BACKGROUND:in environmental epidemiology, critical appraisal of evidence across studies and quantitative synthesis is crucial to inform public health, but it is challenged by the heterogeneity in exposure assessment methods. Even when assessing the same exposure, different studies frequently report risk estimates using varying categorical exposure intervals, making it difficult to compare and synthetize findings quantitatively. Advanced meta-analytical methodologies capable of harmonizing different exposure categorizations and effect estimates are crucial for generating flexible, policy-relevant, and locally applicable evidence that can be used in Health Impact Assessments of the disease burden related to environmental exposures and of the potential impact of mitigation measures. OBJECTIVES:to present a transparent and reproducible approach for harmonizing diverse categorical risk estimates (based on differently defined categories) into a per-unit continuous effect estimate, thereby including them in meta-analyses. The method is exemplified through a practical application. METHODS:the method involves three steps: 1. estimating the midpoint of each exposure category and calculating category-specific per-unit continuous beta coefficients from categorical effect estimates; 2. deriving a study-specific continuous effect estimate as a weighted average of these beta coefficients; 3. calculating the uncertainty (i.e., confidence intervals) of the resulting estimate. This approach assumes linearity of risk within categories and independence of category-specific estimates. The method was illustrated through a practical application to the dataset reported by Mataloni et al. (2016), with the aim of deriving a continuous hazard risk associated with a 1 ng/m³ increase in H2S exposure. Method robustness was assessed by comparing results with the true continuous effect and with those deriving from previously published pooling methods that overcome some limitations, including the absence of risk modelling across categories and covariance estimation. The effect of different definitions of central category exposures was also examined. RESULTS:the proposed method was applied in cases where the same exposure (e.g., H2S) was examined across studies for a given health outcome, but varying exposure intervals. A sample calculation is provided, along with an R script and corresponding Excel formulas. The method appears to provide an unbiased estimation of the 'true' continuous effect and obtained results comparable with other more complex methods both in terms of point and interval estimates pooled across categories and was robust to different central category exposures definitions. CONCLUSIONS:the proposed method provides a practical and replicable approach for converting categorical risk estimates into continuous effect estimates, enabling the harmonization of heterogeneous exposure categories across studies. This allows comparability and enables to carry out meta-analyses even in settings with a limited evidence base, where the addition of a single study can meaningfully contribute to the pooled estimate. The method helps overcome a frequent source of heterogeneity in environmental epidemiology, enhancing the robustness, precision, and interpretability of meta-analytical results. Applying methods such as the one here presented to systematic reviews and meta-analyses in the field of environmental epidemiology - where commonly potential effects of exposures are highly uncertain, as in the case of municipal solid waste disposal sites - more valid and robust estimates of the effects of specific environmental exposures can be obtained, therefore providing a stronger evidence base to inform public health decision-making.

Emerging evidence links air pollution to metabolic dysfunction, including Type 2 diabetes (T2D). However, findings remain inconsistent, particularly in areas with complex environmental pressures. We investigated the association between long-term exposure to multiple ambient air pollutants (PM10, PM2.5, NO2, SO2, C6H6) and the incidence of T2D in River Sacco Valley (RSV), an area in Central Italy designated as a Site of National Interest (SIN) due to severe chemical contamination and air pollution. This retrospective cohort study included 392,133 residents aged ≥35 years in RSV and Frosinone province (2008-2018). Incident T2D cases were identified through administrative databases using a validated algorithm. Individual pollutant exposure was assigned at residential addresses using a dispersion model (1 × 1 km2 resolution). Exposure to critical industrial environments was also considered. Cox proportional hazards models estimated Hazard Ratios (HR) per 1 μg/m3 pollutant increase, adjusting for sex, municipality, socioeconomic status and proximity to industrial plants, River Sacco and SIN municipalities. Effect modification by sex was also evaluated. 31,556 T2D incident cases were identified. SO2 exposure was associated with T2D incidence (HR: 1.01; 95% CI: 1.00-1.02), particularly among women (HR 1.02; 95% CI: 1.01-1.04), suggesting sex-specific vulnerability. Unexpectedly, PM10, PM2.5 and C6H6 showed inverse associations, while NO2 was not linked to T2D. Notably, residing within 1 km from River Sacco consistently increased T2D risk. These findings may reflect local exposure patterns, residual confounding or the influence of β-hexachlorocyclohexane contamination near the river, highlighting the need for environmental health research in burdened areas to inform equitable prevention strategies.

