1. NPHE Phase I Report - Executive Summary
2. NPHE Phase I Report - Volume I
3. NPHE Phase I Report - Volume II
4. NPHE Phase II Report - Executive Summary
5. NPHE Phase II Report - Volume I
6. NPHE Phase II Report - Volume II
7. NPHE Phase II Report - Volume III

Naples Public Health Evaluation Frequently Asked Questions

Q.  When did the Naples Health Evaluation begin?

A.  In response to health concerns expressed by U.S. Navy personnel in 2007, the Commander, Navy Region Europe, Africa, Southwest Asia (CNREURAFSWA) contacted the Navy and Marine Corps Public Health Center (NMCPHC) to conduct a comprehensive Public Health Evaluation to assess the potential health risks for U.S. personnel living in the Naples area. The Public Health Evaluation began in January 2008 and was completed in June 2011.

Q.  Why did the Navy conduct the Naples Public Health Evaluation?

A.  The Naples Public Health Evaluation was conducted as part of the Navy’s commitment to ensuring military and civilian families are safe while serving our country overseas.  The Campania region of Italy has experienced various environmental challenges including episodic trash collection problems and widespread uncontrolled dumping of waste.  In response to health concerns expressed by Navy personnel and their families and news articles in the Italian science and news media, CNREURAFSWA determined that a thorough evaluation should be conducted to determine if the waste practices in the Campania region posed a health risk to our military population.

Q. What was involved in the Naples Public Health Evaluation?

A.  The Naples Public Health Evaluation was designed to determine and characterize what chemicals have been released into the environment, in what concentrations and in what locations.  Once that was determined, the Navy evaluated how people might come into contact with the chemicals in the environment, how exposure to it might affect people’s health and what actions would be needed to protect the health and safety of our U.S. personnel and their families.

To answer these questions, the Navy evaluated:

• Historical information and reports documenting chemical contamination that were developed by the Government of Italy, European Union and non-governmental organizations.

• Environmental data collected by the Navy – such as levels of chemicals and bacteria in water, soil, soil gas, air and food.

• Exposure data on how people could come into contact with chemicals and bacteria.

• Toxicity data on what health effects might be expected due to exposure to chemicals and bacteria.

• Community health concerns, such as reports from Navy personnel on illness and incidences of potential exposure-related illness.

• Actions that could eliminate or mitigate human health risks.

Q.  How did the Navy conduct the study? 

A.  The Naples Public Health Evaluation was extensive. A 395 square-mile regional area was divided into nine discrete study areas. Multiple sampling events took place, which are described below. Environmental samples (air, water and soil) were collected from April 2008 through October 2009. Samples were collected from 543 off-base private rental homes occupied by U.S. personnel and from 10 U.S. Government-related properties. Each sample was analyzed for approximately 240 chemicals as well as microorganisms in eight main categories:

• Volatile organic compounds

• Semi-volatile organic compounds

• Pesticides

• Polychlorinated biphenyls

• Dioxins and furans

• Metals

• Radionuclides

• Microorganisms (bacteria)

The Navy also conducted a year-long ambient air sampling and monitoring study.  The purpose of the ambient air sampling was to characterize air quality at the nine study areas throughout the Campania region.  Sampling involved the construction and operation of none fixed air sampling stations, a continuous air monitoring station and a meteorological monitoring tower.  Over 92,000 individual analyses for 211 chemicals were performed during this one-year period.  Tens of thousands of continuous monitoring measurements for pollutants and meteorological parameters were also obtained and evaluated.

Q.  How did the Navy evaluate the data?

A.  The Navy’s priority is to be protective of the health of Navy personnel and families, so a conservative approach was used to evaluate data.  For example, the risk evaluation was based on an assumption that a person would live in the Campania region for 30 years.  In reality, tour lengths vary:

• Average military tour length is 2.2 years.

• Average civilian tour length is 3.2 years.

• Overall population average tour length is 2.8 years.

• Over 94% of U.S. personnel reside in Naples less than six years.

The Navy placed the risk evaluation results into one of two categories, “acceptable” risks or “unacceptable” risks.  To determine the appropriate category, the Navy compared the results of each chemical analyzed to U.S. Environmental Protection Agency (USEPA) standards and guidance and to criteria established by the Navy for this project.

