LIFE12 ENV/SK/094 FINAL Report 20/12/2017 the Elimination Of

LIFE Project Number LIFE12 ENV/SK/094 FINAL Report Covering the project activities from 01/10/2013 to 30/09/2017

Reporting Date 20/12/2017 The Elimination of Negative Impact of Geological Compound of the Environment on Health Status of Residents in the Krupina District (LIFE FOR KRUPINA)

Project Data Project location Slovak Republic (Krupina district) Project start date: 01/10/2013 Project end date: 30/09/2017 Extension date: Total Project duration (in months) 48 months Total budget 417,750 € Total eligible budget 405,600 € EU contribution: 201,153 € (%) of total costs 48.15 (%) of eligible costs 49.59

Beneficiary Data Name Beneficiary State Geological Institute of Dionýz Štúr Contact person Mr Stanislav Rapant Postal address Mlynská dolina, 1, 817 04, Bratislava, Slovak Republic (SK) Visit address Mlynská dolina, 1, 817 04, Bratislava, Slovak Republic (SK) Telephone ++421-2-59375213 Fax: ++421-2-54771940 E-mail [email protected] Project Website http://www.geology.sk/lifeforkrupina/

1. List of contents 2

2. Executive Summary 3 3. Introduction 6 4. Administrative part 7 4.1 Description of the management system 7 4.2 Evaluation of the management system 9 5. Technical part 10 5.1 Technical progress, per task 10 5.2 Dissemination actions 27 5.2.1 Objectives 27 5.2.2 Dissemination: overview per activity 27 5.3 Evaluation of Project Implementation 32 5.4 Analysis of long-term benefits 35 6. Comments on the financial report 38 6.1 Summary of Costs Incurred 38 6.2 Accounting system 39 6.3 Partnership arrangements 40 6.4 Auditor's report/declaration 41 6.5 Summary of costs per action 41

7. Annexes 7.1 Administrative annexes 7.1.1 Steering Committee Members 7.1.2 Gantt chart 7.2 Technical annexes 7.2.1 List of abbreviations 7.2.2 List of short reports 7.2.3 After-Life Communication Plan 7.2.4 Project output indicators 7.3 List of Dissemination annexes 7.3.1 Oral/Poster presentations 7.3.2 Any media work 7.3.3 Press release 7.3.4 Technical publications 7.3.5 Monographs 7.3.6 Laymanʼs reports 7.3.7 List of participants 7.3.8 Photo documentation 7.4 E-mail communication 7.4.1 E-mail communication with WHO 7.4.2 E-mail communication with MŽP SR and MZ SR 8. Financial report and annexes 8.1 Answers to EC letters 8.2 Invoices of Coordinating and Associated Beneficiary - examples 8.3 Timesheets of Coordinating and Associated Beneficiary - examples 8.4 Financial reporting 8.5 Annex Audit report

2. Executive Summary The main objective of the project is the elimination of negative impact of geological compound of the environment on health status of residents in the Krupina district. The district of Krupina is located in the geological environment of Neogene volcanites. These rock types are of relatively very low solubility and the main impact on human health relates in fact that drinking waters used for public supply of residents are characterized with very low (deficient) contents of essential elements, mainly Ca and Mg. This fact (deficiency of Ca and Mg in drinking water) causes increased mortality for all main causes of deaths, including cardiovascular (CVD) and oncological diseases (OD), diseases of respiratory (RS) and gastrointestinal system (GS) and shorter life expectancy of resident population of the Krupina district (about 4 years compared to the areas with favourable geological environment). Due to this reason the health status of residents in the Krupina district is in the long-term horizon one of the most unfavourable within the whole Slovak territory. The project aims to improve the health status of residents through implementation of the following partial goals defined as key project deliverables: – compilation of data set of environmental indicators (chemical elements/components) for two main compartments of geological environment (groundwater/drinking water and soils), – compilation of data set of health indicators (indicators of demographic growth and health state of population), – assessment of the impact of geological environment on the health state of the resident population through the linking of environmental and health datasets, – biomonitoring – analysis of chemical contents of critical elements in hair, nails and measurements of arterial stiffness for a group of respondents, to confirm the causal relationship between geological environment and health state of residents, – the evaluation of life style and health-care accessibility on health state of residents in Krupina district, – implementation of remedial measures into practice – mainly educative and training activities, particular technological actions – water re-carbonization – addition of carbonate rock into individual local wells, and legislative measurements – proposal of limit values for the influential elements in drinking water on human health.

The project was implemented within the LIFE+ programme Environment, sub-programme Environment Policy and Governance. All the project objectives are successfully implemented. Project administration was based on project management and coordination in accordance with the project proposal and LIFE+ rules, including monitoring of the project progress and planning project tasks through monthly organized consultative meetings, annual sessions of the steering committee and regular reporting (reports to EC, annual monitoring reports). During the project implementation we did not face any serious problem in management process. All EC requests and comments related to reports and monitoring visits were included and explained in respective projects reports (Inception report, Progress report No. 1). Answers on EC letter concerning Mid-term report are included in annexes 8.1. Our answers and corrections were in all cases fully accepted by the Commission. There was one amendment to the Grant Agreement requested by the coordinating beneficiary and accepted by the EC related to the reorganization of the State administration of the Slovak Republic (valid from the 01/10/2013), and subsequent change in legal status of one of the associated beneficiaries of the project LIFE FOR KRUPINA (the District Office for

Environment Zvolen - OU ZP Zvolen was abolished with date 01/10/2013 corresponding to project start). The amendment to the grant agreement was based on partnership modification consisting in the replacement of one of the associated beneficiaries – OU ZP Zvolen by ŠGÚDŠ (coordinating beneficiary), assuming all rights, duties, responsibilities and financial means. All project actions were implemented in accordance with the project plan. Project timetable for respective actions was due to objective reasons (repeated collection of hair and nail samples, repeated measurements of arterial stiffness) slightly modified. During the project implementation we did not face any obstacle (technical/legislative/scientific/time related) that could affect the successful implementation of project goals/actions.

Technical part of the project consists in 7 main technical actions: Action B1: Compilation of data set of environmental indicators Action B2: Compilation of data set of health indicators Action B3: Linking of environmental and health indicators Action B4: Biomonitoring Action B5: Evaluation of lifestyle and health-care accessibility Action B6: Environmental-health analysis Action B7: Realization of measures

As expected, the unfavourable health status of residents of the Krupina district associated to unfavourable geological environment was confirmed by detail analysis of compiled environmental and health indicators and their linking. The health status of population is determined beside the environmental factors (water, air quality etc.) mainly by the lifestyle (type of work, way of life) and level/accessibility of the health-care. Based on the project results (achieved within the action B5) we can conclude that the lifestyle as well as level of health-care in the Krupina district is comparable to the other Slovak districts and they do not have a substantial impact on the impaired health status of resident population. The results of the action B4 “Biomonitoring” brought very significant findings related to the arterial stiffness of residents. The measurements of arterial stiffness were realized in two stages (for the second stage we additionally asked approval from the EC) in a sample of residents supplied by soft drinking water (Ca and Mg deficit contents) and harder water (adequate Ca and Mg contents). “The absolute difference” between the real and arterial age in the case of two evaluated groups of respondents (soft vs. harder water) was in average nearly 5 years. It means that those respondents drinking soft water had significantly worse status of vascular system. The analyses of hair and nail samples of residents confirmed relatively high variability of Ca, Mg, Na, K and Si contents at comparable levels with similar studies performed in other countries. The world literature describes cases when people drinking water with deficient Ca and Mg contents have often increased contents of these elements in their hair. This effect is related to the nutritional imbalance of the essential elements within the human organism due to the deficiency of Ca and/or Mg, leading to the Ca and/or Mg precipitation and accumulation in soft tissues such as hair. Our results also indicate similar trend. Based on the elaboration of environmental-health analysis we can conclude that the world literature documents very high number of studies reporting the impact of Ca and Mg deficit in drinking water on mortality from cardiovascular and oncological diseases. Beside these the most common causes of deaths of human population worldwide our results together with the results of the previous project GEOHEALTH indicate that Ca and Mg deficit in drinking water may have significant impact on the increased mortality from

4 diseases of respiratory systems, gastrointestinal system as well as endocrine system (mainly diabetes). Within the realization of measures (action B7) we have implemented simple technological measures into practice, consisting in addition of carbonate rock (limestone, dolomite, half- burnt dolomite) into seven residential wells. We can conclude that we have reached good results – increased Ca and mainly Mg water contents in six from seven wells. We did not document increase of Ca and Mg in the seventh well because it has a character of captured spring with overflow (groundwater runoff) more than 1 l.s-1. Based on the consultations with the external monitor (Mr. Svoboda) we have excluded this well from further monitoring. Project outputs were disseminated among scientific public, administrative officers as well as layman´s audience as much as was possible. The dissemination of the project results among scientific audience was performed through several scientific presentations and scientific papers. So far, we have published three papers in the international impacted magazine, and one paper is prepared for publishing. Due to disapproval of our general director of ŠGÚDŠ we were not able to travel abroad and disseminate the project results among international scientific audience as we planned in the project proposal (but only in limited extent). We have also widely disseminated project objectives and partial results in media – newspaper, TV, radio. From May 2016 general director of ŠGÚDŠ did not give us approval to make further interview with media representatives. Within the project we were using innovative methods of environmental and health data elaboration and interpretation. Among the results achieved so far following outputs are considered to be the most significant: • linking of EI and HI data through artificial neural network (ANN), • measurements of arterial stiffness in relation to various drinking water hardness, • water re-carbonization applied for individual residential/local wells.

The project quantitative environmental benefits are represented by the long-term improvement of health status of residents in Krupina district living in the unfavourable geological environment (with Ca and Mg deficiency in groundwater/drinking water), if proposed measures are applied into practice. These include simple measures to increase consumption of Ca and Mg by other sources (e.g. mineral water, appropriate diet, and vitamin supplements) with effect on local residents as well as legislative measures with effect on drinking water sources on national level. The results achieved in this project are fully relevant for the European environmental policy and legislation (e.g. Environment Action Programme to 2020 (EAP), Health 2020). Long-term qualitative environmental/social/financial benefits of this project consist in gradual improvement of health status of people in Krupina district. We consider human diseases and deaths caused by consumption of soft water as so-called avoidable causes of deaths. In case of long-term dissemination of project results to raise public awareness (mainly of those consuming soft water for drinking purposes) there is full assumption to improve health status of population drinking soft water. From the point of view of long- term qualitative economic benefits, the financial costs saved within the health care will multiply exceed project costs.

Financial part The total financial costs for the project implementation were in the amount of 321,892.87 € (77.05%). We did not face any big discrepancies between the costs per action set out in the project proposal and incurred project costs except of underspent travel and personnel costs.

