Population-wide measures due to the COVID-19 pandemic and exposome changes in the general population of Cyprus in March-May 2020

Non-pharmacological interventions (e.g., stay-at-home orders, school closures, physical distancing) implemented during the COVID-19 pandemic are expected to have modified routines and lifestyles, eventually impacting key exposome parameters, including, among others, physical activity, diet and cleaning habits. The objectives were to describe the exposomic profile of the general Cypriot population and compliance to the population-wide measures implemented during March-May 2020 to lower the risk of SARS-CoV-2 transmission, and to simulate the population-wide measures' effect on social contacts and SARS-CoV-2 spread. A survey was conducted in March-May 2020 capturing different exposome parameters, e.g., individual characteristics, lifestyle/habits, time spent and contacts at home/work/elsewhere. We described the exposome parameters and their correlations. In an exposome-wide association analysis, we used the number of hours spent at home as an indicator of compliance to the measures. We generated synthetic human proximity networks, before and during the measures using the dynamic-[Formula: see text]¹ model and simulated SARS-CoV-2 transmission (i.e., to identify possible places where higher transmission/number of cases could originate from) on the networks with a dynamic Susceptible-Exposed-Infectious-Recovered model. Overall, 594 respondents were included in the analysis (mean age 45.7 years, > 50% in very good health and communicating daily with friends/family via phone/online). The median number of contacts at home and at work decreased during the measures (from 3 to 2 and from 12 to 0, respectively) and the hours spent at home increased, indicating compliance with the measures. Increased time spent at home during the measures was associated with time spent at work before the measures (β= -0.87, 95% CI [-1.21,-0.53]) as well as with being retired vs employed (β= 2.32, 95% CI [1.70, 2.93]). The temporal network analysis indicated that most cases originated at work, while the synthetic human proximity networks adequately reproduced the observed SARS-CoV-2 spread. Exposome approaches (i.e., holistic characterization of the spatiotemporal variation of multiple exposures) would aid the comprehensive description of population-wide measures' impact and explore how behaviors and networks may shape SARS-CoV-2 transmission.

Rapid increase in neuroinvasive West Nile virus infections in humans, Italy, July 2022

As in 2018, when a large West Nile virus (WNV) epidemic occurred, the 2022 vector season in Italy was marked by an early onset of WNV circulation in mosquitoes and birds. Human infections were limited until early July, when we observed a rapid increase in the number of cases. We describe the epidemiology of human infections and animal and vector surveillance for WNV and compare the more consolidated data of June and July 2022 with the same period in 2018.

COVID-19 response: effectiveness of weekly rapid risk assessments, Italy

Problem

After Italy’s first national restriction measures in 2020, a robust approach was needed to monitor the emerging epidemic of coronavirus disease 2019 (COVID-19) at subnational level and provide data to inform the strengthening or easing of epidemic control measures.

Approach

We adapted the European Centre for Disease Prevention and Control rapid risk assessment tool by including quantitative and qualitative indicators from existing national surveillance systems. We defined COVID-19 risk as a combination of the probability of uncontrolled transmission of severe acute respiratory syndrome coronavirus 2 and of an unsustainable impact of COVID-19 cases on hospital services, adjusted in relation to the health system’s resilience. The monitoring system was implemented with no additional cost in May 2020.

Local setting

The infectious diseases surveillance system in Italy uses consistent data collection methods across the country’s decentralized regions and autonomous provinces.

Relevant changes

Weekly risk assessments using this approach were sustainable in monitoring the epidemic at regional level from 4 May 2020 to 24 September 2021. The tool provided reliable assessments of when and where a rapid increase in demand for health-care services would occur if control or mitigation measures were not increased in the following 3 weeks.

Lessons learnt

Although the system worked well, framing the risk assessment tool in a legal decree hampered its flexibility, as indicators could not be changed without changing the law. The relative complexity of the tool, the impossibility of real-time validation and its use for the definition of restrictions posed communication challenges.

Growth and neurodevelopment in low birth weight versus normal birth weight infants from birth to 24 months, born in an obstetric emergency hospital in Haiti, a prospective cohort study

BACKGROUND

Low birthweight (LBW) infants are at higher risk of mortality and morbidity (growth, chronic disease and neurological problems) during their life. Due to the high incidence of (pre-) eclampsia in Haiti, LBW infants are common. We assessed the anthropometric growth (weight and length) and neurodevelopmental delay in LBW and normal birthweight (NBW) infants born at an obstetric emergency hospital in Port au Prince, Haiti, between 2014 and 2017.

