Few European studies have investigated the effects of long-term exposure to both fine particulate matter (≤ 2.5 µm; PM2.5) and nitrogen dioxide (NO2) on mortality.
We studied the association of ...exposure to NO2, PM2.5, and traffic indicators on cause-specific mortality to evaluate the form of the concentration-response relationship.
We analyzed a population-based cohort enrolled at the 2001 Italian census with 9 years of follow-up. We selected all 1,265,058 subjects ≥ 30 years of age who had been living in Rome for at least 5 years at baseline. Residential exposures included annual NO2 (from a land use regression model) and annual PM2.5 (from a Eulerian dispersion model), as well as distance to roads with > 10,000 vehicles/day and traffic intensity. We used Cox regression models to estimate associations with cause-specific mortality adjusted for individual (sex, age, place of birth, residential history, marital status, education, occupation) and area (socioeconomic status, clustering) characteristics.
Long-term exposures to both NO2 and PM2.5 were associated with an increase in nonaccidental mortality hazard ratio (HR) = 1.03 (95% CI: 1.02, 1.03) per 10-µg/m3 NO2; HR = 1.04 (95% CI: 1.03, 1.05) per 10-µg/m3 PM2.5. The strongest association was found for ischemic heart diseases (IHD) HR = 1.10 (95% CI: 1.06, 1.13) per 10-µg/m3 PM2.5, followed by cardiovascular diseases and lung cancer. The only association showing some deviation from linearity was that between NO2 and IHD. In a bi-pollutant model, the estimated effect of NO2 on mortality was independent of PM2.5.
This large study strongly supports an effect of long-term exposure to NO2 and PM2.5 on mortality, especially from cardiovascular causes. The results are relevant for the next European policy decisions regarding air quality.
Migrants may be susceptible to vaccine barriers and hesitancy. We evaluated the association between migrant status, as measured by the citizenship from a High Migratory Pressure Country (HMPC), and ...COVID-19 vaccination uptake in the resident population in Rome, Italy. We also investigated sex differences. We followed participants for vaccination against COVID-19 in 2021. We calculated crude- and adjusted-vaccination rates and Cox hazard ratios of vaccination for migrants compared to Italians. Among migrants from HMPCs, we estimated HRs for females compared to males, stratifying by geographical area of origin. Models were adjusted for age and deprivation index and stratified by infection history. In 2021, among 1,731,832 18-64-year-olds, migrants were 55% less likely to uptake at least one COVID-19 vaccine dose than their Italian counterpart. Past SARS-CoV-2 infection reduced the difference between migrants and Italians to 27%. Among migrants from HMPCs, we observed a slight excess of vaccination uptake among females compared to males. Focusing on geographical areas, we observed that only females from central-western Asia were 9% less likely to uptake vaccination than males. Health communication strategies oriented to migrants and considering their different languages, cultures, and health literacy should be adopted for prevention before emergencies.
Few studies have explored the role of air pollution in neurodegenerative processes, especially various types of dementia. Our aim was to evaluate the association between long-term exposure to air ...pollution and first hospitalization for dementia subtypes in a large administrative cohort.
We selected 350,844 subjects (free of dementia) aged 65-100 years at inclusion (21/10/2001) and followed them until 31/12/2013. We selected all subjects hospitalized for the first time with primary or secondary diagnoses of various forms of dementia. We estimated the exposure at residence using land use regression models for nitrogen oxides (NOx, NO
) and particulate matter (PM) and a chemical transport model for ozone (O
). We used Cox models to estimate the association between exposure and first hospitalization for dementia and its subtypes: vascular dementia (Vd), Alzheimer's disease (Ad) and senile dementia (Sd).
We selected 21,548 first hospitalizations for dementia (7497 for Vd, 7669 for Ad and 7833 for Sd). Overall, we observed a negative association between exposure to NO
(10 μg/m
) and dementia hospitalizations (HR = 0.97; 95% CI: 0.96-0.99) and a positive association between exposure to O
, NOx and dementia hospitalizations, (O
: HR = 1.06; 95% CI: 1.04-1.09 per 10 μg/m
; NOx: HR = 1.01; 95% CI: 1.00-1.02 per 20 μg/m
).H. Exposure to NOx, NO
, PM
, and PM
was positively associated with Vd and negatively associated with Ad. Hospitalization for Sd was positively associated with exposure to O
(HR = 1.20; 95% CI: 1.15-1.24 per 10 μg/m
).
