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Air pollution is linked to infant deaths and reduced lung function in children

BMJ 2019; 366 doi: (Published 27 September 2019) Cite this as: BMJ 2019;366:l5772

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The real cost of carbon is felt in our lungs

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Turn the spotlight on paediatric health: Can we accept cancer as the first disease-related cause of death in our children? A call for a new vision of epidemiology and medicine committed to changing the world

Concerning the topic of paediatric health recently addressed on BMJ (2019;366:l5772), a clear epidemiological transition has been observed in the last decades (1,2), with cancer becoming the first disease-related cause of death in all paediatric age groups in Europe. Such alarming data emerged 15 years ago and were recently confirmed thanks to the ACCIS project (Automated Childhood Cancer Information System) conducted by IARC on 63 big cancer registries of 19 European countries (3,4). These analyses have highlighted an annual increase of +1-1,5% for all cancers and +2% in the first year of life, with significant increases of lymphomas, sarcomas, germ-cell and nervous system tumours. The highest increase of cancer incidence in the first year of age suggests a trans-placental (maternal-foetal) exposure to pro–carcinogenic agents or transgenerational transmission of epigenetic marks in gametes as a consequence of different environmental exposures including air pollution, recognized among IARC 1 carcinogens (5).

Actually, in childhood it is not possible to hypothesize - as in adult and elderly - a slow accumulation of stochastic/casual DNA mutations according to the classical pathogenic model. The somatic mutation theory (SMT) does not explain the epidemiological observation of increasing cancer incidence among children and young adults. Therefore, a pathogenic role of precocious epigenetic dysregulation (foetal programming) has been suggested, calling for a shift in the etiological paradigm of carcinogenesis theory (6). The issue of children’s cancers should rise relevant concern because they cannot be attributed to occupational exposures, cigarette smoking or to generically defined “unhealthy” life styles and eating habits. The IARC founder Lorenzo Tomatis was among the first scientists to address the issue of perinatal and multigenerational effects of carcinogens – including air pollutants – in subsequent generations (7). However, few voices of condemnation raised about the unacceptability of this dramatic phenomenon, probably because our current social and economic models should be deeply questioned. No international initiatives such as the global strike for climate have been put in place anywhere to highlight the shocking data about tumours suffered by children and the need to remove the exposures to carcinogens and endocrine disruptors in the first thousand days of life, as well as in the whole fertile population. Should we wait for a Greta Thunberg that fosters public opinion and medical community to address the issue of the inacceptable threat to paediatric health represented by air pollution ?

The answer of epidemiologists and medical community cannot be limited to the count of deaths and “incident cancer cases”, usually provided after many years and therefore less useful for health policy makers. We cannot go on aseptically presenting “average rates” as consistent with national and international trends which are known to continuously increase year by year. Indeed, public health policies should be focused on keeping people healthy (primary prevention) and removing the causes of cancer since childhood. As medical community, we have the duty of providing a decisive contribution towards a change of direction in order to safeguard next generations’ health with the same efforts we are putting on climate change topics. We have to stop “the count” and discussions about the consistency between “observed” and “expected rates”. We should simply stop “expecting” to observe a persistent increase in paediatric cancer incidence or we would fail in our primary mission: providing decision makers with evidence and enough information to protect people’s health, giving priority to children. A more comprehensive view of epidemiology is needed as cancer is not the only reliable indicator of paediatric health in relation to air pollution and environmental exposures: respiratory diseases, congenital malformations, autoimmune and metabolic diseases (including type 1 diabetes) are also dramatically increasing (8). Information concerning the main causes of hospitalizations and deaths stratified per age groups and geographical areas should be provided to decision makers almost in real time – within few months – by using the available big dataset owned by Healthcare Systems or insurances. This simple information is fundamental and often enough to monitor population health status over the time and to take decisions concerning health services organization or to make the system more efficient and able to answer people’s needs.

Medicine should be focused on prevention. No generic preventive messages should be launched (i.e. “healthy foods”, “healthy habits”), but specific preventive actions must be adopted based on risk factors which impact on population at local level (i.e. looking at regional-based obesity rates or avoidable morbidity and mortality). Indeed, specific occupational or environmental exposures and life styles have a dissimilar impact on different communities. We ask our colleagues worldwide to come together and address the challenge of a new vision of medicine and epidemiology that can change the world. We should not be aimed at generating statistics but at promptly highlighting the emerging threats to people’s health – with a special focus on children – in order to provide possible solutions by analyzing the different risk factors that impact on well-defined communities. We can start from remarking all together how inacceptable is to have cancer as the first disease-related cause of death in our children.

