environmental models, while there is greater variability in average exposure values, with different behaviour depending on the model and the characteristics of the area investigated. Differences are more pronounced where local risk factors are relevant, e.g., in industrial cities, thus suggesting the need of considering industrial exposure separately from other sources.

CONCLUSIONS

the numerous heterogeneities in the data used make it difficult to draw conclusions about the comparisons studied. Nevertheless, this study suggests that different approaches to the assessment of environmental exposure should be evaluated depending on the national or local level of interest, also according to the specifities of the investigated areas.

Reversals in past long-term trends in educational inequalities in life expectancy for selected European countries

BACKGROUND

Across Europe, socioeconomic inequalities in mortality are large and persistent. To better understand the drivers of past trends in socioeconomic mortality inequalities, we identified phases and potential reversals in long-term trends in educational inequalities in remaining life expectancy at age 30 (e30), and assessed the contributions of mortality changes among the low-educated and the high-educated at different ages.

METHODS

We used individually linked annual mortality data by educational level (low, middle and high), sex and single age (30+) from 1971/1972 onwards for England and Wales, Finland and Italy (Turin). We applied segmented regression to trends in educational inequalities in e30 (e30 high-educated minus e30 low-educated) and employed a novel demographic decomposition technique.

RESULTS

We identified several phases and breakpoints in the trends in educational inequalities in e30. The long-term increases (Finnish men, 1982-2008; Finnish women, 1985-2017; and Italian men, 1976-1999) were driven by faster mortality declines among the high-educated aged 65-84, and by mortality increases among the low-educated aged 30-59. The long-term decreases (British men, 1976-2008, and Italian women, 1972-2003) were driven by faster mortality improvements among the low-educated than among the high-educated at age 65+. The recent stagnation of increasing inequality (Italian men, 1999) and reversals from increasing to decreasing inequality (Finnish men, 2008) and from decreasing to increasing inequality (British men, 2008) were driven by mortality trend changes among the low-educated aged 30-54.

CONCLUSION

Educational inequalities are plastic. Mortality improvements among the low-educated at young ages are imperative for achieving long-term decreases in educational inequalities in e30.

Sector of Employment and Mortality: A Cohort Based on Different Administrative Archives

Administrative data can be precious in connecting information from different sectors. For the first time, we used data from the National Social Insurance Agency (INPS) to investigate the association between the occupational sectors and both non-accidental and accidental mortality. We retrieved information on occupational sectors from 1974 to 2011 for private sector workers included in the 2011 census cohort of Rome. We classified the occupational sectors into 25 categories and analyzed occupational exposure as ever/never have been employed in a sector or as the lifetime prevalent sector. We followed the subjects from the census reference day (9 October 2011) to 31 December 2019. We calculated age-standardized mortality rates for each occupational sector, separately in men and women. We used Cox regression to investigate the association between the occupational sectors and mortality, producing hazard ratios (HRs) and 95% confidence intervals (95%CI). We analyzed 910,559 30+-year-olds (53% males) followed for 7 million person-years. During the follow-up, 59,200 and 2560 died for non-accidental and accidental causes, respectively. Several occupational sectors showed high mortality risks in men in age-adjusted models: food and tobacco production with HR = 1.16 (95%CI: 1.09-8.22), metal processing (HR = 1.66, 95%CI: 1.21-11.8), footwear and wood (HR = 1.19, 95%CI: 1.11-1.28), construction (HR = 1.15, 95%CI: 1.12-1.18), hotels, camping, bars, and restaurants (HR = 1.16, 95%CI: 1.11-1.21) and cleaning (HR = 1.42, 95%CI: 1.33-1.52). In women, the sectors that showed higher mortality than the others were hotels, camping, bars, and restaurants (HR = 1.17, 95%CI: 1.10-1.25) and cleaning services (HR = 1.23, 95%CI: 1.17-1.30). Metal processing and construction sectors showed elevated accidental mortality risks in men. Social Insurance Agency data have the potential to characterize high-risk sectors and identify susceptible groups in the population.