Our results showed a positive association between exposure to NOx and O
and hospitalization for dementia and a negative association between NO
exposure and hospitalization for dementia. In the analysis by subtype, exposure to each pollutants (except O
) demonstrated a positive association with vascular dementia, while O
exposure was associated with senile dementia. The results regarding vascular dementia are a clear indication that the brain effects of air pollution are linked with vascular damage.
The association between short-term air pollution exposure and daily mortality has been widely investigated, but little is known about the temporal variability of the effect estimates. We examined the ...temporal relationship between exposure to particulate matter (PM) (PM
, PM
) and gases (NO
, SO
, and CO) with mortality in a large metropolitan area over the last 17 y.
Our analysis included 359,447 nonaccidental deaths among ≥35-y-old individuals in Rome, Italy, over the study period 1998–2014. We related daily concentrations to mortality counts with a time-series Poisson regression analysis adjusted for long-term trends, meteorology, and population dynamics.
Annual average concentrations decreased over the study period for all pollutants (e.g., from 42.9 to 26.6 μg/m
for PM
). Each pollutant was positively associated with mortality, with estimated percentage increases over the entire study period ranging from 0.19% (95% CI: 0.13, 0.26) for a 1-Mg/m
increase in CO (0–1 d lag) to 3.03% (95% CI: 2.44, 3.63) for a 10-μg/m
increase in NO
(0–5 d lag). We did not observe clear temporal patterns in year- or period-specific effect estimates for any pollutant. For example, we estimated that a 10-μg/m
increase in PM
was associated with 1.16% (95% CI: 0.53, 1.79), 0.99% (95% CI: 0.23, 1.77), and 1.87% (95% CI: 1.00, 2.74) increases in mortality for the periods 2001–2005, 2006–2010, and 2011–2014, respectively, and corresponding estimates for a 10-μg/m
increase in NO
were 4.20% (95% CI: 3.15, 5.25), 1.78% (95% CI: 0.73, 2.85), and 3.32% (95% CI: 2.03, 4.63).
Mean concentrations of air pollutants have decreased over the last two decades in Rome, but effect estimates for a fixed increment in each exposure were generally consistent. These findings suggest that there has been little or no change in the overall toxicity of the air pollution mixture over time. https://doi.org/10.1289/EHP19.
Socioeconomic inequalities have a strong impact on population health all over the world. Occupational status is a powerful determinant of health in rich societies. We aimed at investigating the ...association between occupation and mortality in a large metropolitan study.
Cohort study.
Rome, capital of Italy.
We used the Rome Longitudinal Study, the administrative cohort of residents in Rome at the 2001 general census, followed until 2015. We selected residents aged 15-65 years at baseline. For each subject, we had information on sex, age and occupation (occupational status and type of job) according to the Italian General Census recognition.
We investigated all-cause, cancer, cardiovascular and accidental mortality, major causes of death in the working-age population. We used Cox proportional hazards models to investigate the association between occupation and all-cause and cause-specific mortality in men and women.
We selected 1 466 726 subjects (52.1% women). 42 715 men and 29 915 women died during the follow-up. In men, 47.8% of deaths were due to cancer, 26.7% to cardiovascular causes and 6.4% to accidents, whereas in women 57.8% of deaths were due to cancer, 19.3% to cardiovascular causes and 3.5% to accidents. We found an association between occupational variables and mortality, more evident in men than in women. Compared with employed, unemployed had a higher risk of mortality for all causes with an HR=1.99 (95% CI 1.92 to 2.06) in men and an HR=1.49 (95% CI 1.39 to 1.60) in women. Compared with high-qualified non-manual workers, non-specialised manual workers had a higher mortality risk (HR=1.68, 95% CI 1.59 to 1.77 and HR=1.30, 95% CI 1.20 to 1.40, for men and women, respectively).
This study shows the importance of occupational variables as social health determinants and provides evidence for policy-makers on the necessity of integrated and preventive policies aimed at improving the safety of the living and the working environment.
Land Use Regression models (LUR) are useful to estimate the spatial variability of air pollution in urban areas. Few studies have evaluated the stability of spatial contrasts in outdoor nitrogen ...dioxide (NO₂) concentration over several years. We aimed to compare measured and estimated NO₂ levels 12 years apart, the stability of the exposure estimates for members of a large cohort study, and the association of the exposure estimates with natural mortality within the cohort.