Evidence on the effects of waste incineration on adverse birth outcomes (ABO) and hypertensive disorders of pregnancy (HDP) is limited. We investigated the association between maternal exposure to a waste-to-energy (WTE) plant in Lazio Region and ABO/HDP. Employing a difference-in-differences (DiD) design, we assessed changes related to the plant's deactivation (2017), comparing outcomes to a control WTE plant that remained operational. Mothers with geocoded residential address within 7 km from Colleferro (exposed area) and San Vittore del Lazio (control area) plants who delivered between 2007 and 2023 were enrolled. Information was derived from regional health databases. Outcome-specific multivariate logistic models included interaction terms between a "pre-post" variable (0 for deliveries in the operational period - 1 for deliveries in the post-operational period) and a variable indicating the plant (Colleferro/San Vittore) linked to each delivery. Secondary analyses considered extended buffers around the plants or a control group from a broader area surrounding Colleferro, instead of San Vittore. 25,360 deliveries occurred within 7 km from the two WTE plants. After Colleferro plant's deactivation, pre-eclampsia risk decreased compared to San Vittore (OR = 0.35; 95 % CI: 0.13-0.93). Suggestions of association were noted for ABO, for example preterm birth (OR = 0.83; 95 % CI: 0.62-1.10). Pre-eclampsia risk remained low when using an extended buffer for the delivery selection. Exposure to WTE plant emissions was associated with ABO and HDP. While further research is needed, public health measures should enhance stricter emission monitoring, cleaner waste management, and prevention for pregnant women in affected areas.

OBJECTIVES:to estimate CO2 emissions for different commuting modes before, during, and after the COVID-19 lockdown, and define scenarios to assess their impact on the environment and health. DESIGN:cross-sectional study using data retrieved from a survey. SETTING AND PARTICIPANTS:the study included anonymous participation from both researchers involved in the Climactions project and the general population; the questionnaire was made available through social media. Information was gathered on the transportation modes used to commute, the distance travelled and travel times before, during, and after the COVID-19 emergency, and proposals for actions/solutions to enhance sustainable commuting in urban areas. MAIN OUTCOME MEASURES:the amount of CO2 emissions due to different commuting modes during various stages of the pandemic was estimated based on vehicle-specific emission coefficients provided by the European Environmental Agency, taking into account the average number of passengers per vehicle. Sustainable commuting scenarios were also proposed, including active transportation (walking, cycling, etcetera). RESULTS:the online questionnaire was filled-in by 2,904 persons, predominantly women (62.3%) and residents in Northern Italy (44.6%). Over 80% of the respondents were aged over 40 (0.7% <25 years). On average, the distance travelled on a daily commute was 23.6 km (median: 13 km), with longer distances in the Southern Regions (average: 38.2 km, median: 20 km). The average per-capita CO2 emissions were 2 kg per day in the pre-pandemic situation. The reduction in commuting during lockdown periods led to a significant decrease in estimated CO2 emissions, with an average per capita reduction of about 100 grams per day. From September 2020, the increase in smart working among respondents still allowed for a reduction in estimated CO2 levels, despite an increase in emissions from private vehicle use (1.5 kg per capita per day). Considering sustainable scenarios, a 15-minute walk during the daily commute would lead to a reduction in estimated CO2 levels of up to 0.7 kg per capita per day. Regarding the statement that "improving air quality in cities and reducing greenhouse gas emissions are useful actions to combat climate change", 94% of respondents strongly agreed. CONCLUSIONS:in Italy, road transport accounts for approximately 25% of the total CO2 emissions. The lockdown provided a natural scenario for reducing emissions in urban areas, and the implementation of smart working was associated with a decrease in CO2 emissions due to reduced commuting. However, it is crucial to promote sustainable and active transportation modes for daily commuting such as walking and cycling, also considering the significant health co-benefits.

BACKGROUND:the association between air pollution and human health has been extensivelyinvestigated in the epidemiological literature. However, evidence in non-urban areasaffected by industrial activities is still limited. OBJECTIVES:to assess the association between daily exposure to PM10 and cause-specific mortality in municipalities affected by emissions from industrial plants during the period 2006-2015. DESIGN:two-stage time-series design was applied to assess the relationship between lagged PM10 and the outcomes. In the first stage, the association at the municipal level was analyzed with Poisson regression models adjusted for space-time confounders (trend and temperature). In the second stage, a mixed effects metanalysis of municipal estimates was applied to obtain a pooled estimate. Effect modification for individual variables (sex, age) and type of industrial site (chemical, steel, energy, or mining plant) was assessed. SETTING AND PARTICIPANTS:using the European Pollutant Release and Transfer Register, industrial plants entailing a combustion process were selected. 4x4 km² buffer around the plant was constructed to select the municipalities to be included in the analysis. Daily PM10 was estimated using machine-learning models based on satellite data. MAIN OUTCOMES MEASURES:daily counts of natural, cardiovascular, and respiratory deaths. RESULTS:the average exposure to PM10 was 28.4 μg/m³ (±SD 16.9). During the period under study, 568,804 deaths from natural causes were observed in the 100 municipalities near the 61 industrial sites identified. Percentage risk variations for 10-units increments of lagged 0-1 PM10 were 1.04% (95%CI 0.67;1.41), 1.04% (95%CI -1.21;3.34), and 7.89% (95%CI 0.16;16.23) for natural, cardiovascular, and respiratory mortality, respectively. Higher risk estimates were observed in municipalities near steel plants, especially for respiratory mortality (8.13%; 95%CI -2.85;20.35). No differences were observed in estimates between different age and sex classes. CONCLUSIONS:although not fully able to capture the industrial component of pollution, the results indicate excess risk of mortality in residents of the municipalities under study, especially when considering the presence of steel plants.