METHODS

Infants were followed at discharge and 3, 6, 12, 15, 18, 21 and 24 months of corrected gestational age. At each visit they underwent a physical checkup (weight, length, physical abnormalities, identification of morbidities). At 6, 12, 18 and 24 months they underwent a neurodevelopmental assessment using the Bayley Scale III (motor, cognitive and communication skills). We modelled the trajectories between birth and 24 months of age of NBW compared to LBW infants for weight, length, and raw scores for Bayley III assessments using mixed linear models.

RESULTS

In total 500 LBW and 210 NBW infants were recruited of which 333 (46.7%) were followed up for 24 months (127 NBW; 60.5% and 206 LBW; 41.2%) and 150 died (LBW = 137 and NBW = 13). LBW and NBW babies gained a mean 15.8 g and 11.4 g per kg of weight from discharge per day respectively. The speed of weight gain decreased rapidly after 3 months in both groups. Both groups grow rapidly up to 6 months of age. LBW grew more than the NBW group during this period (22.8 cm vs. 21.1 cm). Both groups had WHZ scores <- 2 up to 15 months. At 24 months NBW babies scored significantly higher on the Bayley scales for gross motor, cognitive and receptive and expressive communication skills. There was no difference between the groups for fine motor skills.

CONCLUSION

LBW babies that survive neonatal care in urban Haiti and live up to 24 months of age, perform similar to their NBW for weight, length and fine motor skills. LBW babies are delayed in gross motor, cognitive and communication skills development. Further research on the clinical significance of these findings and long term implications of this neurodevelopmental delay is needed.

Exposome changes in primary school children following the wide population non-pharmacological interventions implemented due to COVID-19 in Cyprus: A national survey

BACKGROUND

Non-pharmacological interventions (NPI), including lockdowns, have been used to address the COVID-19 pandemic. We describe changes in the environment and lifestyle of school children in Cyprus before the lockdown and during school re-opening, and assess compliance to NPI, using the exposome concept.

METHODS

During June 2020, parents completed an online questionnaire about their children's lifestyle/behaviours for two periods; school re-opening (May 21-June 26) following the population-wide lockdown, and the school period before lockdown (before March).

FINDINGS

Responses were received for 1509 children from over 180 primary schools. More than 72% of children complied with most NPI measures; however, only 48% decreased the number of vulnerable contacts at home. Sugary food consumption was higher in the post-lockdown period with 37% and 26% of the children eating sugary items daily and 4-6 times/week, compared to 33% and 19%, respectively, for the pre-lockdown period (p<0.001). Children's physical activity decreased compared to pre-lockdown (p<0.001), while screen time increased in the post-lockdown period, with 25% of children spending 4-7 hours/day in front of screens vs. 10% in the pre-lockdown period (p<0.001). About half of the children washed their hands with soap 4-7 times/day post-lockdown vs. 30% in the pre-lockdown period (p<0.001).

INTERPRETATION

This national survey showed a high degree of compliance to NPI measures among school children. Furthermore, the exposome profile of children may be affected in the months following NPI measures due to alterations in diet, physical activity, sedentary behaviour, and hand hygiene habits.

FUNDING

Partial funding by the EXPOSOGAS project, H2020 Research and Innovation Programme (grant #810995).

Evaluation of the national surveillance system for invasive meningococcal disease, Italy, 2015-2018

Enhanced laboratory-based surveillance of invasive meningococcal disease (IMD) in Italy was only assessed indirectly by numerically comparing surveillance data cases with hospital discharge records (HDR). In this study, we evaluated the completeness, timeliness and sensitivity of the IMD surveillance in Italy from 2015 to 2018. Completeness and timeliness were described at the national and subnational level. A capture-recapture analysis was conducted to evaluate the sensitivity and positive predictive value (PPV) using HDR as the external source with a combination of deterministic and probabilistic approaches. The characteristics of the unmatched vs. matched cases were compared using multivariable Poisson modeling. Overall, the completeness of data improved, except for specific variables. Timeliness of notifications also improved to a median of 4 days from onset to reporting. For the years 2015-2017, the sensitivity of the surveillance was estimated at 71.4% and the PPV at 77.5%, changing to 80.6% and 66.9% respectively after removing cases with a secondary meningitis diagnosis. We noted substantial sub-national differences. In 2018 sensitivity was 66.5% (135/203) and the PPV was 79.4% (135/170). The adjusted relative risk of being unmatched in 2015-2017 was higher in cases that were ≥60 years, had missing information or symptom onset in December. The IMD surveillance system overall performs well with completeness and timeliness improving in time. Specific challenges identified for individual variables should guide further improvement. Notwithstanding limitations posed by the comparison database, sensitivity and PPV are promising. The study highlights that promoting etiological ascertainment in people ≥60 years and addressing sub-national challenges are the main current challenges to address.

