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Healthy public policies are those that take accountability of all possible health impacts, acknowledging the causal pathways resulting from the modification of upstream health determinants (e.g. transport strategies, etc.), and related risk factors downstream (e.g. air pollutants). The strategy of Health in All Policies (HiAP), promoted by the World Health Organization (WHO) and adopted by the European Union (EU) in 2006, reinforced the need to reduce inequalities and improve health and wellbeing as essential pillars for a sustainable economic development. Central to HiAP is the notion that health is not only the responsibility of the health sector, but also a shared responsibility with many other sectors. In this context, Health impact Assessment (HIA) was proposed as the combination of methods to support HiAP implementation by providing scientific evidence on the positive and negative effects that any new proposal may have on health and health equity. The COVID-19 pandemic, and the climate change threat, are two of the main challenges that emphasise the need of integrated responses across many sectors to mitigate not only effects on health and inequalities, but also in the economy. However, HiAP and HIA implementation remains almost at a conceptual level, with a few remarkable exceptions in Europe. One of the most relevant reported barriers contributing to this uneven HiAP implementation is the lack of political stewardship and commitment. The difficulties in applying the guiding principles of HiAP (and consequently of HIA) at local, regional, or national governance level are in many cases linked to a conflict between the right to work and mobilization of the economy, with the right to health and reduction of inequities. This is where the role and drive of public health actors comes across, as HiAP requires public health professionals to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity, external to the health sector. A good proxy example to HiAP implementation, facilitating local and regional initiatives with communities, is the WHO initiative of Healthy Cities. The present panel discussion intends to analyse, from different perspectives, why HiAP has not gained a meaningful place within governing contexts, the current and future status of the intersectoral approach, and the advocacy role of public health in this context. The session is scheduled with a first overview presentation followed by a debate framed around the following aspects: – Different perceptions regarding the concrete implementation of HiAP at all political levels. – Perceived barriers or trade-offs for a broader implementation of HiAP. – Role of public health actors in the implementation of HiAP at a strategic, policy level, and how it could gain a more prominent role. – Level of understanding and awareness of the utility of HIA for HiAP implementation by public health actors. Key messages • HiAP, a recognised approach requiring all sectors to address decisions’ health and equity implications for reaching better global health, has not yet been implemented with an overarching vision. • Public Health actors can disentangle political and technical aspects, seeking for synergisms, and clarifying to non-health sectors the complexity and interrelatedness of social health determinants.

Health impact assessment (HIA) is a process, which systematically judges the potential, and sometimes unintended effects of any new proposal (policy, project, program or strategy) on the population health, and the distribution of those effects within the population. It was conceived in 1999 as the supporting tool for the implementation of Health in All Policies (HiAP), but its practical use remains quite partial worldwide, with exceptional regions and countries (e.g. Wales (UK), Australia). Several surveys conducted nationally, but also across Europe by the World Health Organization-Regional Office for Europe identified several barriers that hinder a broader and more extensive practical application of HIA. One of these limitations lies in the lack of understanding and knowledge of professionals from non-health sectors about the benefits that addressing health considerations in the planning process of their projects, strategies or programs may have. In this sense, the HIA is frequently seen as an additional bureaucratic burden. Other common constraints reported refer to inadequate resources (guidelines, tools, evidence) and lack of qualified staff experienced in conducting HIA. Respondents from those surveys also deplored a history of unsatisfactory experiences involving intersectoral collaboration with health professionals, decision makers and other public sector stakeholders. Health agencies, such as national and regional Public Health Institutes (PHIs) can play a critical role in overcoming these limitations. They can act by providing independent advice and support based on the best available evidence to governments and proposal developers (projects, programs, strategies). However, they need to have knowledge, resources and capacity to do so. On the other hand, these basic concepts and procedures related to HiAP or HIA are rarely addressed in depth in the university curricular training of health sectors or other sectors such as environmental science or urbanism. Present workshop intends to analyse different experiences in Europe regarding the role of PHIs and also the academia in overcoming those reported exiting barriers, and reach a more sustainable and healthy societies. The fundamentals of what could be a training program on HIA principles across Europe will be also discussed. Key messages • PHIs can demonstrate leadership for HIA and HiAP by providing support to decision makers in better understand the wider health impacts and how they will manifest themselves across the population. • HIA practice requires of the design of proper training programs and of certain validation process, which avoids conflicts regarding consultants’ impartiality and independence in conducting a HIA.

This workshop will present the different methodological approaches relevant to the field of public health. This includes approaches of health systems and health policy research, epidemiology, health technology assessment, health impact assessment, health systems performance and economic evaluations. Presentations will be hold by presidents and vice-presidents of the EUPHA Sections in the form of a panel, presenting the overview of each methodology and providing case examples. All organizers might invite special contributions from their members and students to share innovations of case examples from their counties. During the first half of the workshop the EUPHA Sections will provide input on traditional and innovative methods the following topics: 1. Health Policy and Systems Research (HPSR) applied to Primary Care. 2. The use of traditional and innovative epidemiological study designs for public health relevant inferences. 3. Overview of methods used for the quantification of health impacts, both following a risk assessment approach or an epidemiological approach. 4. Methodologies and techniques applied in Health Technology Assessment (HTA) and how their contribute to decision-making and evidence-informed policymaking. 5. Health Systems Performance Assessment (HSPA) and Economic evaluations. 6. Research methods from the public health policy and politics perspective. In the second half of the workshop we will discuss and share examples on innovation in research methods and seek to find an answer to the question: what is being done in the countries? Input from DGPH-FO, DNVF-IHRS, Charité WG HPSRI and from all participants will be welcome. Target audience: young and old professionals interested in updating their methods skills and sharing their own experiences on innovation in methods for a stronger public health research. Key messages • There are no better or worse research methods; they are just a tool, that when applied properly support evidence and action for a stronger public health. • As knowledge on research methods evolve, sharing knowledge amongst different fields is key to contribute to a stronger health system, better health policy decisions and a better health for all. Speakers/Panellists Lorena Dini Charité Univesitätsmedizin Berlin, Berlin, Germany Piedad Martin-Olmedo Escuela Andaluza de Salud Pública, Granada, Spain Stefania Boccia Italian Society of Hygiene, Preventive Medicine and Public Health, Rome, Italy Chiara de Waure University of Perugia, Perugia, Italy João Vasco Santos Faculty of Medicine, University of Porto, CINTESIS, Porto, Portugal

The COVID-19 pandemic represents one of the most challenging health emergencies faced by humanity in modern history, with global effects on the economy and social well-being of people. This outbreak has abruptly brought public health back to the top of the policy agenda, making even more evident the need for adopting the comprehensive social determinants of health (SDOH) framework in designing effective mitigation and prevention measures. The novelty of the COVID-19 virus and the associated uncertainties about its health consequences and spread led to a massive generation of information from different sources, in some cases conflicting and contradictory. Conducting a systematic analysis and synthesis of existence scientific-evidence, considering all SDOH potentially affected, is crucial for supporting proportionated policy-decisions that reverse the spread of the virus and support health systems across Europe and worldwide. Health Impact Assessment (HIA) aims precisely at supporting the decision-making process by providing information and scientific evidence on the positive and negative effects that any new proposal may have on health and health equity. Its prospective nature also allows the introduction of corrective measures as an ongoing learning process, managing the estimated impacts and optimizing the health results of each proposal. HIA was launched as a methodology/tool by the World Health Organization (WHO) in 1999 and adopted by the EU in 2006 for supporting the development of healthier policies, projects and programs, related to both health and non-health sectors. However, its implementation in Europe is uneven across countries. The COVID-19 outbreak provides a good scenario for analysing the extent to which decision-makers are basing their decisions on the best available scientific evidence, and on the benefits of using the HIA approach. The present workshop will analyse and debate several experiences of using HIA as a supporting tool in the formulation of some of the most conflictive measures adopted by European governments related to the COVID-19 pandemic, such as ‘Lockdowns', ‘Staying at Home' and social distancing policies and requirements to work from home. Some of the questions that we intend to address in this workshop are: To which extent have decisions for managing the COVID-19 pandemic been based on the best scientific evidence available? What are the advantages of adopting an HIA approach in public health policy decisions? Are science and public health experts providing quick, synthetic and useful information for decision-making in the special circumstances of the current pandemic? Key messages COVID-19 pandemic reinforce the need for policy-makers based their decisions on best available scientific evidence through systematic processes such as HIA. Mitigation measures for the control of COVID-19 should go beyond healthcare assistance, making a more extensive implementation of HIA and a comprehensive approach to health.

