Benzene and cause-specific mortality in an Italian national cohort of exposed workers through a proportions analysis.

BACKGROUND: occupational exposure to benzene represents a threat for the health of a still relevant number of workers. An increased risk of leukaemias has been demonstrated among exposed workers, while a weaker association has been found for other malignancies. OBJECTIVES: to evaluate mortality risk among workers exposed to benzene across economic sectors in Italy. DESIGN: proportionate mortality ratios (PMRs) were calculated linking exposure occupational information to national mortality statistics (2005-2018), assuming a Poisson distribution of the data. SETTING AND PARTICIPANTS: data from the Italian national registry on occupational exposure to carcinogens (SIREP) in the period 1996-2018 were selected. MAIN OUTCOMES MEASURES: PMRs by cause of death were reported. Specific analyses by cancer site and activity sector, profession, and cumulative exposure were performed. RESULTS: a total of 858 deaths (97% in men) were identified among 38,704 exposed workers (91% men). An excess of deaths from malignant neoplasm of the lung was found among exposed workers, in both genders (PMR 1.27 in men; PMR 3.00 in women). An increased proportion of deaths was also found from leukaemias (leukaemia of unspecified cell type: PMR in men 2.99; 95%CI 1.24-7.19), and multiple myeloma in the chemical industry (PMR in men 2.27; 95%CI 1.08-4.76). CONCLUSIONS: the risk of leukaemia in the petrochemical industry has been confirmed, while an excess risk of lung cancer mortality was highlighted in the retail sale of automotive fuels. Epidemiological surveillance and air and biological monitoring are recommended for workers exposed to benzene to ensure compliance with regulatory requirements and reduce exposure-related deaths.

[Campaign of labour inspections on the implementation of protection measures against carcinogenic agents in fuel station workers]. / Piano di vigilanza sul rispetto degli obblighi in materia di protezione dagli agenti cancerogeni dei lavoratori addetti alla distribuzione carburanti.

SUMMARY: Following the reduction in levels of exposure to benzene over the last few decades, the cancer risk of refuelers currently represents an occupational hygiene issue potentially underestimated by employers and workers themselves. Based on the literature data, the occurrence of adverse effects of neoplastic nature can not actually be excluded in this professional category, since it is not possible to define a threshold dose. In the period 2016 - 2019, an extensive focused campaign of labour inspections was conducted in the province of Bari by the OSH inspection services of the Health Local Authority in order to verify the compliance with the legislation on the workers' protection from carcinogenic agents at fuel stations. In particular, the obligations referring risk assessment, workplace hygiene, environmental monitoring, personal protective equipment (PPE), health surveillance, biological monitoring and recording of exposure to carcinogens were verified. Although these obligations were documentarily fulfilled by almost all the 162 plants inspected in the province of Bari, several critical issues were found in the approach to carcinogenic risk, including, more frequently, the lack of suitable changing rooms with relative lockers for clothing, the scarce use of gloves when dispensing fuel, the absence or incompleteness of the carcinogenic risk assessment documents, the failed or incorrect execution of biological monitoring. Data of the environmental monitoring carried out by the companies confirm that the current exposures to benzene of fuel distributors are considerably below the limit values set by the Italian legislation. The most frequently used biological exposure indicator was trans, trans-muconic urinary acid (TTMA-U). In order to reduce as much as possible the health risks for refuelers, it is needed that employers, workers and occupational physicians pay more attention to their respective duties, ensuring corrective or ameliorative interventions focused on assessment of the risk of carcinogens, supply and use of PPE, design of workplaces, health surveillance and biological monitoring of workers. The poor value of the end-of-shift TTMA-U as a biological indicator of exposure to low-dose benzene is also confirmed.

Occupational asbestos exposure after the ban: a job exposure matrix developed in Italy.

