Hazardous wastes in Campania (Italy) and health impact

Toxic waste pollution in Campania and cancer incidence

Some reports published by international agencies such as the United Nations Environmental Program (UNEP) and Greenpeace showed that much highly toxic waste derived from Italian and foreign companies was disposed of in Campania illegally. In 2004, K. Senior and A. Mazza 26 published some results on the association between environmental pollution and cancer-related deaths in the Nola area in the prestigious journal “The Lancet Oncology.” The districts of Senior and Mazza reported high mortality rates for colorectal and liver cancer, leukemia, and lymphoma, as compared to the rest of Campania and Italy. Furthermore, Mazza reported the high environmental risk among the Neapolitan towns of Acerra, Nola, and Marigliano^[26] [Table 1]. In this scenario, several studies were performed in order to find the link between toxic waste and the high incidence of different types of cancer. One study was carried out between 1998 and 2001 in the five provinces of the Campania region (Salerno, Avellino, Benevento, Naples, and Caserta) that estimated the standardized mortality ratio (SMR). Pizzuti and colleagues observed that the age-adjusted SMRs for all cancers were higher in the Naples and Caserta provinces when compared with other provinces (Salerno, Avellino, and Benevento). Specifically, the authors detected the highest SMR values for stomach and liver cancer in Caserta and Naples provinces^[27] [Table 1]. Altavista et al.^[28] showed that the mortality rate among citizens living in the Giugliano, Villaricca, and Qualiano municipalities (51 km²) were higher when compared with those expected based on the regional data provided by Istituto Nazionale di Statistica (ISTAT). Specifically, the authors found a cancer high standardized mortality ratios (SMRs) in the population of Giugliano. In addition, increased standardized mortality ratios were observed for different types of cancer, such as lung, brain, liver, larynx, and pleural cancer, in the populations of Qualiano and Villaricca^[28] [Table 1]. Another study analyzed the cancer mortality in a population of approximately 4 million citizens living in 196 municipalities in Naples and Caserta. In this paper, the authors reported an increased mortality rate of pleural cancer in the male population and of esophageal cancer in the female population in the province of Naples. Moreover, in the province of Caserta, the authors showed an increased mortality rate for different types of cancer, such as the stomach (29.3% in the male population and 18.2% in the female population). In addition, the authors pointed out that the cancer death rate increased in 11 municipalities of the southeastern part of the Province of Caserta and 13 adjacent municipalities of the northern part of the Province of Naples^[29] [Table 1]. Moreover, another research was conducted in the same municipalities by estimating the environmental contamination through waste exposure at a municipal level using the regional database of legal waste landfills, and illegal dumping sites after adjustment for social and economic factors. In particular, this study used the Environmental Waste Index (EWI), which considered population density, distance to a waste site, volume and type of waste, and routes of contamination (e.g., food, air, or water). Furthermore, the authors performed the adjustment by the socioeconomic factors (such as education, income, and employment) through an index of socioeconomic deprivation (ID-municipalities that were subdivided into quintiles concerning the value of the deprivation index (1 = least deprived; 5 = most deprived) into a regression model. The authors observed a higher risk of cancer mortality in municipalities with high EWI than those with low EWI for all cancers (both sexes). They specially found mortality risk in the male population caused due to liver, stomach, and lung cancer, whereas in the female population, the risk was primarily due to lung and liver cancer^[30] [Table 1]. Another study was conducted 31 [Table 1] in the same municipalities (classified following a scale of 1 to 5, considering different factors such as high environmental pressure and increased mortality for cancer), Fazzo et al. found a statistically significant risk of cancer mortality rate in the provinces of Naples and Caserta^[31] [Table 1].

The authors found two clusters of lung cancer in the municipalities of Caivano e Casalnuovo di Napoli. Furthermore, the authors reported two clusters in the male population considering the municipalities of Calvizzano and Sant’Anastasia (8 municipalities), with 876 and 496 cases, respectively. Three clusters of liver cancer were detected in the Acerra, Capodrise, and Roccarainola municipalities. In the case of the male population, 4 clusters were identified in the municipalities of Acerra, Marcianise San Cipriano D’aversa, and Roccarainola. Meanwhile, only 2 clusters were described in the female population, specifically in the Marigliano and Gricignano di Aversa municipalities. Moreover, a large cluster of stomach cancer was detected in Teverola. Finally, two clusters of bladder cancer were reported in Marano di Napoli and Casagione^[31] [Table 1]. Furthermore, Fazzo et al. in 2011^[32] calculated municipal standardized incidence ratios (SIR) and hierarchical Bayesian estimators (BIR) in 35 municipalities of Campania through the Cancer Registry. Moreover, they considered municipal spatial clustering and a Poisson regression by municipality index of waste-related exposure for 10 kinds of cancer. In addition, they performed an Environmental Waste Index (EWI), considering socioeconomic factors through an index of socioeconomic deprivation (ID-municipalities). In this study, they found a statistically significant cluster for different cancers (liver, lung, leukemia, soft tissue sarcomas, and, in addition, testis)^[32] [Table 1].

