Caterina Bruno

Asbestos is one of the major worldwide occupational carcinogens. The global burden of asbestos-related diseases (ARDs) was estimated around 231,000 cases/year. Italy was one of the main European asbestos producers until the 1992 ban. The WHO recommended national programs, including epidemiological surveillance, to eliminate ARDs. The present paper shows the estimate of the burden of mortality from ARDs in Italy, established for the first time. National standardized rates of mortality from mesothelioma and asbestosis and their temporal trends, based on the National Institute of Statistics database, were computed. Deaths from lung cancer attributable to asbestos exposure were estimated using population-based case-control studies. Asbestos-related lung and ovarian cancer deaths attributable to occupational exposure were estimated, considering the Italian occupational cohort studies. In the 2010–2016 period, 4400 deaths/year attributable to asbestos were estimated: 1515 from mesothelioma, 58 from asbestosis, 2830 from lung and 16 from ovarian cancers. The estimates based on occupational cohorts showed that each year 271 deaths from mesothelioma, 302 from lung cancer and 16 from ovarian cancer were attributable to occupational asbestos exposure in industrial sectors with high asbestos levels. The important health impact of asbestos in Italy, 10–25 years after the ban, was highlighted. These results suggest the need for appropriate interventions in terms of prevention, health care and social security at the local level and could contribute to the global estimate of ARDs.

Background and history: Italy was the main asbestos producer and one of the greatest consumers in 20th century Europe until the asbestos ban was introduced in 1992. Asbestos exposure affected the population in a wide range of working environments, namely mining and marketing of asbestos, asbestos cement production, shipyards and textile industries. This also determined a widespread environmental asbestos exposure affecting the surrounding communities. Methods: To investigate the drivers and difficulties of the process leading to the asbestos ban and its subsequent implementation, we focused on stakeholder involvement, environmental health policies, capacity building and communication. Results: In the past three decades, stakeholder involvement has been instrumental in advancing the industrial asbestos replacement process, prevention and remediation interventions. Furthermore, involvement also contributed to the integration of environmental and health policies at national, regional and local levels, including capacity building and communication. In a global public health perspective, international scientific cooperation has been established with countries using and producing asbestos. Discussion and Conclusions: Key factors and lessons learnt in Italy from both successful and ineffective asbestos policies are described to support the relevant stakeholders in countries still using asbestos contributing to the termination of its use.

Few months after the publication of the monographic section of Annali dell'Istituto Superiore di Sanità second issue of 2014 "Health impact of fibres with fluoro-edenitic composition", the carcinogenicity of fluoro-edenite was assessed by the International Agency for Research on Cancer (IARC) in the frame of Monograph 111. The IARC Working Group concluded that there is sufficient evidence in humans that exposure to fluoro-edenite fibrous amphibole causes mesothelioma, and sufficient evidence of carcinogenicity in experimental animals. Fluoro-edenite was allocated to Group 1 (the agent is carcinogenic to humans). Now, in view of the recent IARC evaluation, preventive action in Biancavilla requires an upgrade. First of all, environmental monitoring has to be further implemented. All operations of house cleaning should be performed employing wet tools, in order to avoid dust-raising. It is very important that environmental and biological monitoring be related to epidemiological surveillance. The recently approved act of the Sicilian Government concerning a plan of health interventions in Biancavilla will favour cooperation between national, regional and local health institutions with the common goal of improving the quality and appropriateness of diagnostic and therapeutics procedures offered by the health services.