Municipal solid waste incinerators (MSWIs) are widely used for waste management. However, the health effects of their emissions remain uncertain, needing further investigation and monitoring of the potential risks associated with such exposure. The aim of this study is to update and synthesize evidence on the health effects of residential exposure to MSWIs. A systematic review with meta-analysis was conducted following PRISMA guidelines. The systematic search in MEDLINE, EMBASE, and Web of Science (April 2025), using specific search strategies, identified observational studies reporting quantitative estimates on the association between long term residential exposure to MSWIs and health outcomes. Study quality was assessed using the Navigation Guide tool. A narrative synthesis was conducted for all outcomes. When possible, a random-effects meta-analysis was performed and Higgins I2 was used to summarize heterogeneity. For the overall body of evidence, heatmaps were used to visually represent the direction of the associations (positive, negative or lack of association) stratified by study quality. Out of 3,273 records identified, 51 studies were included. The most frequently investigated outcomes were congenital anomalies, pregnancy outcomes, cardiovascular and respiratory diseases, and cancers. The narrative synthesis suggests a weak association for hospitalizations due to cardiovascular and respiratory diseases in high-quality studies and a potential increased risk for non-Hodgkin lymphoma, based on low-quality evidence. The meta-analysis confirms a slight increased risk for respiratory diseases (HR 1.02; 95

Air pollution poses a significant threat to human health, especially for the vulnerable groups such as children. Given that schools are central to their daily lives, ensuring good air quality in these environments is crucial. This study evaluates the impact of traffic restriction interventions around schools by integrating citizen science monitoring data with advanced modeling techniques. From February 4 to March 4, 2023, within the framework of a citizen science project called "NO2, No Grazie!", NO2 concentrations were measured in Milan and Rome (Italy), Italy's two most populated cities, both affected by high traffic-related pollution, using passive samplers. The spatial distribution of NO2 across entire city territories was estimated using Land Use Random Forest (LURF) models. Four traffic restriction scenarios were developed alongside a business-as-usual one; furthermore, each school was characterized by the social vulnerability of its area. In total, 486 samplers were analyzed in Milan and 407 in Rome, with NO2 levels averaging 47.1 μg/m3 and 42.6 μg/m3, respectively. LURF models explained 64 % and 53 % of the measured variability, with traffic proximity as a major predictor. Among 659 schools in Milan and 1595 in Rome, all traffic restriction scenarios led to significant NO2 reductions. The most effective scenario reduced NO2 by 2.7 μg/m3 in Milan and 1.9 μg/m3 in Rome on average, with maximum observed decreases of 11.1 μg/m3 and 16.1 μg/m3, respectively. Schools in socioeconomically deprived areas had lower NO2 levels and were less impacted by the restrictions. The study underscores the value of traffic policies in improving air quality around schools.

Air pollution has no borders. Over 90% of the global population breathes air contaminated daily by pollutants such as fine particulate matter (PM 2.5 and PM 10), ozone, and nitrogen dioxide (NO2), with serious consequences for public health and the environment. Climate change and air pollution are closely interconnected, with the latter contributing to the ongoing climate crisis by causing an increase in ozone and particulate matter levels. In Italy, each year during 2016-2019, 72,083 deaths (11.7%) were estimated to be attributable to annual mean levels of PM 2.5 above 5 µg/m3 (Who - 2021 treshold), mainly in the regions of the Po Valley and in metropolitan areas. Pollutants, transported over long distances, do not respect geographic or political boundaries, requiring regional air quality plans. Interregional collaboration is therefore necessary to prevent disparities in air quality and public health. The Italian network for environment and health (Rias) promotes an integrated approach to improving public health and tackling environmental risks.Crisi climatica e qualità dell'ariaIn un momento storico segnato da muri e nazionalismi, è importante ricordare che l'inquinamento atmosferico è un problema globale che non conosce confini geografici o politici. Oltre il 90% della popolazione mondiale respira quotidianamente aria contaminata da agenti inquinanti quali particolato fine (PM 2,5 e PM 10), ozono (O3), biossido di azoto (NO2), con