The USEPA has various standards and guidance for comparison.  In the Public Health Evaluation, tap water, irrigation water, soil, soil gas and air samples were compared to USEPA risk-based concentrations called screening levels.  The screening levels are for use in situations when there is known or suspected contamination and potential public health risks. 

Tap water and irrigation water samples were also compared to another set of USEPA standards called Maximum Contaminant Levels (MCLs).  Air samples were compared to USEPA National Ambient Air Quality Standards (NAAQS).  MCLs and NAAQS are the basic regulatory standards and apply only to water and air, respectively, while RSLs can be applied to water, air, soil and soil gas.

Based on the categorization of acceptable and unacceptable risks, the Navy determined the appropriate course of action to ensure the safety of navy personnel and their families.

Q.  What did the Navy learn?

A. Through the Public Health Evaluation, the Navy has been able to identify and address public health risks for U.S. personnel living in the Campania region. The Navy established new health protective policies and took immediate actions to protect the health of U.S. personnel and their families. Many of these health protective policies are in place to ensure continued health protection beyond the life of the study. 

The following section provides general information about the sampling results, the Navy’s protective actions, and steps U.S. personnel can take to minimize their risk.  

Tap Water

What we learned: Contamination from bacteria (fecal coliform/total coliform), nitrate and tetrachloroethene (a volatile organic compound, also known as perchloroethylene or PCE) was found in the tap water (primarily well water) of many homes. Lead was found in a limited number of homes, and arsenic was widespread. Arsenic is naturally occurring and is common in volcanic areas such as Naples. Although arsenic is a natural part of the Naples environment, residents should avoid exposure to the chemical by following the bottled water advisory. Tap water from municipal suppliers was typically safe.

The source of contamination for bacteria was likely from the water holding tank and/or indoor plumbing system of the home. Improper maintenance and disinfection of domestic water holding tanks can be a source of contamination. Other contributing factors to tap water contamination include:

• “Blended” water coming out of the tap (contaminated well water mixed with city water).

• Lack of code enforcement for well installation and plumbing.

• Low pressure in the public drinking water system in Campania. 

Volatile organic compounds ([VOCs] – chemicals that readily evaporate at room temperature) were also detected in the tap water in a small percentage of homes. Primary VOCs detected included PCE and chloroform. The majority of these homes were connected to non-permitted, private wells, which were drawing water from potentially contaminated groundwater sources.  In some instances, homes that were connected to the city water supply were also contaminated with VOCs, likely from neighboring homes improperly connected to both a well and the city water supply, since flowback preventers are generally not present to prevent cross-contamination.

What we did: Most risks associated with tap water can be reduced or eliminated by using bottled water. The Navy issued the “bottled water advisory” in July 2008, which states that U.S. personnel living off base should use bottled water for drinking, cooking, food preparation, making ice, brushing teeth, and for pets. As an interim measure, the Navy distributed bottled water to those living off base. A permanent Water Distribution Point at Capodichino was then installed to provide free drinking water to U.S. personnel living off base.  Further, the Navy improved all new off-base rental leases by requiring landlords to:

• Provide bottled water service from a Navy-approved vendor.

• Clean and disinfect the home’s water holding tank and associated plumbing twice a year and prior to the occupancy of a new tenant.

• Connect the home’s plumbing system to the city water supply and disconnect from non-permitted wells. 

For existing leases, the U.S. military population was notified to update their lease with the new provisions.  In addition, the Navy defined areas where leases were discontinued (New Lease Suspension Zones) based on Navy and/or Italian data. As a protective measure, the Navy suspended all new leases in those areas.  Of note, potential exposure to VOCs in tap water also can occur by breathing the chemicals when they evaporate from tap water that is being used for showering, washing clothes and other household uses for which bottled water is not typically used. However, during the Public Health Evaluation, the concentrations of VOCs in tap water were generally not high enough for inhalation of the chemicals to pose a health risk. In the few instances where potential health risks were identified (residences located in Study Area 8 – Casal di Principe – that obtained their tap water from non-permitted, private wells), the Navy relocated the residents to other homes. 