This study was supported by research grants from CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Spain (PI16/01858, PI18/01573, PI20/01568), co-funded by European Union (ERDF), "A way to make Europe"., Supplementary data to this article can be found online at https://doi. org/10.1016/j.envint.2021.106734, Background Despite restrictions on their production and use, most of the population is still exposed to Persistent Organic Pollutants (POPs), including organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs). These chemicals are thought to contribute to the aetiology of highly prevalent chronic conditions, such as cardiovascular diseases (CVDs), although current evidences are still controversial. Objectives To explore the potential contribution of historical POP exposure to 15-year pharmaceutical consumption in relation to CVD. Methods This study is framed within GraMo adult cohort. Participants (n = 387) were recruited in two hospitals in Granada province, Southern Spain (2003–2004). Historical exposure to 5 OCPs and 3 non-dioxine-like PCBs was estimated by analysing adipose tissue concentrations at recruitment. Pharmaceutical consumption from recruitment until year 2017 was quantified by reviewing dispensation databases. Average consumption increase (ACI) in CVD medication was calculated by subtracting average consumption in 2002 to the average yearly consumption during follow-up. ACI was expressed as Defined Daily Dose (DDD)/year units. Data analyses were carried out using a multivariable multinomial logistic regression and weighted quantile sum regression (WQS), with ACI categorized in quartiles (Q) as the dependent variable. Results Concentrations of most pollutants showed a positive trend with the quartiles of ACI. Particularly, PCB-153 showed increasing and statistically significant odds ratios (ORs) for Q2 (OR: 1.27, 95% confidence interval (CI): 1.07–1.52), Q3 (OR: 1.49, 95 %CI: 1.17–1.88) and Q4 (OR: 1.42, 95 %CI: 1.13–1.78) vs Q1. Similarly, beta-hexachlorocyclohexane (β-HCH) also showed increasing ORs, that reached statistical significance in Q4 (OR: 1.36, 95 %CI: 1.06–1.74) vs Q1. These findings were corroborated by WQS analyses, that revealed a significant mixture effect, predominantly accounted for by PCB-153 and β-HCH. Discussion Our results suggest that long-term POP exposure might represent a modifiable risk factor for CVD. These findings are relevant for public health campaigns and management, since pharmaceutical consumption is considered an indicator of both morbidity and health expenditure., CIBER de Epidemiología y Salud Pública, Santa Ana and San Cecilio Hospitals RYC-2016-20155, European Commission, Instituto de Salud Carlos III PI16/01858, PI18/01573, PI20/01568 ISCIII Ministerio de Economía, Industria y Competitividad, Gobierno de España, European Regional Development Fund, Ministerio de Economía, Industria y Competitividad, Gobierno de España

Continuous exposure to low doses of persistent organic pollutant (POPs), such as those occurring in the general population, might contribute to the burden of type 2 diabetes mellitus (T2DM). However, evidences from longitudinal studies are scarce. We aimed to explore the associations of accumulated POP exposure with the development of T2DM by means of 1) longitudinal associations with the 16-year incidence of the disease, and 2) complementary cross-sectional analyses with markers of glucose homeostasis at recruitment. Organochlorine pesticide and polychlorinated biphenyl (PCB) concentrations were analyzed in adipose tissue samples and incident T2DM cases were retrieved from clinical records. Homeostatic model assessment values of insulin sensitivity/resistance and β-cell function at recruitment were calculated. Linear and Cox-regression models were performed. In individuals with normal weight/overweight (n = 293), we observed positive dose–response relationships between the studied POPs and T2DM risk, particularly for hexachlorobenzene (HCB) [hazard ratio (HR): 3.96 for 4th quartile versus 1st quartile (Q1); confidence interval (CI) 95%: 0.79, 19.71]. PCB-180 showed a positive but seemingly non-linear association with T2DM risk [HR of 3er quartile (Q3) versus Q1: 6.48; CI 95%: 0.82, 51.29]. Unadjustment for body mass index considerably increased the magnitude of the associations. In the cross-sectional study (n = 180), HCB and PCB-180 were inversely associated with insulin sensitivity and positively associated with insulin resistance parameters. Our results suggest that a higher burden of specific POPs in adipose tissue may disrupt glucose homeostasis, possibly contributing to increase T2DM risk, especially in nonobese adults., Ramon y Cajal Program (Ministerio de Economia, Industria y Competitividad, Spain) RYC-2016-20155, Instituto de Salud Carlos III, European Commission PI16/01858 PI18/01573 PI20/01568

This work was supported by research grants from CIBER de Epidemiologia y Salud Publica (CIBERESP), Instituto de Salud Carlos III, Junta de Andalucia, European Regional Development Fund-FEDER (PI16/01858, PI16/01812, PI20/01568 and PI-13/02406) and Generalitat Valenciana. Dr. G Cakmak is awarded a grant by The Scientific and Technological Research Council of Turkey (TUBITAK-2219). Dr. JP Arrebola is under contract within the Ramón y Cajal Program (RYC-2016-20155, Ministerio de Economia, Industria y Competitividad, Spain)., These results would not have been achieved without the selfless collaboration of the staff from Santa Ana and San Cecilio Hospitals and the participants who took part in the study., Humans are exposed to a myriad of chemical substances in both occupational and environmental settings. Persistent organic pollutants (POPs) have drawn attention for their adverse effects including cancer and endocrine disruption. Herein, the objectives were 1) to describe serum and adipose tissue retinol levels, along with serum retinol binding protein 4 (RBP4) concentrations, and 2) to assess the associations of adipose tissue POP levels with these retinoid parameters, as well as their potential interaction with the previously-observed POP-related disruption of redox microenvironment. Retinol was measured in both serum and adipose tissue along with RBP4 levels in serum samples of 236 participants of the GraMo adult cohort. Associations were explored by multivariable linear regression analyses and Weighted Quantile Sum regression. Polychlorinated biphenyls (PCBs) 180, 153 and 138 were related to decreased adipose tissue retinol levels and increased serum RBP4/retinol ratio. Dicofol concentrations > limit of detection were associated with decreased retinol levels in serum and adipose tissue. Additionally, increased adipose tissue retinol levels were linked to an attenuation in previously-reported associations of adipose tissue PCB-153 with in situ superoxide dismutase activity. Our results revealed a suggestive link between retinoids, PCBs and redox microenvironment, potentially relevant for both mechanistic and public health purposes., CIBER de Epidemiologia y Salud Publica (CIBERESP), Instituto de Salud Carlos III, Junta de Andalucia, European Commission PI16/01858 PI16/01812 PI20/01568 PI-13/02406, Generalitat Valenciana, European Commission, Turkiye Bilimsel ve Teknolojik Arastirma Kurumu (TUBITAK) TUBITAK-2219, Ramon y Cajal Program (Ministerio de Economia, Industria y Competitividad, Spain) RYC-2016-20155