gravi conseguenze sulla salute pubblica e sull'ambiente. Le città densamente popolate e le aree industriali sono tra le più inquinate, ma anche le zone rurali dove il riscaldamento (biomasse e pellet) e il traffico veicolare sono le principali fonti di inquinamento atmosferico. Contribuiscono al carico di inquinamento anche le emissioni industriali e il contributo significativo delle emissioni di ammoniaca che vengono dall'agricoltura e in particolare dagli allevamenti intensivi: attraverso processi di interazione con altre sostanze presenti in atmosfera, l'ammoniaca prodotta si trasforma in particolato fine. Queste fonti sono spesso concentrate in specifiche aree regionali, soprattutto vicino ai centri urbani o zone industriali, ma gli inquinanti possono essere trasportati per lunghe distanze dal vento e da altri fattori meteorologici, superando i confini regionali (ne è un esempio il fenomeno delle polveri sahariane che colpisce di più le aree contigue, ma raggiunge grandi distanze).L'ultimo rapporto dell'Agenzia europea per l'ambiente ha aggiornato i dati sulla concentrazione di PM 2,5 in circa 370 città europee, con una popolazione maggiore di 50mila abitanti, relativi agli anni 2022 e 2023. I dati, pubblicati lo scorso agosto, evidenziano come, tra le città monitorate, solo 13 (situate quasi tutte in Scandinavia) rispettano il nuovo limite raccomandato dall'Organizzazione mondiale della sanità (Oms) di 5 µg/m3, annui di PM 2,51. Chi vive nelle città della Pianura Padana respira aria di qualità generalmente scarsa, con concentrazioni di inquinanti che superano ampiamente non solo i limiti raccomandati dall'Oms, ma anche quelli stabiliti dalle normative in vigore nel nostro Paese. In particolare, i livelli di PM 2,5 superano spesso il limite attuale di 25 µg/m3 e la qualità dell'aria risulta una delle peggiori in Europa. Questa situazione implica gravi rischi per la salute pubblica e richiede interventi urgenti per ridurre l'inquinamento atmosferico2.La qualità dell'aria sta peggiorando anche a causa dei cambiamenti climatici. L'inquinamento atmosferico è causa dei cambiamenti climatici e a sua volta ne subisce gli effetti: il surriscaldamento del pianeta e la maggiore insolazione aumentano le concentrazione di ozono; l'aumento del rischio di incendi determina un aumento del particolato; alterazioni delle condizioni meteorologiche, come l'incremento della siccità e della ventilazione, influenzano la concentrazione e la dispersione degli inquinanti; fattori meteorologici condizionano il fenomeno delle avvezioni sahariane, con trasporto del particolato anche a grandi distanze3.Gli effetti sulla saluteLe complesse interazioni tra le attività antropiche, la qualità dell'aria e la salute umana nelle aree urbane hanno reso indispensabile l'adozione di una metodologia di valutazione del rischio integrata e multidisciplinare. Le stime di impatto dell'inquinamento ambientale sulla salute consentono di analizzare l'effetto combinato dei fattori ambientali e socioeconomici, fornendo una base solida per lo sviluppo di politiche efficaci volte a tutelare la salute pubblica e migliorare la qualità dell'aria nelle città. L'esposizione media della popolazione italiana supera di oltre tre volte i limiti delle linee guida dell'Oms 2021.Stime recenti indicano che, in Italia, nel periodo 2016-2019, 72.083 decessi sono attribuibili a livelli medi annuali di PM 2,5 superiori a 5 μg/m3, pari all'11,7% della mortalità per tutte le cause. Di questi, 39.628 sono stati registrati nelle regioni della Pianura Padana e 10.232 nelle 6 città italiane con più di 500.000 abitanti4.L'inquinamento atmosferico è ubiquitario, presente sia negli ambienti chiusi sia all'aperto, e può avere effetti negativi sulla salute in una vasta gamma di contesti. Il particolato fine, per esempio, può penetrare profondamente nei polmoni e nel sistema cardiovascolare, causando infiammazioni, aggravando malattie respiratorie croniche come l'asma e la bronchite, e aumentando il rischio di infarto e ictus. Il biossido di azoto e l'ozono troposferico irritano le vie respiratorie, riducono la funzionalità polmonare e possono peggiorare le condizioni preesistenti nei pazienti con malattie polmonari5-7. Mentre le condizioni respiratorie e cardiovascolari sono state tradizionalmente collegate all'inquinamento atmosferico, studi recenti suggeriscono potenziali associazioni con condizioni neurologiche (come la demenza e il morbo di Parkinson), il diabete, varie forme di cancro oltre a quello polmonare8. Gli impatti sulla salute non si limitano solo agli adulti e agli anziani. L'esposizione della mamma in gravidanza è associata a un parto prematuro e basso peso alla nascita del neonato9. Nei bambini, l'esposizione all'inquinamento atmosferico è associata