Prisco Piscitelli, MD, PhD, Euro Mediterranean Scientific Biomedical Institute (ISBEM), Epidemiology and Public Health Unit, Bruxelles, Belgium. Email:

Alessandro Miani, Adjunct Professor of Environmental Prevention, University of Milan and President of the Italian Society of Environmental Medicine (SIMA), Via Celoria 2, 20133, Milan, Italy. Email:

Valerio Gennaro, Oncologist and Epidemiologist, former responsible of the Epidemiology Division at IRCCS San Martino University Hospital, Largo R. Pensi 10, 16132, Genoa, Italy. Email:

Elena Colicino, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, USA. Email:

Maria Triassi, Full Professor of Public Health, Department of Public Health, University Federico II School of Medicine, and President of the Italian Society of Public Health and Digital Medicine (SISPED), Via S. Pansini 5, 80131, Naples, Italy. Email:

Antonella De Donno, Full Professor of Public Health, University of Salento, Department of Environmental and Biological Science and Technology (DISTEBA), Piazza Tancredi 7, 70100, Lecce, Italy. Email:

Alessandro Distante, President of the Euro Mediterranean Scientific Biomedical Institute (ISBEM), Via Reali di Bulgaria, 72024, Mesagne, Italy. Email:

Manuela Pulimeno, PhD Candidate in Human Relation Sciences, University of Bari Aldo Moro, Department of Education, Psychology and Communication Sciences, Piazza Umberto I, 70121, Bari, Italy. Email:

Susanna Esposito, Full Professor of Paediatrics, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126, Parma, Italy. Email:

Francesco Chiarelli, Full Professor of Paediatrics and Paediatric Oncology, University of Chieti, via dei Vestini 5, 66013 Chieti, Italy. Email:

Annamaria Colao, Full Professor of Endocrinology and UNESCO Chair on Health Education & Sustainable Development, at University Federico II School of Medicine, Via S. Pansini 5, 80131, Naples, Italy. Email:

Ernesto Burgio, European Cancer and Environment Research Institute (ECERI), Square de Meeus 38, 1000, Bruxelles, Belgium. Email:


1. Azzopardi, Peter S et al., Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016, The Lancet 393.10176 (2019): 1101-1118.
2. Patton, George C, et al., Our future: a Lancet commission on adolescent health and wellbeing. The Lancet 387.10036 (2016): 2423-2478.
3. Steliarova-Foucher E, Stiller C, Kaatsch P, Berrino F, Coebergh JW, Lacour B, Parkin M., Geographical patterns and time trends of cancer incidence and survival among children and adolescents in Europe since the 1970s (the ACCIS project): an epidemiological study. The Lancet. (2004) 11-17;364 (9451):2097-105.
4. Steliarova-Foucher E et al., International incidence of childhood cancer, 2001–10: a population-based registry study. The Lancet Oncology 18.6 (2017): 719-731.
5. Cavalli G, Heard E, Advances in epigenetics link genetics to the environment and disease, Nature. 2019 Jul; 571(7766):489-499.
6. Burgio E, Piscitelli P, Colao A, Environmental Carcinogenesis and Transgenerational Transmission of Carcinogenic Risk: From Genetics to Epigenetics. Int J Environ Res Public Health. 2018 Aug 20;15(8).
7. Tomatis L, Narod S, Yamasaki H, Transgeneration transmission of carcinogenic risk. Carcinogenesis, 13.2 (1992): 145-151.
8. Burgio E, Environment and fetal programming: the origins of some current “pandemics”, Journal of Pediatric and Neonatal Individualized Medicine 2015;4(2): e040237.

Competing interests: No competing interests

07 November 2019
Prisco Piscitelli
Alessandro Miani, Valerio Gennaro, Elena Colicino, Maria Triassi, Antonella De Donno, Alessandro Distante, Manuela Pulimeno, Susanna Esposito, Francesco Chiarelli, Annamaria Colao, Ernesto Burgio
Euro Mediterranean Scientific Biomedical Institute (ISBEM), Epidemiology and Public Health Unit, Bruxelles, Belgium
Rue de Bellard 20, Bruxelles 1040, Belgium.