3. Introduction The environmental problem addressed by the project was the improvement of health status of residents in the Krupina district. Based on the evaluation of dataset of health indicators we can characterize the health status of residents in the Krupina district as the most unfavourable within the whole territory of the Slovak Republic. It is about 25% worse compared to the Slovak average. From 36 municipalities of the Krupina district in eight municipalities health status is at level comparable to the Slovak average and 28 municipalities are characterized predominantly with worse health status. Our primary hypothesis on which the project objectives were based on consisted in assumption that the unfavourable health status of residents is related to deficit Ca and Mg contents in drinking water used for public supply in the Krupina district. However, according to WHO general declaration, the health status of population is conditioned and influenced mainly by lifestyle (life and work) that accounts for approximately 50%. It is also affected by genetic factors and a level of health care making up between 10 to 20%. About a 20% portion is attributed to the environment. Therefore, in this project we have also analysed and evaluated the level of lifestyle and health-care accessibility for residents of the Krupina district. Based on the results of action B5 (“Evaluation of lifestyle and health-care accessibility”) we can conclude that the lifestyle of residents in the Krupina district as well as the level of health-care accessibility do not differ from other Slovak districts. Thus our hypothesis that the impaired health status of residents relates mainly to the unfavourable geological environment (silicate volcanic rocks) which do not emit to the other compounds of the environment, mainly drinking water, adequate Ca and Mg levels, was confirmed. The negative impact of deficit contents of Ca and Mg in drinking water on health status of residents of the Krupina district was confirmed by realization of measurements of arterial stiffness within the action B4 (“Biomonitoring”). Residents supplied by soft drinking water (with low Ca and Mg contents) had significantly worse status of their vascular system and their arterial age was in average worse (i.e. higher) compared to those residents supplied with harder water (with adequate Ca and Mg levels). The realization of preventive measures consisted in the application of so-called water re- carbonization by addition of carbonate rocks into individual residential wells to increase Ca and Mg water contents. We have reached significant increase of Ca and Mg contents in drinking water. The expected result – improvement of health status of residents can be reached only after wide dissemination of faced environmental-health problem among layman´s audience. This dissemination will be realized through organization of the informative meetings in ten municipalities of the district as well as in the form of media work (TV, newspaper, radio shows) and internet. Environmental benefit of the project consists mainly in determination of causes which lead to impair health status of population in the Krupina district. We have elaborated the set of proposals of measures for Krupina district residents how they can reduce or eliminate the negative impact of unfavourable geological environment on their health. Our results are valid for the whole territory of the Slovak republic as well as for the whole territory of the EU. Therefore, in the future it is necessary to widely disseminate our results within the EU countries and act to highlight the necessity of reconsideration of WHO legislation for drinking water quality and importance of including limit values for Ca and Mg in drinking water guideline. This problem obviously relates also to bottled drinking water. The most significant expected longer-term result is gradual and long-term improvement of the health status of population in Krupina district and the entire Slovak

Republic. This project’s long-term benefit can be reached also in the EU countries after application of our results in the EU and WHO legislation. 4. Administrative part 4.1 Description of the management system The project was implemented in following five main phases. The first phase comprised the collection of all necessary data, mainly data on environmental indicators (EI) and health indicators (HI), (actions B1 – Compilation of data set of environmental indicators, B2 – Compilation date set of health indicators). The second phase consisted in statistical data elaboration and analysis (action B3 – Linking of environmental and health indicators). In the third phase following actions were concurrently implemented: Works within the action B4 – Biomonitoring and action B5 – Evaluation of life style and health-care accessibility and preparatory Works on action B7 – Realization of measures including testing of carbonate rock dilution. The fourth phase was focused on application of simple technological measures – addition of carbonate rock into selected residential wells (within the action B7) as well as implementation of the initial stage of monitoring of changes in chemical composition of treated groundwater (action C2 – Monitoring of environmental impacts of the changes in chemical composition of drinking water). The final phase of the project includes final interpretation of achieved results within the respective project actions with main focus on Environmental-health analysis (action B6), preparation of project publications – technical/scientific papers, organization of informative meetings, seminars, conference etc. These events were planned to be organized at the end of the project (during the last year of project duration). In this final phase of the project implementation we monitored changes in chemical composition of treated groundwater (action C2). All actions were implemented by the coordinating beneficiary ŠGÚDŠ except of action C3 (Monitoring of socio-economic impacts of project actions) which was implemented by associated beneficiary Krupina city. However, the associated beneficiary participated in other implementation, monitoring and dissemination actions. The project was managed and coordinated/monitored within the planned actions C1 and E1. The overall project management and coordination was implemented from the very beginning in accordance with the rules of LIFE+ programme. The project management was established on 30/10/2013 in accordance with the project proposal (milestone deadline 30/10/2013, please see the organigramme). Every month consultative meetings participated by members of project team were organized. Consultative meetings dealt with the evaluation of project progress and planning further tasks to be solved during next period. The records from consultative meetings were regularly published on the website of the project. On November 20th 2013 the Steering committee was established in terms of project’s plan (project milestone with deadline 30/11/2013). All related authorities including Ministry of Environment of the Slovak Republic, Ministry of Health of the Slovak Republic, Statistical Office of the Slovak Republic, Public Health Authority of the Slovak Republic and State Geological Institute of Dionýz Štúr (coordinating beneficiary) and Krupina city (associated beneficiary) delegated their own representatives (list of members is reported in Annex 7.1.1). The three annual sessions of the Steering committee were organized according to planned project schedule. The conclusions and recommendations of the Steering committee were also published at project website. In

7 addition, monitoring report for the project was once a year compiled by the project manager and published at the project website. The only one substantial change in project team occurred on the position of the financial manager. Mr. Tamašovič left the service with ŠGÚDŠ. His position was temporary substituted by economic director Mrs. Sokolíková and from the year 2014 the position of financial manager was held by Mrs. Čárska. Due to the abolishment of the District Office for Environment Zvolen (OU ZP Zvolen), being the associated beneficiary organization in the project LIFE FOR KRUPINA, all planned actions were assumed to be implemented by the coordinating beneficiary ŠGÚDŠ (amendment to grant agreement, please see below more details). Therefore the position of senior environmentalist was assigned to assistant of the project manager Mrs. Cvečková and part of planned project tasks for senior environmentalist were implemented by junior environmentalist, Mrs Alakšová. Based on the agreement between coordinating beneficiary ŠGÚDŠ and associated beneficiary Krupina city the position of junior and senior activist is managed by Mrs. Belláková. Several persons from the permanent staff of the coordinating beneficiary alter the position of the technician. The role of the coordinating and associated beneficiaries in the project management and implementation is presented in the form of the organigramme below:

However, this staffing was planned. Although all planned employees of ŠGÚDŠ had special agreements for project works, the general director was not helpful in reducing their work duties and capacities in other projects implemented by the organization ŠGÚDŠ. Only position of project manager (Rapant) and assistant of project manager (Cveckova) had full working time (100%). Mrs. Fajcikova (coordinator for geology-health, junior statistician) worked on the project 258 days from planned 900 days and her project tasks were assigned to Mrs. Stehlikova (senior statistician) and partially project manager and assistant of project manager. Similarly, the tasks originally planned for coordinator for dissemination (Mr. Szatlmayer) were managed by project manager and assistant of project manager. The tasks for the accountant was in two final years of the project implementation covered by financial manager. Thus, we had to operatively manage this staff shortage to be able to successfully implement planned project objectives. The project progress was regularly reported to the European Commission in accordance with the project proposal. Overall 3 reports were sent to the EC including Inception report (10/10/2014), Progress report No. 1 (15/09/2015) and Midterm report (31/01/2017). The overall project progress including project reports (with reporting dates) is illustrated in Gantt chart attached as Annex 7.1.2. There was one change in the project due to amendment to the Grant Agreement (dated on 10/10/2014). This change was related to the withdrawal of one of two associated beneficiaries – „Obvodný úrad životného prostredia Zvolen (District Office for Environment Zvolen“) from the project. Its role and responsibilities in the project were taken over by the project´s coordinating beneficiary ŠGÚDŠ. The project duration as well as the project budget remained unchanged. The second associated beneficiary – Krupina city remained unchanged. The partnership agreement between the coordinating beneficiary and associated beneficiary was submitted to the Commission with the Inception report.

4.2 Evaluation of the management system The scientific project staff comprised three key project members (permanent staff) who communicated with each other on daily basis, implemented solutions for the problems encountered operatively and on regular basis made plan for further works (Mr. S. Rapant – project manager and scientific coordinator, Mrs. V. Cveckova – assistant of project manager, coordinator for geology and senior environmentalist and Mrs. K. Fajcikova – coordinator for geology-health and junior statistician). The other project team members were invited to participate in consultative meetings (organized monthly) according to actual problems and tasks to be solved. The project was implemented by coordinating beneficiary and one associated beneficiary. The added value of the associated beneficiary was mainly in the communication with residents of the Krupina district (e.g. distribution/collection of questionnaires, participation of residents in biomonitoring) and dissemination of the project results among public. There were no significant deviations from the arrangements established in the Partnership agreement and all planned actions for which the associated beneficiary was responsible were implemented in accordance with the project. During the project management process, we did not face any serious problem that could affect negatively the project implementation. The communication with the Commission and Monitoring team was always very correct. All recommendations and remarks of the Commission were appropriate and valid for the successful project implementation within the rules of LIFE+ programme. Similarly, the external project monitor (Mr. Svoboda) was always supportive and helpful during the whole period of the project implementation.

5. Technical part 5.1. Technical progress, per task Technical part of the project consists in seven main technical actions and three monitoring actions implemented during the project to reach the main project objective and partial goals: Action B1: Compilation of data set of environmental indicators Action B2: Compilation of data set of health indicators Action B3: Linking of environmental and health indicators Action B4: Biomonitoring Action B5: Evaluation of lifestyle and health-care accessibility Action B6: Environmental-health analysis Action B7: Realization of measures Action C1: Monitoring Action C2: Monitoring of environmental impacts of the changes in chemical composition of drinking water Action C3: Monitoring of socio-economic impacts of project actions

Coordinating beneficiary ŠGÚDŠ was responsible for the implementation of overall technical actions. Associated beneficiary Krupina city was responsible for implementation of partial goals within the technical actions B1, B4 and B7. For each action all planned deliverables and milestones were successfully fulfilled in accordance with the project proposal. The list of abbreviations used is attached as Annex 7.2.1. The list of short reports is attached as Annex 7.2.2. These short reports represent also the output indicators within main project deliverables (defined as Others – short reports).