Exposome-based public health interventions for infectious diseases in urban settings

The COVID-19 pandemic placed public health measures against infectious diseases at the core of global health challenges, especially in cities where more than half of the global population lives. SARS-CoV-2 is an exposure agent recently added to the network of exposures that comprise the human exposome, i.e. the totality of all environmental exposures throughout one's lifetime. At the same time, the application of measures to tackle SARS-CoV-2 transmission leads to changes in the exposome components and in characteristics of urban environments that define the urban exposome, a complementary concept to the human exposome, which focuses on monitoring urban health. This work highlights the use of a comprehensive systems-based approach of the exposome for better capturing the population-wide and individual-level variability in SARS-CoV-2 spread and its associated urban and individual exposures towards improved guidance and response. Population characteristics, the built environment and spatiotemporal features of city infrastructure, as well as individual characteristics/parameters, socioeconomic status, occupation and biological susceptibility need to be simultaneously considered when deploying non-pharmacological public health measures. Integrating individual and population characteristics, as well as urban-specific parameters is the prerequisite in urban exposome studies. Applications of the exposome approach in cities/towns could facilitate assessment of health disparities and better identification of vulnerable populations, as framed by multiple environmental, urban design and planning co-exposures. Exposome-based applications in epidemics control and response include the implementation of exposomic tools that have been quite mature in non-communicable disease research, ranging from biomonitoring and surveillance to sensors and modeling. Therefore, the exposome can be a novel tool in risk assessment and management during epidemics and other major public health events. This is a unique opportunity for the research community to exploit the exposome concept and its tools in upgrading and further developing site-specific public health measures in cities.

Epidemiological characteristics of COVID-19 cases and estimates of the reproductive numbers 1 month into the epidemic, Italy, 28 January to 31 March 2020

BackgroundOn 20 February 2020, a locally acquired coronavirus disease (COVID-19) case was detected in Lombardy, Italy. This was the first signal of ongoing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the country. The number of cases in Italy increased rapidly and the country became the first in Europe to experience a SARS-CoV-2 outbreak.AimOur aim was to describe the epidemiology and transmission dynamics of the first COVID-19 cases in Italy amid ongoing control measures.MethodsWe analysed all RT-PCR-confirmed COVID-19 cases reported to the national integrated surveillance system until 31 March 2020. We provide a descriptive epidemiological summary and estimate the basic and net reproductive numbers by region.ResultsOf the 98,716 cases of COVID-19 analysed, 9,512 were healthcare workers. Of the 10,943 reported COVID-19-associated deaths (crude case fatality ratio: 11.1%) 49.5% occurred in cases older than 80 years. Male sex and age were independent risk factors for COVID-19 death. Estimates of R₀ varied between 2.50 (95% confidence interval (CI): 2.18-2.83) in Tuscany and 3.00 (95% CI: 2.68-3.33) in Lazio. The net reproduction number R_t in northern regions started decreasing immediately after the first detection.ConclusionThe COVID-19 outbreak in Italy showed a clustering onset similar to the one in Wuhan, China. R₀ at 2.96 in Lombardy combined with delayed detection explains the high case load and rapid geographical spread. Overall, R_t in Italian regions showed early signs of decrease, with large diversity in incidence, supporting the importance of combined non-pharmacological control measures.

Epidemiological characteristics of COVID-19 cases and estimates of the reproductive numbers 1 month into the epidemic, Italy, 28 January to 31 March 2020

BackgroundOn 20 February 2020, a locally acquired coronavirus disease (COVID-19) case was detected in Lombardy, Italy. This was the first signal of ongoing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the country. The number of cases in Italy increased rapidly and the country became the first in Europe to experience a SARS-CoV-2 outbreak.AimOur aim was to describe the epidemiology and transmission dynamics of the first COVID-19 cases in Italy amid ongoing control measures.MethodsWe analysed all RT-PCR-confirmed COVID-19 cases reported to the national integrated surveillance system until 31 March 2020. We provide a descriptive epidemiological summary and estimate the basic and net reproductive numbers by region.ResultsOf the 98,716 cases of COVID-19 analysed, 9,512 were healthcare workers. Of the 10,943 reported COVID-19-associated deaths (crude case fatality ratio: 11.1%) 49.5% occurred in cases older than 80 years. Male sex and age were independent risk factors for COVID-19 death. Estimates of R0 varied between 2.50 (95% confidence interval (CI): 2.18-2.83) in Tuscany and 3.00 (95% CI: 2.68-3.33) in Lazio. The net reproduction number Rt in northern regions started decreasing immediately after the first detection.ConclusionThe COVID-19 outbreak in Italy showed a clustering onset similar to the one in Wuhan, China. R0 at 2.96 in Lombardy combined with delayed detection explains the high case load and rapid geographical spread. Overall, Rt in Italian regions showed early signs of decrease, with large diversity in incidence, supporting the importance of combined non-pharmacological control measures.

