Background:

Evidence on the association between colorectal cancer and exposure to disinfection by-products in drinking water is inconsistent.

Objectives:

We assessed long-term exposure to trihalomethanes (THMs), the most prevalent group of chlorination by-products, to evaluate the association with colorectal cancer.

Methods:

A multicenter case–control study was conducted in Spain and Italy in 2008–2013. Hospital-based incident cases and population-based (Spain) and hospital-based (Italy) controls were interviewed to ascertain residential histories, type of water consumed in each residence, frequency and duration of showering/bathing, and major recognized risk factors for colorectal cancer. We estimated adjusted odds ratios (OR) for colorectal cancer in association with quartiles of estimated average lifetime THM concentrations in each participant’s residential tap water (micrograms/liter; from age 18 to 2 years before the interview) and estimated average lifetime THM ingestion from drinking residential tap water (micrograms/day).

Results:

We analyzed 2,047 cases and 3,718 controls. Median values (ranges) for average lifetime residential tap water concentrations of total THMs, chloroform, and brominated THMs were 30 (0–174), 17 (0–63), and 9 (0–145) μg/L, respectively. Total THM concentration in residential tap water was not associated with colorectal cancer (OR = 0.92, 95% CI: 0.66, 1.28 for highest vs. lowest quartile), but chloroform concentrations were inversely associated (OR = 0.31, 95% CI: 0.24, 0.41 for highest vs. lowest quartile). Brominated THM concentrations showed a positive association among men in the highest versus the lowest quartile (OR = 1.43, 95% CI: 0.83, 2.46). Patterns of association were similar for estimated average THM ingestion through residential water consumption.

Conclusions:

We did not find clear evidence of an association between detailed estimates of lifetime total THM exposure and colorectal cancer in our large case–control study population. Negative associations with chloroform concentrations and ingestion suggest differences among specific THMs, but these findings should be confirmed in other study populations.

Citation:

Villanueva CM, Gracia-Lavedan E, Bosetti C, Righi E, Molina AJ, Martín V, Boldo E, Aragonés N, Perez-Gomez B, Pollan M, Gomez Acebo I, Altzibar JM, Jiménez Zabala A, Ardanaz E, Peiró R, Tardón A, Chirlaque MD, Tavani A, Polesel J, Serraino D, Pisa F, Castaño-Vinyals G, Espinosa A, Espejo-Herrera N, Palau M, Moreno V, La Vecchia C, Aggazzotti G, Nieuwenhuijsen MJ, Kogevinas M. 2017. Colorectal cancer and long-term exposure to trihalomethanes in drinking water: a multicenter case–––control study in Spain and Italy. Environ Health Perspect 125:56–65; http://dx.doi.org/10.1289/EHP155

Background:

Trihalomethanes (THMs) are widespread disinfection by-products (DBPs) in drinking water, and long-term exposure has been consistently associated with increased bladder cancer risk.

Objective:

We assessed THM levels in drinking water in the European Union as a marker of DBP exposure and estimated the attributable burden of bladder cancer.

Methods:

We collected recent annual mean THM levels in municipal drinking water in 28 European countries (EU28) from routine monitoring records. We estimated a linear exposure–response function for average residential THM levels and bladder cancer by pooling data from studies included in the largest international pooled analysis published to date in order to estimate odds ratios (ORs) for bladder cancer associated with the mean THM level in each country (relative to no exposure), population-attributable fraction (PAF), and number of attributable bladder cancer cases in different scenarios using incidence rates and population from the Global Burden of Disease study of 2016.

Results:

We obtained 2005–2018 THM data from EU26, covering 75% of the population. Data coverage and accuracy were heterogeneous among countries. The estimated population-weighted mean THM level was 11.7μg/L [standard deviation (SD) of 11.2]. The estimated bladder cancer PAF was 4.9% [95% confidence interval (CI): 2.5, 7.1] overall (range: 0–23%), accounting for 6,561 (95% CI: 3,389, 9,537) bladder cancer cases per year. Denmark and the Netherlands had the lowest PAF (0.0% each), while Cyprus (23.2%), Malta (17.9%), and Ireland (17.2%) had the highest among EU26. In the scenario where no country would exceed the current EU mean, 2,868 (95% CI: 1,522, 4,060; 43%) annual attributable bladder cancer cases could potentially be avoided.

