Metodologia e "case studies" per la valutazioned'impatto sanitario in grandi aree industriali

Metodologia e “case studies” per la valutazione d’impatto sanitario in

grandi aree industriali. L’approccio dell’OMS

Roberto Bertollini MD MPH Chief Scientist and WHO Representative to the EU Brussels, Belgium

Outline •  The WHO environment and health

framework •  Industrial sites and health: a european

issue •  Case studies: methodological challenges

and interpretation •  Conclusions

The WHO European Region

•  53 Member States •  900 000 000 pop •  Extending to central Asia

The Fifth Ministerial Conference on Environment and Health

Environment and Health in Europe:

Fifth Ministerial Conference Parma, Italy, 10-12 March 2010

WHO Regional Office for Europe

Photo G. Basilico Photo Carra

Priorities from Parma Conference We are committed to act on the key environment and health challenges of our

time. These include: (a) the health and environmental impacts of climate change and

related policies; (b) the health risks to children and other vulnerable groups posed by

poor environmental, working and living conditions (especially the lack of water and sanitation);

(c) socioeconomic and gender inequalities in the human environment and health, amplified by the financial crisis;

(d) the burden of noncommunicable diseases, in particular to the extent that it can be reduced through adequate policies in areas such as urban development, transport, food safety and nutrition, and living and working environments;

(e) concerns raised by persistent, endocrine-disrupting and bio-accumulating harmful chemicals and (nano)particles; and by novel and emerging issues;

(f) insufficient resources in parts of the WHO European Region.

The Fifth Ministerial Conference on Environment and Health Parma, Italy 10-12 March 2010

About 250,000 sites in European Environment Agency-‐EEA member countries are defined as requiring clean up (h?p://themes.eea.europa.eu/)

Sources of contaminaFon in soil and water of European contaminated sites

http://www.eea.europa.eu/data-and-maps/figures/breakdown-of-activities-causing-local-soil-contamination

Industrial sites and health •  Large concentrations of industrial facilities

–  Chemical, petrochemical –  Waste treatment –  Power generation –  Heavy industry, manufacture – …

•  Environmental impacts on: –  Air –  Water –  Soil –  Food (fruit and veg, meat, fish) –  Noise –  Activities (e.g., transport) – …

Studi OMS “Aree a rischio”

1.  Rapporto Ambiente e Salute in Italia pubblicato nel 1997 (dati 1980-87)

2.  Studio di mortalità 1990-94 (2002) •  confondimento

socioeconomico, •  analisi spaziali e temporali •  stima di impatto

Studying health effects: exposure •  Occupational vs environmental •  Many (mixed) contaminants •  Many exposure pathways •  Often low quality/resolution data

– Emissions – Concentrations – People’s mobility and activities

•  Difficult to identify an exposure gold standard for

•  Residential information often used

Kidney cancer, men municipalities of Caserta district

Geographical distribution of the Risk applying a Standard indicator

(Standardized Mortality Ratio (SMR))

Geographical distribution of the Risk applying a Smoothed indicator

(Bayesian Hierarchical Estimator (BMR))

Number of municipalities

500 1000 1500 2000 2500 3000 3500

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Basse di Stura landfill

Bladder cancer - men

Distance from the landfills (mt)

Cases by census tracts

Area of Massa Carrara (2 municipalities)* Mortality: chronic respiratory diseases

Men: 90% of RRs between 43.2 and 143.7 Homogeneity test: p < 0.01

Women: 90% of RRs between 59 and 149.8 Homogeneity test : p < 0.01

*Circle with radius of 26 km and centre in Massa (38 munic.)

Men Women

> 125 (10) 110-125 (0) 90-110 (7) 75-90 (6) 0-75 (15)

> 125 (15) 110-125 (2) 90-110 (4) 75-90 (2) 0-75 (15)

SMRs SMRs

> 125 (3) 110-125 (4) 90-110 (19) 75-90 (12) 0-75 (0)

> 125 (1) 110-125 (3) 90-110 (25) 75-90 (8) 0-75 (1)

EBRs EBRs

0

Km

10 20

0

Km

10 20

Area of Massa Carrara: respiratory diseases - men

1920 1925 1930 1935 1940

Cohort of birth

7.05

6.09

5.1

4.01

1.36

Cum

ulat

ive

risk

% (0

-64)

0 2

4 6

8 10

12

What health endpoints? •  Need to consider broad spectrum

– Short- and long- term – Severe (mortality, cancer, hospital admission)

and less severe (respiratory conditions) – Mostly a-specific

•  Strong competing determinants involved – Occupational vs environmental – Lifestyle – Predispostion – Quality of health care