Spatiotemporal distribution and determinants of measles incidence during a large outbreak, Italy, September 2016 to July 2018

Background

Measles is still endemic in Italy and outbreaks are frequent. From 2016 to 2018, more than 7,000 measles cases were reported to the national integrated measles and rubella surveillance system, the largest outbreak since implementation of this system.

Aim

We aimed to describe the characteristics and spatiotemporal distribution of measles cases in Italy and explore determinants of incidence at municipality level.

Methods

We performed a retrospective observational study, mapping by municipalityall measles cases reported to the national surveillance system with symptom onset between 1 September 2016 and 31 July 2018. We also analysed measles–mumps-rubella (MMR) vaccination coverage (VC) data (2000–2017) for the first and second dose, collected from the Ministry of Health. We used regression analysis to explore factors associated with measles incidence at municipality level.

Results

We analysed 7,854 cases, 3,927 (50%) female. Median age was 26 years; 475 cases (6%) were younger than 1 year. The outbreak occurred in two epidemic waves. The first started in central/northern regions (end of 2016), the second (mostly within 2018) was concentrated in southern regions. In 2016 and 2017, national VC was below 95% for both MMR doses. In 2017, only one region reported VC above 95% for the first dose. At municipality level, incidence was associated with higher urbanisation, less deprivation and fewer adults.

Conclusion

The spread of measles between September 2016 and July 2018 in Italy indicates the need to improve VC and to explore further how societal and other parameters might be linked to incidence.

West Nile virus in Europe: after action reviews of preparedness and response to the 2018 transmission season in Italy, Slovenia, Serbia and Greece

Background

After Action Reviews (AAR) with a One Health perspective were performed in Slovenia, Italy, Serbia and Greece following a severe West Nile virus (WNV) transmission season in 2018. A protocol combining traditional techniques and organizational process analysis was developed and then implemented in each country.

Results

In 2018, response to the unusually intense transmission season of WNV in Slovenia, Italy, Serbia and Greece took place through routine response mechanisms. None of the four countries declared a national or subnational emergency. We found a very strong consensus on the strengths identified in responding to this event. All countries indicated the availability of One Health Plans for surveillance and response; very high laboratory diagnostic capacity in the human, veterinary and entomology sectors and strong inter-sectoral collaboration with strong commitment of engaged institutions as critical in the management of the event. Finally, countries implementing One Health surveillance for WNV (in terms of early warning and early activation of prevention measures) consistently reported a positive impact on their activities, in particular when combining mosquito and bird surveillance with surveillance of cases in humans and equids. Recurring priority areas for improvement included: increasing knowledge on vector-control measures, ensuring the sustainability of vector monitoring and surveillance, and improving capacity to manage media pressure.

Conclusions

The AARs presented here demonstrate the benefit of cross-sectoral and cross-disciplinary approaches to preparedness for West Nile virus outbreaks in Europe. In the coming years, priorities include fostering and strengthening arrangements that: enable coordinated One Health surveillance and response during WNV transmission seasons; ensure adequate laboratory capacities; strengthen risk communication; and fund longer-term research to address the knowledge gaps identified in this study.

A cluster-randomized crossover trial of organic diet impact on biomarkers of exposure to pesticides and biomarkers of oxidative stress/inflammation in primary school children

Despite suggestive observational epidemiology and laboratory studies, there is limited experimental evidence regarding the effect of organic diet on human health. A cluster-randomized 40-day-organic (vs. 40-day-conventional) crossover trial was conducted among children (11–12 years old) from six schools in Cyprus. One restaurant provided all organic meals, and adherence to the organic diet intervention was measured by parent-provided diet questionnaire/diary data. Biomarkers of pyrethroid and neonicotinoid pesticide exposures were measured using tandem mass spectrometry, and oxidative stress/inflammation (OSI) biomarkers using immunoassays or spectrophotometry. Associations were assessed using mixed-effect regression models including interactions of treatment with time. Seventy-two percent of neonicotinoid biomarkers were non-detectable and modeled as binary (whether detectable). In post-hoc analysis, we considered the outcome of age-and-sex-standardized BMI. Multiple comparisons were handled using Benjamini-Hochberg correction for 58 regression parameters. Outcome data were available for 149 children. Children had lower pesticide exposures during the organic period (pyrethroid geometric mean ratio, GMR = 0.297; [95% confidence interval (95% CI): 0.237, 0.373], Q-value<0.05); odds for detection of neonicotinoids (OR = 0.651; [95% CI: 0.463, 0.917), Q-value<0.05); and decreased OSI biomarker 8-OHdG (GMR = 0.888; [95% CI: 0.808, 0.976], Q-value<0.05). An initial increase was followed by a countervailing decrease over time in the organic period for OSI biomarkers 8-iso-PGF2a and MDA. BMI z-scores were lower at the end of the organic period (β = -0.131; [95% CI: 0.179, -0.920], Q-value<0.05). Energy intake during the conventional period was reported to be higher than the recommended reference levels. The organic diet intervention reduced children’s exposure to pyrethroid and neonicotinoid pesticides and, over time lowered biomarkers of oxidative stress/inflammation (8-iso-PGF2a, 8-OHdG and MDA). The several-week organic diet intervention also reduced children’s age-and-sex-standardized BMI z-scores, but causal inferences regarding organic diet’s physiological benefits are limited by the confounding of the organic diet intervention with caloric intake reduction and possible lifestyle changes during the trial.