Discussion:

Efforts have been made to reduce THM levels in the European Union. However, assuming a causal association, current levels in certain countries still could lead to a considerable burden of bladder cancer that could potentially be avoided by optimizing water treatment, disinfection, and distribution practices, among other possible measures. https://doi.org/10.1289/EHP4495

Background and Aims: Chlorate is a disinfection by-product (DBP) originating from chlorine dioxide water disinfection, which can be a contaminant of sodium hypochlorite solutions as well. Due to its not yet well investigated genotoxic and carcinogenic potential effects, it is considered, together with other DBPs , an emerging DBP for which further research on occurrence levels and toxicological properties is a prior need. The aim of this study was to evaluate in some Italian regions the potential exposure to chlorate via drinking water of the general population and of a specific population (swimmers).

Methods: Chlorate levels were investigated in drinking water samples collected form 12 waterworks located in Emilia-Romagna, Friuli Venezia Giulia and Lombardia Regions. To investigate spatial and seasonal variability, different water samples (n.194) were collected at different points along the distribution system and over four seasons. In the same period 20 swimming pools in the Emilia-Romagna Region were investigated for the occurrence of chlorate in water pools. Chlorate analysis was performed by ion chromatography (detection limit: 1 µg/l).

Results: Chlorate occurred in 97% of the drinking water samples, (median:18, range: 2-399µg/l) and resulted always below the provisional WHO guidelines (700µg/l). Nevertheless, significant differences in levels were observed according to disinfection methods, and the highest levels occurred in water disinfected both with chlorine dioxide and ozone (median:163, range:83-399µg/l). No clear spatial or seasonal trends were observed. Swimming pool waters showed much more higher chlorate levels (median:4347, range: 5-19537µg/l) and significant differences according to disinfectant applied were also observed.

Conclusions: In the Italian investigated regions, chlorate appears to be widespread both in drinking and swimming pool waters; in the latter particularly high levels were observed in different settings. Swimmers are therefore a potentially highly exposed population subgroup: to evaluate health implications of this specific exposure pathway, however, further investigation is needed.

Background and Aims: Trichloramine (NCl₃) is a volatile disinfection by-product (DBP) which is formed when chlorine in water reacts with nitrogen-containing compounds. NCl₃ is a strong mucous membrane irritant and it has been recently linked with respiratory symptoms and asthma in swimmers, mainly in children, and in pool attendants. However, there are some issues to clarify about NCl₃ exposure in indoor swimming pools and one of them deals with the analytical determination of NCl₃ in ambient air. The aim of this study was to investigate the feasibility of a new modified DPD/KI colorimetric method, recently proposed in literature, for the analysis of airborne NCl₃ in indoor swimming pools. The relationships between NCl₃ ambient air levels and some other DBPs in these environments were also evaluated.

Methods: Airborne NCl₃ levels were investigated in 20 indoor swimming pools. Technical characteristics and disinfection treatments were collected together with physical and chemical parameters in water. Trihalomethanes (THMs) levels in water and air were also investigated.

Results: The airborne NCl₃ levels ranged from 204 to 1020 µg/m and the mean value was 648.7 ± 201.4 µg/m. High levels of combined chlorine in water were observed: only 25% of the investigated swimming pools showed levels ≤ 0,4 mg/l, which is the Italian limit value. The average and highest THMs levels in water were 41.4 and 134 µg/l, respectively. Mean ambient air THMs value was 86.0 ± 47.9 µg/m and 187 µg/m was the maximum value. Airborne NCl₃ levels were found associated only with combined chlorine (r= 0.441; p < 0.05) and with THMs levels in ambient air (r= 0.554; p < 0.05).

Conclusions: Airborne NCl₃ levels are in line with other studies in literature. However more than 50% of the investigated indoor swimming pools showed NCl₃ levels higher than the recommend provisional value of 500 µg/m, as suggested in WHO guidelines.

Background and Aims: The aim of this cross-sectional study was to investigate the association between airborne NCl₃ exposure in indoor swimming pools and the prevalence of self-reported respiratory and ocular symptoms in occupationally exposed subjects.