Action B1: Compilation of data set of environmental indicators The dataset of environmental indicators – characterizing the chemical composition of groundwater and soils was compiled. We used all available analytical materials as well as new collected samples – 24 chemical analyses of groundwater and 18 chemical analyses of soils. Final dataset of environmental indicators consists of 304 chemical analyses of groundwater (project plan was 300 analyses) and 208 chemical analyses of soils (project plan was at minimum 200 analyses). Results of chemical analyses of groundwater and soils were elaborated into the form of environmental indicators – expressed as mean concentration values of respective chemical elements and compounds / parameters in groundwater and soils for each municipality of the Krupina district. They are presented in the table as well as map form on the project website, session “Results – partial results”. Within this action, 6 informative meetings (5 meetings were planned in the project) were organized in 6 municipalities of the Krupina district with participation of about 250 residents. Information on these meetings is published on the project website within session “Events - meetings”. This action was finished in planned deadline 30/12/2014. There was one deliverable (“Dataset of environmental indicators for the Krupina district”) and five milestones (“Purchase of 2 PC”, Purchase of GIS software”, “Completion of the excerption of environmental data”, “Completion of water and soil sample collection”, “Completion of laboratory works, analyses of water and soils”) related to this action. All of them were successfully completed. Compiled datasets in 2 forms (table/map) for 2 evaluated media type (groundwater, soils) represent completed output indicators (as main project deliverables). Organized meetings (1 for mayors of the Krupina realized already in December 2013) and 5 for the residents of the municipalities of the district Krupina (May 2014) are considered as output indicator – “Training sessions” (total No. 6). They also represent project milestone.

Action B2: Compilation of data set of health indicators This action was implemented in the form of external assistance mainly. Subcontractor of these works (National Health Information Centre) compiled for the project dataset of 65 health indicators at municipal level for the Krupina district as well as for the district as a whole administrative unit. This big dataset of health indicators was optimalized also on the basis of the outputs of the international workshop (organized within the project in September 2014) to 38 the most relevant health indicators. Optimalized dataset of health indicators characterizes in various forms the most significant causes of deaths in the Krupina district, including cardiovascular and oncological diseases, diseases of gastrointestinal, respiratory and endocrine systems. This dataset is published on the project website within session “Results – partial results”. This action was finished in planned deadline 01/02/2015. There was one deliverable (“Dataset of health indicators for the Krupina district”) and one milestone (“Public tender for compilation of dataset of health indicators”) associated to this action. Both were successfully completed. Compiled dataset in 2 forms (table/ map) represents completed output indicators (as main project deliverables).

Action B3: Linking of environmental and health indicators Within this action linking of environmental and health indicators was realized based on mathematical-statistical methods of data correlation (linear correlation, Spearman correlation, neural network analysis). We linked dataset of 38 health indicators (optimalized dataset) with 34 environmental indicators for soils and 33 environmental indicators for groundwater. All input data including characteristics of environmental and health indicators as well as realized calculations are published on the project website in the form of short report (attached as Annex 7.2.2a). This short report includes the results of two completed deliverables of the project: “Linking of environmental and health indicators and optimized datasets of environmental and health indicators” and “Proposal for legislative guidelines for water and soil”. Based on the achieved results we must conclude that the realized calculations unfortunately did not bring any relevant results with statistical significance. There are several reasons including following aspects: 1. The primary datasets are due to low number of data – only 36 municipalities – of low statistical significance. 2. In five municipalities there is no drinking water source within the public supply and water in local residential wells is often anthropogenically contaminated. 3. After the division of primary datasets for municipalities of the district according to water hardness small partial sets were obtained – 9 municipalities with hard water and 27 municipalities with soft water. These partial sets are too small for representative statistical analysis. 4. Even if municipalities are supplied by public drinking water source, about 10% of resident population still use for drinking purposes the water from their own wells. This fact again leads to the distortion of achieved results. 5. No relevant relations were found in the case of soils. We assume that the human health is impacted by the soil quality through the food chain. At present the foodstuff is of global origin with the source outside the territory of the study area. This is the case also of Krupina district.

Since the achieved results due to the above mentioned reasons did not match the expected results, we use the results obtained within the project GEOHEALTH (LIFE10 ENV/SK/086) to define the influential elements for human health and their limit values in drinking water. These results with significance at national as well as regional level are summarized in table below:

Proposed limit values for the influential elements in drinking water used for public supply and bottled drinking water:

Recommended values Parameter Bottled drinking Drinking water for public supply water Ca + Mg 2 – 5 mmol . l-1 2.5 – 5 mmol . l-1 Ca 50 – 180 mg . l-1 60 – 180 mg . l-1 Mg 25 – 50 mg . l-1 30 – 60 mg . l-1

The proposal for legislative guidelines (project deliverable) was completed only for drinking water characterized as media with significant impact on human health of residents. For soils no proposal of limit values due to the obtained results was elaborated.

The works within this action were implemented with a slight delay compared to the project timetable (please see Gantt chart). The reason was a delay in realization of statistical calculations due to a long-term sick leave of senior statistician (heavy car accident). Finally, statistical works were successfully completed. There was one deliverable “Evaluation of the impact of geological environment on health status of residents in the Krupina district” completed with deadline on 01/02/2017 according to the project timetable. In addition, one milestone was associated to this action “Purchase of software for calculation of neural networks and fuzzy cluster analysis” which was completed only partially. Due to extreme price excess of software for calculation of artificial neural networks (from planned 2,000 € to 14,000 €) we decided not to buy this software and we realized the calculations through free-access software. We purchased only additive software for visualization of data calculations including artificial neural networks and fuzzy cluster analysis.

Action B4 – Biomonitoring Within this action two main sub-actions were implemented: 1. Analysis of contents of critical elements in biological materials of residents, 2. Measurements of arterial stiffness.

The results of these sub-actions were summarized in three separate short reports within one project deliverable associated to this action “Evaluation of the results of biomonitoring in the Krupina district” and published on the project website (session Results/partial results): “Content of essential elements in hair and nails of residents of the Krupina district” (Annex 7.2.2b, in Slovak, English version is in final brochure LIFE FOR Krupina ), “Short report on measurements of elasticity of blood vessels” (Annex 7.2.2c, in Slovak, English version is in final brochure LIFE FOR Krupina) and “The impact of calcium and magnesium contents in drinking water on arterial stiffness of residents of the Krupina district” (Annex 7.2.2d, in Slovak/English). There were two associated milestones “Completion of sample collection of biological materials” and “Completion of laboratory works, analyses of biological materials” which were successfully completed. The chemical contents of critical elements in biological materials of residents were analysed in hair and nails on sample of 111 residents (48 adults, 63 children). Overall 152 samples were collected and analysed including 91 hair samples and 61 nail samples (project plan was 150 samples in total) for the contents of the following elements: Ca, Mg, Na, K and Si. From these elements Ca and Mg are present in geological environment of the Krupina district at deficient contents, Na and K in increased contents and Si in very high contents. Generally, the evaluated biological samples show high variability. The contents of analysed elements in nails are markedly higher than in hair (about 2 – 5 times higher). For women deficit Mg and K contents were documented. The works on this sub- action were finished approximately one year later compared to the project timetable. The reason was the necessity of repetition of sample collection due to low amount of sample (hair, nails) needed for realization of chemical analyses. The measurements of arterial stiffness were realized in two phases. The first phase of measurements was carried out in accordance with the project on sample of 44 respondents, 22 of them supplied with soft water (with deficit Ca and Mg contents) and 22 of them supplied with hard water (with increased Ca and Mg contents). The first phase brought very significant results leading to very important conclusions. The status of arteries in case of residents drinking soft water was markedly impaired compared to residents drinking harder water. “The absolute difference” between the real and arterial age in the case of two evaluated groups of respondents (soft vs. harder water) was 5.5 year. Since these achieved results were very significant we asked the Commission for possibility to repeat the measurements in the second phase on bigger group of respondents. We were given approval by the Commission and we have realized the second phase of measurements on sample of 100 respondents (50 respondents supplied with soft water and 50 respondents supplied with harder water). The achieved results confirmed the impaired status of arteries in case of residents using soft water for drinking purposes (higher arterial age compared to the real age). This action was completed on 30/07/2016.

Action B5: Evaluation of life style and health-care accessibility Within this action the character of lifestyle and level of health-care accessibility of residents of the Krupina district was evaluated to verify their role in resident life in the Krupina district in relation to their health status. In accordance with the project proposal we have evaluated lifestyle through 342 questionnaires (project plan was 300) and 71 interviews with residents in years 2014 and 2015. This part of action B5 was completed and achieved results were published in the form of short report entitled “Evaluation of lifestyle of residents in the Krupina district” on the project website, in session “Results – partial results” (attached to this report as Annex 7.2.2e). The main result of this partial work was that lifestyle in the Krupina district is comparable with the lifestyle of general Slovak population and that is why we suppose that lifestyle of residents in the Krupina district does not play any special role in their impaired health status. Within years 2015 – 2016 evaluation of health-care accessibility was performed based on excerpted available information from national/regional health statistics and registers. The results were summarized in the second short report entitled Evaluation of lifestyle and health-care accessibility of residents in the Krupina district (Annex 7.2.2f) which was published also on the project website. The primary assumption, that the level of life style and health-care accessibility in the Krupina district is comparable with other Slovak districts and regions, was confirmed. Thus, we can conclude that these factors do not play significant role in the impaired health status of residents in the Krupina district. The associated project deliverable “Evaluation of lifestyle in the Krupina district” was completed by elaboration of two partial short reports mentioned above in accordance with the project timetable (deadline dated on 01/03/2016). This action was completed in accordance with the project timetable up to date 01/03/2016.

Preventive gynaecological Preventive urological examinations examinations of respondents. of respondents.

Preventive medical examinations Preventive medical examinations of respondents by the general practitioner. of respondents by the dentist.

Action B6: Environmental-health analysis This action consisted in the evaluation of the impact of geological environment on health status of residents in the Krupina district based on the analysis and elaboration of all potential health effects, and identification of main types of associated diseases (cardiovascular, oncological, diabetes, gastrointestinal tract etc.). From the results achieved we can definitely confirm that the most significant direct impact on human health is associated to water quality regularly consumed by residents for drinking purposes. Soil quality plays less significant role since potential health effects can be expected only in case of extreme soil contamination (significantly increased contents of potentially harmful elements). Such contamination was not determined in case of soils in the Krupina district. One deliverable is associated to this action – “Environmental-health regionalization of the Krupina district” (deadline dated on 01/04/2017). The environmental-health regionalization was elaborated in accordance with planned project timetable. The results are published in the form of short report on the project website (Annex 7.2.2l). All necessary information on quality of local environment within respective municipalities (water, soil quality) as well as on health status of residents are elaborated in graphic and table form easy to follow by layman´s public. In addition, literary review on health effects of individual chemical elements on humans is elaborated within this action. Since similar and detailed review was elaborated within the project GEOHEALTH (LIFE10 ENV/SK/086) we focused our attention on detailed health data excerption for critical elements including Ca, Mg and water hardness present in deficiency and Si present in high contents in the geological environment of the Krupina district. For these four chemical parameters factsheets (catalogue form) “cause – effect – measure” had been compiled. This action was finished in accordance with the project timetable (dated on 01/04/2017).