In the course of the COVID-19 pandemic, it has become clear that primary healthcare systems play a critical role in clinical care, such as patient screening, triage, physical and psychological support and also in promoting good community advice and awareness in coordination with secondary healthcare and preventive care. Because of the role of social and environmental factors in COVID-19 transmission and burden of disease, it is essential to ensure that there is adequate coordination of population-based health services and public health interventions. The COVID-19 pandemic has shown the primary and community healthcare (PCHC) system's weaknesses worldwide. In many instances, PCHC played only a minor role, the emphasis being on hospital and intensive care beds. This was compounded by political failures, in supporting local community resilience. Placing community building, social cohesion and resilience at the forefront of dealing with the COVID-19 crisis can help align solutions that provide a vision of a € planetary health'. This can be achieved by involving local well-being and participation in the face of any pervasive health and environmental crisis, including other epidemics and large-scale ecological crises. This paper proposes that PCHC should take on two critical roles: first, to support local problem-solving efforts and to serve as a partner in innovative approaches to safeguarding community well-being; and second, to understand the local environment and health risks in the context of the global health perspective. We see this as an opportunity of immediate value and broad consequence beyond the control of the COVID-19 pandemic., SCOPUS: ar.j, info:eu-repo/semantics/published

The 2030 Agenda for Sustainable Development calls for tackling environmental risks at their root, that is, through a shift towards primary preventive actions and the promotion of healthy choices. Reducing the 13 million deaths resulting from environmental risks each year requires efficient scale-up of primary preventive action involving all key stakeholders, across all sectors. Decisions taken on the drivers of health risks should have the attainment and protection of good health as an explicit aim in key sectors such as energy, transport, housing, labour, industry, food systems and agriculture, water and sanitation, and urban planning. A key tool for such actions can be seen in Health Impact Assessments (HIAs) and an enhanced integration of health assessments into environmental impact assessments (EIA). In many countries worldwide, legally binding instruments exist which are concerned with assessing the impacts of policies, programmes, plans and projects on the environment to contributes to a high level of protection of the environment and human health. Within the European Union (EU) the EIA Directive 2014/52/EU names human health among the topics to be addressed when conducting an EIA. The amended EIA Directive also includes issues that are relevant to human health, for example, climate change and vulnerability (exposure and resilience) to major accidents and/or disasters. These amendments are relevant also beyond EU borders through, for example, the policies of the European Investment Bank. A paper recently developed by IAIA and EUPHA provides insights to the EIA Directive to raise awareness among health authorities and public health professionals on the potential for primary preventive actions and promotion of healthy choices outside the health sector. Key messages will be presented and further discussed with the audience on how achieving the 2030 Agenda can be supported through impact assessments and the enhanced involvement of health authorities.

Human exposure to chemicals can occur via different sources and routes. Understanding the (combined) exposure to chemicals is often hampered by a lack of data or difficulties in sharing data. This was recognized in the Commission Communication on Chemical Mixtures (252, 2012) and the Information Platform on Chemical Monitoring (IPCHEM) was developed. The aim of IPCHEM is to support a coordinated approach for collecting, storing, sharing and assessing data on the occurrence of chemicals and chemical mixtures in humans and the environment. IPCHEM covers four thematic areas to support a holistic approach to exposure assessment, including human biomonitoring, environmental monitoring, food and feed monitoring and indoor air and consumer products. The shared occurrence data support exposure assessment, the identification of sources and hot spots, the analysis of time trends and can also support the evaluation of the impact of regulatory measures to restrict exposure to specific chemicals. In particular, human biomonitoring data can provide insights into internal combined exposure, integrating across different exposure sources and routes. The ongoing EU funded project HBM4EU generates and uses human biomonitoring to assess human exposure to chemicals in Europe, to better understand the associated health impacts and to improve chemical risk assessment. Associations between chemical exposures and development of disease can be further supported using toxicological/mechanistic information to establish causal links. The presentation will focus on relevant types and sources of data available to support health impact assessments of chemical exposure.

The assessment of the health implications of human exposure to low doses of multiple environmental chemical pollutants represents an important challenge for environmental epidemiology. Current studies must go beyond simple exposure-disease associations and need further characterization of a complete exposure disease continuum, including exposure routes, adverse outcome pathways, potential subclinical effects, interactions between chemicals, and intra-individual susceptibility. This needs an effective synergism with basic sciences, which can enrich epidemiologic findings with very detailed information at a molecular level, but also with clinicians, who would help to provide accurate diagnoses and interpretation in a real-world scenario. On the other hand, environmental exposures can affect the general population at different levels, including economic and social dimensions, which have been frequently overlooked. These approaches would require specific methodologies that are relatively novel in the field of environmental epidemiology, such as cost-benefit analyses and qualitative techniques. Public health campaigns can clearly benefit from these mixed approaches.

Humans worldwide are exposed to a wide range of chemicals through their diets, consumer products and the environment, often changing in concentrations, combinations and over time. Health impact assessment (HIA) for exposure to chemicals is poorly defined and its contribution to the global burden of disease is difficult to quantify and certainly underestimated. The importance of taking actions for reducing deaths and illness associated to hazardous chemicals is reflected in the UN Sustainable Development Goals target 3.9, as well as in the 7th European Environment Action Programme or in the European Green Deal (Communication of the European Commission, COM (2019) 640 final). Recent discussions suggest that current EU Legislation, while contributing to reducing the overall risks of chemicals in the environment, is protecting mainly against highly toxic chemicals in the workplace. However, the assessment of potential health impacts over the general population is limited by uncertainties related to data collection, health indicators and confounding factors. Concerns have also been reported regarding the increased introduction in the market and the environment of new substances with unknown properties as well as referring to the chronic, low-level exposure to chemical mixtures, which are considered to be poorly characterised and yet to be systematically addressed. Notably, in recent years the European Commission (EC), acknowledging that the assessment and management of mixtures is only partly covered by current legislation, has identified several gaps and areas for action. With regard to carcinogens, the proportion of non-genotoxic carcinogens in the environment is expected to increase, since industrial chemists are designing compounds without overly reactive moieties. In addition, the manufacture and use of novel types of substances including nanomaterials, new generation pesticides and pharmaceuticals (e.g. biologicals, cell and gene therapies) are expected to increase. This raises new challenges for the assessment and risk management of the carcinogenicity impacts of chemicals. The present workshop intends to provide an overview of the different initiatives conducted in Europe at different scales (European, national and regional), to address such defies related to the HIA of chemicals. Specifically, we will debate about existing data sets for characterising both human exposure and health effects related to chemicals, new approaches and guidance for the assessment of exposure to mixtures, and the carcinogenicity impacts as well as how all that is being translated to policy actions. Key messages Increasing global trend of human exposure to chemicals demands holistic approach for action. Several research/policy initiatives for improving HIA-chemicals are ongoing, with expected strong impacts.

Most scientific communities and governments accept that a global warming process is occurring, and are concerned about its alarming potential environmental and health consequences. The extreme conditions associated to climate change such as severe storms, floods and prolonged heatwaves and droughts, are expected to increase considerably the burden of climate-sensitive diseases (e.g. heat-related illness, new and emerging infectious diseases, respiratory diseases or threats to food security). Poor countries are most at risk, but developed economies can also be strongly affected as illustrated by the large number of deaths associated to the European heat wave of 2003. Conducting health impact assessment of climate change (HIA-CCh) requires the analyses of complex interactions between humans and natural ecosystems, demanding an interdisciplinary approach and a wide range of tools and techniques. Those analyses should be simultaneously context specific and extend over time to track not only the full dimension of health impacts but also the efforts needed to adapt and build resilience. Standard indicators for climate-sensitive health outcomes alone will not adequately capture the changing risks typically related to climate change. In addition to them, indicators of vulnerability and exposure, adaptation planning and resilience for health, and learning and knowledge management are required. The present workshop aims at analysing and sharing expertise on how to conduct an HIA-CCh, with the following elements for discussion: Definition of the scope (both temporal and spatial) and the interdisciplinary team to be involved in the processSelection of indicators that will allow not only characterization of health impacts but also promoting and tracking adaptation activities at national and local health departmentsForesight climate change scenarios and how this can be incorporated into the decision-making processVulnerability risk in relation to impact assessment and health / health equity in the context of climate changeHow the proper HIA-CCh can have an impact on learning and changes in management frameworks Key messages Increasing public health’s adaptive capacity to face climate-sensitive threats is needed. Conducting HIA-CCh requires innovative management strategies and proper selection of indicators.