Methods: Twenty indoor swimming pools in the Emilia-Romagna region of Italy were included in the study. Information about the health status of 128 employees was collected using a self-administered questionnaire. Exposure to airborne NCl₃ was evaluated in indoor swimming pools by a modified DPD/KI method.

Results: The airborne NCl₃ levels ranged from 204 to 1020 µg/m with a mean value of 648.7 ± 201.4 µg/m. More than 50% of the swimming pools showed airborne NCl₃ levels higher than 500 µg/m (recommended WHO guidelines). Both ocular and upper respiratory symptoms were very frequent in the 128 employees: red eyes, runny nose, voice loss and cold symptoms were declared more frequently by pool attendants (lifeguards and trainers) when compared with employees working in other areas of the facility (office, cafe, etc.). Pool attendants exposed to airborne NCl₃ levels higher than 500 µg/m experienced higher risks for runny nose (OR: 2.9; 95% CI: 1.22-6.94), red eyes (OR: 3.2; 95% CI: 1.5-6.8), voice loss (OR: 3.6; 95% CI: 1.6-8.0), itchy eyes (OR: 2.2; 95% CI: 1.0-4.8) than other employees. When high levels of airborne NCl₃ were taken into account (airborne NCl₃ levels ≥ 800 µg/mvs. < 800 µg/m) ocular and respiratory symptoms became much more evident, with higher risks (as ORs) in exposed subjects (lifeguards and trainers) compared with other employees.

Conclusions: This study confirms that lifeguards and trainers are at risk for respiratory and ocular irritative symptoms more than other employees in indoor swimming pools, in particular in presence of high airborne NCl₃ levels.

Background and aim As a part of an Italian study on health effects of swimming pools employees, the aim of this study was to investigate the prevalence of self-reported cutaneous symptoms in indoor swimming pools workers, as some epidemiological studies suggested high prevalence rates of eczema in subjects working inside the pool water as trainers, pool attendants and hydro therapists. Materials and methods Information about the health status of 133 employees was collected by a structured questionnaire. The questionnaire recorded demographic characteristics, lifestyle, working related activities (kind of job, number of working hours by day and week, previous or parallel jobs) and symptoms related to cutaneous apparatus (verruca, mycosis, eczema and rash). Results Most of the swimming pool workers were females (52.6%), with a mean age of 33 ys, non-smokers (48.9%), working in swimming pools for an average of 8 years: no statistical differences were observed.. According to the questionnaire data, 50% of the subjects had attended indoor swimming pools for more than 20 years, mainly as swimmers. The prevalence of cutaneous diseases in the investigated subjects was: rash (20.3%), verruca (16.5%), mycosis (15.8%) and eczema (9.0%). However, subjects who declared to spend some hours inside the pool water during their working activities experienced generally more verruca (20.8% vs 3.1%), mycosis (17.8% vs 9.4%) and eczema (9.9% vs 6.2%) than other employees without any activities in the pool water. Rash frequency was very similar (20.3% and 21.9%) in both the categories of workers. Conclusion This study confirms that lifeguards and trainers are more at risk for cutaneous diseases than subjects with other occupations at swimming pool facilities. However, even though our study does not specifically include hydro-therapists, we did not find more eczema or rash in trainers who entered the pool water during their teaching activities when compared with other investigated employees.

On May 2012, two major earthquakes hit the Province of Modena (Emilia Romagna Region, Northern Italy): the country suffered 27 deaths and several hundred injured citizen; 15000 local resident were left homeless. Post-Traumatic Stress Disorder (PTSD) is a major debilitating psychological disorder that frequently occurs after natural disasters, including earthquakes, with a prevalence ranging, according to different authors, from 28 to 70%. Many cases will remit within 12 months, however about one-third of cases will have a chronic course. Given the high PTSD rates in children and adolescents, the long term impact on their well-being and the relevant social costs of chronic mental disorders, it is of primary importance to recognize and effectively treat cases as soon as possible and to identify potential individual and social risk and protective factors to be addressed in future effective preventive interventions. An epidemiological cross-sectional study has been set up and is on progress in a randomly selected sample of school children and adolescents (9-14 years) exposed to the earthquake with the aim to assess the PTSD prevalence and to explore potential risk (demographic, parental factors and level of trauma exposure) and protective factors (e.g. social support) associated to PTSD development and persistence. The assessment protocol includes the administration of an exposure questionnaire on objective/subjective experiences during the earthquake, the UCLA PTSD Index for DSM-IV questionnaire, and the Strengths and Difficulties Questionnaire. Parental symptomatology will be also assessed using the Symptom Checklist-90-R questionnaire, in order to evaluate the influence of parental psychopathology on children conditions. The present research will have important implications for the prevention in Italy of chronic PTSD, for treatment of traumatized children and adolescents, as well as for the development of effective post-trauma interventions.