Evaluated health indicators - district Krupina sum_negHI – PYLL100-PYLLI99: sum of negative health indicators; average of the Slovak Republic 7,784.23, average of the Krupina district 10,248.24, health status: very good ≤ 4,800; good > 4,800 ≤ 6 800; average > 6,800 ≤ 8,800; impaired > 8,800 ≤ 9,800; unfavourable > 9,800

health indicators exceeding Slovak health indicators exceeding average of the health indicators exceeding Slovak health indicators exceeding average of the municipality sum_negHI – PYLL100-PYLLI99 health status average 10 – 50 % Krupina district 10 – 50 % average >50 % Krupina district >50 %

PYLL100, ReE00-C99, ReI00-I99, ReJ00-J99, PYLL100, Rec00-C97, ReI00-I99, ReJ00-J99, PYLL100, Rec00-C97, ReI00-I99, ReJ00-J99, SMRC00- ReK00-K93, SMRE00-E99, SMRK00-K93, SMRC18- ReE00-C99, ReK00-K93, SMRE00-E99, SMRK00- SMRC00-C97, SMRC18-C21(25–64), SMRI60- C97, SMRC18-C21(25–64), SMRI60-I69(25–64), C21(25–64), SMRE00-E99(25–64), SMRI00- K93, SMRE00-E99(25–64), SMRI00-I99(25–64), Cerovo 14,964.33 unfavourable I69(25–64), SMRK00-K93(25–64), SMRK70- SMRK00-K93(25–64), SMRK70-K76(25–64), I99(25–64), SMRI20-I25(25–64), SMRI60- SMRI20-I25(25–64), SMRC30-C39(65), PYLI00- K76(25–64), PYLLC00-C97 PYLLC00-C97 I69(25–64), SMRK00-K93(25–64), SMRK70- I99(65) K76(25–64), SMRI60-I69(65), PYLI00-I99(65)

PYLL100, ReN00-N99, SMRC15-C26(25–64), Rec00-C97, SMRI00-I99(25–64), SMRI20- Rec00-C97, SMRI00-I99(25–64), SMRI20-I25(25–64), SMRI00-I99(25–64), SMRI20-I25(25–64), SMRI60- PYLL100, SMRC15-C26(25–64), SMRC15- I25(25–64), SMRK00-K93(25–64), SMRK70- SMRK00-K93(25–64), SMRK70-K76(25–64), SMRC00- Čekovce I69(25–64), SMRK00-K93(25–64), SMRK70- C26(25–64), SMRI60-I69(25–64), SMRE00-E99(65), 14,498.03 unfavourable K76(25–64), SMRC00-C97(65), SMRC15-C26(65), C97(65), SMRC15-C26(65), SMRC18-C21(65), K76(25–64), SMRE00-E99(65), SMRI60-I69(65), PYLI00-I99(65) SMRC18-C21(65), PYLLC00-C97 PYLLC00-C97 PYLI00-I99(65)

ReI00-I99, ReJ00-J99, ReK00-K93, ReN00-N99, SMRI00-I99, SMRJ00-J99, SMRK00-K93, SMRN00- ReJ00-J99, ReN00-N99, SMRJ00-J99, SMRN00-N99, ReI00-I99, ReK00-K93, SMRI00-I99, SMRK00-K93, ReI00-I99, ReK00-K93, SMRI00-I99, SMRK00-K93, N99, SMRC15-C26(25–64), SMRC18-C21(25–64), SMRC15-C26(25–64), SMRC15-C26(25–64), Devičie 11,988.32 unfavourable SMRI00-I99(25–64), SMRI20-I25(25–64) SMRI00-I99(25–64), SMRI20-I25(25–64) SMRI00-I99(25–64), SMRI20-I25(25–64), SMRI60- SMRC18-C21(25–64), SMRI60-I69(25–64), SMRK00- I69(25–64), SMRK00-K93(25–64), SMRK70- K93(25–64), PYLI00-I99(65) K76(25–64), SMRI60-I69(65), PYLI00-I99(65)

PYLL100, ReE00-C99, ReJ00-J99, ReK00-K93, ReN00-N99, SMRE00-E99, SMRK00-K93, SMRN00- ReE00-C99, ReN00-N99, SMRE00-E99, SMRN00- N99, SMRC00-C99(25–64), SMRC15-C26(25–64), N99, SMRC00-C99(25–64), SMRC15-C26(25–64), PYLL100, Rec00-C97, ReJ00-J99, ReK00-K93, PYLL100, Rec00-C97, ReJ00-J99, ReK00-K93, Domaníky SMRC18-C21(25–64), SMRE00-E99(25–64), SMRC15-C26(25–64), SMRC18-C21(25–64), 12,877.69 unfavourable SMRC15-C26(65), SMRI00-I99(65), SMRI20-I25(65) SMRC15-C26(65), SMRI00-I99(65), SMRI20-I25(65) SMRI20-I25(25–64), SMRC18-C21(65), SMRE00- SMRE00-E99(25–64), SMRC18-C21(65), SMRE00- E99(65), SMRI00-I99(65), SMRI60-I69(65), E99(65), PYLLC00-C97(65) PYLLC00-C97(65)

PYLL100, ReJ00-J99, ReK00-K93, SMRJ00-J99, PYLL100, ReJ00-J99, ReK00-K93, SMRJ00-J99, SMRK00-K93, SMRC00-C99(25–64), SMRC18- SMRK00-K93, SMRC00-C99(25–64), SMRC18- C21(25–64), SMRI00-I99(25–64), SMRI20- C21(25–64), SMRI00-I99(25–64), SMRI20- Drážovce SMRI00-I99(65), SMRI20-I25(65), SMRI60-I69(65) SMRI00-I99(65), SMRI20-I25(65), SMRI60-I69(65) I25(25–64), SMRI60-I69(25–64), SMRK00- 18,335.01 unfavourable I25(25–64), SMRI60-I69(25–64), SMRK00- K93(25–64), SMRK70-K76(25–64), SMRI00- K93(25–64), SMRK70-K76(25–64), SMRK00- I99(65), SMRI20-I25(65), SMRI60-I69(65), SMRK00- K93(65), SMRK70-K76(65), PYLI00-I99(65) K93(65), SMRK70-K76(65), PYLI00-I99(65)

PYLL100, ReC00-C97, ReI00-I99, ReJ00-J99, ReI00-I99, ReJ00-J99, ReN00-N99, SMRN00-N99, ReK00-K93, ReN00-N99, SMRN00-N99, SMRC15- PYLL100, Rec00-C97, SMRJ00-J99, SMRI00- PYLL100, Rec00-C97, SMRJ00-J99, SMRI00-I99(65), SMRC15-C26(65), SMRC18-C21(65), SMRC30- Drienovo C26(65), SMRC18-C21(65), SMRI00-I99(65), 11,439.68 unfavourable I99(65), SMRI20-I25(65) SMRI20-I25(65) C39(65), SMRI60-I69(65), SMRK00-K93(65), SMRI60-I69(65), SMRK00-K93(65), SMRK70- SMRK70-K76(65) K76(65)

ReN00-E99, SMRJ00-J99, SMRC00-C97(65), ReN00-E99, SMRJ00-J99, SMRC00-C97(65), SMRC15- SMRN00-N99, SMRI60-I69(25–64), SMRK00- Dudince SMRN00-N99, SMRK00-K93(65), SMRK70-K76(65) 6,950.06 average SMRC15-C26(65), SMRC18-C21(65) C26(65), SMRC18-C21(65) K93(65), SMRK70-K76(65)

ReE00-C99, ReI00-I99, ReN00-N99, SMRE00-E99, SMRN00-N99, SMRC00-C99(25–64), SMRC15- ReE00-C99, ReI00-I99, ReN00-N99, SMRE00-E99, SMRC00-C97(25–64), SMRI00-I99(25–64), SMRI20- SMRC00-C97(25–64), SMRI00-I99(25–64), SMRI20- C26(25–64), SMRE00-E99(25–64), SMRI00- SMRN00-N99, SMRC15-C26(25–64), SMRC15- Žibritov 10,985.54 unfavourable I25(25–64), SMRI00-I99(65), SMRI20-I25(65) I25(25–64), SMRI00-I99(65), SMRI20-I25(65) I99(25–64), SMRI20-I25(25–64), SMRI60- C26(25–64), SMRE00-E99(25–64), SMRI60- I69(25–64), SMRE00-E99(65), SMRI00-I99(65), I69(25–64), SMRE00-E99(65), PYLLC00-C97(65) SMRI20-I25(65), PYLLC00-C97(65)

Action B7: Realization of measurements This action includes the following three main sub-actions: 1. Technological measures, 2. Edification and environmental-health education of resident population, 3. Legislative measures.

Technological measures consisted in addition of carbonate rock in selected residential wells. Before their implementation into practice, laboratory tests of carbonate rock solubility in water including limestone, dolomite and half-burnt dolomite were realized. “Short report on realization of long-term laboratory tests for analysis of carbonate rock solubility in groundwater” describing the applied methodology and achieved results was compiled and published on the project website within session “Results – partial results” (attached as Annex 7.2.2g). From more than 120 sampled wells 7 of them were selected to be involved in application of technological measures – addition of carbonate rocks into individual residential wells (project plan was at least 5 wells). Results of model laboratory tests led to decision to add following rock types into wells: half-burnt dolomite, dolomite and limestone in grain size between 4 – 12 mm in ratio about 1:1:1. For the implementation of technological measures into practice we let to manufacture 7 “baskets” from stainless steel which we have put into wells and which we have filled by mixture of carbonate rocks. At the beginning of July 2015 (06/07/2015) we started to add carbonate rocks into 6 of 7 individual wells. One well could not be filled by carbonate rock due to extremely hot and dry weather and no presence of water. Therefore, the rock material was added in this well three months later. Together with start of technological measures realization (addition of carbonate rock) we began to monitor groundwater quality including realization of field measurements (pH, electric conductivity, and groundwater table) and laboratory analyses (determination of Ca and Mg contents). Also because of conventional reasons we decided to add smaller amount of the rock mixture to prevent rapid change of water taste. We gradually add carbonate rock into wells in three cycles. After the third cycle of carbonate rock addition we reached expected increase of Ca and Mg contents in water. This sub- action is in more detail described within the Action C2. The most significant output of this action is reaching adequate increase of Ca and Mg groundwater contents after implementation of technological measures.