We aimed to assess the influence of long-term exposure to POPs on the risk of metabolic syndrome, combining a cross-sectional with a 10-year longitudinal follow-up design. Residues of eight POPs were quantified in adipose tissue samples from 387 participants recruited between 2003 and 2004 in Granada province (Spain). The outcome (“metabolically compromised”) was defined as having ≥1 diagnosis of type 2 diabetes, hypertension, hypertriglyceridemia, and/or low HDL cholesterol. The cross-sectional analysis was conducted in the initial cohort, while the 10-year longitudinal analysis was conducted in those 154 participants free of any of the so-mentioned metabolic diseases and classified as “metabolically healthy” at recruitment. Statistical analyses were performed using single and multi-pollutant approaches through logistic and Cox regression analyses with elastic net penalty. After adjusting for confounders, β-hexachlorocyclohexane (β-HCH) and hexachlorobenzene (HCB) were independently associated with an increased risk of being metabolically compromised (unpenalized ORs=1.17, 95% CI=1.01–1.36 and 1.17, 95% CI=0.99–1.38, respectively). Very similar results were found in the 10-year longitudinal analysis [HRs=1.28, 95% CI=1.01–1.61 (β-HCH); 1.26, 95% CI=1.00–1.59 (HCB)] and were in line with those obtained using elastic net regression. Finally, when the arithmetic sum of both compounds was used as independent variable, risk estimates increased to OR=1.25, 95% CI=1.03–1.52 and HR=1.32, 95% CI=1.02–1.70. Our results suggest that historical exposure to HCB and β-HCH is consistently associated with the risk of metabolic disorders, and that these POPs might be partly responsible for the morbidity risk traditionally attributed to age and obesity. Keywords: Metabolic syndrome, Metabolic disruption, Persistent organic pollutants, Organochlorine pesticides, Polychlorinated biphenyls

EIA is an obligation for many projects in many countries. Consideration of human health within EIA is also an obligation. This results in an invaluable opportunity for early consideration of a variety of environmental health determinants, leading to minimization of noxious exposures and promotion of the salutogenic factors involved in plans and projects in many sectors. In other words, EIA can be an extremely powerful vehicle to scaling up primary prevention - by far the most effective strategy in public health. This opportunity is further enriched by the recent revision of the EU Directive on EIA, which makes better provision for human health considerations in EIA, in particular referring to the need to address “significant” health effects of plans and projects - without elaborating further. The health sector can play a key role in EIA by: recognizing the opportunity and its potential, so far under-exploited; engage in dialogue with other sectors, on specific applications; make institutional arrangements so as to secure manpower and competences to contribute to EIA; advocate for a high level of human health consideration in EIAs on the ground. This process requires careful consideration of needs and constraints of EIA, including a need to establish a common language with other sectors, the identification of realistic, achievable goals, as well as long-term objectives, the consolidation of available methods and tools and a need to engage in possibly unfamiliar conversations. A pragmatic, operational decision on what constitutes significant health effects in the context of EIA may be a good starting point to measure the readiness of the health sector to undertake this journey.

Environmental Impact Assessment (EIA) is conducted by the developer as part of the process of seeking consent to proceed with the project. The developer may be a public authority or a private company. The Directive for Environmental Impact Assessment (EIA) (2011/92/EU) was amended in 2014 (2014/52/EU). The changes are now transposed into national regulations across European Union Member States. These changes have an influence beyond EU borders, for example, through the policies of the European Investment Bank and the European Bank of Reconstruction and Development. The amendments to the Directive create both opportunities and challenges for public health. The opportunities stem from the changes that have been made to the Directive. Population and human health are now on the list of core topics that must be considered in an EIA. The other core topics to be assessed are each ‘determinants of health’, for example: biodiversity; land, soil, water, air and climate; and material assets, cultural heritage and the landscape. The Directive now requires the interaction between these factors to be considered. The amended Directive includes other issues that are relevant to human health, for example, climate change and vulnerability (exposure and resilience) to major accidents and/or disasters. The developer’s assessment must be prepared by Competent Experts. The changes also pose challenges. These are technical. For example, human health needs to be assessed within the framework of EIA. The changes also pose challenges to the public health workforce. There is a need to ensure there is capacity to participate in EIA. The EIA is typically prepared by the developer and reviewed by the competent authority. There is a role for public health expertise in these complementary activities. This presentation will focus on the opportunities created by the changes to the Directive and the opportunities this creates. It will also touch on the challenges.

There is an increasing awareness in Europe that health is determined largely by factors outside the health sector. Thus, as public policies in all sectors and at different levels of governance may have a significant impact on population health, a new approach for tackling health is needed. Health in All Policies is an approach to public policies across sectors that systematically considers the health implications of decisions, seeks synergies, and optimises them to improve population health and health equity. Therefore, engagement of the health sector in other policies should be a priority within public health. However, it is bound to meet some resistances as it entails new roles in public health practice, bringing some practitioners out of their comfort zone. Implementing the health in all policies agenda on the ground is challenging, and tools such as Health Impact Assessment (HIA) are needed to enable policy-makers to predict and govern the consequences of their proposals on the well-being of the affected population, and to optimise them. Advocacy and support from the public health sector are imperative to achieve these goals. This also means placing public health professionals outside their usual area of expertise, confronted with alien sectors such as urban planning or infrastructure development. HIA expertise and capacity are still scarce and unevenly distributed in Europe. Indeed, lack of awareness, capacities and resistance from public health officials are usually cited as some of the barriers preventing its establishment as a field of work in many countries. To deal with this problem, many countries and subnational entities have been developing resources such as databases and websites, while others have embarked on capacity building. As a result, there has been a widespread use of HIA in Europe in recent years and sharing some successful case studies is important. The WHO Europe Regions for Health Network (RHN) aims at documenting and disseminating best practices to improve populations’ health across Europe. Andalusia (Spain), through its Regional Ministry of Health, has been implementing HIA over the last five years, focusing on the development of tools and procedures, identifying elements of success, conflicts and reluctances, and windows of opportunity. This workshop is intended to share the existing experiences on HIA and to launch a new RHN case-study publication collecting best practices on HIA across Europe. After an introduction by the chairperson, a presentation by WHO will provide an overview of HIA in Europe, followed by a representative from Andalusia who will focus on the challenges and opportunities found in implementing HIA as a stand-alone document partially integrated with Environmental Impact Assessment procedures. The presentations will be followed by a panel discussion with panelists representing the subnational level of governance, from 5 different countries in Europe: Belgium, Germany, Russian Federation, Spain, Switzerland. Key messages HIA is a tool for implementation of the health in all policy agenda; a resource for addressing complex environmental health determinants and a way of being faithful to WHO’s definition of health. HIA can be simple, if needed. In HIA, too, the best is the enemy of the good. It “operates deliberately in imperfection” as in many cases where stakes are high, decisions urgent and evidence uncertain.