Trial registration: This trial is registered with ClinicalTrials.gov, number: NCT02998203.

High rate of transmission in a pulmonary tuberculosis outbreak in a primary school, north-eastern Italy, 2019

Italy is a low-incidence country for tuberculosis (TB). We describe a TB outbreak in a primary school in north-eastern Italy, involving 10 cases of active pulmonary disease and 42 cases of latent infection. The index case was detected in March 2019, while the primary case, an Italian-born schoolteacher, was likely infectious since January 2018. Administration of a pre-employment health questionnaire to school staff with sustained contact with children should be considered in low-incidence countries.

Application of the urban exposome framework using drinking water and quality of life indicators: a proof-of-concept study in Limassol, Cyprus

Background

Cities face rapid changes leading to increasing inequalities and emerging public health issues that require cost-effective interventions. The urban exposome concept refers to the continuous monitoring of urban environmental and health indicators using the city and smaller intra-city areas as measurement units in an interdisciplinary approach that combines qualitative and quantitative methods from social sciences, to epidemiology and exposure assessment.

Methods

In this proof of concept study, drinking water and quality of life indicators were described as part of the development of the urban exposome of Limassol (Cyprus) and were combined with agnostic environment-wide association analysis. This study was conducted as a two-part project with a qualitative part assessing the perceptions of city stakeholders, and quantitative part using a cross-sectional study design (an urban population study). We mapped the water quality parameters and participants’ opinions on city life (i.e., neighborhood life, health care, and green space access) using quarters (small administrative areas) as the reference unit of the city. In an exploratory, agnostic, environment-wide association study analysis, we used all variables (questionnaire responses and water quality metrics) to describe correlations between them.

Results

Overall, urban drinking-water quality using conventional indicators of chemical (disinfection byproducts-trihalomethanes (THM)) and microbial (coliforms, E. coli, and Enterococci) quality did not raise particular concerns. The general health and chronic health status of the urban participants were significantly (false discovery rate corrected p-value < 0.1) associated with different health conditions such as hypertension and asthma, as well as having financial issues in access to dental care. Additionally, correlations between THM exposures and participant behavioral characteristics (e.g., household cleaning, drinking water habits) were documented.

Conclusion

This proof-of-concept study showed the potential of using integrative approaches to develop urban exposomic profiles and identifying within-city differences in environmental and health indicators. The characterization of the urban exposome of Limassol will be expanded via the inclusion of biomonitoring tools and untargeted metabolomics.

Occupational exposures to disinfectants and pre-diabetes status among active nurses in Cyprus

Objectives A cross-sectional study was designed in two hospitals of Cyprus to: (i) examine the possible association between exposure to disinfectants/trihalomethanes (THM) with point of care glycosylated hemoglobin (HbA1c) levels among active nurses, and (ii) identify the main determinants of pre-diabetes metabolic risk among active nurses in Cyprus. Methods In total, 179 nurses from two public hospitals in Cyprus were recruited excluding pregnant or nurses working <5 years (participation rate ~25.6%). End-of-shift urine samples were used to measure exposures to THM, and questionnaire items were used to construct improved exposure classification matrices, ie, the job exposure matrix (JEM) and the job-task exposure matrix (JTEM). Results Results showed associations between JEM- and JTEM-derived metrics of exposure and HbA1c for few disinfectants (eg, peracetic acid), but no consistent trends were derived. In multivariable models, adjusted for age, BMI, sex, smoking status and alcohol consumption, the number of night shifts per month, and (ln)chloroform (a THM compound) were associated with HbA1c levels [β 0.11 (95% confidence interval (CI) 0.05-0.17) and 0.05 (95% CI 0.00-0.11), respectively]. Conclusion A significant association between the number of monthly night shifts and HbA1c was observed, but no consistent associations were found between three exposure metrics of eleven different disinfectants, or urinary THM and point of care HbA1c levels in active nurses. Replication of the study findings in larger prospective sample is warranted. This is a novel occupational health dataset shedding light on the possible metabolic effects of exposures to disinfectants/by-products that have not been studied before.