Stainless steel baskets

Photo: Cvečková, 2015

Krupina, Kňazová dolina 1208, well No. 3, installation of basket into well and rock carbonate addition

Photo: Rapant, 2014, Cvečková, 2015

Within the edification and environmental-health education of resident population there were organized five informative meetings in selected municipalities of the Krupina district during the last year of project implementation. During these meetings we informed residents about faced environmental-health problem in their municipality and gave them detail explanation of how they can prevent related negative health effects. It can almost certainly be assumed that at least 1000 people (participants in information meetings and their family members) will change their habits and drink mineral and bottled water with higher Ca and Mg contents. Informative meetings were set as project milestones and were implemented four weeks in advance according the project timetable (26/06/2017). They are published in the form of short report on the project website (Annex 7.3.7d, e). Legislative measures include the elaboration of proposal for legislative guideline for water based on the results of action B3 – mathematical-statistical data analysis. As stated within

20 the action B3 the whole dataset of environmental and health indicators which was analysed was too small and too heterogeneous to be able to reach relevant results with statistical significance. Therefore the legislative proposal was elaborated based on the results of the project GEOHEALTH (LIFE10 ENV/SK/086). As the most influential elements on human health of residents in the Krupina district we identified following parameters: Ca, Mg water contents and water hardness. These parameters have decisive role in the impaired health status of residents, including the most common causes of deaths such as cardiovascular diseases, oncological diseases, and diseases of gastrointestinal system, respiratory system as well as endocrine system (diabetes). The derived recommended values are provided in table form within the description of technical action B3. Works on this action were running in accordance with the project schedule and this action was completed according to the project timetable. There was one related deliverable “Evaluation of the results of technological measures” (30/08/2017). This deliverable was implemented in the form of two short reports (Action B7: Short report on realization of long-term laboratory tests – 30/10/2015 and Action C2: Monitoring of environmental impacts of changes of chemical composition of drinking water 01/11/2016). There were two milestones associated to this action which were successfully completed according to the project timetable: “Completion of rock preparation for technological measures” and “Addition of rock into water sources”.

Action C1: Monitoring Within this action we regularly monitor and check the implementation of project actions in accordance with project timetable and schedule including indicators of progress, timetable for each action as well as deadlines and completion of deliverables and milestones. Project monitoring is based via consultative meetings of project team members once per 2 months. The records from consultative meetings are published on the project website, in session “Dissemination - Project administration”. In case of delay of some of implemented project actions, project team members discussed problems encountered and tried to find the most effective solutions. Project manager together with project team elaborated once per year monitoring report on project progress. During the project implementation 5 monitoring reports were elaborated (10/03/2014, 30/01/2015, 30/11/2015, 30/11/2016 and 31/11/2017) and five monitoring reports of associated beneficiaries - Krupina City (01/10/2013 - 31/12/2013, 01/01/2014 - 30/06/2014, 01/07/2014 - 31/12/2014, 01/01/2015 - 31/12/2015, 01/01/2016 - 31/12/2016). All monitoring reports were published on the project website, session "Dissemination - Project administration". This action was completed in accordance with the project timetable.

Action C2: Monitoring of environmental impacts of the changes in chemical composition of drinking water Immediately after starting the realization of technological measures – addition of carbonate rocks into individual wells within the action B7 (09/07/2015, local sources of water for residents), we also started to monitor potential environmental impacts of the changes in chemical composition of drinking water. Monitoring was realized in the following periodicity after the rock addition: 1st day, 1 week later, 2 weeks later. Only slight changes of chemical composition of water that we have documented - increase of Ca (about 5 mg.l-1) and Mg (about 10 mg.l-1), led to change of monitoring period to once per month. We monitored following chemical parameters: pH, electric conductivity, water hardness, groundwater table in wells and Ca and Mg contents. Gradual addition of carbonate rock into selected residential wells reflected in positive changes monitored parameters. Increase of Ca, Mg water contents and increase of water hardness was observed in all wells however each well is characterized with own hydrogeochemical regime. The changes in Ca and Mg water contents were highly dependent from the amount of rainfall and natural groundwater runoff from wells (in three cases wells were constructed on captured springs). In case of extreme rainfall as well as intensive water pumping (for irrigation of residential gardens) we documented water dilution and subsequent Ca and Mg water contents decrease. We provide a figure below to illustrate trend in changes of chemical composition of drinking water in well No. 4. Detail information on the results of water quality monitoring is summarized in the short report entitled “Monitoring of environmental impacts of the changes in chemical composition of drinking water” (Annex 7.2.2h) which is published on the project website (session Results – partial results). Finally we can conclude that in six residential wells we reached significant increase of water hardness and Mg contents, partially also Ca contents, at recommended (target) levels. Water with increased Ca and Mg contents in six home wells uses 23 people for drinking purposes. In case of one residential well with higher natural runoff (more than 1 l.s-1) we reached only low increase of Ca and Mg water contents. The reason is mainly the effect of water dilution due to high inflow of low mineralized water. This well was after consultations with project monitor Mr. Svoboda excluded from further monitoring. In summer 2017 we added the additional amount of carbonate rock into monitored wells and we monitored the changes in chemical composition of water in 3 – 4-month cycle. This action was implemented fully in accordance with the project timetable and schedule.

Changes in chemical composition of groundwater/drinking water – case of well No. 4 (Krupina, Kňazová dolina 1207) a b Conductivity Ca

600,00 45,00

- - 40,00 500,00 R² = 0,6899 mg .l R² = 0,4062

S S cm . 35,00 

400,00 R² = 0,6864 30,00 R² = 0,414

300,00 25,00 20,00 200,00 15,00

100,00 10,00

5,00 0,00

0,00

11.12.205

14.112016

23.07.2014 02.03.2016 14.05.2015 27.10.2015 28.10.2015 06.05.2016 08.06.2016 19.07.2016 13.09.2016 28.03.2017 16.08.2017

11.12.205

14.112016

23.07.2014 14.05.2015 27.10.2015 28.10.2015 02.03.2016 06.05.2016 08.06.2016 19.07.2016 13.09.2016 28.03.2017 16.08.2017 sampling date logarithmic trend exponencial trend logarithmic trend exponencial trend sampling date c d Mg Ca + Mg

3,50

1 -

1 60,00

.l . l . R² = 0,7982 3,00 R² = 0,7472

50,00 mg mg

2,50 40,00 R² = 0,7262 R² = 0,7183 2,00 30,00

1,50 20,00 1,00 10,00 0,50 0,00

0,00

11.12.205

14.112016

28.10.2015 16.08.2017 23.07.2014 14.05.2015 27.10.2015 02.03.2016 06.05.2016 08.06.2016 19.07.2016 13.09.2016 28.03.2017

11.12.205

14.112016

Field measurements within monitoring of changes in water quality in residential wells

Photo: Cvečková, 2016

Action C3: Monitoring of socio-economic impacts of project actions Monitoring of socio-economic impacts of the project implementation is realized in two phases: at the beginning of the project and at the project end. The first phase of monitoring was realized in the form of questionnaires (published on the project website in electronic format as well as hard copy) with focus on evaluation of public awareness on potential negative impact of unfavourable geological environment on health status of residents in the Krupina district and potential behavioural changes of residents after they become familiar with the environmental-health problem. Overall 184 questionnaires were collected (project plan was 100 questionnaires). About 2/3 of respondents were informed about the project objectives (through TV, internet, newspaper articles) and they were aware on implemented environmental-health problem (health impacts of water deficient in Ca and Mg). Very positive result was the fact that the majority of respondents (51.37%) answered that given information on environmental-health problem in their district will affect their behaviour. The second phase of monitoring of socio-economic impacts of project actions was realized in the last year of the project implementation. Again, we have compiled the questionnaire and distributed it among residents of the Krupina district. Overall 150 filled in questionnaires were returned to us (project planned 100 collected questionnaires). More than one third of respondents stated the change in their eating habits to eliminated negative health impact of drinking soft water. Approximately half of them stated no change in their eating habits and drinking regime due to economic reasons but they do not strictly deny the behavioural changes in case their economic situation will improve. The detailed evaluation of the achieved results within both phases of monitoring were summarized in the form of short report entitled “Results of the first stage of monitoring of public awareness on potential negative impact of unfavourable geological environment on health status of residents in the Krupina district” and “Results of the second stage of monitoring of public awareness on potential negative impact of unfavourable geological environment on health status of residents in the Krupina district” (Annex 7.2.2i). These reports are also published on the project website (session Results – partial results). This action was implemented in accordance with the project timetable and schedule.

5.2 Dissemination actions 5.2.1 Objectives The project results, reporting the relationship between the impaired health status of people of Krupina district (higher mortality from CVD, OD, GTS, RS, diabetes, lower life expectancy) and deficiency of Ca and Mg in drinking water due to unfavourable (silicate) geological environment, represent level of basic research and are of society- wide importance. They cannot be measured directly, and the achieved outputs can be from the quantitative point of view estimated only indirectly. On the other hand, they are of very high significance for the improvement of health status of population in Krupina district and all Slovak population as well as in other EU countries. Therefore, the objective of the dissemination plan set out in the project proposal was the very wide dissemination of the project results and outputs at national as well as international level among public and scientific audience (e.g. representatives of public health authorities, epidemiologists, experts in environmental sciences, medical geochemistry, water management etc.). This wide dissemination represents in this project a unique and very effective tool to raise awareness, knowledge and transfer of achieved findings on this environmental-health problem leading to higher concern of related authorities in implementation of proposed measures into legislative. The outputs of dissemination activities represent in the overall project concept the quantifiable indicators. The overall number of project presentations performed at national/international forums includes 27 oral presentations and 7 poster presentations. Their list is attached in the Annex 7.3 to this report and full versions are attached due to their large amount in electronic format (as ppt/pdf files) as Annexes 7.3.1a, b, c. All planned dissemination activities were implemented according to the project plan with exception of presentations planned to be presented at national and international conferences. The reason was the disapproval of the general director of ŠGÚDŠ for participation in these planned events. During 4 years of the project implementation only one member of the project team participated in two international conferences, namely one organized in Brussels, Belgium (SEGH 2016) and one organized in Galway, Ireland (ISEH 2016, ISEG 2016 & Geoinformatics 2016). Two members of project team participated the international conference MedGeo2017 (Moscow, Russia). Other travels were not approved by our general director including the participation in WHO. Beside these problems we successfully reached the objectives of dissemination plan. All dissemination outputs including scientific articles, short reports, propagation materials, presentations, final posters etc. were visibly marked with the LIFE+ logo and when possible also acknowledgment to the financial support by the LIFE+ programme was given.

5.2.2 Dissemination: overview per activity All dissemination activities were implemented by project team of the coordinating beneficiary (ŠGÚDŠ). Associated beneficiary Mesto Krupina (Krupina city) was responsible for dissemination and propagation of achieved project results among resident population of the Krupina district.

