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Background: endometriosis is a chronic condition with a significant impact on women's health, featured by endometrial tissue outside the uterine cavity. A limited number of studies have been conducted in the general population, and the true prevalence of endometriosis is unknown for many areas of the country., Objectives: to better estimate the prevalence of endometriosis in three Italian regions (Friuli Venezia Giulia, Tuscany, Apulia) and to assess the relationship between endometriosis and environmental factors in three participating areas (Trieste, Barga, and Taranto), with a focus on Tuscany Region., Design: implementing a specific epidemiological registry for endometriosis, aimed at estimating the incidence and prevalence data. The registry collected information from hospital discharge records and anatomopathological reports of women residing in the three considered regions, aged 15 years or older. Additionally, the analysis includes the assessment of the spatial distribution of endometriosis at both regional and municipal levels in the three study areas. Further research investigations in these areas involve a multilevel screening of a sample of women of childbearing age. Women who test positive in the initial screening (through a self-administered questionnaire) will have the opportunity to undergo a second level of screening, consisting of a gynecological examination, transvaginal ultrasound, a swab for vaginal microbiome analysis, and the collection of blood and urine samples to assess the presence of polychlorinated biphenyls (PCBs) or heavy metals. The adopted scientific approach is based on post-normal science (PNS) concerning the extended peer community., Setting and Participants: women aged 15 years or older residing in the three regions., Main Outcomes Measures: estimating the incidence and prevalence of endometriosis based on data collected from the epidemiological registry. The analysis extends to assessing the spatial distribution of endometriosis at municipal levels in the three areas of interest., Results: the preliminary results of the study allowed for the estimation of the spatial distribution of endometriosis incidence in Tuscany. In particular, it was found that there is variability within the region, with some coastal and North-Western areas showing values 20% higher than the regional average. Cities such as Pisa, Lucca, Livorno, Grosseto, Orbetello, and the Serchio Valley with Barga had a probability of excess risk of more than 90% compared to the regional average., Conclusions: the study is ongoing and requires the active participation of women living in the region to ensure the completeness and accuracy of the collected data. This research effort represents an important contribution to understanding endometriosis in Tuscany and its possible environmental causes.

The SENTIERI Project analyses the health profile of the populations residing in Italian national priority contaminated sites in specific calendar periods using a cross-sectional approach. An aspect that has not been evaluated so far is the analysis over a long period, for understanding the changes in health profiles over time and studying them also in function of the changes occurred in the territories. This article studies temporal trends by birth cohort and calendar period for overall mortality and lung cancer mortality from 1980 to 2018, separately for men and women, for three sites: Priolo (Sicily Region, Southern Italy), Pitelli (Liguria Region, Northern Italy), and Terni-Papigno (Umbria Region, Central Italy). A method for selecting the temporal model that best fits the data is then proposed. General mortality presents complex temporal profiles when considering cumulative risks, and usually the most important temporal axis is the birth cohort for cumulative SMRs (i.e., after adjusting for trends in the reference population). For lung cancer, the most important time axis is the birth cohort and the age-cohort model is the most appropriate, in particular for men of Priolo and Terni.

The p-value has been widely criticized in the scientific literature for its naive use in classifying results as 'significant' and 'non significant'. Much has been written about it; for example, see the American Statistical Association position statement of march 2016. To date, few alternative measures have been suggested and few changes were observed in the scientific practice regarding the use of p-value despite general agreement on the critics raised on it. In this paper, we use an alternative measure to p-value. It consists in the probability of the direction of the effect, that is the strength of empirical evidence in favour of the alternative directional hypothesis. In the context of scientific research, reporting the probability of the direction of the effect is easier to understand. Moreover, it focuses on the effect in the study rather than on the value under the null hypothesis, which sometimes has little meaning or has been used opportunistically. The proposal is not intended as an alternative to using the confidence interval, but as a probabilistic metric to be used instead of the p-value when we refer to particular hypotheses to be tested.

Currently, there are more and more requests for a characterization of the health profile by populations living in areas affected by several types of environmental contaminations, notably for the presence of previously unknown and accidentally discovered landfills. The aim of the present paper is to describe the mortality profile of the residents of Piazzola sul Brenta (Veneto Region, Northern Italy). In this area, it was discovered an environmental contamination of the soil in the nearby of a large school building, where was formerly located a phosphate fertiliser plant. Using cause of death data provided by the Italian National Institute of Health, 10th International Classification 2013-2018, standardised mortality ratios (SMRs) and 90% confidence intervals (CIs) were calculated by gender and specific causes of death. Compared to the provincial reference population, no excess was found, for both genders, for all-causes mortality and for circulatory diseases. However, an excess for malignant tumours was found, 523 observed deaths over 498 expected deaths, an SMR of 105 (IC90% 98-113), and 85% probability of excess cancer mortality; lung cancer (SMR 117; IC90% 100-135) and lympho-hematopoietic tumours (in men only, SMR 134; IC90% 101-178).In light of these results and of the potential human exposure to carcinogenic substances, present results support further epidemiological investigations and environmental remediation.

