Tables 24 and 25 report the incidence rates of the major cancer types during the period 2002–2005 in the City of Syracuse, in the pool of the five cities included in the high-risk area of environmental crisis and in the whole Province of Syracuse. For comparison, the last column in each of these two tables reports the corresponding rates in the pool of Italian cancer registries early in the new millen-nium (AIRTUM, 2006). Most of the registries in this pool, in those years, were located in Central and Northern Italy. In 2009, the proportions for populations served by cancer registration were 48%, 26%
and 16%, respectively, for Northern, Central and Southern Italy.
Over the four-year period 2002–2005, a total of 34 male and 7 female residents of the Province were diagnosed as having mesothelioma: among them, 12 males and 3 females were residents of the City of Syracuse, 13 males and 3 females were residents of the other five cities included in the high-risk area and 9 males and 1 female were residents of the rest of the Province.
None of the differences between the City of Syracuse, the five cities included in the at-risk area and the whole of the Province are statistically significant – that is, in all comparisons, the 95% CIs of the rates overlapped. However, when the rates were estimated for each city, a number of significantly in-creased rates (over to rest of the Province) were detected, particularly in Augusta. In this city, the an-nual age-standardized incidence rate per 100 000 population for all cancers in males was 603.8, which is greater than the corresponding rate in the pool of Italian registries (552.8). Augusta was also the city where the highest incidence rate per 100 000 population (based on 9 cases) for pleural mesothelioma in males was estimated: 12.0 versus 2.5 in the pool of Italian cancer registries.
Table 24. Cancer incidence rates for males, 2002–2005 a
Cancer site City of Syracuse Other cities included in the
high-risk area b Overall Province of
Syracuse Pool of Italian cancer registries 1999
All cancers 500�3 505�9 466�7 552�8
Stomach 11�0 15�4 15�0 27�4
Colon/rectum 50�5 44�2 47�8 61�7
Liver c 26�2 27�8 24�9 23�3
Pancreas 14�1 8�8 10�4 11�8
Larynx 11�6 7�5 9�8 12�5
Lung 69�4 58�2 64�1 78�5
Pleura 4�2 6�9 3�6 2�5
Prostate 59�2 56�2 52�9 76�2
Kidney d 9�5 12�0 9�7 18�3
Bladder 58�9 60�1 54�1 49�4
Brain 9�0 9�3 8�1 8�6
Thyroid 5�1 4�7 4�5 4�3
Lymphoma 21�0 20�0 17�9 21�0
Myeloma 5�9 7�9 6�1 6�2
Leukaemia 14�2 9�8 10�6 12�7
a The incidence rates are annual, per 100 000 population, and age standardized on the Italian population�
b This includes the cities of Augusta, Melilli, Priolo Gargallo, Floridia and Solarino�
c This includes the biliary tract�
d This includes the upper urinary tract�
Conclusions
The set of analyses in the present chapter provides a mixed picture, and many observations are puzzling.
For instance, in the area of Augusta, the lower mortality of females living within the contaminated area compared with those living in the local reference area might reflect better access to medical attention, but it is not clear why the phenomenon should be limited to one gender. The only statistically significant finding in the analysis of the trends of mortality for birth cohorts has been the trend towards lower SMRs in the younger generations in the local comparison of females in Augusta and in Syracuse; again, why this should occur only in one gender is not clear.
In estimating the health status of residents in highly polluted areas, such as those described in the pre-sent book, there are two important reasons for focusing attention on overall mortality rates. First, overall mortality provides an extensive image of the major hazards to health to which a population is exposed.
Second, recording mortality is exhaustive and not subject to diagnostic bias.
Residents in highly polluted areas are likely to belong to the poorer socioeconomic segment of society.
Therefore, peculiar patterns in mortality may reflect the consequences of a mix of environmental (includ-ing occupational) exposures, behavioural traits associated with socioeconomic status and limited access to medical attention. Thus, poverty is a confounder of the association between environmental pollution and health (and vice versa), but the interaction between the two is difficult to disentangle. Poverty is associat-ed with exposure to risks to health, such as poor dietary habits, tobacco smoke, obesity and sassociat-edentariness.
Also, for residents in the poorer areas, the offer and quality of medical attention may be limited.