We measured NO₂ at 67 locations in Rome in 1995/96 and 78 sites in 2007, over three one-week-long periods. To develop LUR models, several land-use and traffic variables were used. NO₂ concentration at each residential address was estimated for a cohort of 684,000 adults. We used Cox regression to analyze the association between the two estimated exposures and mortality.
The mean NO₂ measured concentrations were 45.4 μg/m³ (SD 6.9) in 1995/96 and 44.6 μg/m³ (SD 11.0) in 2007, respectively. The correlation of the two measurements was 0.79. The LUR models resulted in adjusted R2 of 0.737 and 0.704, respectively. The correlation of the predicted exposure values for cohort members was 0.96. The association of each 10 μg/m³ increase in NO₂ with mortality was 6 % for 1995/96 and 4 % for 2007 LUR models. The increased risk per an inter-quartile range change was identical (4 %, 95 % CI:3-6 %) for both estimates of NO₂.
Measured and predicted NO₂ values from LUR models, from samples collected 12 years apart, had good agreement, and the exposure estimates were similarly associated with mortality in a large cohort study.
Several physiological abnormalities that develop during COVID-19 are associated with increased mortality. In the present study, we aimed to develop a clinical risk score to predict the in-hospital ...mortality in COVID-19 patients, based on a set of variables available soon after the hospitalisation triage.
Retrospective cohort study of 516 patients consecutively admitted for COVID-19 to two Italian tertiary hospitals located in Northern and Central Italy were collected from 22 February 2020 (date of first admission) to 10 April 2020.
Consecutive patients≥18 years admitted for COVID-19.
Simple clinical and laboratory findings readily available after triage were compared by patients' survival status ('dead' vs 'alive'), with the objective of identifying baseline variables associated with mortality. These were used to build a COVID-19 in-hospital mortality risk score (COVID-19MRS).
Mean age was 67±13 years (mean±SD), and 66.9% were male. Using Cox regression analysis, tertiles of increasing age (≥75, upper vs <62 years, lower: HR 7.92; p<0.001) and number of chronic diseases (≥4 vs 0-1: HR 2.09; p=0.007), respiratory rate (HR 1.04 per unit increase; p=0.001), PaO
/FiO
(HR 0.995 per unit increase; p<0.001), serum creatinine (HR 1.34 per unit increase; p<0.001) and platelet count (HR 0.995 per unit increase; p=0.001) were predictors of mortality. All six predictors were used to build the COVID-19MRS (Area Under the Curve 0.90, 95% CI 0.87 to 0.93), which proved to be highly accurate in stratifying patients at low, intermediate and high risk of in-hospital death (p<0.001).
The COVID-19MRS is a rapid, operator-independent and inexpensive clinical tool that objectively predicts mortality in patients with COVID-19. The score could be helpful from triage to guide earlier assignment of COVID-19 patients to the most appropriate level of care.
Low socioeconomic position (SEP) is associated with high overall stroke mortality, but its contribution to stroke prognosis is unclear. We evaluated socioeconomic disparities in stroke incidence and ...poststroke outcomes.
We collected hospital discharge and mortality data for all 35- to 84-year-old Rome residents who had a first acute ischemic or hemorrhagic stroke in 2001 to 2004. We used a small-area SEP index. We calculated age-adjusted incidence rates and rate ratios by SEP for fatal and nonfatal stroke subtypes using Poisson regression. Logistic regression was used to study outcomes by SEP (30-day mortality, and among 1-month survivors: 1-year mortality, hospital readmissions for a successive stroke, and cardiovascular diseases).
A total of 10 033 incident strokes (75% ischemic) were observed. Incidence rates (per 100 000) for ischemic and hemorrhagic stroke were: 104 and 34 in men and 81 and 28 in women, respectively. There were socioeconomic disparities in stroke incidence in both genders (rate ratios between extreme SEP categories in ischemic and hemorrhagic stroke: 1.76; 95% CI,1.59 to 1.95; 1.50; 95% CI, 1.26 to 1.80 in men; 1.72; 95% CI, 1.55 to 1.91; 1.37; 95% CI, 1.15 to 1.63 in women). No association was found for SEP and mortality after stroke. Men with low SEP with an ischemic event were more likely to be hospitalized for a new stroke than men with high SEP. Women with low SEP with hemorrhagic stroke were more likely to be hospitalized for cardiovascular disease compared with women with high SEP.
Stroke incidence strongly differs between socioeconomic groups reflecting a heterogeneous distribution of lifestyle and clinical risk factors. Strategies for primary prevention should target less affluent people.