Impact of COVID-19 pandemic on inequalities in mortality: an analysis in Piedmont and Emilia-Romagna

Background

Italy was heavily hit by the COVID-19 pandemic. According to official statistics, during 2020 there were more than 75,000 excess deaths compared to the average expected mortality in 2015-2019. General mortality (GM) is a good measure of both the direct and indirect effects of the pandemic because it's exempt from potential bias due to misclassification of events. Evidence shows a greater burden of disease and mortality attributable to COVID-19 among disadvantaged populations, with the risk of an exacerbation of existing health inequalities. We aim to analyse the trend of social inequalities in mortality during the first pandemic year in two Italian regions (Piedmont and Emilia-Romagna) using data from Administrative Population Registries (APR) and statistical databases.

Methods

Data on deaths occurred between Jan 2015 and Jan 2021 in subjects ≥65, stratified by educational level, were obtained from Regional APR and the Census. Using a time series approach, we computed Standardized Mortality Rates (SMR), Relative Index of Inequalities (RII) and Slope Index of Inequalities (SII), adjusted by age, gender, month and region. SMR, RII and SII from March 2020 were forecasted using Holt-Winters method and compared to the observed values in the same period.

Results

SMRs were higher than expected during the two 2020 epidemic waves (Mar-Apr, Oct-Dec) in both regions. RII didn't increase significantly. Absolute inequalities instead rose in Piedmont during both pandemic waves, mostly among women, and in Emilia-Romagna in March among men.

Conclusions

The impact of the pandemic on inequalities in GM has been at least of the same size of the impact of other mechanisms of unequal mortality. APR coupled with sociodemographic data are a quick and reliable source for assessing the unequal impact of the COVID-19 pandemic on health. Further research is needed to explore mechanisms underlying these effects e.g. inequalities in cause-specific mortality and access to health services.

Key messages

Suicide among adolescents in Italy: a nationwide cohort study of the role of family characteristics

Suicide is a leading cause of death among adolescents and is recognized as a serious public health problem. This study aimed to investigate the relationship between family characteristics and the risk of suicide among adolescents in Italy using nationwide official data. We carried out a cohort study based on the record linkage between the 15th Italian Population Census, the Italian Population Register, and the National Register of Causes of Death. Suicides in adolescents aged 10-19 years from 2012 to 2016 were analyzed. Hazard ratios of mortality from suicide were estimated through a multivariable Cox regression model using time-on-study as the time scale. We included 8,284,359 children and adolescents (51% males, 49% females). Over the 5-year follow-up, we registered 330 deaths from suicides (74% males), mostly occurred in the age class 15-19 years (86%). The suicide rate was 1.71 per 100,000 person-years among males and 0.65 among females. We found some familial characteristics associated with a higher risk of dying by suicide, including: living in single-parent or reconstructed families (among boys), a 40-year or more age gap between mother and child (among girls), having highly educated parents, an age difference between parents greater than 5 years. Furthermore, the study showed a lower risk for boys living in urban areas and for both boys and girls living in South Italy. Our results could help in identifying adolescents at high risk of suicide who could benefit from the planning of targeted intervention strategies.

Socioeconomic inequalities in suicide mortality in European urban areas before and during the economic recession

BACKGROUND

Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis.

METHODS

This ecological study of trends was based on three periods, two before the economic crisis (2000-2003, 2004-2008) and one during the crisis (2009-2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model.

RESULTS

Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24-3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35-0.68) in the third period.

CONCLUSIONS

Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied.

Towards a national health equity monitoring strategy

The 2017 Italian Review on health inequalities identified two main needs with regards to Italian health equity monitoring. (1) The need to collect a social covariate at individual level in each health information system at local, regional and national level. Such a social covariate is fundamental for monitoring if any avoidable inequality in access, use, quality of care and health outcome is occurring at local, regional, national level. (2) The need to re-engineer and frame the different health equity monitoring surveys already established into an explicit health inequalities monitoring strategy (HIMS). Both challenges are accounted for by Italy in the Joint Action Health Equity Europe workplan.