Action D1: Networking with other projects Within this action we performed ongoing study and excerption of all relevant works of similar character to ensure networking with other implemented projects. So far, we did not find any other similar study dealing with the issue of evaluation of negative impact of geological environment on human health and realization of appropriate measures. We 27 tried to disseminate project objectives and outputs on scientific conferences and found in this way some connections with similar projects, including national scientific forum (Geochémia 2014, 04-05/12/2014) as well as international scientific forum (International conference of the Society for Environmental Geochemistry and Health, SEGH 2015, 22- 26/2015, Bratislava), SEGH 2016 Brussels and ISEH 2016, ISEG 2016 & Geoinformatics 2016 Galway and MedGeo 2017 Moscow. Within the project dissemination of results, five international events were planned with participation of three project team members. Only three international conferences were attended, two participated by Mrs. Fajčíková and one participated by Mr. Rapant and Mrs. Cvečková, due to disapproval for travelling given by the general director of ŠGÚDŠ. Conference “MedGeo´17” in Moscow, Russia – participation in this event was approved by the EC in the letter of 05/08/2016). During the presentation of project results on national conference organized yearly by Slovak hygienic-epidemiologic society (Nový Smokovec, 28– 29/09/2016) the project team members were not refunded the costs for accommodation by general director of ŠGÚDŠ and due to this we were not able to continue in dissemination of the project results on other national events. We compensated the absence of travels abroad and international forum discussions by intensive electronic (e-mail) communication with the international as well as local (national) experts in the field of environmental geochemistry, medicine, epidemiology, public health. We contacted various scientific and expert groups and institutions from the related fields of research (e.g. US EPA, WHO, National Institute of Public Health in Czech Republic, Dallas University in Texas, U. S. Food and Drug Administration, WHO Centre for Environment and Health, Slovak Regional Public Health Authorities, National Health Information Centre in Slovakia, Charles University in Prague, etc.) and discussed with them scientific background of this project mainly through e-mail communication as well as during the conferences and similar events. Our communication was supported by the previous experience and contacts achieved within the implementation of the project GEOHEALTH (LIFE10 ENV/SK/086). We also planned to realize travel to WHO centre in Bonn, Germany during summer 2017 where we wanted to present the results of project. This travel was not realized due to disapproval of general director of ŠGÚDŠ. Although we were not able to network with any concrete project we consider this action to be fulfilled through intensive communication with experts and scientists (mainly through the e-mail) from countries inside/outside EU as well as from the Slovak Republic and active dissemination of project results and awareness raising among international scientific audience (participation in three international conferences).

Action D2: Any media work Within this action widespread propagation of project results to layman and professional audience was realized to rise general interest in objectives and achievement of project results. The review of completed dissemination activities within any media work which are defined also as output indicators of the project is summarized in table below. Outputs of media works (TV and radio reportages, articles in newspaper articles…) were regularly published on the project website and reported to the Commission within the project reports. They are listed in Annex 7.3 and attached to this final report in electronic form in Annex 7.3.2. TV and radio reportages and internet articles are available only on the project website (TV and radio archives are available only online without possibility to make downloads).

Project Total No. of Output indicators – Media plan within completed this action outputs Press releases made by the project 2 1 General public article in national press 5 5 General public article in local press 5 5 Internet article 10 6 TV news/reportage 5 11 Radio news/reportage 2 1

In summer 2016 we were forbidden by the general director to communicate with media therefore we did not perform any media work in the last year of project implementation. Due this attitude of our general director we did not contact media for any further communication. However, due to effective collaboration with the associated beneficiary Krupina city we reached project plan within the media work and respective defined output indicators (please see the table above).

Action D3: After – LIFE communication plan After – LIFE Communication plan was elaborated by the project manager during the final stage of project implementation. It is published on the project website and attached as Annex 7.2.3 to this report.

Action D4: Notice board Two notice boards about the project with the logo LIFE+ and project logo were displayed at strategic places in accordance with the project plan. One notice board was placed in the premises of ŠGÚDŠ and one was placed by the premises of city Krupina on the main square. Both places are frequently visited by public. All information was reported within the Inception report (photos, invoice). 2 notice boards are also included in output indicators within “Media and other communication and dissemination work”. This action was successfully completed.

Action D5: Website The website of the project started to run through the website of the coordinating beneficiary in accordance with the project plan, on 10/01/2014. It is fully functional and continuously actualized. Project website is one of the output indicators within “Media and other communication and dissemination work”. The planned number of visitors per month was set to 100. Up to date of the project end we had more than 5000 visitors of the project website (monthly average over 110 visitors since the start of the website). The calculation of number of visitors does not include web addresses of the workers from the coordinating beneficiary (ŠGÚDŠ) as well as repeated visiting by the same address. This action was successfully completed.

Action D6: Layman´s report Layman’s report was elaborated as project deliverable during the final stage of the project implementation (30/08/2017) according to the project schedule. It was compiled in Slovak as well as in English language and published on the project website in electronic form as well as distributed in paper form (Annex 7.3.6a, b). This action was successfully completed.

Action D7: Technical publications of the project The project results were published in various form of publications, including 2 monographs, scientific current contents international magazines (3 papers), conference books from international events (7 papers), scientific national magazines (2 papers), scientific book of proceedings - monographs (3 papers) and conference books from national events (6 papers). The list of published technical publications is included in Annex 7.3 and they are attached in paper/electronic format as Annexes 7.3.4.1, 7.3.4.2, 7.3.5. Technical publications of the project were included in output/outcome indicators and they are summarized in the final table of outcome indicators (Part 3, Publications) attached as Annex 7.2.4 to this report. We can conclude that all planned activities related to technical publications of the project were successfully implemented with higher number of the publications than planned in the project proposal (as well as within output indicators). All scientific articles and papers were published regularly on the project website. The two monographs (Slovak and English) were published only in the printed form. They were officially distributed to all concerned organizations and authorities as well as libraries. Following institutions were provided the hardcopy of both monographs: Slovak National Library, University Library in Bratislava, Central Archive of Geodetic and Cartographic Institute in Bratislava, Ministry of Environment of the Slovak Republic – the minister; State secretaries; Directorate for environment policy, EU and international affairs; Directorate for climate change and air protection; Directorate for water; Directorate for geology and natural resources (geology department, environmental geology department, department of state geological administration); Directorate for nature, biodiversity and landscape protection, Library of the Ministry of Environment of the Slovak Republic; Library of Public Health Office of the Slovak Republic; Libraries of State Geological Institute of Dionýz Štúr in Bratislava, Košice, Spišská Nová Ves and Banská Bystrica. Both monographs will be distributed among scientific audience (in case of interest also public audience) within the implementation of the After-LIFE Communication Plan. Within this action there were two deliverables defined – “Publications of the project results (01/09/2017) and Monograph in Slovak language (15/09/2017)”. We have successfully fulfilled these deliverables according to the project timetable. This action was successfully completed.

Action D8: Workshop, seminar, conference Within this action we organized several events to share the project results with scientific community and public audience. In accordance with the project we organized one workshop, one conference and one seminar. In the project two seminars were planned – one for professionals and one for public. Due to the fact that we were given approved order for refreshment and conference room for event to be organized in the Krupina district only 24 hours before the conference date we were not able to manage its organization. We were not able to provide sufficient number of residents of the Krupina district to participate in such event. That is why we joined two events for professionals and public in one event. Only 10 residents from the Krupina district participated in this event. We have organized international workshop on topic “Chemical elements in the environment and human health” (25 - 26 September 2014) in Bratislava, Slovak Republic, with participation of 4 foreign experts and 10 Slovak specialists. More detailed information about the workshop programme and results (presentations, final conclusions) was published on the project website, within session “Events – workshop” (only in Slovak). The list of participants is attached as Annex 7.3.7a and photo documentation is

30 attached as Annex 7.3.8c. Organized workshop is considered as output indicators of the project and is included in table of output indicators in section “Workshops, seminars and conferences” (international workshop, 0-25 participants). At the project beginning we planned to organize final international conference under the auspices of the Medical Geology association in 2017 (at the end of the project). We had preliminary agreement with this event from competent representatives of this association during first years of the project implementation. We planned to discuss the details during the conference of Medical Geology organized in 2015. Since we did not participate in this conference due to problems with the approval of travel by the general director of ŠGÚDŠ we were not able to finalize this agenda in time and thus this conference was not organized within this project. Final conference (project milestone 30/06/2017) was organized directly in the Krupina district in Dudince city, on 27 – 28 April 2017. It was attended by 57 participants, among them 48 specialists, mainly environmental geologists, and 9 local residents. Photo documentation of this event is attached as Annex 7.3.8j and the list of participants is attached as Annex_7.3.7g to this final report. During the conference, participants were provided with refreshment and they were given propagation materials (including T-shirts, eco bags, badges, USB-keys with conference presentations), with logo LIFE+ and logo of the project. We organized also one scientific event – seminar in Bratislava (project milestone 30/04/2017) on “Hard/soft water and its impact on human health” with 2-month delay (07/06/2017). This delay was due to huge work agenda within the project, mainly organization of informative meetings for residents of the Krupina district and preparation of the final monographs. This event was attended by 85 specialists, mainly from health science (doctors, hygienists, epidemiologists) as well as specialists from water science. Photo documentation of this event is attached as Annex 7.3.8k and the list of participants as Annex 7.3.7f to this final report. During the seminar, participants were provided with refreshment and they were given propagation materials (including T-shirts, eco bags, badges, USB-keys with seminar presentations) with logo LIFE+ and logo of the project. This action was successfully implemented, and all planned events were organized according to the project proposal.

TABLE OF EVENTS Workshop Bratislava 25-26/09/2014 14 participants Conference Dudince 27-28/04/2014 57 participants Seminar Bratislava 07/06/2017 85 participants

5.3 Evaluation of Project Implementation For the confirmation of the hypothesis that soft drinking water impairs health status of residents in the Krupina district, several actions were implemented. The elaboration of datasets of environmental and health indicators and further data analysis brought confirming results that the health status in the Krupina district is unfavourable compared to other Slovak districts/regions. From 36 municipalities of the Krupina district in eight municipalities health status is at level comparable to the Slovak average and 28 municipalities are characterized predominantly with worse health status than Slovak average. The results of the evaluation of the lifestyle and health-care accessibility in the Krupina district documented comparable status with other Slovak districts/regions. These factors do not play any specific role in the unfavourable health status of residents in this district. Thus, the unfavourable geological environment, specifically deficient Ca and Mg drinking water contents, was identified as the most significant factor of the impaired health status of residents in this district. Through the measurements of arterial stiffness, we documented significantly impaired status of arteries of respondents drinking soft water (with Ca and Mg deficit) compared to those respondents drinking harder water. The results of implementation of technological measures – addition of carbonate rock mixture into individual residential wells – confirmed the effectiveness of this method of water treatment to increase Ca and Mg contents in drinking water to adequate levels. Applying this method in practice – addition of carbonate rock the increase of Ca and Mg contents also in larger drinking water sources used for public supply – can be expected. In the table below, we provide a review of the main project objectives (deliverables, milestones).