What you can do: The most important thing that U.S. personnel living off base can do is to continue to follow the bottled water advisory to avoid exposure to harmful levels of bacteria and chemicals that may be in your tap water. Make sure your tap water supply is disconnected from non-permitted wells and connected only to the city water system. Also, make sure your landlord disinfects your water holding tank twice per year and provides approved containerized water as required by your lease. Do not exchange your bottled water service for other desirable residential perks.  Also, ventilate your home, when practical, by opening windows to allow a higher air exchange rate.

Soil Gas

What we learned:   PCE and chloroform were the chemicals responsible for most of the potential health risks associated with soil gas. Soil gas is a term used to describe volatile chemicals that are present in the small spaces between particles of soil beneath the ground surface. Typically, the presence of chemicals in soil gas indicates that underlying soil or groundwater may be contaminated. If conditions are right, chemicals in soil gas can move upward through the soil and potentially make their way into the indoor air of overlying buildings. This process is called “vapor intrusion.” The highest incidences of soil gas contamination and potential vapor intrusion were in Study Area 8 – Casal di Principe – an area already identified as a New Lease Suspension Zone.

Where soil gas results indicated a potential health risk, additional soil gas investigations were conducted for nearby homes. For residences with unacceptable soil gas concentrations that indicated the potential for vapor intrusion, the residents were relocated. Additionally, residences with soil gas values that exceeded the Naples Public Health Evaluation criteria were further examined to determine whether these homes would be eligible to lease in the future. 

Of note, the Navy also conducted a vapor intrusion study at Capodichino and the Support Site to determine whether there were potential health risks from soil gas into the indoor air of buildings at these locations.  Although some soil gas results were initially found to be unacceptable, follow-up indoor air sampling demonstrated that it is safe to live and work in buildings on base.

What you can do: The following are actions you can take to help prevent the possibility of vapor intrusion into a home you select:

• The higher you live, the less risk you potentially have from vapor intrusion. Look for homes where the living space is higher than the ground floor. For example, a building with a ground floor parking garage that is well ventilated.

• Avoid living in basements.

• Ventilate the home by opening windows to encourage more air exchanges, when practical.

Soil

What we learned:  Surface soil contamination was not found to present a health issue, with the exception of a few isolated instances that were addressed by the landlord.  Chemicals found at concentrations typical of urban environments included polycyclic aromatic hydrocarbons and dioxins/furans.  In addition, soil was found to contain low concentrations of arsenic in virtually all soil samples.  The presence of naturally occurring arsenic is common in volcanic areas such as Naples.

What we did:  At those few locations where soil contamination was detected, the Navy required landlords to remove or cover the soil to prevent exposure.  Because the health risks for soil in almost all cases were found to be acceptable, soil sampling was discontinued early in Phase II.  To address arsenic in the soil, the Navy recommended actions residents could take to minimize their exposure to this chemical.  Because arsenic is a natural part of the Naples environment, it cannot be removed from the soil.

What you can do:  Due to the presence of arsenic in soil, limit direct contact with soil.  Be sure to wash after playing and working in the soil and limit the amount of soil tracked in from outdoors.

Air

What we learned:   The health risks did not vary significantly between the nine study areas.  Many of the contaminants in Naples outdoor (ambient) air were likely associated with diesel or gasoline exhaust, industrial emissions, or agricultural burning.  The chemicals 1,2-dibromo-3-chloropane and arcrolein were responsible for most of the potential health risks associated with outdoor air.  Also, the risks associated with ambient air were not significantly greater on days when trash was burned than on days when trash was not burned.  While most of the contaminants were similar to those found in the U.S. when the Navy compared them to six major U.S. cities, they were not identical.  Therefore, direct comparison of the risk between typical urban air quality in the U.S. and the air quality in Naples is not appropriate.  The difference is associated with a higher percentage of diesel exhaust than found in the U.S. as well different registered pesticides in Italy than in the U.S.

The Navy applied the results of the air study to the 2010 asthma study and found that increased air pollution levels did not affect the number of asthma-related medical visits.  However, as the levels of the air pollutant PM10 increased, people that had an asthma-related medical visit were more likely to be diagnosed with worse asthma symptoms.