Background For connecting health-related “scientific knowledge” and “policy-making” with each other, there is a range of approaches, including health reporting, health needs / impact / technology / systems performance assessment as well as evaluative activities. The improved understanding of their communalities and differences provides opportunities for mutual learning and synergetic practice. Goal and method The goal is to strengthen the coverage of health within EIAs. We apply the “Family of health assessments” approach, as worked out by the EUPHA “health assessments” working group (EJPH 2017, pp.609-16), for connecting EIA to other approaches used to support decision-making. Results Applying this “family” approach leads to various insights, including the following: (i) Existing local health (or environmental) reports provide baseline information, as required in impact assessments. (ii) An existing Health Needs Assessment (HNA) can point to vulnerable populations, Health Systems Performance Assessment (HSPA) to specific weaknesses of local health care, potentially relevant for expected impacts. (iii) Where other impact assessments beyond EIA, e.g. Social Impact Assessment (SIA), are conducted, assessors need to be aware of potential overlap or even contradictions which could irritate decision-makers and the public. (iv) Ex-post evaluations of similar projects can inform prospective EIA. (v) The competencies required for assessing human health in EIA overlap with those required for other types of health assessments, e.g., health reporting or evaluation. Therefore, teaching modules might jointly be developed. Lessons The “family” perspective helps to make best use of existing (local) knowledge (which is often embedded in diverse forms of health assessments); and to assure consistent practice across assessments. The inter-relationship of health assessments is a reason to reconsider training courses and to develop more integrated approaches.

human exposure to mixtures of chemicals of toxicological interest, typically found in industrial contaminated sites (ICSs), has been associated with a broad range of different health outcomes. Deprived population groups endure most of the burden of disease and premature death associated to the exposure to those pollutants. Characterising the impacts on health of an ICS is a challenging process. Currently the two main methodological approaches used are Human Health Risk Assessment (HHRA) and Environmental Epidemiological (EE) studies.review existing guidance and scientific evidence for HHRA and EE studies applied to contaminated sites that orientate in selecting the most suitable methodological approach for characterising health impacts in ICSs according to the site characteristics, and the availability of environmental, health and sociodemographic data.HHRA has evolved into a more holistic approach, placing more emphasis in planning, community involvement and adapting the dimension of the assessment to the problem formulation and to the availability of resources. Many different HHRA guidelines for contaminated sites has been published worldwide, and although they share a similar framework, the scientific evidence used for deriving reference values and the variet of policy options can result in a wide variability of health risk estimates. This paper condenses different options with the recommendations to use those tools, default values for environmental and exposure levels and toxicological reference values that most suit to the population and characteristics of the ICSs under evaluation.the suitability to use one or another approach to assess the impact of ICSs on health depends on the availability of data, cost-benefit aspects and the kind of problem that needs to be answered. Risk assessment based on toxicological data can be very rapid and cheap, providing direct information when the intervention to protect the health of population is urgent and no suitable dose-response functions are available from epidemiological studies. Conducting EE studies provide a deeper insight into the problem of the exposure to industrial pollutants that do not require extrapolation from data obtained from toxicological studies or other population, addressing the community concern's more directly. Complementing the results obtained from different approaches, including those from public health surveillance systems, might provide an efficient and complete response to the impact of ICSs.

the mixed and complex nature of industrially contaminated sites (ICSs) leads to heterogeneity in exposure and health risk of residents living nearby. Health, environment, and social aspects are strongly interconnected in ICSs, and local communities are often concerned about potential health impact and needs for remediation. The use of human biomonitoring (HBM) for impact assessment of environmental exposure is increasing in Europe. The COST Action IS1408 on Industrially Contaminated Sites and Health Network (ICSHNet) decided to reflect on the potential and limitations of HBM to assess exposure and early health effects associated with living near ICSs.to discuss challenges and lessons learned for addressing environmental health impact near ICSs with HBM in order to identify needs and priorities for HBM guidelines in European ICSs.based on the experience of the ICSHNet research team, six case studies from different European regions that applied HBM at ICSs were selected. The case studies were systematically compared distinguishing four phases: the preparatory phase; study design; study results; the impact of the results at scientific, societal, and political levels.all six case studies identified opportunities and challenges for applying HBM in ICS studies. A smart choice of (a combination of) sample matrices for biomarker analysis produced information about relevant time-windows of exposure which matched with the activities of the ICSs. Combining biomarkers of exposure with biomarkers of (early) biological effects, data from questionnaires or environmental data enabled fine-tuning of the results and allowed for more targeted remediating actions aimed to reduce exposure. Open and transparent communication of study results with contextual information and involvement of local stakeholders throughout the study helped to build confidence in the study results, gained support for remediating actions, and facilitated sharing of responsibilities. Using HBM in these ICS studies helped in setting priorities in policy actions and in further research. Limitations were the size of the study population, difficulties in recruiting vulnerable target populations, availability of validated biomarkers, and coping with exposure to mixtures of chemicals.based on the identified positive experiences and challenges, the paper concludes with formulating recommendations for a European protocol and guidance document for HBM in ICS. This could advance the use of HBM in local environmental health policy development and evaluation of exposure levels, and promote coordination and collaboration between researchers and risk managers.

industrially contaminated sites (ICSs) have been recognised as a major public health concern since they involve exposure to multiple environmental stressors, normally distributed unevenly within population. The COST Action on Industrially Contaminated Sites and Health Network (ICSHNet) comprises a European network of experts and institutions to clarify needs and priorities for better characterising the impact on environment and health of ICS.evaluate the availability of information and studies concerning selected ICSs in participating Countries within the ICSHNet, with particular consideration on the accessibility to environmental, health and demographic data, and research and assessment tools.to evaluate the availability of data, an Action Questionnaire (AQ) was developed based on previous questionnaires used in different European projects and on expert consultation. The AQ, with 84 items organised in eight sections, was adapted to an on-line version using the software LimeSurvey. The survey was sent to 47 participants within the ICSHNet, to report over a list of 99 ICSs previously identified.information was gathered from 81 sites out of the initially selected 99, reported by 45 participants from 27 Countries (82% of Countries in the ICSHNet). The predominant polluting activities were waste disposal (46%) and chemical industries (37%), affecting all environmental media, but more extensively surface and groundwater (70%) and soil (68%). Main categories of contaminants affecting different media were heavy metals and chlorinated hydrocarbons, but also BTEX (benzene, toluene, ethylbenzene, and xylene) and ambient air pollutants (e.g., particulate matter, SOx). Human health risk assessment was the most prevalent methodological approach for characterising impacts on health (32%), followed by epidemiological studies (26%), and health impact assessment (12%). The low reporting, both referring to data availability or methodologies, could be due to absence of data, or to the fact that the reporting person (many of them from the public health sector) did not know how to reach the environmental information.survey findings suggest that improving the collection and access to specific environmental, health and demographic data related to ICSs is crucial to meet the methodological requirement to better analyse the health impact of ICSs.

The aim was to evaluate the associations of environmental phenol and paraben concentrations with the oxidative microenvironment in adipose tissue. This study was conducted in a subsample (n=144) of the GraMo cohort (Southern Spain). Concentrations of 9 phenols and 7 parabens, and levels of oxidative stress biomarkers were quantified in adipose tissue. Associations were estimated using multivariable linear regression analyses adjusted for potential confounders. Benzophenone-3 (BP-3) concentration was borderline associated with enhanced glutathione peroxidase (GPx) activity [exp(β)=1.20, p=0.060] and decreased levels of reduced glutathione (GSH) [exp(β)=0.55, p=0.070]. Concentrations of bisphenol A (BPA) and methylparaben (MeP) were associated to lower glutathione reductase (GRd) activity [exp(β)=0.83, exp(β)=0.72, respectively], and BPA was borderline associated to increased levels of oxidized glutathione (GSSG) [exp(β)=1.73, p-value=0.062]. MeP was inversely associated to both hemeoxygenase-1 (HO-1) and superoxide dismustase (SOD) activity, as well as to the levels of thiobarbituric acid reactive substances (TBARS) [0.75 < exp(β) < 0.79]. Our results suggest that some specific non-persistent pollutants may be associated with a disruption of the activity of relevant antioxidant enzymes, in addition to the depletion of the glutathione stock. They might act as a tissue-specific source of free radicals, contributing to the oxidative microenvironment in the adipose tissue., This research was supported in part by research grants from the European Union Commission (H2020-EJP-HBM4EU and SOE1/P1/F0082), Biomedical Research Networking Center-CIBER de Epidemiología y Salud Pública (CIBERESP), from the Institute of Health Carlos III, supported by European Regional Development Fund/FEDER (FIS-PI13/02406, FISPI14/ 00067, FIS-PI16/01820, FIS-PI16/01812, FIS-PI16/01858 and FIS-PI17/01743), and from the Consejería de Salud, Junta de Andalucía (PS-0506-2016). Funding for the equipment used was provided by Velux Fonden, Augustinus Fonden and Svend Andersen Fonden. The authors thank Kirsten og Freddy Johansens Fond and the International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC, Rigshospitalet, Copenhagen University) for economic support. Dr. Juan Pedro Arrebola is under contract within Ramón y Cajal Program (Ministerio de Economía, Industria y Competitividad de España, RYC-2016-20155).