In a wide area among the provinces of Vicenza, Verona, and Padua (Veneto Region, Northern Italy), one of the larger known massive contamination of the environment by per- and polyfluoroalkyl substances (PFASs) occurred since the year 1965. The most important source of human exposure was through aquiferous and contaminated water supplies (the regional authorities distinguished red zone A - aquiferous - and red zone B - water supply) for a total of slightly less than two hundred thousand exposed people. Food contamination and food contribution to total human exposure were assessed by a food monitoring campaign on the years 2016-2017 by the National Health Institute sponsored by Veneto Region.Thanks to the availability of the individual records of the monitoring campaign, we evaluated the spatial distribution of PFAS contamination by food matrix. Generally speaking, PFAS contamination was widespread over the entire red zone (either A or B). Some zones appeared to be higher contaminated consistently with the water plume. Other higher contaminated zones were less consistent and such result raises questions about routes of environmental pollution.

Background: the first confirmed cases of COVID-19 in WHO European Region was reported at the end of January 2020 and, from that moment, the epidemic has been speeding up and rapidly spreading across Europe. The health, social, and economic consequences of the pandemic are difficult to evaluate, since there are many scientific uncertainties and unknowns., Objectives: the main focus of this paper is on statistical methods for profiling municipalities by excess mortality, directly or indirectly caused by COVID-19., Methods: the use of excess mortality for all causes has been advocated as a measure of impact less vulnerable to biases. In this paper, observed mortality for all causes at municipality level in Italy in the period January-April 2020 was compared to the mortality observed in the corresponding period in the previous 5 years (2015-2019). Mortality data were made available by the Ministry of Internal Affairs Italian National Resident Population Demographic Archive and the Italian National Institute of Statistics (Istat). For each municipality, the posterior predictive distribution under a hierarchical null model was obtained. From the posterior predictive distribution, we obtained excess death counts, attributable community rates and q-values. Full Bayesian models implemented via MCMC simulations were used., Results: absolute number of excess deaths highlights the burden paid by major cities to the pandemic. The Attributable Community Rate provides a detailed picture of the spread of the pandemic among the municipalities of Lombardy, Piedmont, and Emilia-Romagna Regions. Using Q-values, it is clearly recognizable evidence of an excess of mortality from late February to April 2020 in a very geographically scattered number of municipalities. A trade-off between false discoveries and false non-discoveries shows the different values of public health actions., Conclusions: despite the variety of approaches to calculate excess mortality, this study provides an original methodological approach to profile municipalities with excess deaths accounting for spatial and temporal uncertainty.

Epidemiological surveillance on high risk environmental areas or areas covered by cancer registration yields long inventories of relative risks. Summaries of the results' tables must be produced to identify priorities and tailor public health actions. The aim is, therefore, to draw conclusions from each area's disease profile, or from the area signature of each disease.With this inmind, we used data on cancer incidence from 17 Cancer Registries that participated in the ISS-AIRTUM (National Institute of Health-Italian Network of Cancer Registries) study, and we produced conditional and marginal rankings of areas/diseases using a multivariate hierarchical Bayesian model. In this context, it is important to obtain an uncertainty evaluation by calculating the credibility intervals of ranks. The areas marginal ranking shows a large overlapping of credibility intervals, such that it is not possible to speak of a limited number of ISS-AIRTUM areas as being particularly affected. Every ISS-AIRTUMarea, therefore,must be considered individually and ordering themby ranking of cancer incidence wouldn't be appropriate. Instead,marginal ranking of diseases highlights the impact of asbestos exposure in all the analyzed areas.