a un aumento delle infezioni respiratorie, all'incidenza di asma bronchiale, a una ridotta crescita polmonare e a problemi nello sviluppo cognitivo10,11.Gli effetti dell'inquinamento atmosferico interessano soprattutto i Paesi più poveri e le fasce di popolazione più vulnerabili della società, contribuendo ad aumentare le disuguaglianze sociali, economiche e di salute. I bambini e gli anziani tendono a subire le peggiori conseguenze sulla salute a causa della respirazione di aria inquinata, mentre le persone a basso reddito spesso vivono nelle aree più inquinate.Le nuove linee guida Oms e i piani della qualità dell'ariaCome già ricordato, nel 2021 l'Oms ha emanato linee guida aggiornate e più restrittive sulla qualità dell'aria che abbassano i limiti già raccomandati. Tali limiti si basano sulla revisione sistematica della letteratura scientifica degli ultimi 15 anni, degli studi epidemiologici sugli effetti sulla salute e sulla meta-analisi della stima degli effetti quantitativi osservati, evidenziando effetti negativi sulla salute anche a concentrazioni più basse di quelle riconosciute in precedenza indispensabili per tutelare i gruppi più vulnerabili (bambini, anziani e persone con malattie croniche)12.È stata di recente approvata dal Parlamento europeo la revisione della Direttiva per la qualità dell'aria13. Si tratta dello strumento base che regola la tutela dei cittadini europei nei confronti degli inquinanti dell'aria e l'azione degli Stati membri. La normativa ha fissato valori limite e obiettivi più rigorosi da raggiungere entro il 2035, per diversi inquinanti, tra cui PM 2,5 e PM 10, NO2, anidride solforosa (SO2) e O3. La nuova Direttiva mira ad allineare le regole UE con le più recenti linee guida dell'Oms per la qualità dell'aria. Tra i cambiamenti principali troviamo un abbassamento dei valori limite annuali per gli inquinanti con documentato impatto sulla salute umana (tabella 1).Gli strumenti che le regioni adottano per ridurre l'impatto dell'inquinamento atmosferico sull'ambiente e sulla salute umana sono i piani per la qualità dell'aria, strumenti fondamentali attraverso cui ogni regione sviluppa strategie mirate per affrontare le problematiche specifiche del proprio territorio, stabilendo obiettivi di riduzione delle emissioni e promuovendo pratiche sostenibili nei settori chiave come il traffico, l'industria e l'agricoltura. I piani mirano a migliorare la qualità dell'aria definendo gli obiettivi e le azioni necessarie per raggiungerli, come ridurre le emissioni e promuovere comportamenti sostenibili. I piani regionali di qualità dell'aria permettono di affrontare l'inquinamento a livello locale, tenendo conto delle specificità territoriali. Tuttavia, questi piani variano da una regione all'altra, creando disparità nella qualità dell'aria e nella salute delle popolazioni locali. Dovrebbe essere promossa invece una stretta collaborazione tra le regioni per coordinare le loro azioni e garantire che le misure adottate siano efficaci non solo a livello locale, ma anche su scala nazionale. Una cooperazione interregionale permetterebbe di affrontare l'inquinamento in maniera sistematica e integrata, ridurre le disparità tra le diverse aree e assicurare una qualità dell'aria più omogenea su tutto il territorio nazionale, sfruttando al meglio le risorse e le competenze di ciascuna regione, promuovendo soluzioni innovative e ottimizzando le politiche ambientali. L'obiettivo finale dovrebbe essere quello di integrare il tema della riduzione dell'inquinamento atmosferico nella questione più ampia e globale della mitigazione del cambiamento climatico, con benefici duraturi a lungo termine per la salute dei cittadini e la sostenibilità ambientale.In Italia, la Rete italiana ambiente e salute (Rias)14 nasce per promuovere l'interazione virtuosa tra centri che si occupano istituzionalmente del binomio ambiente e salute per migliorare la salute pubblica, mitigare gli effetti nocivi dei contaminanti ambientali, promuovere strategie di adattamento ai cambiamenti climatici, preservare la biodiversità, nell'ottica dei co-benefici e della riduzione delle diseguaglianze sociali. Il progetto Rias, finanziato dal Ministero della salute, ha contribuito al consolidamento di una integrazione operativa tra Servizio sanitario nazionale (Ssn) e Sistema nazionale protezione ambiente (Snpa) che è sfociata nell'istituzione del Sistema nazionale prevenzione salute dai rischi ambientali e climatici (Snps); l'approccio di rete è di grande rilevanza anche per la gestione dei recenti finanziamenti governativi in tema di ambiente e salute, per la pianificazione strategica e il coinvolgimento attivo di tutti gli attori interessati.Conflitto di interessi: le autrici dichiarano l'assenza di conflitto di interessi.