The framework of urban exposome: Application of the exposome concept in urban health studies

Horizontal challenges, such as climate change or the growing populations, and their manifestations require the development of multidisciplinary research synergies in urban health that could benefit from concepts, such as the human exposome. Cities are composed of interconnected systems which are influenced, by global trends, national policies and local complexities. In this context, the exposome concept could be expanded having the city setting in its core, providing the conceptual framework for the new generation of urban studies. The objectives of this work were to define the urban exposome and outline its utility. The urban exposome can be defined as the continuous spatiotemporal surveillance/monitoring of quantitative and qualitative indicators associated with the urban external and internal domains that shape up the quality of life and the health of urban populations, using small city areas, i.e. neighborhoods, quarters, or smaller administrative districts, as the point of reference. Research should focus on the urban exposome's measurable units at different levels, i.e. the individuals, small, within-city areas and the populations. The urban exposome framework applied in the city of Limassol, Cyprus combines three elements: (i) a mixed-methods study on stakeholders' opinions about quality of life in the city; (ii) a systematic assessment of secondary data from the cancer and death registries, including city infrastructure data; and (iii) a population health and biomonitoring survey. Continuous assessment of environmental and health indicators that are routinely collected, and the incorporation of primary data from population studies, will allow for the timely identification of within-city health and environmental disparities to inform policy making and public health interventions. The urban exposome could facilitate evidence-based public health response, offering researchers, policy-makers, and citizens effective tools to address the societal needs of large urban centers.

Biomarkers of end of shift exposure to disinfection byproducts in nurses

Increased disinfectant use commonly takes place in hospitals and other health care settings. A cross-sectional study among active nurses in two Cypriot public hospitals (n=179) was conducted to examine the prevalence of exposure to disinfection byproducts (DBPs), such as trihalomethanes (THMs) using both self-reported information and biomarker measurements. The objectives of this study were to: i) quantify the magnitude and variability of occupational exposure to disinfectants/DBPs in nurses, ii) generate job exposure matrices (JEM) and job task exposure matrices (JTEM) for disinfectants, and iii) assess the major determinants of urinary THMs in nurses. End of shift urinary total THM values showed high variability among the nurses, but did not differ between hospitals. The disinfectant group of alcohols/phenols was used by >98% of nurses, followed by octenidine (82%), iodine and chlorine (39%, each), chlorhexidine (25%), formaldehyde (12%), hydrogen peroxide (11%), and peracetic acid/ammonia/quaternary ammonium compounds (QACs), all being <8% each. Chlorine use during the past 24hr was associated with significantly (p<0.05) lower brominated THMs (BrTHMs) after adjusting for age, gender and BMI, while a positive association was shown for TCM and the sum of all THMs (TTHMs), albeit not significant. Nurses were exposed to nearly double the levels of TTHMs and BrTHMs (median and IQR, 1027 [560, 2475] ng/g and 323 [212, 497] ng/g, respectively) when compared to those of the general population (552 [309,989] ng/g and 152 [87,261] ng/g, respectively). This was the first occupational health dataset reporting measurements of biomarkers of end of shift exposures to disinfectants/DBPs.

Spatial characteristics of urinary BTEX concentrations in the general population

Benzene, toluene, ethylbenzene, o-, m-, and p-xylenes (BTEX) are ubiquitous outdoor and indoor air pollutants associated with both environmental and health effects. The objective of this exploratory study was to determine the magnitude and variability of urinary BTEX levels among residents of two areas located in the same city (Nicosia, Cyprus). The two areas differed with respect to their proximity to an industrial cluster and an intercity-highway. First morning urine voids were collected during a random campaign from selected households in the two urban areas (n = 48). Urinary BTEX measurements were obtained using headspace solid phase micro extraction coupled with gas chromatography-mass spectrometry. The majority of participants were females (65%) and non-smokers (85%) with a mean age of 49 years. Median urinary BTEX levels were: 118 ng L^-1, 124 ng L^-1, 9 ng L^-1, 29 ng L^-1 and 28 ng L^-1 for benzene, toluene, ethylbenzene, (p + m)-xylene and o-xylene, respectively. With the exception of benzene, participants from area 2 (closer to the industrial cluster and an intercity road than area 1) had significantly (p < 0.05) higher urinary BTEX levels than those from area 1 (regression analysis). The residence location (in area 2) was the sole significant (p < 0.05) predictor of urinary BTEX levels after adjusting for sex, smoking, age, body mass index, and educational level. This observational study showed differences in BTEX exposures between two urban areas of the same city. This baseline BTEX dataset may prove useful for future activities of natural gas extraction and handling nearby urban settings.