In line with these studies, SENTIERI Project^[33] [Table 1] (studies mortality of residents living close to sites of national interest for environmental remediation - Italian polluted sites, IPSs that are located in the vicinity of industrial areas, either active or dismissed, near incinerators or dumping sites of industrial or hazardous waste) found high-risk mortality for liver larynx cancer in males; in the 77 municipalities of Caserta (Litorale Domizio Flegreo) and Naples Provinces (Agro Aversano).^[33] In addition, in the Litoral Vesuviano area, this report found an excess of liver cancer tumors for both sexes, as reported in other studies.^[19,20,31] Furthermore, the authors described an increased risk of pleural and lung cancer in this area correlated with the presence of asbestosis (as indicated in IPSs)^[33] [Table 1]. This research underlined an increased mortality risk for all cancers in the 77 municipalities of Caserta and Naples Provinces (Litorale Domizio Flegreo e Agro Aversano) in comparison with mortality expected from the Italian rate in females^[33] [Table 1]. Within the SENTIERI project, another epidemiological study was conducted in the 55 municipalities in the “Land of Fires.” The authors reported increased hospitalization and mortality rates for different types of cancer, such as stomach, liver, lung, bladder, pancreatic, laryngeal, kidney, and breast cancer, and non-Hodgkin’s lymphoma in the municipalities of Naples province,). At the same time, they found significant mortality and hospitalization rates for different types of cancer (stomach, liver, lung, bladder, and laryngeal and leukemia) in the municipality of Caserta provinces^[34] [Table 1].

Another review underlined the association between the high mortality of cancer rate and long-term exposure to toxic wastes^[35] [Table 1]. In 2019, the update of the SENTIERI Project detected an excess of many diseases in people living close to National Priority Contaminated Sites (NPCSs). The methodological approach used in this study did not allow adjusting for several confounding factors being risk factors for the diseases (e.g., smoking, alcohol consumption, obesity). Furthermore, the environmental characterization of the studied NPCSs was not uniform in terms of quality and detection of the pollutants because of the lack of information in different databases. Another limitation of the statistical method was the small population size of many NPCSs and the low frequency of several health outcomes^[36] [Table 1]. However, the authors of this report found an increase in the incidence and mortality of liver, bladder, colorectal, breast, and gastric cancer in Litorale Domizio Flegreo (LDF) (Caserta). In contrast, an increase in mortality rate was observed for liver, bladder, breast, and cervix cancer in Area Litorale Vesuviano (ALV) (Naples)^[36] [Table 1]. Furthermore, they also noted for the first time the health status of children and adolescents (1,160,000 subjects, aged 0–19 years) and young adults (660,000 subjects, aged 20–29 years) in some areas of Campania- Specifically, in AVL, this report showed increased deaths from blood and lymphatic malignancies (in both genders (18 cases; SMR = 156; 90% CI 106–229) and in particular from chronic lymphocytic leukemia in both genders (6 cases; SMR = 210; 90% CI 109–407) among young adults (20–29 years) in comparison to the regional average. Furthermore, an increase in death rate was observed for central nervous system central (CNS) cancers in children aged 0–14 years (6 cases SHR = 140; IC90 = 73–271 between 2006–2013 in comparison to the regional average) and in young adults (0–19 years (7 cases SHE = 129 IC90% = 70–237 between 2006–2013 respect to regional average) with uncertain data. In LDF (Caserta Province) and AVL (Naples Province) areas, an increased incidence of non-Hodgkin lymphoma was observed in children aged 0–14 years between 2006–2013 (64 cases; SHR = 137; IC90% 111–168) when compared with a regional average^[36] [Table 1]. Two previous studies reported the number of children affected by different types of cancer in the Campania region^[37,38] [Table 1]. In the first article,^[37] the authors reported the number of cancer cases registered by the AIEOP (Association Italian Pediatric Hematology-Oncology) between 1990–2014 years: 2059 cases in Naples province, 625 cases in Salerno province, 589 in Caserta province, 229 in Avellino province and 153 cases in Benevento province-37 [Table 1], The authors underlined that the overall ratio between observed (O) and expected (E) was increased during these years^.[37] The second article (the EPIKIT study)^[38] [Table 1] found 465 cases of cancers in pediatric age (0–19 years) between 2007 and 2011. In the last decades, a review published in Lancet Oncology reported an increase in incidence of childhood tumors in Europe, especially Italy.^[39] In the sixth report of the ISS published in February 2023)^[40] [Table 1], the authors reported an increase in mortality from all cancers in the LDF area. Additionally, there was evidence between the incidence of breast cancer and the presence of landfills that contained toxic substances such as dioxins and polychlorinated biphenyls. The authors showed increased mortality rates from prostate cancer (680 cases, SMR 116; 90% CI 109–124) and leukemia among males (303 cases, SMR 111; 90% CI 101–122). In addition, the report found a high mortality rate in non-Hodgkin’s lymphoma among the female population aged 0–29 years (4 cases, SMR 341; 90% CI 153–760). In female children (aged 0–14), there was an excess of mortality rate for Hemo-lymphopoietic cancers (4 cases, SMR 238; IC90% 107–531). Moreover, in young people (aged 20–29), the mortality rate was increased for CNS cancers (8 cases, SMR 214; IC90% 121–380) and leukemia (SMR 178; IC90% 100–316) in the male population, meanwhile it was noted that there was an excess of the mortality rate of Hodgkin lymphoma in the female population (3 cases, SMR 256; IC90% 102–640). In the end, an increased mortality rate for Hemo-lymphopoietic cancers (in particular Hodgkin lymphoma) was found in both genders and for non-Hodgkin lymphoma in the male population (4 cases, SMR 341; IC90% 153–760) [Table 1]. In the same report, the situation of the ALV area was also described, and the authors underlined the high mortality for breast cancer in females and testis cancer in males. Moreover, in young people, the author found an excess of mortality for lymphoma cancers (10 cases), leukemias (7 cases of lymphoid leukemia, 5 cases), and also for lymphomas 3 cases). They also noted an excess of CNS cancers in pediatric age (among males people: SMR 238; 90% CI 107–529)^[40] [Table 1].