Introduction

Pharmaceuticals and illicit drug residues are common contaminants of the aquatic environments and appear to be widespread, with consumers being the major source. Even if environmental levels are low, risks for human health cannot be excluded.

Methods

We present the results on the environmental levels of a group of pharmaceuticals and illicit drugs in surface waters, drinking and pool waters in the Province of Modena (Italy). We tested drugs of abuse (cocaine, opioids, amphetamines and cannabis derivatives), and/or their metabolites and 31 pharmaceuticals which have been previously found in significant concentrations in the environment in Italy. Surface waters of Panaro River were sampled upstream, before receiving the input of waters from the sewage treatment plant of Modena, and then downstream. Drinking waters were collected from three different points in water supplies in the Province and one swimming pool water sample was also investigated, because human release of body fluids may be relevant in swimming pool settings. Pharmaceuticals and illicit drug residues were measured by (HPLC–MS/MS), after solid phase extraction (SPE).

Results

Surface water from the Panaro River, before receiving wastewaters, shows the presence, at very low levels, of 9 out of 31 investigated pharmaceutical substances: cocaine and its metabolites were the most detected among illicit drugs. High levels of both pharmaceuticals and illicit drugs were observed in surface waters, immediately after receiving wastewaters from the sewage treatment plant. Pharmaceuticals were rarely detected in drinking water samples, while in swimming pool water the anti-inflammatory pharmaceuticals ibuprofen and ketoprofen were observed. Illicit drugs were found at trace levels both in drinking and in swimming pool waters.

Conclusions

Future research is needed to characterize potential health risks from long-term, low-level exposure to these substances, particularly for sensitive subpopulations.

Introduction: Post-traumatic stress disorder (PTSD) is the most frequent psychological disorder occurring after natural disasters. Some cases have a chronic, unremitting course causing long term health impacts and relevant social costs. On May 2012, two earthquakes of high Richter magnitude hit Modena (Italy), causing 27 deaths, several hundred of injured citizen and more than 15000 homeless. The aim of this study was to investigate the prevalence of chronic PTSD in children and adolescents, two extremely sensitive subpopulations, and to identify individual and social predictive risk and protective factors

Methods: A cross-sectional study approved by Ethical Committee was conducted. Subjects aged 9-14, providing a written informed consent, were recruited from local schools, randomly selected from the earthquake area (EA) and an extra-earthquake area (EEA), with similar demographic and geographic characteristics. The UCLA-PTSD Index for DSM-IV was used to assess PTSD in students; risk/protective factors were investigated using a traumatic exposure checklist and the Strengths and Difficulties Questionnaire. Parental psychopathology was assessed by Symptom Checklist-90-R.

Results: 683 students (2% of residents) and 1161 parents were enrolled. Overall, 9 subjects (1.3%) showed chronic PTSD symptoms. Most (8) were living in EA. The risk of suffering from PTSD symptoms was higher in girls, older students and subjects most directly affected by earthquake. Distressing factors no earthquake-related appeared predictive of distress as well. Further, psychopathological symptoms in parents were significantly associated with high PTSD scores in children.

Conclusions: PTSD prevalence appeared lower than observed in similar studies. However, anxiety and depressive symptoms were widespread and correlate with several predictive factors. We hope that our findings will help planning future preventive and supportive effective public health interventions in similar distressing situations.

Introduction: As part of the authorization process for the expansion of the solid waste incinerator (SWI), a cross-sectional biomonitoring study was conducted to identify markers of chronic exposure. Metals were measured in toenails, as a single sample is assumed to represent long-term exposure.