Foreseen in the revised Task (action) Achieved Evaluation proposal Dataset environmental > 500 chemical analyses 512 chemical analyses of fulfilled indicators (B1) of groundwater/soil groundwater/soil Training activities (B1) 5 informative meetings 6 informative meetings fulfilled Dataset of health 50 HI 65 HI fulfilled indicators (B2) Linking of environmental 1 short report 1 short report fulfilled and health indicators (B3) Biomonitoring – chemical analyses (hair/nails) and 2 short reports 3 short reports fulfilled measurements of arterial stiffness (B4) Evaluation of life style and health-care 1 short report 2 short reports fulfilled accessibility (B5) Realization of measures: environmental–health 5 informative meetings 5 informative meetings fulfilled edification (B7) Legislative proposal of limit values for 1 short report 1 short report fulfilled influential elements (B3, B7) Realization of measures – Water treatment in 6 (7) Water treatment in 5 technological measures wells fulfilled wells (B7) 1 short report

Foreseen in the revised Task (action) Achieved Evaluation proposal Publishing of results in international impacted 3 publications 3 publications fulfilled magazine (D7) Organization of international workshop 1 workshop 1 workshop fulfilled (D8) Organization of 3 events 2 events fulfilled conference/seminars (D8)

The information included in the table clearly documents that all significant project outputs were successfully fulfilled in accordance with the project timetable and schedule. Mainly the results of the action B4 (Biomonitoring) and application of method of arterial stiffness measurement is immediately visible. One of the main project conclusions is the recommendation of use of this method (determination of arterial age) in further practice to identify the health impacts of consumption of soft drinking water on residents. Thus, residents can practice appropriate measures – additional intake of Ca and Mg from water (e.g. mineral water) or food immediately to eliminate negative health effects. The main project objective – the improvement of health status of residents in the Krupina district, but also Slovak and even EU population from other areas suffering from Ca and Mg deficiency in drinking water is a long-term process. We assume that we clearly documented negative health implications of deficit Ca and Mg contents on humans. Therefore, it is necessary to highlight the necessity of the increase of Ca and Mg contents in drinking water used for public consumption by appropriate technological measures. We presented the project results at organized events (seminars/conference) as well as at internationals scientific forum through a series of oral and poster presentation and publish our results in international and national journals. We communicated this statement to the EC through e-mail with our comments on the currently discussed WHO concepts for a review of drinking water parameters (Drinking Water Directive 98/83/EC) and necessity of definition of limit values for Ca and Mg contents in drinking water. This communication is attached to the Final report of the project as Annex 7.4.1. We have submitted the proposal for inclusion of Ca and Mg contents in drinking water among regulated elements within the Slovak drinking water guideline in collaboration with the Slovak Ministry of Environment at occasion of revision process of this guideline. This communication is attached to this final report as Annex 7.4.2. We find the dissemination of project partial results to public as well as scientific audience effective and successfully implemented. The identified and confirmed environmental- health problem was object of concern of public audience and thus we were often contacted by media to make reportage. Due to our continuous problems with approvals for media communication to be given by our general director we were not able to present the project results in full extent. We had very good communication also with Layman public. Many persons found information on the project results on the website or they were informed through media (TV, radio) and contacted us through the e-mail or phone with questions related mainly to possible measures to eliminate negative impact of geological environment on their health status. We have added the carbonate rock into the local wells of other three residents of the Krupina district. We disseminate the addressed environmental-health problem within resident population during the first informative meetings organized at the very beginning of the project (within the action B1). During the final informative meetings organized in 2017 we explained in more detail to residents of 5 municipalities of the Krupina district

33 how they can reduce the adverse health effects associated to deficit Ca and Mg contents in their drinking water (e.g. by increased consumption of mineral/bottle water with higher Ca and Mg contents). Based on the huge presentation of the project results we can finally conclude the project dissemination impact in 4 levels (as reported regularly in the project reports): 1. Community of professionals / experts, 2. Media, 3. Administrative organs, 4. Inhabitants, mayors of municipalities.

Within the project, also educational activities were implemented. Project team members trained hundreds of students with emphasis mainly on the new methodology used for environmental-health data elaboration, including: - Medical University, University of Pavol Jozef Šafárik, Košice (subject “Hygiene of the Environment”, lecturer Z. Dietzová), - University (higher education) – Comenius University Bratislava (division of environmental geochemistry, subject – “Environmental Geochemistry 2”, lecturer S. Rapant, K. Fajčíková). In addition, the project team member (Mrs. Fajčíková) was leader of 1 Diploma thesis (2014 – 2016) and 1 PhD (2013 – 2017) thesis focused on the issue solved within the project (relationship between environmental and health data).

5.4 Analysis of long-term benefits The project quantitative environmental benefits are represented by the long-term improvement of health status of residents in Krupina district which is expected after implementation of appropriate measures. These measures consist mainly in the drinking water re-carbonization (enrichment of water by Ca and Mg contents) or increased additional intake of Ca and Mg in food chain (consumption of mineral water rich in Ca, Mg, intake of various vitamin supplies, etc.). We are not legitimate to govern legislative process of implementation of limit values for Ca and Mg in drinking water. Our results show that low mineralized drinking water with deficit content of Ca and Mg are for human health unfavourable. The increase of Ca and Mg contents in drinking water will be beneficial for health status leading to prolongation of life expectancy. Of course, also costs for health-care will subsequently decrease. The results achieved in this project are fully relevant for the European environmental policy and legislation. They are directly applicable in main strategic EU documents dealing with the environment and human health, namely: 1. “Environment Action Programme to 2020 (EAP)” and 2. “Health 2020”. Within the 7th EAP the third key action covers the issue of the human health: “Healthy environment for healthy people”. The important part of this key action is the improvement of legislation relating to drinking water. The environment impacts health through many factors including inadequate water quality. Within “Health 2020” the policy framework aims to support actions across government and society to: “significantly improve the health and well-being of populations…”. Good health status of population brings benefits to all sectors and the entire society. The supply of population by “safe” drinking water is one of the most important health determinants. We have submitted proposal for inclusion of Ca and Mg among regulated parameters in drinking water to competent bodies in the Slovak Republic as well as at EU level. Long-term qualitative environmental benefits of this project consist in gradual and long- term improvement of health status of human population after the application of proposed measures into Slovak and EU legislation. The value of human health and human life is priceless. Neither in the EU nor anywhere in the world, any regulations, methodologies or guidelines exist to measure price of life. We consider human diseases and deaths caused by consumption of soft water as so called avoidable causes of deaths. This is an environmental factor – character of geological background namely silicate rock environment that is associated with the formation of soft water. Of course, it is senseless and impossible to move the residents from such unfavourable geological environment. The simple solution is to increase Ca and Mg contents in drinking water by implementation of appropriate measures. These measures were verified within this project. The results of application of water re-carbonization in seven individual residential wells based on addition of carbonate rock into local water sources demonstrated that it is possible to increase Ca and Mg contents in drinking water using this technological measure. However, this technological measure should be applied in future on larger drinking water sources used for public supply to affect higher number of residents. About 20–25 % of the Slovak territory as well as of the EU territory is built of silicate geological environment. In Slovakia about 1 million inhabitants and in the EU about 60 million of inhabitants are impacted in relation to consumption of drinking water deficient in Ca and Mg contents. In case the project results will be disseminated enough to raise public awareness (mainly of those consuming soft water for drinking purposes) there is full assumption to improve health status of population drinking soft water at national level – at least 1% of Slovak population (minimum 10,000 residents) and international

35 level – at least 1 ‰ of EU population (minimum 120,000 inhabitants). Special case is the issue of the consumption of bottled drinking water which is often deficient in Ca and Mg (except of the water for babies) and there is a need of legislative measures also in this field. From the point of view of long-term qualitative economic benefits, the financial costs saved within the health care by application of proposed measures into practice, will every year multiply exceed project costs. We find long-term qualitative social benefits in everyday application of project results (proposed measures) into practice. When a human is healthy, he/she is happier and can live longer and work full life. We find also important to arrange the continuation of the project actions, mainly in 3 levels: . Environmental-health edification to highlight the environmental-health problem associated to health risks from consumption of soft drinking water and to disseminate appropriate measures to eliminate these risks and improve the health status of residents (need of additional intake of Ca and Mg), . Gradual but long-term incorporation of the project results into national as well as EU legislation process, . Compilation of new project „Improvement of health status of population of the Slovak Republic through drinking water re-carbonization“. The project will aim to improve health status of inhabitants by increasing of Ca and Mg drinking water contents (water sources used for public supply) at required levels through development and application of prototype for drinking water re- carbonization. The project result dissemination leads to raised awareness and transfer of knowledge and new findings among experts and scientific communities. Main project topic – the improvement of health status of residents by implementation of appropriate measures to increase intake of Ca and Mg by residents – was the object of high concern. We demonstrated that water re-carbonization through addition of carbonate rock into water sources is a suitable method how to increase Ca and Mg contents in drinking water. The replicability of this measure is easy and low-cost and based on the project results we highly recommend its application also in case of bottled water to ensure human population adequate Ca and Mg intake also via this drinking water source. At present, project results were used for preparatory works and included in one project proposal submitted within the programme HORIZON 2020. The team members of the two LIFE+ projects LIFE FOR KRUPINA and GEOHEALTH were invited to cooperate on this project. The transferability and wider replication of the project results is highly affected by the needed running costs for similar projects and available grant programmes and funding. The best practice lessons related to this project are represented mainly by direct edification and environmental-health education of residents. The informative meetings organized in the municipalities of the Krupina district lead to direct communication with local people and discussion of faced environmental-health problem and importance of measures. Once people are well informed and in easy way explained that the geological environment has negative impact on their health and how they can reduce or avoid potential health risks there is very high presumption that they will apply the proposed measures in their every-day life successfully. Another approach used within this project was active presentation and discussion of the results at national as well as international forums which enable us to give feedback from other experts and researchers and thus review our methodology and applied procedures in

36 way to increase its quality and effectivity. The result of this approach is e.g. publication of scientific papers in impacted international magazines (three papers already published within the project) which are highly appreciated among the scientific community. We find the used strategy of project result dissemination and training activities appropriate in relation to overall project objective and concept. Project innovation and demonstration value consists in the following issues: . Compilation of national datasets of environmental indicators (chemical analyses of groundwater and soils) and health indicators (statistical data on demographic growth and mortality from selected causes of deaths) in numeric and map form. We are not aware of any similar datasets of regional/national significance. . Proposal of limit values (based on ANNs – Artificial Neural Networks) for critical chemical elements in drinking water with high influence on human health of residents, . Increase of Ca and Mg contents in drinking water in several residential wells through water re-carbonization, . Demonstration of negative impact of unfavourable geological environment – reflected in deficiency of Ca and Mg contents in drinking water used for public supply on human health of residents, . By direct medical measurements – measurements of arterial stiffness we directly confirmed for the first-time impaired health status of residents due to consumption of soft drinking water.