Human Exposures to Bisphenol A, Bisphenol F and Chlorinated Bisphenol A Derivatives and Thyroid Function

Although the increasing prevalence of thyroid nodular disease (TND) has been partially attributed to the more frequent usage of improved diagnostics, environmental factors, such as exposures to thyroid-disrupting chemicals may contribute to TND and altered thyroid function. We investigated the association between exposures to bisphenol A (BPA), its chlorinated derivatives (ClxBPA), and bisphenol F (BPF) with TND and thyroid measures in adult women. A case-control study in Cyprus and Romania (n = 212) was conducted, where cases were those with thyroid nodules (diameter >3mm), and controls without nodules. Serum TSH and free thyroxine and urinary levels of BPA, BPF and ClxBPA were measured using immunoassays and tandem mass spectrometry, respectively. The association between exposures to BPA compounds and TND, adjusting for age, BMI, thyroid hormones and urinary iodine was assessed using logistic regression. Linear regression was used to explore associations between urinary BPA, BPF and ClxBPA and serum thyroid hormones. With the exception of a chlorinated BPA compound (30%), the rest of bisphenols were quantified in 100% of urine samples. A positive and significant (p<0.05) association was observed between urinary BPA and serum TSH that remained after adjusting for urinary creatinine, age, BMI, study site and disease status; there was no significant association between BPF or ClxBPA with TSH. None of the BPA compounds were associated with higher odds of TND. Our study found associations of urinary BPA with TSH but not with BPF or ClxBPA. A larger study would be justified.

Association between exposures to brominated trihalomethanes, hepatic injury and type II diabetes mellitus

Non-alcoholic fatty liver disease (NAFLD) is considered the most common liver disorder in the Western world, commonly diagnosed in the majority of obese patients with type 2 diabetes mellitus (T2DM). Metabolic disrupting chemicals with short half-lives, such as those of halogenated structure (trihalomethanes, THM) have been linked with hepatic insulin resistance phenomena in animal studies. However, human studies evaluating the role of THM exposure on liver pathogenesis and T2DM disease process are scarce. The objectives of this study were to: i) determine the association of urinary brominated THM (BrTHM) levels and T2DM disease status, and ii) investigate the association between urinary BrTHM levels and serum alanine aminotransferase (ALT) concentrations, often used as surrogate markers of NAFLD. A pilot case-control study was conducted in Nicosia, Cyprus (n=95). Cases were physician-diagnosed T2DM patients and controls were healthy individuals. Liver enzymes, leptin and TNF-α were measured in sera, while urinary THM levels were measured using tandem mass spectrometry. Diabetics had higher levels of serum leptin, body mass index and ALT than the controls. Among all study participants those with serum ALT levels above the median (17IU/L) had higher mean tribromomethane (TBM) concentrations compared to those with serum ALT below 17IU/L. A significant increase in the odds of having above the median serum ALT levels [OR 6.38, 95% CI: 1.11, 42.84 (p=0.044)] was observed for each unit increase in creatinine-unadjusted urinary TBM levels, along with BMI and past smoking, after adjusting for possible confounders, such as urinary creatinine, age, sex, and leptin; no other THM compound showed a significant association with serum ALT. Logistic regression models for T2DM using the urinary BrTHM as exposure variables did not reach the predetermined level of significance. The interplay between exposures to BrTHM and the initiation of key pathophysiological events relating to hepatic injury (ALT) and inflammation (leptin) was recognized via the use of selected biomarkers of effect. Our evidence that THM could act as hepatic toxins with a further initiation of diabetogenic effects call for additional studies to help us better understand the disease process of the two co-morbidities (NAFLD and T2DM).

Investigation of thyroid nodules in the female population in Cyprus and in Romania

Background and aims

The most common thyroid disorders, with an increasing detection worldwide, are the thyroid nodules and thyroiditis, which leads to an increase of thyroid cancer incidence . In two different countries with a different exposure to risk factors for thyroid cancer, such as Cyprus and Romania, the rank of thyroid cancer among other neoplasms is very different: the 3^rd most prevalent cancer among females in Cyprus and the 12^th in Romania, respectively. Environmental chemicals, such as bisphenol A have a proven effect on the thyroid function. However, the relation between the exposure to the endocrine disruptor and the development of thyroid nodules, with a potential of malignant transformation has not been previously studied. The aim of the study was to investigate the potential factors that lead to the difference of thyroid nodules incidence in the mentioned countries.

Methods

A pilot case-control study has been conducted in 2014–2015 in the “Prof. Dr. Ion Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania and the Endocrinology Department of Archbishop Makarios III Hospital, Nicosia, Cyprus. Females older than 20 years with no medical history were recruited. Cases were women with ultrasound-confirmed thyroid nodules of size >3mm. Controls were women without thyroid nodules after ultrasound confirmation. All participants provided blood samples for measurements of the thyroid stimulating hormone (TSH), free thyroxin (FT4), anti-thyroglobulin (ATg) and anti-thyroid peroxidase (ATPO); urine samples. Demographics, anthropometrics and other relevant information were provided through the administration of a questionnaire.