Biomonitoring Analysis in Campania

Since a lot of hazardous waste was illegally burned by releasing dangerous chemicals (such as 2,3,7,8-tetracas lhorodibenzo-p-dioxins-TCDD) in the Campania region, several studies were carried out to better understand the link between waste-related pollution and biomarkers assessment in humans, by using different approaches. A study was conducted on amniotic fluid samples derived from women living close to toxic sites in Campania (in the north-east Naples area and compared with control samples of women who lived in non-polluted areas (Avellino, Campania). The authors evaluated the genetic impact of these amniotic fluids on Paracentrotus lividus embryos. They observed DNA damage through RAPD (Random Amplified Polymorphism DNA) profiles only in embryos exposed to samples derived from women living in polluted areas. Using this method, they found two target regions for DNA alterations in the genome of Paracentrotus lividus.^[41] Another study found that PCDD/Fs and PCB serum levels in the population of the Naples area were low when compared with those of populations living in exposed areas.^[42] On the contrary, a study conducted by De Felice et al. reported that pregnant women living in reported that pregnant women living polluted waste landfill sites had shorter telomerases than pregnant women living in non-polluted area.^[43] Moreover, Rivezzi et al.^[44] analyzed milk samples derived from 94 primiparas living in municipalities of the provinces of Naples and Caserta. They found a significant correlation with the age of sampled women, illegal waste fires, and environmental dioxin risk index (EDR).^[44] Similarly, another article reported the high dioxin levels in the breast milk of mothers living in Naples and Caserta provinces. In this case, the authors reported a positive correlation between the age of mothers and a high concentration of PCDDs/Fs and PCBs in their milk.^[45] Furthermore, the SEBIOREC (Studio Epidemiologico Biomonitoraggio Regione Campania) study reported biomarkers’ levels in the Campania region per European and Italian values, except for some pollutants (arsenic, mercury, dioxins) detected in four municipalities of Naples.^[46] In accordance with these data, in another study, the authors analyzed the levels of polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and polychlorinated biphenyls in blood sample derived from donors living in area of Naples city and its province Acerra, Nola, Marigliano (high polluted area) and Pompei, Portici, Pozzuoli, Torre del Greco. The concentrations of the pollutants were almost the same in both people living in polluted areas (Acerra, Nola Marigliano) and those living in low polluted areas (including Naples city, Pompei, Portici, Pozzuoli, Torre del Greco).^[47] Furthermore, Bergamo et al.^[48] a pilot study (EcoFoodFertility initiative) was carried out on human semen in 110 healthy males living in two different areas of Campania: one with high and another with low environmental pressure. The authors found that the population living in areas had high levels of zinc, copper, chromium, and decreased iron levels. Additionally, there was reduced sperm motility and higher sperm DNA Fragmentation Index (DFI) in the semen of men. Another pilot biomonitoring study was carried out in 112 clinically healthy, normospermic men living in different locations of the Campania region with high or low environmental impact on telomere length (TL) in both leukocytes (LTL) and sperm cells (STL). In this study, the authors found that telomeres were longer in sperm cells derived from young people living in highly polluted areas than that of young people living in polluted regions.^[49]