Methods: Around 500 subjects aged 18-69 yrs. and living within 4-km from the plant were enrolled between Oct. 2013-May 2014. Sampling method implied stratification by exposure, gender and age-group. Toenails were disintegrated by acid mineralization and analyzed through inductively coupled plasma mass spectrometry for concentrations of Cd, Cr, Mn and Ni. SWI exposure was estimated through fallout maps. Biannual PM₁₀ level prior to sampling was assigned according to subjects’ residence and workplace. Confounders were assessed by questionnaire covering personal and health data, lifestyle, residential and occupational information, traffic exposure and diet. Multivariate regression models were performed.

Results: Cd, not detectable in >50% of samples, was not further analyzed. Cr, Mn and Ni were detectable in >95% of samples. Significant positive relations were observed for diet, personal and lifestyle characteristics, as well as for SWI exposure.

Conclusions: results appear consistent with literature-known associations, suggesting that toenails can be appropriate in assessing chronic exposures of Ni, Mn and Cr, while Cd is probably poorly accumulated in nails. Relations observed with SWI exposure should be accurately considered.

Background: Human milk is the best source of nutrition for the newborns, and exclusive breastfeeding is recommended by WHO up to 6 months of age. It contains all the nutrients and essential trace elements necessary to ensure correct functioning of the organism. Infant formulas, the most common substitutes for human milk, usually contain nutrient levels modeled to have a composition similar to human milk. However, few recent data on nutrient levels in breast milk and infant formula are available from women living in Italy.The aim of this study was to determine the levels of five essential (Fe, Zn, Cu, Mn, Se) and four non-essential/toxic elements (Ni, Cr, Cd, Pb) in infant formulas and breast milk of women living in Modena, Italy and to compare them with recommended values.Methods: 130 samples of human milk (mature milk: 30-40 days postpartum) and a representative sample of infant formulas (0&#8211;6 months) sold in Italy were analyzed by ICP-MS in triplicate after microwave digestion.Results: Breast milk showed adequate levels of essential trace elements, despite the inter-individual variability observed, which was not influenced by women&#8217; characteristics and dietary habits. Non-essential/toxic elements content was well below the maximum tolerable limits set by the European Food Safety Authority (EFSA). In infant formulas as well, essential element levels were within the European recommended values, however, Fe and Mn levels, were significantly higher than in breast milk.Conclusions: The levels of essential micronutrients in lactating women living in Modena are suitable for the proper development of infants and no risk for excessive toxic elements intake was detected. Infant formulas show high fortification with Fe and Mn. Considering the growing evidence of cognitive development effects due to an excessive Mn intake, a deeper discussion on infants&#8217; Mn requirement is needed. According to our findings, breastfeeding should be still encouraged and recommended.

Background: Human exposure to phthalates, endocrine disruptors ad reproductive toxicants, is ubiquitous because of their extensive use as plasticizers. Breast milk is the optimal source of nutrition for newborns, however, it can be a source of exposure to several environmental contaminants, Including phthalates. Up to date limited information exists on lactational exposure to phthalates and their metabolites in Italy: the aim of this study, therefore, was to determine the levels of 8 different phthalates diesters and monoesters in breast milk of women living in Modena, Italy, and to investigate the relationship with women&#8217;s diet and other habits.Methods: 130 women (mean age: 33; range: 19 - 45 years) provided a sample of breast milk (30-40 days postpartum) and filled in a questionnaire on personal data and on potential sources exposure to phthalates. After solid extraction, samples were analysed by triple Quad LC/MS Mass Spectrometry.Results: Phthalate diesters, due to their metabolic degradation, resulted almost undetectable. Phthalate monoesters appeared more widespread. Among them, mono-isononylphthalate (MiNP) was detected in 125 breast samples (mean: 1.63 &#177; 2.71; range: 0.10 - 18.4 µg/l) and mono-ethylphthalate (MEP) in 106 samples (mean: 2.35 &#177; 7.36; range: 0.04 - 69.0 µg/l). Their levels appeared higher in lactating women more frequently using cosmetics or consuming food and beverages preserved in plastic containers. Differences, however, were not statistically significant. Further, levels appeared well below the daily intake levels established by the European Food Safety Authority (EFSA).Conclusions: Although a number of phthalate monoesters were detected in maternal breast milk, their concentrations tended to be lower than those reported in other international studies and the values recommend by EFSA. Human milk represent a unique nourishment for infants in a crucial period of their life: its use should not be discouraged.