UNIVERSITÀ DEGLI STUDI DI PAVIA SCUOLA DI ALTA FORMAZIONE DOTTORALE DOTTORATO DI RICERCA IN PSICOLOGIA, NEUROSCIENZE E STATISTICA MEDICA Coordinatore: Chiar.ma Prof.ssa Gabriella Bottini HEALTH IMPACT OF THE EMISSIONS FROM A REFINERY: CASE-CONTROL STUDY ON THE ADULT POPULATION LIVING IN TWO MUNICIPALITIES IN LOMELLINA, ITALY Tutor: Chiar.ma Prof.ssa Simona Villani Candidato: Marco Gnesi ANNO ACCADEMICO 2017/2018 Compré varios botes de óleo y una tela de dos por dos, diciéndome que si fracasaba era mejor hacerlo a lo grande. Coloqué el lienzo en el suelo y con una precaución algo impostada marqué un gran punto negro en lo que podía ser su parte central: enseguida me pareció un gesto petulante. Pensé que debía “complejizar” aquel signo y extraerlo de las fauces de la boutade. Pinté otro punto del mismo color y tamaño a su lado: el cuadro se volvió insoportablemente “dialéctico”. Además parecía que me miraba. Para destruir la simetría hice un nuevo punto lejos del centro. La tela se desordenó con tan sólo tres intervenciones. Valentín Roma, El enfermero de Lenin Editorial Periférica, 2017 INDEX INDEX ............................................................................................................................. II ABBREVIATIONS ......................................................................................................... VII ABSTRACT .....................................................................................................................XI ACKNOWLEDGEMENTS .............................................................................................. XV THESIS 1. Introduction .............................................................................................................2 1.1. Environmental health: from science to social justice ....................................... 3 1.2. Basic vocabulary ............................................................................................... 6 1.3. Exposure assessment for environment and health .......................................... 8 1.3.1. Main issues of exposure assessment for epidemiological purposes ......... 8 1.3.2. Overview of the assessment methodologies .............................................. 9 1.4. Industrially Contaminated Sites ...................................................................... 11 1.4.1. Industrial contamination and environmental health............................... 11 1.4.2. Assessing the impact of ICSs .................................................................... 12 1.4.2.1. Assessment through modelling frameworks ..................................... 12 1.4.2.2. Integrated approaches in the Italian experience: VIIAS ................... 16 1.4.2.3. Limitations of modelling .................................................................... 17 1.4.2.4. Assessment through the epidemiological approach .......................... 17 1.4.2.5. Examples of the epidemiological approach ...................................... 20 1.5. An oil refinery in Lomellina ............................................................................ 22 1.5.1. Environmental background ..................................................................... 22 1.5.2. Main characteristics of the refinery ......................................................... 23 1.5.3. A new facility for the refinery .................................................................. 24 1.5.4. The authorisation procedure for the EST facility ..................................... 25 II 1.6. Environmental risks due to a refinery ............................................................. 27 1.6.1. Emissions of pollutants in the environment ............................................ 27 1.6.1.1. Sulphur oxides (SOX) ....................................................................... 28 1.6.1.2. Nitrogen oxides (NOX) ..................................................................... 29 1.6.1.3. Particulate matter (PM) .................................................................... 30 1.6.1.4. Carbon monoxide (CO) ..................................................................... 32 1.6.1.5. Volatile Organic Compounds (VOC) ..................................................33 1.6.2. Brought to the lunch table: pollutants and food chain ............................33 1.6.3. Health risks associated to a refinery: epidemiological perspectives ...... 34 1.7. EPI-EST: the CONSAL Project ....................................................................... 38 2. Aims ...................................................................................................................... 40 3. Methods ................................................................................................................. 41 3.1. Study design ..................................................................................................... 41 3.1.1. Case definition .......................................................................................... 41 3.1.2. Advantages and limitations of the case-control design .......................... 42 3.1.3. Implications for statistical analysis and interpretation .......................... 43 3.2. Population and sample ................................................................................... 44 3.2.1. Target population and eligibility ............................................................. 44 3.2.2. Sample size estimation ............................................................................ 44 3.2.3. Data sources .............................................................................................. 45 3.2.3.1. Regional Registry of Health Insurance .............................................. 45 3.2.3.2. Hospital Discharge Database ............................................................. 45 3.2.3.3. A focus on the Hospital Discharge Records ...................................... 46 3.2.4. Sample selection ...................................................................................... 46 3.3. Study implementation .................................................................................... 49 3.3.1. Data collection ......................................................................................... 49 3.3.2. Data management ..................................................................................... 52 3.4. Exposure assessment ....................................................................................... 54 3.4.1. Dispersion modelling approach ................................................................ 54 3.4.2. Individual exposure estimation ................................................................ 55 3.5. Other individual-level variables ...................................................................... 57 3.5.1. Questionnaire ............................................................................................ 57 3.5.2. Survey variables used in the study ........................................................... 59 III 3.6. Statistical analyses ........................................................................................... 61 3.6.1. Evaluation of non-respondence bias ........................................................ 61 3.6.2. Quality check of survey data .................................................................... 62 3.6.3. Descriptive analysis ................................................................................. 63 3.6.4. Univariate analyses .................................................................................. 63 3.6.5. Main multivariate analyses ...................................................................... 64 3.6.6. Secondary multivariate analyses ............................................................. 66 3.7. Ethics and conflicts of interest ........................................................................ 67 4. Results ................................................................................................................... 68 4.1. Analysis of respondence .............................................................................. 68 4.2. Consistency of survey data ........................................................................... 72 4.2.1. Socio-demographic characteristics ....................................................... 72 4.2.2. Housing .................................................................................................. 73 4.2.3. Lifestyle .................................................................................................. 73 4.2.4. Health .................................................................................................... 75 4.3. Characteristics of respondents ..................................................................... 76 4.3.1. Health outcome ..................................................................................... 76 4.3.2. Demographics ........................................................................................ 77 4.3.3. Environmental exposure ....................................................................... 79 4.3.3.1. Distance from the refinery ................................................................. 79 4.3.3.2. Continuous PM10 concentration ...................................................... 80 4.3.3.3. Clustered PM10 concentration ......................................................... 82 4.4. Description of survey data .........................................................................