Of the 18 National Priority Contaminated Sites (NPCSs) analysed in this Report, some have a single source of environmental contamination (such as fluoro-edenite in Biancavilla). In most cases, however, we are looking at multiple heterogeneous sources of contamination. In this respect, the a priori causal evaluation of the association between diseases and environmental exposures in NPCSs, based on epidemiological evidence, can help trace the health impact back to specific types of environmental exposure. There are several cases in which the project's findings have been consistent with a priori evidence: stomach cancer (both genders, excess cancer incidence) in the Fidenza NPCS; stomach cancer (women, excess mortality, cancer incidence and hospital discharges) in the Laguna di Grado e Marano NPCS; excess hospitalisation from respiratory diseases in Brescia-Caffaro, Milazzo and Terni Papigno NPCSs; excesses for non-Hodgkin lymphomas and melanoma (incidence and hospitalisation in men and women) and breast cancer (incidence and hospital discharges, women) in Brescia-Caffaro NPCS. In preorder to properly evaluate the population's health profile, we must also observe whether results remain consistent for all three health outcomes or in both genders. The first is the case of excess mortality, cancer incidence and hospital discharges for bladder cancer (men) in Porto Torres and diseases of the urinary tract in the Basso bacino del fiume Chienti NPCS). Gender consistency is observed, for instance, for all cancer in Bolzano, Porto Torres, Venice, Litorale Domizio Flegreo, Priolo, and Taranto, for all causes in Taranto, Litorale Domizio Flegreo and Trieste. The health impact in the various NPCSs needs to be considered carefully and used as a springboard for further analytical research that could confirm and explain causal links to specific environmental exposures. The observations can, however, already be considered as a basis for mandatory primary prevention measures.

The municipality of Pace del Mela, together with Milazzo and San Filippo del Mela, has been recognized as a contaminated site of national concern. The purpose of the present study is to evaluate the health status of subjects resident in the Gabbia district, which is close to the industrial areas of both, Pace del Mela and Milazzo. All streets and addresses of the area of interest have been identified, taking into account their changes in name over time. The cohort of subjects who lived in the area for any period of time from September 1st, 1984, through December 31st, 2007 has been reconstructed by manual consultation of the Registrar Office files. Standardized mortality ratios, specific for cause, age class, gender and calendar period, have been computed using as reference the Sicilian population. Standardised incidence ratios, based on regional hospital discharge files, have been computed for the years 2001-2007. The cohort is constituted by 457 subjects, 230 men and 227 women. Ascertainment of vital status has not been possible for 39 subjects, corresponding to 8.5% of the cohort. Observed mortality for all causes and for all cancers is consistent with expected figures (62 observed vs 63 expected and 14 observed vs 15 expected, respectively). Observed cancer morbidity is inferior to the corresponding expected figure (SIR=0.49, CI 95%: 0.31-0.79). The health profile of the Gabbia district population, as estimated from mortality and hospital discharge records, does not show major departures from expected figures.

The present paper estimates the burden of asbestos-related disease among asbestos-cement production workers of the Sacelit plant that operated in San Filippo del Mela (Province of Messina) from 1958 through 1993. The cohort was enumerated by the local committee of formerly exposed workers, with whom a collaboration was set up. The cohort includes 198 subjects with complete individual anagraphic information, out of 231 previous workers identified by the committee. A record-linkage with the Sicilian centre of the National mesothelioma registry enabled estimation of mesothelioma incidence for the years 1998-2008. Standardised proportionate mortality (SPMR) for asbestos-related causes was computed for the years 1986-2009. Sicilian Region constituted the reference population. The rationale for using SPMR rather than standardized mortality ratio (SMR) was a consequence for the lack of company files from which to obtain dates of start and termination of employment, and thus to compute person-years of observation, following the guidelines of the international scientific literature. Standardised incidence ratio (SIR) for mesothelioma in the overall cohort was 251 (4 observed, 0.02 expected). Proportionate mortality analysis among male subjects showed significant increases for pneumoconiosis (SPMR 80.1, 5 observed), lung cancer (SPMR 2.81, 10 observed) and pleural neoplasms (SPMR 19.4, 2 observed). Notwithstanding limitations in cohort reconstruction, for which the proportion of eligible subjects was 87.5% of those detected by the local committee, and the lack of information on duration of employment, it was possible to estimate a significant increase of the incidence of pleural mesothelioma with respect to Sicilian population. Also mortality from asbestos-related causes was in excess with respect to the regional reference population.