The work described in the present report has been requested by the Secretary of Hygiene, Health and Social Welfare of the Sardinia Region (Italy). It has been carried out by the Regional Epidemiological Observatory within the domain of ESA (Epidemiology Development and Environment) and with the support of the European Union. Eighteen areas (for a total of 73 municipalities) were identified a priori as "potentially polluted", accounting for a population of 917,977 in 2001 census (56% of the total population of Sardinia). The areas have been named after the most important town, as listed below (in brackets rounded 2001 population), major activities in industrial areas are briefly described., Industrial Areas: Portoscuso (59,000). Processing of aluminium and other metals. Foundry. Power plants. Dismissed mines (mainly coal mining, lead, zinc). Plants for storing and treating special wastes. Italian Law 349/1986 classified this area as "at high risk of environmental crisis" and classified some plants as being "at high technological risk" (Norma Seveso Decree 334/1999). The area is part of the Sulcis National Restoration site. San Gavino (24,000). Industrial and commercial activities. Lead and zinc foundry. Dairy factories. Food industry. Sarroch (52,000). Petrochemical and refinery industry. Power plants. Mining. Incinerator. Plants for storing and treating special wastes. Gas and mineral oil deposits. Ottana (15,000). Chemical industry. Production of plastics and synthetic fibres. Denim production. Porto Torres (168,000). Chemical industry: production of basic chemicals (benzene, toluene, ethylene, propylene and others), polyethylene, elastomers and vinyl chloride. Textile industry. First and second category landfills. Some plants have been classified "at high technological risk" (Norma Seveso Decree 334/1999). The area is a National Restoration site. The town of Sassari is included. Tortolì (23,000). Construction of steel structures for offshore facilities of the oil and gas industry. Paper industry. Tempio Pausania (21,000). Cork production. Stone quarries. Macomer (17,000). Textile industry (velvet). First and second category landfills. Incinerator., Mining Areas: Arbus (30,000). Extraction of zinc, lead and silver. Iglesias (39,000). Extraction of zinc, lead and silver., Military Sites: Teulada (16,000). La Maddalena (11,000). Naval army shipyards. Salto di Quirra (31,000). Mining area., Urban Areas: Cagliari (299,000). Petrochemical plants, port, airport. Nuoro (37,000). Olbia (47,000). Port and airport. Oristano (31,000). Sassari (121,000)., Results: THE COMPARISON SARDINIA-ITALY: In 1997-2001, the age-standardized mortality rate (x1,000 person-years) among males was higher than in Italy (84.4 vs 80.8) while the reverse occurred in females (50.9 vs 52.0). Ill defined causes of death were 1.4% in males and 2.5% in females (vs corresponding estimates of 1.1% and 1.4% in Italy). Compared to Italian national data, regional age-standardized estimates were higher in Sardinia for infectious diseases (23% in males and 12% in females), respiratory diseases (22% and 14%: pneumoconiosis was more than 6 times more frequent in Sardinia than in Italy), diseases of the digestive system (26% and 9%: for liver cirrhosis, the excess was 33% in males and 9% in females; corresponding figures for liver cancer were 13% and 16%), breast cancer in females (5%). On the other hand, regional mortality rates were lower than the national rates for cardiovascular diseases (-1.3% and -7.4% in males and females respectively), all cancers considered as a whole (-9% and -7%) and lung cancer (-5% and -32%). Regional and national death rates for non Hodgkin lymphoma in both sexes and for leukaemia in females were almost identical, whereas the latter rate in males was slightly higher in Sardinia than in Italy (9.4 vs 8.4 x100,000 person-years). Particularly in men, the differences in mortality rates from all causes and from cardiovascular, respiratory diseases and lung cancer among the four traditional Provinces (Cagliari, Nuoro, Oristano and Sassari) were greater than the difference between Sardinia and Italy. Remarkably enough, also death rates from lymphohaemopoietic tumours were more heterogeneous within Sardinia., Results in the Investigated Areas: Rates of hospital discharges in Sardinia showed a high variability, which is partly attributable to differences in the availability of both hospital beds and alternative forms of care. This heterogeneity must be taken into account in the interpretation of rates of hospital discharge. These were relatively high in some areas (Cagliari, Iglesias, Portoscuso, Tortolì) and low in others (Olbia, Porto Torres, Sassari). All the reported observed/expected ratios were based on material deprivation adjusted figures. All the estimated statistics were reported with 90% Confidence Interval., Industrial Areas: In 1997-2001, deaths from respiratory diseases were significantly in excess in males in Portoscuso (obs/exp 205/124.77) and in San Gavino (69/46.77). Deaths from pneumoconiosis were recorded sporadically, with the exception of Portoscuso, where the excess was impressive (obs/exp 112/30.46). SMRs for lung cancer in males ranged between 0.62 in Ottana and 1.22 in San Gavino, with statistically significant departure from expected values in Portoscuso and Sarroch (both with SMR significantly in excess in males: 1.24). In Porto Torres mortality from all causes was in significant excess in both sexes (SMRs 1.04 in males and 1.09 in females), for respiratory diseases (1.08 and 1.28), for diseases of the digestive system (1.13 and 1.21), for all cancers (1.04 and 1.09). Liver cancer deaths were also in excess in both sexes (SMRs 1.18 and 1.21). The latter finding is confirmed by incidence rates from the local cancer registry. Among industrial areas, Porto Torres was also the one with a stronger evidence of an excess of deaths from lymphohaemopoietic cancer in males (obs/exp 99/83.60) and females (73/68.20)., Mining Areas: These areas are characterized by statistically significant excesses of mortality in males, largely caused by non neoplastic respiratory conditions (obs/exp 119/86.41 in Iglesias and 156/62.55 in Arbus). In recent years, deaths from pneumoconiosis averaged 20 per year in Arbus and 10 per year in Iglesias. Lung cancer in males was also significantly in excess in both areas (obs/exp 72/56.38 in Arbus and 108/72.14 in Iglesias). There is a time trend (1981-2001) towards a decrease of mortality from respiratory conditions, which nevertheless remains largely in excess over the regional average also in the most recent period., Military Areas: Statistically significant excesses of deaths and hospital discharges for non Hodgkin lymphoma were detected in La Maddalena (mortality, 1981-2001, in males 17 observed cases vs 6.13 expected, in females 8/5.64). In Salto di Quirra in 1997-2001 deaths from myeloma (in males 5/2.3) and leukaemias were increased in both sexes (total obs/exp 20/13.3, statistically non significant)., Urban Areas: Urban areas in Sardinia are relatively well developed with high values of socioeconomic indicators. The health profile in Cagliari and Sassari is typical of towns of the Western world. In Cagliari there is a higher mortality for colorectal, breast, cervical and lung cancer., Conclusions: Environmental (non occupational) pollution might explain some of the observed excesses of disease in the investigated industrial areas of Sardinia, particularly in women, less likely to be exposed to hazards in the work environment, whereas in the mining areas studied the disease pattern suggests a major role of occupational exposures. On the other hand, the causal links between disease occurrence and exposures in the screened military areas remain uncertain. The disease patterns in the cities of Sardinia are likely to be associated with lifestyle and urban pollution. Historically, southern Italian Regions have been characterized by an advantage over the rest of the country in terms of health, but during the last decade such advantage tended to vanish. Sardinia confirms this secular trend. However in the most recent years studied, overall age-standardized mortality rate in Sardinian females still remains lower than Italian average, but this is not the case for males any more. Differences in the health profile between residents in different areas of Sardinia have been found to be far greater than the difference between Sardinia as a whole and Italy. A major contribution to intraregional differences is given by the 18 investigated areas where excesses were registered for: respiratory diseases (including cancer) in the industrial areas of Portoscuso, Sarroch and Porto Torres, and in the mining areas; diseases of the digestive tract, liver cancer and lymphohaemopoietic cancer in the area of Porto Torres; cancer of the lymphohaemopoietic system in some military areas; cancers of the colon and rectum, lung, breast and uterus in some of the major cities of the Region.