BACKGROUND: Asbestos is a well-known carcinogen for humans. The aim of this study is to develop a tool to estimate occupational asbestos exposure in Italy after the ban using information collected in a national dataset. METHODS: Data were collected from firm registries of workers exposed to asbestos in the period 1996-2016. Descriptive statistics (arithmetic mean, standard deviation, geometric mean and geometric standard deviation) were calculated for the main exposure-related variables (activity sector, occupational group and exposure period). An estimate of workers potentially exposed to asbestos was also performed. RESULTS: A total of 19 704 airborne measurements of asbestos exposure was selected from the national database of occupational exposures in the sectors of asbestos abatement. Overall, a geometric mean of 7.93 f l-1 was found, and chrysotile was the asbestos type that had more exposures (41%). A total of 46 422 workers was estimated to be potentially at asbestos exposure risk. Exposure data were summarized by calendar period, activity sector and occupational group. CONCLUSIONS: The construction of a job exposure matrix for different occupation/industry combinations may allow the assessment of occupational exposure to asbestos in several removal and disposal activities, and the estimate of the risks associated with asbestos-related diseases in epidemiological studies.

The epidemiological surveillance of malignant mesothelioma in Italy (1993-2015): methods, findings, and research perspectives.

BACKGROUND: as a legacy of the large asbestos consumption until the definitive ban in 1992, Italy had to tackle a real epidemic of asbestos related diseases. The Italian National Registry of Malignant Mesotheliomas (ReNaM) is a permanent surveillance system of mesothelioma incidence, with a regional structure. Aims, assignments and territorial network of ReNaM are described, as well as data collection, recording and coding procedures. OBJECTIVES: to describe the Italian epidemiological surveillance system of mesothelioma incidence, to provide updated data about occurrence of malignant mesothelioma in Italy, and to discuss goals, attainments, and expectations of registering occupational cancer. DESIGN: analysis of data by malignant mesothelioma incident cases surveillance system. SETTING AND PARTICIPANTS: Italy, network of regional surveillance system, all Italian regions. MAIN OUTCOME MEASURES: a Regional Operating Centre (COR) is currently established in all the Italian regions, actively searching incident malignant mesothelioma cases from health care institutions. Occupational history, lifestyle habits, and residential history are obtained using a standardized questionnaire, administered to the subject or to the next of kin by a trained interviewer. The extent of dataset, epidemiological parameters, and occupations involved are reported updated at 31.12.2016, and standardized incidence rates are calculated. RESULTS: at December 2016, ReNaM has collected 27,356 malignant mesothelioma cases, referring to the period of incidence between 1993 and 2015. The modalities of exposure to asbestos have been investigated for 21,387 (78%) and an occupational exposure has been defined for around 70% of defined cases (14,818). CONCLUSIONS: the Italian experience shows that epidemiological systematic surveillance of asbestos related diseases incidence has a key importance for assessing and monitoring the public health impact of occupational and/or environmental hazards, programming preventive interventions, including remediation plans and information campaigns, and supporting the efficiency of insurance and welfare system. Monitoring the incidence of malignant mesothelioma through a specialized cancer registry is essential to follow-up the health effects of changing modalities and extent of occupational exposures over years and of environmental contamination. Such consolidated surveillance system is recommended also for occupational cancers with low aetiological fraction.

The epidemiology of malignant mesothelioma in women: gender differences and modalities of asbestos exposure.

INTRODUCTION: The epidemiology of gender differences for mesothelioma incidence has been rarely discussed in national case lists. In Italy an epidemiological surveillance system (ReNaM) is working by the means of a national register. METHODS: Incident malignant mesothelioma (MM) cases in the period 1993 to 2012 were retrieved from ReNaM. Gender ratio by age class, period of diagnosis, diagnostic certainty, morphology and modalities of asbestos exposure has been analysed using exact tests for proportion. Economic activity sectors, jobs and territorial distribution of mesothelioma cases in women have been described and discussed. To perform international comparative analyses, the gender ratio of mesothelioma deaths was calculated by country from the WHO database and the correlation with the mortality rates estimated. RESULTS: In the period of study a case list of 21 463 MMs has been registered and the modalities of asbestos exposure have been investigated for 16 458 (76.7%) of them. The gender ratio (F/M) was 0.38 and 0.70 (0.14 and 0.30 for occupationally exposed subjects only) for pleural and peritoneal cases respectively. Occupational exposures for female MM cases occurred in the chemical and plastic industry, and mainly in the non-asbestos textile sector. Gender ratio proved to be inversely correlated with mortality rate among countries. CONCLUSIONS: The consistent proportion of mesothelioma cases in women in Italy is mainly due to the relevant role of non-occupational asbestos exposures and the historical presence of the female workforce in several industrial settings. Enhancing the awareness of mesothelioma aetiology in women could support the effectiveness of welfare system and prevention policies.