Despite growing in vitro and in vivo evidence of the putative role of persistent organic pollutants (POPs) in the induction of oxidative damage in cell structures, this issue has been poorly addressed from an epidemiologic perspective. The aim of this study was to explore associations between adipose tissue POP concentrations and the in situ oxidative microenvironment. A cross-sectional study was conducted in a subsample (n = 271) of a previously established cohort, quantifying levels of eight POPs and four groups of oxidative stress biomarkers in adipose tissue. Associations were explored using multivariate linear regression analyses adjusted for potential confounders. We assessed the combined effect of POPs on oxidative stress/glutathione system biomarkers using weighted quantile sum regression (WQS). Increased concentrations of p,p'-DDE, HCB, β-HCH, dicofol, and PCBs (congeners -138, -153, and -180) were predominantly associated with higher lipid peroxidation (TBARS) [exp(β) = 1.09-1.78, p0.01-0.04)] and SOD activity [exp(β) = 1.13-1.48, p0.01-0.05)] levels. However, only a few associations were observed with glutathione system biomarkers, e.g., PCB-180 with total glutathione [exp(β) = 1.98, p = 0.03]. The WQS index was found to be positively associated with SOD activity, and PCB-138, PCB-180, and β-HCH were the main contributors to the index. Likewise, the WQS index was positively associated with TBARS levels, with the three PCBs acting as the main contributors. This is the first epidemiological evidence of the putative disruption by POPs of the adipose tissue oxidative microenvironment. Our results indicate that POP exposure may enhance alternative pathways to the glutathione detoxification route, which might result in tissue damage. Further research is warranted to fully elucidate the potential health implications.

Addressing the characterization of social and economic determinants of health (SDH) properly is a key aspect in conducting a Health Impact Assessment (HIA). This article explores the level of knowledge on HIA environmental and public health professionals have as well as their perception regarding key concepts such as the definition of ‘health’ and the relevance of SDH. With this purpose in mind, a survey was conducted among experts (n = 41) who attended a technical session on HIA within the framework of the most important conference on the Environment on a national level in Spain. A hierarchical cluster analysis was conducted to categorize groups of respondents depending on their working profile and professional expertise and a Friedman test was used to compare mean ranks so as to assess the importance given to SDH according to the target respondents' perception. Strong differences were found in the relevance given to diverse SDH according to their contribution to a good state of health, the block referring to ‘Habits and lifestyle’ being the one perceived as more significant. SDH were ranked in a diverging order from that reported in the scientific evidence regarding the association between SDH and a wide range of health outcomes. Also, some diverging trends were illustrated between groups of respondents according to the relevance given to each block of SDH. However, differences in responses between groups of respondents were not statistically significant. A self-appraisal by respondents also revealed that the practitioner's level of knowledge on HIA ranged between low to medium. Therefore, it is recommended to improve their capacity.

Background: Adipose tissue has been acknowledged as a potential target of obesogenic pollutants, including metals. However, the presence of these chemicals in the adipose tissue has been poorly characterized. Assessment of adipose tissue metal content may provide valuable information for the study of metabolic disturbances related to human exposure to metals. Objective: To examine the distributions of adipose tissue concentrations of five toxic metals (i.e., arsenic [As], nickel [Ni], lead [Pb], tin [Sn], and titanium [Ti]) in adults, and potential socio- demographic and lifestyle factors associated with metal concentrations. Methods: The study population consisted of a subsample of 228 subjects from GraMo cohort in Southern Spain (N=387). Adipose tissue samples were intra- operatively collected from adults recruited in 2003-2004 in two public hospitals, and concentrations of metals in adipose tissue were analyzed in 2015 by High-Resolution Inductively Coupled Plasma Mass Spectrometry. Data on socio-demographic and lifestyle factors were obtained by baseline questionnaire completion. Linear and multinomial regression was used to identify factors associated with metal levels. Results: Ni, Pb, Sn, and Ti were detected in all adipose tissue samples, and As in 51%. Ni was the metal showing the highest median concentration (0.56 µg/g), followed by Ti (0.31 µg/g), Pb (0.08 µg/g), Sn (0.06 µg/g), and As (0.003 µg/g). Predictors of As levels included area of residence, social class, and oily fish intake ; for Ni: area of residence and consumption of cheese, meat, eggs, and canned food ; for Pb: vegetables intake and industrial occupation ; for Sn: age, body mass index, and consumption of lean fish, eggs, and milk ; and cheese intake for Ti. Some of these predictors were sex-specific, particularly those regarding dietary intake. Conclusions: This exploratory study provides the first evidence of the wide occurrence of Ni, Pb, Sn, Ti, and As in adipose tissue from adult population, and highlights the potential of this tissue as a biological matrix for studying exposure levels and chronic health effects of toxic metals.

This study was conceived as a first step to evaluate the suitability of adipose tissue cadmium (Cd) concentrations as a biomarker for the assessment of long-term exposure. Specifically, the aim of this work was to explore the socio-demographic, dietary, and lifestyle determinants of adipose tissue Cd concentrations. The study population is a subsample of GraMo cohort. Adipose tissue samples were intraoperatively collected from 226 adult volunteers recruited in two public hospitals from Granada, Spain. Cd concentrations in adipose tissue were analyzed by High-Resolution Inductively Coupled Plasma Mass Spectrometry (HR-ICP-MS). Data on socio-demographic characteristics, lifestyle, diet and health status were collected by face-to-face interviews. Predictors of Cd concentrations were assessed by multivariable linear regression with a stepwise variable selection. We found detectable levels of Cd in the adipose tissue of all the study participants, with a mean concentration (±standard deviation) of 12.66 ± 18.91 μg/kg. Smoking habit at recruitment was associated with increased adipose tissue Cd concentrations (β for smokers = 0.669 p 0.001; β for former smokers = 0.502, p 0.001; reference = non-smokers). Age was positively associated with Cd concentrations (β = 0.014, p 0.001), and men showed lower concentrations than women (β = -0.424, p 0.001). Obesity, measured as Body Mass Index (BMI), showed an inverse association with Cd concentrations (β = -0.038, p 0.001). Egg consumption ≥2 portions/week (β = 0.241, p = 0.025) was positively associated with Cd concentrations. Perceived exposure to paints was also positively associated with Cd concentrations. The observed associations with age, smoking habit, BMI, and egg and meat consumption did not substantially change after sex/gender stratification. Our results are consistent with currently-known Cd sources and suggest other potential pathways, which might be population-specific. As a whole, our findings underline the potential relevance of adipose tissue as a biological matrix for exposure characterization to Cd, as well as for the assessment of long-term clinical implications of the exposure, particularly in obesity-related diseases.