Table 25. Cancer incidence rates for females, 2002–2005 a
Cancer site City of Syracuse Other cities included in the
high-risk area b Overall Province of
Syracuse Pool of Italian cancer registries 1999
All cancers 374�6 390�3 362�3 453�1
Stomach 6�4 7�6 7�3 17�7
Colon/rectum 37�7 43�4 40�4 48�6
Liver c 18�6 19�4 17�2 14�3
Pancreas 12�6 12�9 10�8 11�0
Larynx 0�3 0�5 0�9 1�2
Lung 13�2 8�6 13�0 20�1
Pleura 1�0 1�8 0�7 0�8
Breast 95�4 98�3 93�4 122�0
Uterus d 28�4 25�6 28�4 28�0
Ovary 12�9 9�4 10�6 13�0
Kidney e 6�8 4�5 4�6 9�5
Bladder 9�4 10�6 8�1 11�1
Brain 4�7 4�4 6�3 7�1
Thyroid 15�8 18�2 17�1 13�7
Lymphoma 13�1 18�7 13�7 18�0
Myeloma 6�7 4�9 5�3 5�6
Leukaemia 6�5 7�1 8�0 9�5
a The incidence rates are annual, per 100 000 population, and age standardized on the Italian population�
b This includes the cities of Augusta, Melilli, Priolo Gargallo, Floridia and Solarino�
c This includes the biliary tract�
d The corpus and cervix are considered together�
e This includes the upper urinary tract�
In the present analyses, an attempt was made to estimate the burden of poverty through comparisons of indicators of risk of death that have and have not been standardized by an index of deprivation. Although standardization may have been imperfect, some patterns arise from the comparison. In Gela – the most deprived among the contaminated Sicilian areas – poverty contributes greatly to the excess of mortality;
overall, it is difficult to envisage a unifying hypothesis based on all findings about this area. In the other two areas (Augusta–Priolo, including the City of Syracuse, and Milazzo–Valle del Mela), particularly in males, standardizing SMRs for the deprivation index highlighted (to a certain extent) the role of environ-mental contamination. Compared with the rest of Sicily, even after standardization for socioeconomic factors, females living in Milazzo–Valle del Mela seem protected somehow.
Also, ecological epidemiological studies in highly contaminated areas may be important for two reasons.
They can be used to: (a) identify new, previously unsuspected, etiological associations; and (b) assess the impact of environmental contamination on the health of residents. In the case of the highly contaminated Sicilian areas, the formulation of new hypotheses is impaired by the paucity of information on the nature of contaminants to which residents are (and/or have been) exposed throughout life.
However, the health statistics presented in this chapter highlight some circumstances that require a public health intervention. A variety of agents are known to have highly contaminated the three high-risk areas, and evidence of an adverse effect on the health of the area’s residents has been produced for all these con-taminated areas. The evidence is particularly compelling for Gela.
In spite of the limitations imposed by the paucity of environmental data, some specific points can be de-rived from the analyses of current health statistics in the three contaminated areas.
The consequences of the presence of asbestos are obvious. Pleural cancer is an excellent indicator of previ-ous occupational (and perhaps environmental) exposure to asbestos. The relevance of asbestos-induced pleural cancer is confirmed in the Province of Syracuse, which is served by a cancer registry. In males, the incidence rate of mesothelioma was higher in the Province of Syracuse than in Italy as a whole. Both the City of Syracuse and the other five cities included in the high-risk area contributed significantly to this excess. In Italy, the production, importation, exportation and trade of asbestos and materials that contain it were banned in 1992. Given the long latency period of asbestos-related cancers, excesses of mesothelio-mas are expected over several decades. Unlike other regions of Italy (Cavariani et al., 2010), Sicily has no figures on the amount of anthropogenic asbestos-related materials present at the time of the ban or on the speed with which they are being removed from the environment. Asbestos-induced mesotheliomas will continue to occur as long as asbestos is present in the environment. At present, the priority is to verify the extent to which the post-ban removal of asbestos-containing materials from the environment has pro-gressed, and work on verification is far from complete.
Other findings from the Province of Syracuse cancer registry deserve comment. Differences between the cancer incidence rates of the Province and the pool of Italian registries correspond to a north–south gradient, which is partly attributable to lifestyle, including the protective effect of the Mediterranean diet, which has been known for decades (Berrino & Muti, 1989). In the past, this diet was typical of southern-ers – which is no longer the case.
Also, findings from the files of hospital discharge records for 2001–2006 were given limited attention, because in those years the files had not yet been fully validated. Nevertheless, some observations provided by the hospital discharge records deserve attention and action, for the sake of public health. In all three ar-eas, an excess of hospitalizations for acute respiratory conditions was recorded for both genders, which is consistent with the presence of poor air quality in industrially contaminated areas. With the exception of Gela, such excess is consistent with estimates based on mortality data. The excess risk for hospitalization for asthma of children living in Gela is likely to be caused by air pollution, although it might also reflect the limited availability of additional medical support outside the hospital in the same area. In any case, an immediate medical intervention is needed in the area to control children’s respiratory health.