As for the social covariate, a pilot project is conducted. Data from 2011 census (education and area deprivation) and the national identification code used to link individual data on health and services utilization in four representative regions is linked. This will allow monitoring the social variation in selected performance indicators by region, across regions and through time.

As for HIMS, previous research projects have designed and successfully piloted different models of low-cost data linkage for already established longitudinal studies. Now these pilot results will evolve into a national HIMS. As a first step, a special project of consensus building will be implemented among institutional partners responsible for the following national longitudinal studies based on record linkage: a) Work Histories Italian Panel followed up prospectively for health outcomes; b) Italian Longitudinal Study: 2000, 2015, 2013 Health Interview Surveys followed up prospectively for health outcomes; c) differential mortality 2011-2017 in the 2011 censused Italian population; d) the network of the metropolitan and regional census based longitudinal studies followed up prospectively for mortality disease registries and health care utilization. Experiences gained will be shared and discussed.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND AND AIMS

Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.

METHODS AND RESULTS

A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.

CONCLUSION

Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility

Background

Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries.

Methods

Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region.

Results

In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix.

Conclusion

Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.

Socioeconomic deprivation worsens the outcomes of Italian women with hormone receptor-positive breast cancer and decreases the possibility of receiving standard care

BACKGROUND

Socioeconomic factors influence access to cancer care and survival. This study investigated the role of socioeconomic status on the risk of breast cancer recurrence and on the delivery of appropriate cancer care (sentinel lymph node biopsy and breast-conserving surgery plus radiotherapy), by patients' age and hormone receptor status.

METHODS

3,462 breast cancer cases diagnosed in 2003-2005 were selected from 7 Italian cancer registries and assigned to a socioeconomic tertile on the basis of the deprivation index of their census tract. Multivariable models were applied to assess the delivery of sentinel lymph node biopsy and of breast-conserving surgery plus radiotherapy within socioeconomic tertiles.

RESULTS

In the 1,893 women younger than 65 years, the 5-year risk of recurrence was higher in the most deprived group than in the least deprived, but this difference was not significant (16.4% vs. 12.9%, log-rank p=0.08); no difference was seen in women ≥65 years. Among the 2,024 women with hormone receptor-positive cancer, the 5-year risk was significantly higher in the most deprived group than in the least deprived one (13.0% vs. 8.9%, p=0.04); no difference was seen in cases of hormone receptor-negative cancer. The most deprived women were less likely than the least deprived women to receive sentinel lymph node biopsy (adjusted odds ratio (ORa), 0.69; 95% CI, 0.56-0.86) and to undergo breast-conserving surgery plus radiotherapy (ORa=0.66; 95% CI, 0.51-0.86). Conclusions: Socioeconomic inequalities affect the risk of recurrence, among patients with hormone receptor-positive cancer, and the opportunity to receive standard care.

The socio-economic impact of cervical cancer on patients and their families in Argentina, and its influence on radiotherapy compliance. Results from a cross-sectional study

OBJECTIVE

We aimed to measure the socio-economic impact of cervical cancer borne by patients and their families in Argentina, and to analyze its influence on radiotherapy compliance.

METHODS

We carried out a cross-sectional survey of 120 new cervical cancer patients. We measured impact of disease in 6 domains of family life: employment, income, household budget, education, access to health-care, and child care. Data on compliance with radiotherapy were also collected.

RESULTS

Households of patients reported a reduction in hours worked (45%), work interruption (28%), loss of family income (39%), a reduction in the daily amount of food consumed (37%), delays in paying for essential services such as electricity or telephone (43%), and the sale of property or use of savings (38%). In 28% of households children regularly missed school days. An increased risk of non-compliance with radiotherapy was found in patients from households that lost family income (OR: 3.8, 95% CI 1.5-9.5), or where a member reduced school attendance (OR: 3.6, 95% CI 1.4-9.1).

CONCLUSIONS

The socio-economic impact of cervical cancer is considerable and can have negative consequences on treatment compliance. Cervical cancer prevention must be considered a public health priority. Effective social support systems for cancer patients should be implemented.