Background: Air pollution health risk assessment (HRA) has been typically conducted for all causes and cause-specific mortality based on concentration–response functions (CRFs) from meta-analyses that synthesize the evidence on air pollution health effects. There is a need for a similar systematic approach for HRA for morbidity outcomes, which have often been omitted from HRA of air pollution, thus underestimating the full air pollution burden. We aimed to compile from the existing systematic reviews and meta-analyses CRFs for the incidence of several diseases that could be applied in HRA. To achieve this goal, we have developed a comprehensive strategy for the appraisal of the systematic reviews and meta-analyses that examine the relationship between long-term exposure to particulate matter with an aerodynamic diameter smaller than 2.5 µm (PM 2.5 ), nitrogen dioxide (NO 2 ), or ozone (O 3 ) and incidence of various diseases. Methods: To establish the basis for our evaluation, we considered the causality determinations provided by the US Environmental Protection Agency Integrated Science Assessment for PM 2.5 , NO 2 , and O 3 . We developed a list of pollutant/outcome pairs based on these assessments and the evidence of a causal relationship between air pollutants and specific health outcomes. We conducted a comprehensive literature search using two databases and identified 75 relevant systematic reviews and meta-analyses for PM 2.5 and NO 2 . We found no relevant reviews for long-term exposure to ozone. We evaluated the reliability of these studies using an adaptation of the AMSTAR 2 tool, which assesses various characteristics of the reviews, such as literature search, data extraction, statistical analysis, and bias evaluation. The tool’s adaptation focused on issues relevant to studies on the health effects of air pollution. Based on our assessment, we selected reviews that could be credible sources of CRF for HRA. We also assessed the confidence in the findings of the selected systematic reviews and meta-analyses as the sources of CRF for HRA. We developed specific criteria for the evaluation, considering factors such as the number of included studies, their geographical distribution, heterogeneity of study results, the statistical significance and precision of the pooled risk estimate in the meta-analysis, and consistency with more recent studies. Based on our assessment, we classified the outcomes into three lists: list A (a reliable quantification of health effects is possible in an HRA), list B+ (HRA is possible, but there is greater uncertainty around the reliability of the CRF compared to those included on list A), and list B− (HRA is not recommended because of the substantial uncertainty of the CRF). Results: In our final evaluation, list A includes six CRFs for PM 2.5 (asthma in children, chronic obstructive pulmonary disease, ischemic heart disease events, stroke, hypertension, and lung cancer) and three outcomes for NO 2 (asthma in children and in adults, and acute lower respiratory infections in children). Three additional outcomes (diabetes, dementia, and autism spectrum disorders) for PM 2.5 were included in list B+. Recommended CRFs are related to the incidence (onset) of the diseases. The International Classification of Diseases, 10th revision codes, age ranges, and suggested concentration ranges are also specified to ensure consistency and applicability in an HRA. No specific suggestions were given for ozone because of the lack of relevant systematic reviews. Conclusion: The suggestions formulated in this study, including CRFs selected from the available systematic reviews, can assist in conducting reliable HRAs and contribute to evidence-based decision-making in public health and environmental policy. Future research should continue to update and refine these suggestions as new evidence becomes available and methodologies evolve.

On Feb 6, 2023, a magnitude 7·8 earthquake occurred in southeastern Türkiye and northern Syria. Approximately 9 h later a second earthquake of magnitude 7·6 followed. The official death toll surpassed 40 000,1Afet ve Acil Durum Yönetimi BaşkanlığıKahramanmaraş'ta meydana gelen depremler hk—basın bülteni 36.https://www.afad.gov.tr/kahramanmarasta-meydana-gelen-depremler-hk-36Date: March 1, 2023Date accessed: December 7, 2023Google Scholar but the number could be much higher due to the unofficial presence of Syrian refugees and complicated rescue conditions. Around 26 million people have been directly affected by the earthquakes.2Berdyklychev B Türkiye earthquakes: six months of resilient response and support.https://www.who.int/europe/news/item/01-08-2023-turkiye-earthquakes-ix-months-of-resilient-response-and-supportDate: Aug 1, 2023Date accessed: December 7, 2023Google Scholar WHO defined it as the worst natural disaster of the past century in Europe.3WHOStatement—Türkiye/Syria earthquakes.https://www.who.int/europe/news/item/14-02-2023-statement-turkiye-and-syria-earthquakesDate: Feb 14, 2023Date accessed: December 7, 2023Google Scholar After 12 months, one of the main public health problems concerns the management of the enormous quantity of rubble. The UN estimated that the earthquake generated 210 million tons of rubble.4UN Development ProgrammeMillions of tons of earthquake rubble await removal in Türkiye.https://www.undp.org/turkiye/press-releases/millions-tons-earthquake-rubble-await-removal-turkiyeDate: Feb 24, 2023Date accessed: December 7, 2023Google Scholar A Turkish report on March 6, 2023, stated that 221 755 buildings needed to be demolished because of damage and 148 000 still needed to be evaluated,5Presidency of the Republic of Türkiye—Direction for Strategy and Budget. Kahramanmaraş ve hatay depremleri raporu.https://www.sbb.gov.tr/wp-content/uploads/2023/03/2023-Kahramanmaras-ve-Hatay-Depremleri-Raporu.pdfDate: March, 2023Date accessed: December 7, 2023Google Scholar but numbers vary according to the source. Demolishing started immediately and continues even today. Throughout the day, heavy machinery, such as bulldozers and trucks, continuously operate, demolishing buildings and clearing the resulting debris. We are concerned that the rubble and waste are not being adequately removed and accumulate along the streets, not far from the tented camps where evacuees are residing. Unfortunately, there appear to be insufficient precautions in place to mitigate the dispersion of dust generated by the collapsing buildings. The persistent release of dust and asbestos fibres exerts a substantial and detrimental influence on air quality, thereby posing a serious public health threat.6Toksabay E Arranz A Chowdhury J Kiyada S Scarr S Turkey's toxic dust.https://www.reuters.com/graphics/TURKEY-QUAKE/TOXINS/znvnbmyrzvl/Date: May 11, 2023Date accessed: December 7, 2023Google Scholar The concerns are the inadequate and inconsistent implementation of fundamental measures to mitigate these adverse effects, such as the regular wetting of debris, and the lack of essential information provided to the population and workers to reduce personal exposure, such as the recommendation to wear respirators. We urge the Turkish Government and humanitarian organisations to promptly establish collaborative efforts that should be directed towards the swift implementation of comprehensive public health measures aimed at safeguarding the health of communities and exposed workers. We declare no competing interests.