Long-term indicator of the project success is gradual and long-term improvement of health status of residents in the Krupina district which can be monitored based on future statistical data on health status, mainly mortality from CVD, OD, GTS, RS and diabetes. These are the most common diagnoses related to the impaired health status and decisive causes of deaths across the EU countries including Slovak Republic.

6. Comments on the financial report Answers to the EC comments and recommendations stated in EC letters addressed after the submission of the Mid-term report (Ref. Ares (2017)5412137 – 07/11/2017, are attached as Annex 8.1. We provide examples of invoices as well as examples of timesheets, salary slips for the Coordinating Beneficiary (Annex 8.2a, 8.3a) and the Associated Beneficiary (Annex 8.2b, 8.3b), separately. Financial annexes including signed “Standard Payment Request and Beneficiary's Certificate”, “Consolidated Cost Statement for the Project” and “Financial Statement of the Individual Beneficiary” are attached separately for the Coordinating Beneficiary (Annex 8.4a) and the Associated Beneficiary (Annex 8.4b) in paper as well as electronic format to this Final Report.

6.1. Summary of Costs Incurred The total incurred costs for the project were in the amount of 321,892.87 €. The eligible costs were in the amount of 317,988.14 €. Total financial costs of the Coordinating Beneficiary were in the amount of 311,108.51 € (eligible costs in the amount of 307,203.77 €). Total financial costs of the Associated Beneficiary were in the amount of 10,784.36 €. All financial means were spent in accordance with the project actions and project budget. No changes were made in the individual cost categories. Due to some savings in several budget categories, non-realizing of some purchases of equipment and reduced number of international travels, the total project costs are lower than foreseen. Below we explain the main reasons of cost recoveries for the main items of the budget. Personnel: The increased Time units rates for Mr Rapant and Mrs. Fajcikova (permanent staff) were explained and the EC accepted in the Mid-term report as part of the responses to financial issues Progress report No1 (12/12/2015). The detailed justification for increased Time Unit rates for Mr Rapant and Mrs. Fajcikova was substantiated and accepted by the EC in the Final Report of GEOHEALTH (LIFE10 ENV / SK / 086).In case of temporary external workers, namely Mrs. Stehlíková (senior statistician) and Mrs. Čárska (financial manager) the daily salary exceeded their planned financial covering, mainly due to the changes applied in the Slovak legislation. Change in Slovak legislation: From 01/01/2013 based on law 461/2003 of Coll. on social insurance and amendment to the Act. No. 580/2003 on health insurance the salaries of external employees (temporary work agreement) are burdened with levies related to social and health insurance in total amount of 24.8%. It means that total personnel costs for these employees increased by 24.8%. The second reason was that Mrs. Stehlíková was working in the project also in position of junior statistician (instead of Mrs. Fajčíková) and Mrs. Čárska was working in the last year also in the position of accountant (instead of Mrs. Strelecká). In 2015, the Slovak legislation changed in that way that the external workers can be employed for a maximum of 350 hours per year. Therefore, we were forced to increase their daily salary costs to ensure the job is done. These are the reasons of higher daily rates for temporary staff in comparison with the project proposal. Travel: Due to disapproval of general director of ŠGÚDŠ the major part of planned travels abroad was not realized. In addition, we were not able to participate national conferences due to disapproved cost recoveries for accommodation by general director (we had to pay the costs ourselves). Another reason of low travel cost drawing was restriction of the general director of ŠGÚDŠ to use private cars. Therefore, we used official cars in own of the organization (ŠGÚDŠ) in case of which only reimbursement of

fuel costs without amortization costs was done. This last reason is valid also for the Associated beneficiary – Mesto Krupina. As confirmed during the joint monitoring visit in 2015 and also during the visit to Associated Beneficiary in June 2017 only the real fuel costs are reimbursed by the project (number of kilometres x official consumption x real costs of fuel). Equipment: Due to problems with public procurement for purchase of the software for calculation of neural networks, the calculations were realized through free-ware software. We have bought only two auxiliary softwares for visualization of the results of calculations. Their price was much lower than planned costs for this item within the project budget. Further, we were not able to realize purchase of six devices (conductometers) for measurement of water conductivity. During period of 2.5 year the public procurement was not finished. This did not influence the results as we used institute’s equipment. Other costs: Due to withdrawal of our participation in the international conferences we did not draw the item of conference fees. Due to long-term problems with disapprovals by our general director in case of event participation and organization we merged two originally planned seminars for public and experts in one event.

In table below, we provide a summary of the incurred project costs according to the categories within the project budget.

PROJECT COSTS INCURRED

Cost category Budget according to the Costs incurred within %** grant agreement* the project duration 1. Personnel 237,996 206,311.69 86.69 2. Travel 30,120 11,054.76 36.70 3. External assistance 74,000 61,812.95 83.53 4. Durables: total non- 0 depreciated cost - Infrastructure sub- 0 tot. - Equipment sub-tot. 24,300 7,809.47 32.14 - Prototypes sub-tot. 0 5. Consumables 16,200 11,660.70 71.98 6. Other costs 8,600 2,440.34 28.38 7. Overheads 26,534 20,802.96 78.40 TOTAL 417,750 321,892.87 77.05 *) If the Commission has officially approved a budget modification indicate the breakdown of the revised budget. Otherwise this should be the budget in the original grant agreement. **) Calculate the percentages by budget lines: e.g. the % of the budgeted personnel costs that were actually incurred

6.2. Accounting system Coordinating Beneficiary implemented a special accounting system SW GARIS of the State Geological Institute. Accountancy centre (No. 780) was set up for the project.

Accounting system included well separated Analytical accounts and follows accounting rules of governmental institution. The project manager approved the invoices (costs) and instructed the Economic Director that the payment was approved. Payment was done by the economist of finance department. In case of cost selected under public procurement principles, the procedure was implemented according to national legislation – Public Procurement Act. Timesheets were completed electronically – MS Excel and also archived signed in paper format. Time registration system of employees was made electronically on a daily basis in GARIS System. A monthly sheet served as a basis for salary calculation. The beneficiary requested suppliers to issue invoices with a clear reference to the LIFE+ project (project code and acronym). The eligible travel costs include also the travel costs of lecturers in the workshop (Mr. Zvara, Ms. Zvarová, Mr. Bencko and Mr. Kozisek), who are not employees of the Coordinating Beneficiary.

Associated Beneficiary implements a special accounting system - SRS by the EMEL s.r.o. Bratislava. Accountability centre (No. 05.5.0) is set up for the project. Accounting system includes well separated Analytical accounts and follows accounting rules of local self-government. The project manager of the Krupina city (Mrs. Bellakova) approves the invoices (costs) and instructs the Head of the Economic department that the payment is approved. Payment is done by the Head of the Economic department. In case of cost selected under public procurement principles, the procedure is implemented according to national legislation – Public Procurement Act. Timesheets are completed electronically – MS Excel and also archived signed in paper format. Time registration system of employees is made electronically on a daily basis in BIOMETILIC ATTENDANCE PLOW-Mesto Krupina system. A monthly sheet serves as a basis for salary calculation.

6.3. Partnership arrangements The Coordinating Beneficiary (ŠGÚDŠ) and the Associated Beneficiary (Mesto Krupina/Krupina city) made at the very beginning of the project implementation the partnership agreement in which basic rules of their collaboration were defined. This partnership agreement was reported to the Commission within the Inception Report. Based on this partnership agreement, the Associated Beneficiary elaborates annuall monitoring report documenting the status of technical works as well as detailed financial cost summary. The reports are published on the project website (session dissemination – project administration). Based on this monitoring report, the Coordinating Beneficiary makes transaction of the financial means to the Associated Beneficiary from the budget provided by the Commission at the beginning of the project. The financial reporting is made separately by the Coordinating Beneficiary and Associated Beneficiary, i.e. each beneficiary enters the information in the financial tables separately. The consolidated statement is summarized by the Coordinating Beneficiary.

6.4. Auditor's report/declaration The project audit was performed by the external auditor TAX-AUDIT Slovensko®, spol. s r. o, established in Kapitulská 14, 917 01 Trnava, Slovak Republic. Audit was included among the project milestones and it was realized within the action B3 in accordance with the project proposed timetable. The auditor´s report was made in accordance with the rules of the Common Provisions and it is included with the financial report as Annex 8.5. The auditor´s licence is attached to the Audit report. The auditor stated that the financial report is in compliance with the LIFE+ Programme Common Provisions, the national legislation and accounting rules.

6.5 Summary of costs per action

The table below presents an allocation of the costs incurred per action. We did not face any big discrepancies between the costs per action set out in the project proposal and incurred project costs with exception of reduced financial costs practically in case of all actions.

2. 3. 7. Action Short name of 1. 4.b 6. Travel and External Other TOTAL number action Personnel Equipment Consumables subsistence assistance costs Compilation of data set of B1 18,569.77 1,339.59 5,482.07 4,010.23 29,401.66 environmental indicators Compilation of data set of B2 3,414.20 14,991.9 18,406.10 health indicators Linking of environmental B3 40,578.80 1,586.4 42,165.20 and health indicators B4 Biomonitoring 12,502.92 83.45 10,620 23,206.37 Evaluation of life style and B5 7,863.00 198.63 8,061.63 health-care accessibility Environmental- B6 12,149.7 10,149.70 health analysis Realization of B7 25,432.4 1,911.08 5,277.41 2,327.4 22,948.29 measures C1 Monitoring 3,973.89 1,973.85

Monitoring of environmental impacts of the C2 changes in 999.29 999.29 chemical composition of drinking water Monitoring of socio- C3 economic 0.00 impacts of project actions Networking D1 with other 5,631.89 5,941.82 2336 13,342.55 projects Any media D2 2,756.62 2,756.62 work

2. 3. 7. Action Short name of 1. 4.b 6. Travel and External Other TOTAL number action Personnel Equipment Consumables subsistence assistance costs After – LIFE D3 communication 0.00 plan D4 Notice board 1,203.50 1,317.12 2,520.62

D5 Website 6,200.00 4,200.00 Layman´s D6 3,000 report Technical D7 publications of 20,370 13,538.12 18,908.62 the project Workshop, D8 seminar, 12,145 576.40 1,058.40 6,064.07 15,843.87 conference Overall project E1 operation and 30,520 4.5 9,190 104.34 24,818.84 monitoring E2 Audit 5,820 5,820 Over- 20,802.96 heads TOTAL 206,311.69 11,054.76 61,812.95 7,809.47 11,660.7 2,440.34 €321,892,87