What we did:  The Navy informed the Navy community and U.S. Naval Hospital medical providers about the results of the asthma study and provided recommendations that people with asthma could follow.   Also, as a result of the 2010 asthma study, MNPHC recommended that U.S. Naval Hospital Naples consider the impact of the air quality on those with documented respiratory problems, especially persistent asthma, before granting an overseas screening waiver.

What you can do:  Avoid lengthy periods outdoors when open burning is taking place and keep windows closed when air conditions are poor.  If you suffer from asthma or other upper respiratory illnesses, consult your medical provider about actions you can take to help control your symptoms.

Irrigation Water

What we learned:  Capodichino, Carney Park, and the Support Site in Gricignano have wells that are used for irrigation purposes only.  The Navy collected samples of irrigation water at these locations.  The testing results showed that many of the wells on these sites contained nitrates, total and fecal coliform bacteria, and other chemicals that exceeded health-based standards.  These findings reaffirmed that irrigation water is not suitable for drinking and should only be used for irrigation.

What we did: To remind the Navy community that children and pets should not drink, wash or play in irrigation water; more than 20 bilingual signs were posted on pavilions and poles around Capodichino, the Support Site in Gricignano, and Carney Park.

What you can do:  Do not drink, wash or play in irrigation water.  However, avoiding freshly irrigated areas (for example, wet grass) is not necessary.

Q.  What happens now that the study has ended?

A.  The Navy is committed to sharing the results of the Public Health Evaluation with military and civilian personnel and their families, Department of Defense leadership, and the Italian government and landlords. In addition to sharing the findings, the Navy has taken appropriate actions to address the findings. The Navy’s health-protective processes that have already been implemented will remain in place indefinitely to ensure continued health protection beyond the life of this project.  

Health protective processes already implemented that will remain in place included: 

• Bottled water advisory.

• Health-protective lease clauses for off-base rentals.

  • Landlords must provide containerized water service from a Navy-approved vendor.

  • Leased home must be supplied by city water or permitted wells.

  • Landlords must disconnect all non-permitted wells and provide proof of connection to the city water system or that the well is permitted.

  • Landlords must clean and disinfect domestic water holding tanks every six weeks.   

• New Lease Suspension Zones.

• Health information updates on the Naples Community Health Awareness website.

•  Education and counseling at the U.S. Naval Hospital Naples, Public Health.

• Maintain the U.S. Naples PHE website and the U.S. Navy Regional Water Quality Board

• NSA Naples will continue the monitoring of Italian environmental and health-related information and make public health information available to U.S. personnel.

Q.  Who can I contact if I have a health related questions?

A. U.S. personnel who have health related questions should contact the U.S. Naval Hospital Naples, Public Health.  The phone number is 629-6457 (DSN) or 39-081-811-6457 (commercial).  Health professionals are available for one-on-one consultations to discuss personal health concerns.

1. Air Quality Sampling & Meteorological Monitoring
2. Asthma Epidemiological Study
3. Background Arsenic Levels in Soil and Water
4. Birth Defects Epidemiological Study
5. Bottled Water Safety
6. Buffalo Mozzarella Cheese
7. Cancer Epidemiological Study
8. Chemicals and Microorganisms Analyzed
9. Enduring Processes
10. Food On and Off Base
11. Hard Water
12. How to Seek Assistance if You Have Tap Water Concerns
13. Naples Public Health Evaluation Summary of Study Findings for Phase I and II
14. Navigating Italian Air Quality
15. Tap Water Bacteria
16. Vapor Intrusion
17. Water Quality Monitoring
18. Why is the Navy Requiring Italian Landlords to Provide Containerized Water Service from an Approved Vendor
19. Water Holding Tank Disinfection

1. Centers for Disease Control and Prevention
2. Defense Commissary Agency
3. FDA Food and Drug Administration
4. Navy and Marine Corps Public Health Center (NMCPHC)
5. U.S. ARMY Veterinary Service
6. U.S. Environmental Protection Agency
7. U.S. State Department (Italy)
8. Water Information System for Europe (WISE)
9. Basic Air Quality Awareness

1. Marcianise Area
2. Villa Literno Area
3. Arzano Area
4. NPHE Study Areas