The present study was conceived on the basis of the few previous reports suggesting a potential relevance of the oxidative stress microenvironment in the adipose tissue, a biological matrix which is closely related to the development of several chronic pathologies. Thus, our aim was to describe the levels of enzymatic and non-enzymatic antioxidants and markers of oxidative damage in adipose tissue samples from a Spanish cohort, as well as their main sociodemographic, lifestyle, and dietary predictors. The study was conducted in a subsample (n = 271 adults) of GraMo cohort, recruited in Granada (Southern Spain). A face-to-face questionnaire was used to gather data regarding sociodemographic characteristics, lifestyle, dietary habits, health status, and perceived exposure to chemicals. We analyzed adipose tissue levels of lipid peroxidation (TBARS), total superoxide dismutase (SOD) activity, heme oxygenase-1 (HO-1) activity, and glutathione cycle biomarkers. Potential predictors of oxidative stress markers were assessed using stepwise multivariable linear regression analyses. SOD and TBARS levels were mainly related to sociodemographic and occupational characteristics, while the components of the glutathione cycle and HO-1 were predominantly associated with dietary habits. Men showed significantly lower levels of oxidative stress levels than women. In the regression models including only women, the use of oral contraceptive and hormonal therapy was associated with lower levels of oxidative stress, while the number of children was positively associated with increased oxidative biomarkers. Our results suggest that adipose tissue is potentially important matrix for the assessment of oxidative stress, which can be affected by specific environmental factors. These findings might be relevant for public health.

this paper is based upon work from COST Action ICSHNet. Public health surveillance (PHS) of industrially contaminated sites (ICSs) is likely to play a role in supporting the monitoring of harmful aspects of ICSs and related interventions. Environmental public health tracking (EPHT) has been proposed and developed as an approach to PHS when environmental factors affecting health are involved.to identify existing arrangements for continuous collection and analysis of environmental and health data to guide the development of an optimal EPHT approach which would support the characterization of the impact on health of ICS.a literature search was conducted in PubMed following a structured approach to identify methodological aspects relevant to surveillance of ICSs. In addition, eight further studies on this topic, mainly from three European Countries (Spain, Italy, and France), were included by the research team.the identified 17 examples of surveillance studies include a heterogeneous variety of industrial activities, covering from cross-national to local scenarios. Continuous monitoring systems for gathering environmental data related to ICSs were used only in two cases; a qualitative approach and/or punctual sampling for soil, air, and water of local foodstuff took place in the rest. Exposure assessment was conducted according to four main methods: qualitative definition for the presence/absence of a source, distance to a source, dispersion modelling, and biomonitoring. Health data relied on routinely vital statistics, hospital admission records, specific morbidity registers, and cancer and congenital abnormalities registries.our revision identified an overall lack of national surveillance programmes of ICSs, rather than gaps in individual dimensions of surveillance. The epidemiological approaches reviewed provided methods, some of which could be adopted for an EPHT in ICSs. However, a large proportion of examples suffers from poor exposure characterization, relying on a qualitative definition approach, which cannot account for the multiple pathways that take place in ICSs. Use of more individual data from health registries combined with improved environmental data collection and exposure assessment would improve future surveillance.

The official procedure adopted in Andalusia (Southern Spain) for implementing the hazard analysis and critical control points (HACCP) flexibility criteria for the control of the cold chain in the retail self-service sector set out in Regulation (CE) 852/2004 is based on a daily determination of the display temperature of the equipment. The main objective of our study was to test whether this approach was effective for the safety of the storage products, considering the influence of the position occupied by the foodstuffs inside the cooling equipment, and also possible seasonal fluctuations. The study was conducted in all self-service refrigerating equipments from every food retail store (11 supermarkets representing different national chain-store groups) located in various municipalities from Southern Spain. Statistically significant (p ≤ 0.05) breaches in the cold chain were recorded in the case of products located at the top shelf (TST) for all kinds of foodstuffs during the summer period, and also during winter time in the cases of TST of dairy products and refrigerated vegetables. Furthermore, using predictive microbiology as a tool, we calculated the potential reduction caused by those failures on the shelf life recorded in the food labelling of smoked salmon, cooked chicken breast and fresh cheese, which counted up to 40%, 57% and 25%, respectively. These findings show that the official procedure adopted does not ensure compliance with safety specifications of perishable food in the retail self-service sector. A revision of such procedure would be necessary, especially in those regions such as Andalusia where important temperature fluctuations throughout the year are recorded.

Resumen Introduccion y objetivos La cardiopatia isquemica es la primera causa de muerte y una de las cuatro principales causas de carga de enfermedad en el mundo. El objetivo de este trabajo es evaluar los efectos edad-periodo-cohorte la mortalidad por cardiopatia isquemica en Andalucia (sur de Espana) y en cada una de sus provincias durante el periodo 1981-2008. Metodos Se realizo un estudio ecologico poblacional. Se analizaron las 145.539 defunciones por cardiopatia isquemica ocurridas en Andalucia durante el periodo de estudio a edades comprendidas entre 30 y 84 anos. Se estimo un modelo de regresion no lineal con funciones spline para cada sexo y area geografica. Resultados En la tasa de mortalidad masculina y femenina a partir de 30 anos de edad se observa tendencia a aumentar. El riesgo de muerte para varones y mujeres fue descendiente para las cohortes nacidas despues de 1920 y con una pendiente mas pronunciada despues de 1960 entre los varones. El analisis del efecto periodo mostro que el riesgo de mortalidad masculina y femenina se mantuvo estable desde 1981 hasta 1990, aumento entre 1990 y 2000 y volvio a disminuir desde 2000 hasta 2008. Conclusiones Los efectos edad-periodo-cohorte en la mortalidad fueron similares en todas las provincias de Andalucia y el conjunto de la comunidad autonoma. Si los efectos cohorte y periodo persisten, la mortalidad masculina y femenina por enfermedad isquemica cardiaca continuara disminuyendo.

Urinary concentrations of non-persistent environmental pollutants (npEPs) are widely assessed in biomonitoring studies under the assumption that they are metabolised and eliminated in urine. However, some of these chemicals are moderately lipophilic, and their presence in other biological matrices should also be evaluated to estimate mid/long-term exposure to npEPs and its impact on human health. The present study aims to explore concentrations and potential determinants of npEPs in adipose tissue from a hospital-based adult cohort (GraMo cohort, Southern Spain). Concentrations of bisphenol-A (BPA), benzophenone-3 (BP-3), triclosan (TCS), three chlorophenols (2,4-DCP, 2,5-DCP and 2,4,5-TCP) and two phenylphenols (2-PP and 4-PP), triclocarban (TCCB) and parabens [methyl- (MeP), ethyl- (EtP), propyl- (n-PrP and i-PrP), butyl- (n-BuP and i-BuP) and benzyl-paraben (BzP)] were analysed in adipose tissue samples from a subcohort of 144 participants. Spearman correlation tests were performed, followed by stepwise multivariable linear regression analyses to assess determinants of the exposure. Detection frequencies and median concentrations were: BPA (86.8%, 0.54 ng/g tissue), BP-3 (79.2%, 0.60 ng/g tissue), TCS (45.8%,LOD), 2-PP (18.8%,LOD), MeP (100.0%, 0.40 ng/g tissue), EtP (20.1%,LOD) and n-PrP (54.2%, 0.06 ng/g tissue). The remaining npEPs were detected in10% of the samples. BPA, MeP, EtP and n-PrP levels were significantly and positively correlated, while BP-3 showed a positive correlation with TCS and 2-PP. Older participants showed higher concentrations of TCS and MeP, while BMI was inversely associated with most of the analysed compounds and perceived recent weight loss was inversely associated with 2-PP. Female participants and residents of rural areas had increased BP-3 concentrations. npEP concentrations were positively associated with the consumption of fatty food but negatively associated with the consumption of vegetables and fruit. This study reveals the widespread presence of numerous npEPs in adipose tissue from adults in southern Spain, suggesting a generalized distribution of these environmental compounds in fatty tissues. In these adults, many of the determinants of npEP concentrations in adipose tissue were similar to those of more lipophilic and persistent compounds.