The association between air pollution exposure and emotional and behavioural problems in children is unclear. We aimed to assess prenatal and postnatal exposure to several air pollutants and child's ...depressive and anxiety symptoms, and aggressive symptoms in children of 7–11 years.
We analysed data of 13182 children from 8 European population-based birth cohorts. Concentrations of nitrogen dioxide (NO2), nitrogen oxides (NOx), particulate matter (PM) with diameters of ≤10 μm (PM10), ≤ 2.5 μm (PM2.5), and between 10 and 2.5 μm (PMcoarse), the absorbance of PM2.5 filters (PM2.5abs), and polycyclic aromatic hydrocarbons (PAHs) were estimated at residential addresses of each participant. Depressive and anxiety symptoms and aggressive symptoms were assessed at 7–11 years of age using parent reported tests. Children were classified in borderline/clinical range or clinical range using validated cut offs. Region specific models were adjusted for various socio-economic and lifestyle characteristics and then combined using random effect meta-analysis. Multiple imputation and inverse probability weighting methods were applied to correct for potential attrition bias.
A total of 1896 (14.4%) children were classified as having depressive and anxiety symptoms in the borderline/clinical range, and 1778 (13.4%) as having aggressive symptoms in the borderline/clinical range. Overall, 1108 (8.4%) and 870 (6.6%) children were classified as having depressive and anxiety symptoms, and aggressive symptoms in the clinical range, respectively. Prenatal exposure to air pollution was not associated with depressive and anxiety symptoms in the borderline/clinical range (e.g. OR 1.02 95%CI 0.95 to 1.10 per 10 μg/m3 higher NO2) nor with aggressive symptoms in the borderline/clinical range (e.g. OR 1.04 95%CI 0.96 to 1.12 per 10 μg/m3 higher NO2). Similar results were observed for the symptoms in the clinical range, and for postnatal exposures to air pollution.
Overall, our results suggest that prenatal and postnatal exposure to air pollution is not associated with depressive and anxiety symptoms or aggressive symptoms in children of 7 to 11 years old.
•We included air pollution data from eight European birth cohorts.•Concentrations of the analysed pollutants varied substantially across Europe.•We assessed emotional and aggressive behaviour symptoms in children of 7–11 years.•Air pollution was not associated with depressive and anxiety symptoms in children.•Air pollution was not associated with aggressive behaviour symptoms in children.
To face the second wave of COVID-19, Italy implemented a tiered restriction system with different limitation levels (yellow = medium; orange = medium-high, red = high) at the beginning of November ...2020. The restrictions systematically reduced the transmission of SARS-CoV-2 with increasing strength for increasing tier. However, it is unknown whether the effect of limitations was equal between provinces with different socioeconomic levels. Therefore, we investigated the association between the province's socioeconomic level and SARS-CoV-2 infection daily reproduction number in each restriction level.
We measured the province's socioeconomic level as the percentage of individuals whose 2019 total yearly income was lower than 10,000€, using the measure as a proxy of economic disadvantage. We estimated the daily reproduction number (Rt) at the province level using the SARS-CoV-2 daily incidence data from November 2020 to May 2021. We then used multilevel linear regression models with random intercepts stratified by restriction level to estimate the association between economic disadvantage and Rt. We also adjusted the analyses for potential confounders of the association between the province's economic disadvantage and the Rt: the percentage of people with 0-5 years, the quartiles of population density, and the geographical repartition.
Overall, we found increasing Rt in yellow (+ 0.004 p < 0.01, from Rt = 0.99 to 1.08 in three weeks) and containing effects for the orange (-0.005 p < 0.01, from Rt = 1.03 to 0.93) and the red tier (-0.014 p < 0.01, from Rt = 1.05 to 0.76). More economically disadvantaged provinces had higher Rt levels in every tier, although non-significantly in the yellow level (yellow = 0.001 p = 0.19; orange = 0.002 p = 0.02; red = 0.004 p < 0.01). The results showed that the association between economic disadvantage and Rt differed by level of restriction. The number of days into the restriction and the economic disadvantage had statistically significant interactions in every adjusted model. Compared to better off, more economically disadvantaged provinces had slower increasing trends in yellow and steeper Rt reductions in orange, but they showed slower Rt reductions in the highest tier.
Lower tiers were more effective in more economically disadvantaged provinces, while the highest restriction level had milder effects. These results underline the importance of accounting for socioeconomic level when implementing public health measures.
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