Gender differences in occupational exposure to carcinogens among Italian workers.

BACKGROUND: Many carcinogenic chemicals are still used or produced in several economic sectors. The aim of this study is to investigate differences in occupational exposure patterns to carcinogens by gender in Italy. METHODS: Information about the most common carcinogens recorded in the Italian occupational exposures database (SIREP) for the period 1996-2015 was retrieved. Descriptive statistics were calculated for exposure-related variables (carcinogenic agent, occupational group, economic activity sector, and workforce size). The chi-square(χ2) test was used to verify differences between genders, and logistic regression analysis was performed to evaluate the association between gender and risk of having higher exposure levels, after adjusting for age. Concurrent exposures to multiple carcinogens were investigated using the two-step cluster analysis. RESULTS: A total of 166,617 exposure measurements were selected for 40 different carcinogens. Exposed workers were only in a small proportion women (9%), and mostly aged 20-44 years (70%) in both genders. Women were more likely to be exposed than men to higher levels for several carcinogens even after correction for age at exposure, and the exposure level was significantly (p < 0.01) associated with occupation, economic sector and workforce size. The five main clusters of co-exposures identified in the entire dataset showed a differential distribution across economic sectors between genders. CONCLUSIONS: The exposures to occupational carcinogens have distinguishing characteristics in women, that are explained in part by work and job segregation. Because of the presence of high-exposed groups of female workers in many industrial sectors, further research and prevention efforts are recommended.

The psychological distress and care needs of mesothelioma patients and asbestos-exposed subjects: A systematic review of published studies.

BACKGROUND: The purpose of this study is to present the results of a systematic review of published research that focuses on psychological aspects of malignant mesothelioma patients and asbestos-exposed people. METHODS: Our research includes primary studies published between 1980 and 2016, using information from the Cochrane Library, the Psychology Behavioral Sciences Collection, PsychINFO, PubMed, PubGet, PubPsych, and Scopus, in compliance with PRISMA guidelines. RESULTS: We identified 12 papers that investigated the psychological distress and care needs of mesothelioma patients, and nine papers for asbestos-exposed subjects. CONCLUSIONS: This paper highlights the paucity of studies on the psychological distress and care needs of mesothelioma patients and asbestos-exposed subjects. It confirms that malignant mesothelioma is associated with the physical, emotional, and social functioning of patients, while also suggesting that the risk of developing asbestos-related diseases among asbestos-exposed subjects is associated with high levels of psychological distress, despair, and mental health difficulties.

Occupational diseases in Italian national priority contaminated sites.

BACKGROUND: The aim of this study was to evaluate the occupational health risks in the Italian National Priority Contaminated Sites (NPCSs). METHODS: Established cases of occupational diseases in 2010-2014 were extracted from the Italian National Institute for Insurance against Accidents at Work (INAIL) archives. Standardized incidence ratios with 95% confidence intervals were estimated by site and by disease group separately for genders. RESULTS: In the 44 NPCSs evaluated, 11 015 cases of occupational diseases (8877 in men and 2138 in women) were ascertained. Overall, an excess of occupational diseases with respect to expected cases of 24.2% was found in men residing in NPCSs. An increased occurrence was detected in 21 NPCSs for men and in eight for women. CONCLUSIONS: The findings suggest a role of occupational diseases in the health profile of NPCSs, reinforcing the need for a permanent surveillance system.

Sinonasal cancer in the Italian national surveillance system: Epidemiology, occupation, and public health implications.