Worldwide, many many studies have suggested that congenital malformations are a possible adverse effect of exposure to environmental contamination, which makes the concern of residents in high-risk areas of Sicily quite understandable. Unfortunately, Sicily has lacked a continuous, quality-controlled population-based registry of congenital malformations. In the two above-mentioned surveys in Gela and Syracuse, both of which indicate an excess of congenital malformations, methods for registration did not completely correspond to international standards. Thus, overreporting cannot be excluded. Nevertheless, the eligibil-ity of each case was controlled by an experienced geneticist.
Also, it is hard to believe that flaws in the registration mechanisms may have led to an artefactual twofold excess in a variety of categories of malformations. In particular, the high prevalence of hypospadias found in Gela and Augusta was in agreement with suggested causal associations with endocrine disruptors (Baskin, 2004). In an overall evaluation of the health effects intended to set priorities for rehabilitation and prevention, the available findings, albeit imperfect, cannot be dismissed.
Other specific aspects of the environment-related health of residents in the contaminated areas of Sicily will become visible through further consideration of the data currently available, as well as further analy-ses and integration of epidemiological knowledge into ad hoc studies. For the time being, health statistics add to social and environmental knowledge and emphasize the vital importance of rehabilitation in Sicily.
6. EnvironMEnTAl PolluTion in AugusTA–Priolo And gElA
Loredana Musmeci, Fabrizio Falleni, Maria Rita Cicero and Mario Carere
Introduction
The Italian National Institute of Health and the Italian Ministry of the Environment, Land and Sea carried out a project, from 2007 to 2009, to study the chemical quality of environmental matrices in the contami-nated areas of Gela and Augusta–Priolo. The study evaluated the possible toxicological effects of chemical substances on the local human population.
The Gela and Augusta–Priolo areas are characterized by diffuse environmental contamination, due to the presence of large chemical industrial complexes. During the last few decades, these complexes have caused progressive contamination of the different environmental matrices through the presence of compounds that are mainly toxic, persistent and can bioaccumulate. The Gela and Augusta–Priolo areas have been included in the list of sites of national concern for which specific legislation is in force in Italy (Ministry of the Environment and Territory, 2000a, 2001a; Parliament, 2006).
All data on chemicals available in the scientific literature, regional reports, local projects and legislative monitoring plans in the Gela and Augusta–Priolo areas were collected to assess the risks the different ex-posure routes present to the local human population. Environmental data on soil, inland and marine wa-ters, sediment, groundwater, drinking-water, air, and food were screened and evaluated for their relevance to the health of the local population.
During the period of the study, the following major European legislation on the protection of the environ-ment and health was considered:
• Commission Regulation 1881/2006, setting the maximum levels for certain contaminants in food-stuffs (EC, 2006a) – in particular, the levels of some substances (relevant to the present study) in fish and shellfish to be placed on the market;
• Council Directive 98/83/EC on the quality of water intended for human consumption (EU, 1998), setting the threshold values for a long list of compounds in drinking-water;
• Directive 2000/60/EC (EU, 2000), establishing a framework for European Commission action in the field of water policy, to achieve a good chemical and ecological status in all European surface water by 2015 through a stepwise approach and technical milestones – such as the characterization of risks (pollution risks, for example), analyses of the pressures and effects of human activity, and the moni-toring and design of action programmes – and also through obligations placed on Member States to manage water resources on a river–basin scale;
• Directive 2006/118/EC (EU, 2006) on the protection of groundwater against pollution and deteriora-tion, which aims to protect groundwater resources by setting threshold values for a series of sub-stances in groundwater; and
• Directive 2008/105/EC on environmental quality standards in the field of water policy (EU, 2008), setting standards for the list of European priority substances in surface water.
All these European laws have been transposed into national legislation and represent a key element for evaluating environmental contamination and for protecting human health.
The following four steps were applied to evaluate the risks environmental contamination present to the human population:
1. select local priority substances of concern in the two areas;
2. elaborate on the toxicological profiles of these substances, focusing on the adverse effects on human health;
3. compare the levels of concentration of these substances with the threshold values or quality stand-ards present in the legislation or in scientific studies; and
4. draft preliminary hazard assessments for these substances.