Aim: Aim of the study is to investigate mortality for lymphoematopoietic tumours and soft tissue sarcoma of people resident near an urban waste incinerator., Materials and Methods: We have considered death certificates recorded by National Statistical Institute (ISTAT) for the period 1981-2001 of the residents in 277 municipalities included in a circle of 80 km of radius centered at Campi Bisenzio municipality. Mortality data have been analyzed by calendar period (1981-1985, 1986-1992, 1993-2001) and by specific causes of death. In particular we have considered mortality for soft tissue sarcoma and lymphoematopoietic tumours. Standardized mortality ratios (SMR) have been evaluated for each calendar period using the population of the circle as standard population., Results: Our findings point out that males resident in Campi Bisenzio municipality had a higher risk of non-Hodgkin lymphoma in the period 1986-1992, with 14 observed cases versus 7.6 expected (SMR 184.2 CI 90% 111-273). The excess risk is present also for all Lymphomas with 18 cases versus 9.07 expected. In the same period, in Campi Bisenzio, we observed 2 deaths for soft tissue Sarcoma., Conclusion: The study shows the presence of a localized cluster of deaths for non-Hodgkin lymphoma, for males, in the calendar period 1986-1992. In the same municipality an urban waste incinerator was operating from 1973 to 1986, when it was closed following evidence of dioxin soil contamination.