[Effects of Asbestos on Human Health. Document of the Italian Epidemiological Association (AIE)]

OBJECTIVES

the Italian Epidemiological Association (AIE) intends to formulate assessments and recommendations on the most relevant and critical aspects in the preparation, conduct, and interpretation of epidemiological investigations on the health effects of exposure to asbestos and asbestos-like fibres.

DESIGN, SETTING, AND PARTICIPANTS

the document was prepared by a working group of AIE associates, with a broad curriculum of epidemiological investigations, starting from the evaluation of scientific evidence, and was subsequently evaluated by the AIE governing body.

RESULTS

the topics covered included: • consumption and presence of asbestos; • association between asbestos exposure and disease; • epidemiological surveillance of asbestos related diseases in Italy; • risk function for asbestos related diseases; • increased risk and anticipation of the disease; • interaction between asbestos and other carcinogens; • diagnosis in epidemiological studies; • assessment of exposure to asbestos; • epidemiological evidence on asbestos related diseases.

CONCLUSIONS

the document ends with a summary of the conclusions of scientific research shared by AIE, with reflection on the methodology to be followed for the application at individual level of the results of epidemiological studies, and the proposal of themes on which to direct research.

Initial plans for a large-scale investigation into the chronic health effects of earthquakes in Italy: building on Barbara Pacelli's legacy

Barbara Pacelli, a young Italian epidemiologist, passed away unexpectedly in September 2019. During her prolific professional life, she gave several scientific contributions to natural disaster epidemiology, particularly in relation to the medium and long-term health effects of earthquakes. In this opinion paper, we reflect on Barbara's legacy and outline potential actions that could arise from her work. Particularly, availability of electronic health records would enable a systematic and large-scale investigation into the long-term health effects of earthquakes in Italy, a country with high seismic risk. This effort would have high societal value as it would likely enable mitigation of substantial morbidity and mortality in areas affected by earthquakes. In this paper, we define scope, objectives, potential data sources, and analysis methods that could be used to systematically assess the chronic health effects of recent earthquakes in Italy. Keywords: earthquakes; chronic diseases; electronic health records; retrospective cohort; case crossover study.

Host metabolic factors and prognosis in patients treated with immune checkpoint inhibitors for advanced malignancies

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Background: It is well established that an altered host metabolism has an impact on cancer outcome, possibly mediated by several mechanisms, including hyperglicaemia, hyperinsulinemia and presence of chronic inflammation. The aim of our analysis was to evaluate the correlation between host metabolism and clinical outcome in patients with advanced melanoma, kidney and non-small cell lung cancer (NSCLC), treated with immune checkpoint inhibitors (anti-CTLA4, anti PD1 and anti PDL1). Methods: The relationship between presence of type 2 diabetes mellitus (DMII) at baseline and outcome was assessed in 187 patients treated with immune checkpoint inhibitors in two cancer centers. Progression Free Survival (PFS) and Overall Survival (OS) were calculated by Kaplan-Meier estimation; multivariate Cox analysis was performed according to age, gender, BMI (normal < 25 kg/m2, overweight 25-30 kg/m2, obese > 30 kg/m2), type of cancer and line of treatment. Results: One-hundred-sixty-eight patients were available for our analysis. Twenty-eight patients (17%) were diabetic at baseline. Median age was 65 (range 25-80); 83 patients were males (49%); 82 (48%) had advanced melanoma, 83 (49%) NSCLC and 3 (3%) kidney cancer. One-hundred-two (60%) patients had BMI < 25, 51 (30%) were overweight and 16 (10%) were obese. The first line of treatment was immunotherapy in 83 (49%) patients. By univariable analysis median PFS was 4.2 months in non diabetics vs 6.4 in diabetics patients (HR 0.95; 95%CI 0.58-1.58); median OS was 6.17 and 9.1 months, respectively (HR 1.00; 95%CI 0.58-1.75). At multivariable analysis, taking into account DMII, BMI, sex, age, line of treatment and type of cancer, we found that BMI ≤25 was associated with a two fold increase in risk of progression (PD) or death (p = 0.005), whereas patients who received immunotherapy as second or subsequent line had a two fold increase in risk of PD or death (p = 0.003). Conclusions: The results of our analysis show that in patients with advanced cancer treated with immune checkpoint inhibitors, the presence of DMII does not adversely affect the clinical outcome. Conversely, lower BMI was associated with a significantly worse PFS and OS, independently from type of cancer, age and gender. As expected, patients who received immunotherapy in later lines of treatment had a significantly shorter survival.

[Efficacy and effectiveness of prevention programs in the population: for a more rational choice of public health interventions.]

INTRODUCTION

Evidence Based Prevention is becoming increasingly important to guide the policy-makers to choose preventive interventions to be offered to the population. Sometimes however the impact of an intervention in real conditions (effectiveness) may be smaller than the efficacy estimated in studies conducted in experimental settings. This can be due for example to suboptimal coverage of the intervention or to poor compliance of the involved subjects. Regrettably, this aspect is rarely taken into account in the planning of preventive interventions. To evaluate the discrepancy between efficacy and effectiveness of prevention programs we used as examples two interventions for smoking cessation currently available in Italy: 1) Interventions offered by Smoking Cessation Centers; 2) "Minimal Advice" provided by family doctors.

METHODS

Using epidemiological data we estimated the expected effectiveness of interventions under different scenarios.

RESULTS

Even assuming that Smoking Cessation Centers always offer the best available intervention (efficacy: 82%), they do not seem able to have a major effect on smoking cessation in the population (effectiveness: 0.8%). This is due to the very small number of smokers that seek help to these centers (1%). On the contrary, interventions based on minimal advice are anticipated to have much higher effectiveness (21%).

CONCLUSION

Evidence of efficacy of an intervention is not sufficient to ensure that this will have a significant impact on health. The decision to implement a preventive action should be preceded by a careful evaluation of the expected effectiveness and be followed by a post-implementation monitoring to estimate the real impact of the intervention.