In recent years, the number of members of the Italian Association of Epidemiology (AIE) has increased considerably, and their profile has undergone many changes. The aim of this work is to describe the characteristics of the members, with particular attention to those who have been continuously enrolled. To evaluate these characteristics, the data from membership forms submitted to the Association and information available on the new website in the personal profile area (period 2016-2024) were used. The characteristics considered were: gender, age, education, and job position of the member, Region, and type of affiliated institution. Members with at least three registrations during the period considered, including at least one in the last three years (2022-2024), are considered continuous members. In 2024, AIE counts 557 members, of whom 340 (61.0%) are female and 182 (32.7%) are under 35 years old. This data confirms the growing trend observed since 2015, when the number of members was just above 300, considering that each year there is a quota of new members amounting to about 30%. A total of 382 members can be considered continuous. Over 90% of these members work in 8 Regions (Lazio, Piedmont, Emilia-Romagna, Lombardy, Tuscany, Veneto, Puglia, and Sicily), while the other regions are scarcely or not represented at all. Over time, and with the arrival of new members, the Association is shifting towards the academic world, while the proportion of professionals working in public health institutions has decreased. Members are overall highly educated; however, while older cohorts have predominantly a medical and biological education, younger cohorts increasingly have statistical/mathematical education. Seventy percent of the members have a permanent contract, 5% have a fixed-term contract, and 13% have an atypical contract. Precarious contracts tend to be lower among medical graduates and remain higher in other health professions and non-health-related degrees. AIE is dealing with a period of dynamism and openness, marked by the increase in the number of the members and the transformation of their occupational and educational profile. It is crucial to support and promote the ongoing positive changes, such as the wider geographic representativeness and the entry of new recruits, also facilitated by multiple activities carried out by AIE, including congresses, working groups, webinars, training courses, and collaborations with other scientific societies. At the same time, it might be useful to open a discussion on the meaning and consequences of the increase of academic members and the reduction, at least in relative terms, of individuals coming from public health. Finally, it will be necessary to approach some critical issues, such as the still poor multidisciplinarity and the persistence of job insecurity, especially among graduates in educational pathways that still do not fit into the professional profiles recognized by the NHS.

BACKGROUND:after the outbreak of the SARS-CoV-2 pandemic in 2020, several waves of pandemic cases have occurred in Italy. The role of air pollution has been hypothesized and investigated in several studies. However, to date, the role of chronic exposure to air pollutants in increasing incidence of SARS-CoV-2 infections is still debated.OBJECTIVES:to investigate the association between long-term exposure to air pollutants and the incidence of SARS-CoV-2 infections in Italy.DESIGN:a satellite-based air pollution exposure model with 1-km2 spatial resolution for entire Italy was applied and 2016-2019 mean population-weighted concentrations of particulate matter < 10 micron (PM10), PM <2.5 micron (PM2.5), and nitrogen dioxide (NO2) was calculated to each municipality as estimates of chronic exposures. A principal component analysis (PCA) approach was applied to 50+ area-level covariates (geography and topography, population density, mobility, population health, socioeconomic status) to account for the major determinants of the spatial distribution of incidence rates of SARS-CoV-2 infection. Detailed information was further used on intra- and inter-municipal mobility during the pandemic period. Finally, a mixed longitudinal ecological design with the study units consisting of individual municipalities in Italy was applied. Generalized negative binomial models controlling for age, gender, province, month, PCA variables, and population density were estimated.SETTING AND PARTICIPANTS:individual records of diagnosed SARS-2-CoV-2 infections in Italy from February 2020 to June 2021 reported to the Italian Integrated Surveillance of COVID-19 were used.MAIN OUTCOME MEASURES:percentage increases in incidence rate (%IR) and corresponding 95% confidence intervals (95% CI) per unit increase in exposure.RESULTS:3,995,202 COVID-19 cases in 7,800 municipalities were analysed (total population: 59,589,357 inhabitants). It was found that long-term exposure to PM2.5, PM10, and NO2 was significantly associated with the incidence rates of SARS-CoV-2 infection. In particular, incidence of COVID-19 increased by 0.3% (95%CI 0.1%-0.4%), 0.3% (0.2%-0.4%), and 0.9% (0.8%-1.0%) per 1 μg/m3 increment in PM2.5, PM10 and NO2, respectively. Associations were higher among elderly subjects and during the second pandemic wave (September 2020-December 2020). Several sensitivity analyses confirmed the main results. The results for NO2 were especially robust to multiple sensitivity analyses.CONCLUSIONS:evidence of an association between long-term exposure to ambient air pollutants and the incidence of SARS-CoV-2 infections in Italy was found.