Pirastu R & Comba P. E&P 35 (5-‐6) se?embre-‐dicembre 2011 Suppl.2

298 municipaliFes

5,551,878 residents at 2001 Census

North

Central

South and Islands

44 Italian Polluted Sites in SENTIERI Project. MunicipaliFes and residents by geographic macroarea

SENTIERI: Summing up

•  9,969 excess deaths in 8 years, ie 1,200/year

•  2.5% increase in mortality, compared to regional backgrounds

SENTIERI: Mortality cause distribution

Excess deaths

All deaths

Excess deaths

All deaths

Cancers/men

Cancers/women

Excess deaths

All deaths

Interpretation

•  Mix of occup. and environmental exposures –  Airborne –  Water- and foodborne –  Indirect: stress

•  Competing risk factors for mortality excess –  Residual socio-economic confounding –  Lifestyle –  Quality of secondary prevention

and health care

•  Difficult to assess “attributable” risk, but…

…we have a partial view •  “Softer” health outcomes

–  Morbidity –  Hospital admission –  Reproductive effects

•  Quality of life near industrial areas –  Psychosocial effects –  Smell –  Noise –  Impact on landscape

Questions •  What is the health profile of resident

populations, as described by mortality and morbidity?

•  What is the contribution of environmental contamination?

•  How does it interplay with other health determinants?

•  How far can well being be addressed? •  What implications for remediation, clean

up, future development?

Expert consultation

http://www.euro.who.int/__data/assets/pdf_file/0003/ 186240/Contaminated-sites-and-health.pdf

•  Three expert meetings, 2011-12 •  Case studies •  Priorities, interests, needs •  Methodological options •  Environmental characterisation •  Data availability •  Exposure assessment •  Biomonitoring (separate report) •  Health impacts

http://www.hindawi.com/journals/jeph/si/480565/ NOT YET COMPLETED

High risk areas in Sicily

Milazzo-Valle del Mela

Augusta – Priolo (SR) Gela (CL)

WHO work in Sicily •  Starts in 1995, with MoE •  Since 1996, with projects

funded by Regional Govt •  Aims

–  Describe health profile of residents

–  Advise on env remediation •  Invoved strong partnerships

–  ISS, CNR, research centres, –  OER, Cancer Registries,

Universities, …

General objectives •  Updated of health profiles of local

populations •  Integrated exposure assessment •  Role of food chain as a vehicle for human

exposure •  Consolidation of European scientific

network on contaminated areas •  Sicilian data in international context;

Consolidate European network

Support to policy and governance •  Question: “What is the health impact of

industrial site?” •  Includes but is not limited to:

– What is the impact of contaminant X? •  Aims at identifying and promoting health-

friendly policies – Early adoption of clean technologies and

alternatives – Abatement of emissions – Clean-up of contaminated areas – Protection of vulnerable groups

Broader assessments needed •  “Hard” health impacts •  Vulnerability to accidents •  Quality of life near industrial areas

– Smell –  Impact on landscape – Psychosocial effects – Property values – Selective migration patterns – Environmental justice – …

•  Lead: an “evergreen” •  Large burden of disease in Europe •  Clean up in Zg Mežiška dolina, mining site,

Slovenia – contaminated for centuries (Otorepec et al, 2013)

Remediation works

Risk perception

R = H + O •  Sandman’s formula: Perceived risk = Hazard + Outrage •  “Outrage” factor always high in contaminated sites •  The 12 principal components of outrage (P Sandman, 2003).

“Safe” “Risky” 1.  Voluntary Coerced 2.  Natural Industrial 3.  Familiar Exotic 4.  Not memorable Memorable 5.  Not dreaded Dreaded 6.  Chronic Catastrophic 7.  Knowable Unknowable 8.  Individually controlled Controlled by others 9.  Fair Unfair 10.  Morally irrelevant Morally relevant 11.  Trustworthy sources Untrustworthy sources 12.  Responsive process Unresponsive process

International WHO network

•  Contaminated sites are a significant public health issue in many countries in Europe and beyond

•  Many experiences, but heterogeneous: definitions, priorities, needs, methodology and international comparisons difficult

•  Public health and environmental agencies both engaged – more cooperation beneficial

•  Request of common approaches and tools for: –  Health impact assessment, i.e. define health risk/profiles of populations living

close to contaminated sites –  Environmental monitoring and Epidemiological surveillance, i.e. verify the

effectiveness of remediation activities and Public Health interventions

Objectives of the WHO network •  Production of guidelines:

–  data –  methodology –  interpretation –  communication

•  Develop methodology •  Development of training modules •  Carry out studies (within and between countries,

including on children)

Conclusions •  Contaminated sites are a relevant public health issue –

not fully appreciated •  An acute case of EH inequalities and environmental

injustice •  Literature is sparse •  Rich available methodology for analysis •  Integrate better across disciplines (eg, biomonitoring) •  Invest in more inclusive approaches •  Strengthen international collaboration

à WHO Collaborating Centre established at ISS in 2013 (Director, I Iavarone)

Metodologia e "case studies" per la valutazioned'impatto sanitario in grandi aree industriali

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