title: Arsenic in Drinking Water and Mortality for Cancer and Chronic Diseases in Central Italy, 1990-2010.
abstract: BACKGROUND
  In several volcanic areas of Italy, arsenic levels exceed European regulatory limits (10 μg/L in drinking water). There is still uncertainty about health risks from arsenic at low-medium doses (<100 μg/L).
  
  
  OBJECTIVE
  A large population-based study using an administrative cohort of residents in the Viterbo province (Central Italy), chronically exposed to low-medium arsenic levels via drinking water, was investigated to evaluate the effects of a lifetime exposure to arsenic on mortality from cancers and chronic diseases.
  
  
  METHODS
  The study population consisted of 165,609 residents of 17 municipalities, followed from 1990 until 2010. Average individual arsenic exposure at the first residence (AsI) was estimated through a space-time modeling approach using residential history and arsenic concentrations from water supply. A time-dependent Cumulative Arsenic dose Indicator (CAI) was calculated, accounting for daily water intake and exposure duration. Mortality Hazard Ratios (HR) were estimated by gender for different diseases using Cox proportional models, adjusting for individual and area-level confounders. A flexible non-parametric approach was used to investigate dose-response relationships.
  
  
  RESULTS
  Mean AsI exposure was 19.3 μg/L, and average exposure duration was 39.5 years. Associations of AsI and CAI indicators with several diseases were found, with greatest risks found for lung cancer in both sexes (HR = 2.61 males; HR = 2.09 females), myocardial infarction, peripheral arterial disease and COPD in males (HR = 2.94; HR = 2.44; HR = 2.54 respectively) and diabetes in females (HR = 2.56). For lung cancer and cardiovascular diseases dose-response relationship is modelled by piecewise linear functions revealing effects even for doses lower than 10 μg/L, and no threshold dose value was identified as safe for health.
  
  
  CONCLUSIONS
  Results provide new evidence for risk assessment of low-medium concentrations of arsenic and contribute to the ongoing debate about the threshold-dose of effect, suggesting that even concentrations below 10 μg/L carry a mortality risk. Policy actions are urgently needed in areas exposed to arsenic like in the Viterbo province, to comply with current EU regulations.
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Daniela
authors.initials: D
authors.lastname: D'Ippoliti
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Enrica
authors.initials: E
authors.lastname: Santelli
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Manuela
authors.initials: M
authors.lastname: De Sario
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Scortichini
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Marina
authors.initials: M
authors.lastname: Davoli
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Michelozzi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001151:Arsenic / Q000032:analysis*; D020261:Arsenic Poisoning / Q000453:epidemiology; D002648:Child; D002908:Chronic Disease / Q000453:epidemiology*; D060766:Drinking Water / Q000737:chemistry* / Q000592:standards; D004781:Environmental Exposure / Q000032:analysis / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology*; D014874:Water Pollutants, Chemical / Q000032:analysis*; D014881:Water Supply / Q000592:standards; D055815:Young Adult
chemical_list: D060766:Drinking Water; D014874:Water Pollutants, Chemical; D001151:Arsenic