OBJECTIVES:to estimate the impact of PM2.5 and PM10 in the Italian industrial areas included in the SENTIERI project characterized by industrial plants with combustion processes deriving from point emissions.DESIGN:using satellite data, the Population Weighted Exposure (PWE) to PM2.5 and PM10 for 2011 and 2015 was estimated. The concentration-response functions available were used to estimate the number of premature deaths attributable to exposure to industrial emissions. The counterfactual levels recommended by the new WHO Air Quality Guidelines were used.SETTING AND PARTICIPANTS:for the selection of industrial plants, the European database on emissions of the European Pollutant Release and Transfer Register was used. Residents in areas of 1 km x 1 km and 4 km x 4 km around the selected industrial plants were considered.MAIN OUTCOME MEASURES:the number of premature deaths from non-accidental causes, cardiovascular and respiratory diseases, and lung cancer was estimated.RESULTS:residents were exposed to PM2.5 values of 17.3 µg/m3 (Northern Italy: 23.3) and to 24.3 µg/m3 (Northern Italy: 30.3) of PM10. PWE for both pollutants tends to increase as the size of the area under study is reduced and it is generally higher everywhere in 2011 than in 2015, with values that are always higher than the average (overall) in the Norther Italy. In 2011, 1,709 (IC95% 1,309-1,903) and 1,611 (IC95% 1,225-2,353) non accidental premature deaths were estimated attributable to PM2.5 and PM10, respectively, in residents close to the industrial plants (1 km x 1 km). Deaths attributable to exposure to PM2.5 and PM10 tend to follow a North-Central-South&Islands gradient for all observed causes and for both years of analysis.CONCLUSIONS:although exposure assessment of the population by using random-forest model does not allow to disentangle the contribution of the industrial component, the results of the study are suggestive of an impact on health from PM exposure in the industrial areas considered, with a greater impact in the vicinity of the plants, recommending the implementation of urgent impact reduction actions.

OBJECTIVES:the health status of people living near industrial plants is often exposed to several environmental risk factors, including air pollution. The aim of this study is to assess the relationship between daily PM10 levels and cause-specific mortality in a selection of municipalities near two industrial plants from 2006 to 2015. DESIGN:a time-series design with Poisson regression adjusted for a predefined set of confounders was used to quantify the association between exposure, calculated as daily PM10 levels extrapolated from machine-learning models using satellite data, and cause-specific mortality. SETTING AND PARTICIPANTS:twenty municipalities near the thermal power plants in Civitavecchia and Brindisi were selected. The municipalities were then divided into three scenarios of chronic exposure derived from SPRAY simulation models of pollutant deposition. MAIN OUTCOME MEASURES:daily cause-specific non-accidental, cardiovascular, and respiratory deaths defined according to the International Classification of Diseases code at the municipality level. RESULTS:a total of 41,942 deaths were observed in the entire area (10,503 in the Civitavecchia area and 31,439 in the Brindisi area), of which approximately 41% were due to cardiovascular causes and 8% due to respiratory causes. The association showed an increase in shortterm effects in municipalities with higher chronic levels of pollution exposure. For example, risk estimates reported as percentage increases per 10-unit increase in PM10 were 6.7% (95% CI 0.9, 12.7%) in scenario 3 (highest exposure) compared to 4.2% (-1.2, 9.9%) and 2.7% (-4.2, 10.2%) in scenarios 2 and 1, respectively, in the area near the Civitavecchia plant. Similar effects were observed for the Brindisi area. CONCLUSIONS:despite the well-documented relationship between short-term pollution and mortality, it appears that greater chronic exposure to industrial pollutants leads to increased short-term effects of PM10. The limited number of events suggests that this study could serve as a starting point for a larger investigation.