Results

In Romania we selected 51 patients with thyroid nodules (case group) and 41 without thyroid nodules (control group) and in Cyprus 57 cases, respectively 65 controls. After the statistical analysis of the data collected we observed statistically significant differences between the populations of the two countries regarding BMI and the value of the thyroid hormones and antibodies.

Conclusions

Using the data observed in this study, differences were found between Cyprus and Romania among females with thyroid nodules the BMI, and the level of thyroid hormones had statistically significant differences. This study reports preliminary data, further analysis of environmental exposures to chemical factors that might have a certain influence over the thyroid in the two countries will follow.

Preliminary evidence of the association between monochlorinated bisphenol A exposure and type II diabetes mellitus: A pilot study

Evidence for the association of bisphenol A (BPA) with type II diabetes mellitus (T2DM) has been inconsistent in human studies. In-vitro and animal studies indicate that chlorinated BPA derivatives aggravate BPA health effects via higher estrogenic activity and alteration of membrane-initiating signaling pathways. We evaluated the association between urinary monochlorinated BPA (mono-ClBPA) concentrations and the incidence of T2DM. In our cross-sectional study, we identified 20 adult participants (≥18 yr) who reported having T2DM (doctor-diagnosed) and 131 adults with normal health. First morning void urine samples were analyzed for total BPA and mono-ClBPA. Detection limits of the analytical method were 95 ng L(-1) for BPA and 32 ng L(-1) for mono-ClBPA. Multivariable logistic regression analyses and additive Bayesian network modeling were performed. After adjusting for age, gender, BMI, urinary total BPA and other confounders, the odds of having T2DM was 3.29 times higher (95% confidence interval, CI: 1.10, 11.4; P < 0.05) per unit increase in log-transformed and creatinine-adjusted urinary mono-ClBPA levels (n = 151); this relation did not hold for total BPA. The globally optimum Bayesian model corroborated the results of the logistic regression by expressing mono-ClBPA in the pathway of T2DM, and not for total BPA. An age-matched sensitivity analysis confirmed the increase in OR of T2DM by 3.04 times (95% CI: 1.10, 11.0; P < 0.05) per unit increase in log-transformed and creatinine-adjusted urinary mono-ClBPA concentration (n = 68). The urinary monochlorinated BPA derivative was significantly associated with T2DM, whereas the parent compound (total BPA) was not. Caution should be applied in interpreting these findings, as this is the first study to report this association and the sample size of participants with T2DM is small. Additional research with a larger sample size coupled with relevant toxicological studies is warranted.

Spatial and seasonal variability of urinary trihalomethanes concentrations in urban settings

A complex network of sources and routes of exposure to disinfection by-products (DBP), such as trihalomethanes (THM) has been driving the wide variability of daily THM intake estimates in environmental epidemiological studies. We hypothesized that the spatiotemporal variability of THM exposures could be differentially expressed with their urinary levels among residents whose households are geographically clustered in district-metered areas (DMA) receiving the same tap water. Each DMA holds unique drinking-water pipe network characteristics, such as pipe length, number of pipe leaking incidences, number of water meters by district, average minimum night flow and average daily demand. The present study assessed the spatial and seasonal variability in urinary THM levels among residents (n=310) of geocoded households belonging to two urban DMA of Nicosia, Cyprus, with contrasting water network properties. First morning urine voids were collected once in summer and then in winter. Results showed that the mean sum of the four urinary THM analytes (TTHM) was significantly higher during summer for residents of both areas. Linear mixed effects models adjusted for age, season and gender, illustrated spatially-resolved differences in creatinine-adjusted urinary chloroform and TTHM levels between the two studied areas, corroborated by differences observed in their pipe network characteristics. Additional research is warranted to shed light on the contribution of spatially-resolved and geographically-clustered environmental exposures coupled with internal biomarker of exposure measurements towards better understanding of health disparities within urban centers.

ExTopoDB: a database of experimentally derived topological models of transmembrane proteins

ExTopoDB is a publicly accessible database of experimentally derived topological models of transmembrane proteins. It contains information collected from studies in the literature that report the use of biochemical methods for the determination of the topology of α-helical transmembrane proteins. Transmembrane protein topology is highly important in order to understand their function and ExTopoDB provides an up to date, complete and comprehensive dataset of experimentally determined topologies of α-helical transmembrane proteins. Topological information is combined with transmembrane topology prediction resulting in more reliable topological models.

AVAILABILITY

http://bioinformatics.biol.uoa.gr/ExTopoDB.