There is increasing evidence linking levels of trace elements (TEs) in adipose tissue with certain chronic conditions (e.g., diabetes or obesity). The objectives of this study were to assess concentrations of a selection of nine essential and possibly-essential TEs in adipose tissue samples from an adult cohort and to explore their socio-demographic, dietary, and lifestyle determinants. Adipose tissue samples were intraoperatively collected from 226 volunteers recruited in two public hospitals from Granada province. Trace elements (Co, Cr, Cu, Fe, Mn, Mo, Se, V, and Zn) were analyzed in adipose tissue by high-resolution inductively coupled plasma mass spectrometry (HR-ICP-MS). Data were collected on socio-demographic characteristics, lifestyle, diet, and health status by face-to-face interview. Predictors of TE concentrations were assessed by using multivariable linear and logistic regression. All TEs were detected in all samples with the exception of Se (53.50%). Iron, zinc, and copper showed the highest concentrations (42.60 mg/kg, 9.80 mg/kg, and 0.68 mg/kg, respectively). Diet was the main predictor of Cr, Fe, Mo, and Se concentrations. Body mass index was negatively associated with all TEs (β coefficients = -0.018 to -0.593, p = 0.001-0.090) except for Mn and V. Age showed a borderline-significant positive correlation with Cu (β = 0.004, p = 0.089). Residence in a rural or semi-rural area was associated with increased Co, Cr, Fe, Mo, Mn, V and Zn concentrations and with β coefficients ranging from 0.196 to 0.544 (p 0.05). Furthermore, individuals with higher educational level showed increased Cr, Co, Fe and V concentrations (β coefficients = 0.276-0.368, p = 0.022-0.071). This is the first report on the distribution of these TEs in adipose tissue and on their determinants in a human cohort and might serve as an initial step in the elucidation of their clinical relevance.

There is an increasing trend in the incidence of cancer worldwide, and it has been accepted that environmental factors account for an important proportion of the global burden. The present paper reports preliminary findings on the influence of the historical exposure to a group of persistent organic pollutants on total cancer risk, at year 9 in the follow-up of a cohort from Southern Spain. A cohort of 368 participants (median age 51 years) was recruited in 2003. Their historical exposure was estimated by analyzing residues of persistent organic pollutants in adipose tissue. Estimation of cancer incidence was based on data from a population-based cancer registry. Statistical analyses were performed using multivariable Cox-regression models. In males, PCB 153 concentrations were positively associated with total cancer risk, with an adjusted hazard ratio (95% confidence interval) of 1.20 (1.01–1.41) for an increment of 100 ng/g lipid. Our preliminary findings suggest a potential relationship between the historical exposure to persistent organic pollutants and the risk of cancer in men. However, these results should be interpreted with caution and require verification during the future follow-up of this cohort., This study was supported in part by research grants from the Spanish Ministry of Health (FIS 02/974, EUS2008-03574), CIBER de Epidemiología; Junta de Andalucía (01/264, P09-CTS-5488 Project of Excellence, PI-0675-2010, and PI-0513-2012), and the Instituto de Salud Carlos III (FIS PI11/0610).

The aim of this research was to study the association of the accumulated human exposure to persistent organic pollutants with serum lipid levels and obesity, in a cohort of 298 adults. In the multivariable analyses, HCB concentrations evidenced a significant quadratic association with levels of total cholesterol, HDL, LDL, and total serum lipids. Likewise, PCBs 138 and 180 were associated with triglycerides and total serum lipids, and PCB 153 with LDL. HCB, p,p′-DDE, and β-HCH showed quadratic associations with BMI. All quadratic models showed a positive trend at low exposure levels, while the slope decreased or even became negative at higher exposure levels. Additionally, PCB 138 was positively associated with BMI but in a linear manner. Our results suggest a potential relationship between historical POP exposure and serum lipids/obesity, which followed a non-linear pattern in most cases.

espanolEl desempleo, la privacion economica y la pobreza son indicadores de bienestar social. Todos forman un ciclo de factores encadenados que comienza con la perdida del empleo. Los objetivos de este estudio fueron describir la evolucion del desempleo, la privacion economica, la pobreza y el autoempleo en hombres y mujeres en Andalucia durante el periodo 2000-2013, asi como evaluar cambios en la tendencia tras el inicio de la Gran Recesion. Los resultados muestran un empeoramiento significativo de los indicadores de desempleo, privacion economica y riesgo de pobreza en Andalucia desde 2008 y una mejora del autoempleo en ambos sexos. EnglishUnemployment, economic deprivation and poverty are social welfare indicators. All form a cycle of chained factors which begins with the loss of employ. The objectives of this study were to describe the trend of unemployment, economic deprivation, poverty and self-employment in men and women in Andalusia during the period 2000-2013, as well as evaluating possible significant changes in trend after the beginning of the Great Recession. The results showed a significant worsening of the indicators of unemployment, economic deprivation and risk of poverty in Andalusia since 2008. On the other hand, an improvement of self-employment was observed in both sexes

There is increasing evidence that environmental factors play an important role in the development of type 2 diabetes. Several persistent organic pollutants are suspected to contribute to the increasing prevalence and risk of type 2 diabetes. The aim of this study was to investigate the association of the body burden of three organochlorine pesticides and three polychlorinated biphenyls and the overall estrogenic activity with the risk of type 2 diabetes in a sample of adults from Southern Spain. Samples of adipose tissue and serum were obtained from 386 subjects undergoing non-cancer-related surgery and were extracted using validated methodologies. Residues of persistent organic pollutants were analyzed by means of high-resolution gas chromatography with a mass spectrometry detector in tandem mode. The overall estrogenicity of the adipose tissue extracts was measured by using the total effective xenoestrogen burden (TEXB) biomarker. Data on lifestyle, dietary habits, and health status were gathered from face-to-face interviews and clinical records. Statistical analyses were performed with unconditional logistic regression and different adjustment levels. In the models adjusted for adipose tissue origin, sex, age, and body mass index, the 2nd and 3rd tertiles of adipose tissue concentrations of p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE) were positively associated with the risk of diabetes [odds ratios (95% confidence interval)=3.6 (0.8-17.3) and 4.4 (1.0-21.0), respectively]. A positive association with β-hexachlorocyclohexane was also found when body mass index and adipose tissue origin were removed from the models, with odds ratios (95% confidence interval) of 3.3 (1.0-10.4) and 5.5 (1.7-17.3), for the 2nd and 3rd tertiles of exposure, respectively. In addition, a statistically significant interaction was observed between p,p'-DDE and body mass index, such that the risk of diabetes increased with tertiles of exposure in a linear manner in non-obese subjects but not in the obese, in whom an inverted U-shape pattern was observed.

Industrially contaminated sites (ICS) are of high concern from an environmental public health perspective, since industrial plants may produce a widespread contamination that can result in several health impacts on the populations living in their neighbourhood. The objective of this contribution is to briefly explore available options in studying the health impact of ICS, mainly referring to information provided by documents and activities developed by the WHO and the WHO Collaborating Center for Environmental Health in Contaminated Sites. In current practice the health impact of ICS is evaluated using studies and assessments falling in two broad types of strategies: one based on epidemiology and the other on risk assessment methods. In recent years, traditional approaches to assess relationships between environmental risks and health has been evolved considering the intricate nature between them and other factors. New developments should be explored in the context of ICS to find common strategies and tools to assess their impacts and to guide public health interventions.

Introduction Past and current industrial activities have left a legacy of areas contaminated by a mix of toxic substances. Studies conducted in such areas have provided relevant pieces of evidence,...

Hexachlorobenzene (HCB) was measured in adipose tissue intraoperatively collected from 387 subjects over 16 years old undergoing surgery in two hospitals in Granada (Southern Spain). HCB was quantified in 90.7% of subjects. The concentrations and frequencies of HCB were similar to those reported in adipose tissue samples in other recent European studies. Exposure patterns differed between females and males: higher HCB concentrations were found in females than in males (geometric mean 18.3 vs. 6.8 ng/g, p