BACKGROUND: Sinonasal cancer (SNC) is a rare tumor with predominant occupational etiology associated with exposures to specific carcinogens. The aim of this study is to describe SNC cases recorded in Italy in the period 2000-2016. METHODS: Clinical information, occupational history, and lifestyle habits of SNC cases collected in the Italian Sinonasal Cancer Register were examined. Age-standardized rates were estimated. RESULTS: Overall, 1529 cases were recorded. The age-standardized incidence rates per 100 000 person-years were 0.65 in men and 0.26 in women. Occupational exposures were predominant among the attributed exposure settings, primarily to wood and leather dusts. Other putative causal agents included chrome, solvents, tannins, formaldehyde, textile dusts, and pesticides. Many cases had unknown exposure. CONCLUSIONS: Epidemiological surveillance of SNC cases and their occupational history is fundamental for monitoring the occurrence of the disease in exposed workers in industrial sectors generally not considered at risk of SNC as well as in non-occupational settings.

Economic impact of malignant mesothelioma in Italy: an estimate of the public and social costs.

BACKGROUND: Despite their considerable interest for public health policies and for occupational disease management and assessment, the economic costs of asbestos-related diseases (ARDs) for society have not been fully estimated or even frequently discussed. OBJECTIVES: The aim of this study was to estimate the economic burden of mesothelioma in Italy by assessing the overall societal cost of the disease, applying an econometric model. METHODS: We analyzed two main cost groups, public and social. The first includes expenditure borne by the State and other public bodies (medical care costs, insurance, tax and benefits), while the latter uses the human capital approach to measure the loss of productivity suffered by the economy as a whole. RESULTS: We provide an estimate of euro 33,000 per patient for medical care costs and euro 25,000 for insurance and compensation; tax and benefits seem to roughly compensate. We estimated a loss of more than euro 200,000 per patient, in terms of loss of production. CONCLUSIONS: This study offers a practical approach for estimating the economic impact of mesothelioma, and provides empirical evidence of the huge economic burden linked to this disease, with its high etiologic fraction.

Occupational exposure in the removal and disposal of asbestos-containing materials in Italy.

PURPOSE: A great variety of asbestos-containing materials are present in both residential and work settings because of the widespread use made in the past, and many occupational activities still entail the risk of asbestos exposure in Italy, more than 2 decades after the total national ban, mainly those involved in the removal and disposal of asbestos. The aim of the study was to evaluate the level and extent of asbestos exposure in Italy between the years 1996-2013 in the sector of asbestos abatement. METHODS: Data were collected from firm registries of asbestos-exposed workers and descriptive statistics were calculated for exposure-related variables. RESULTS: Overall, 15,860 measurements of asbestos exposure were selected from the national database of registries, mostly referring to the construction sector (N = 11,353). Despite the mean exposure levels are low, the air concentration of asbestos fibers measured during these activities may overcome the action level established by the Italian legislation and, in a limited number of cases, can exceed even the occupational limit value. Among occupations at higher risk, there are also garbage collectors and insulation workers. CONCLUSIONS: Starting from the analysis of the Italian database of occupational exposure registries, this study outlines the current levels of asbestos exposure in abatement-related sectors, discussing their possible implications for public health policies and surveillance programs.

[Pleural mesothelioma mortality in Italy: time series reconstruction (1970-2009) and comparison with incidence (2003-2008)]. / Mortalità per mesotelioma pleurico in Italia: ricostruzione della serie storica (1970-2009) e confronto con l'incidenza (2003-2008).

BACKGROUND: the large amount of asbestos used in many Countries (including Italy) is causing an epidemic of asbestos related diseases, which is still ongoing because of their long latency. OBJECTIVES: this study is aimed at reconstructing Italian time series of deaths for mesothelioma in the period 1970-2009 and comparing Italian incidence and mortality data. DESIGN, SETTING, AND PARTICIPANTS: deaths for pleural cancer (1970-2003,2006-2009) and mesothelioma (2003, 2006-2009) were recorded by the Italian Institute of Statistics (Istat) and provided by the Italian National Agency for New Technologies, Energy and the Environment (ENEA), incidence cases (1993-2008) were provided by the Italian mesotheliomas register (ReNaM) at the Italian National Workers' Compensation Authority (Inail). For the period before ICD-10 implementation (1970-2002) and when Istat data (2004-2005) are lacking, mesothelioma deaths were estimated through statistical models (logistic, Poisson). National incidence and mortality data were compared during the overlapping period (2003, 2006-2008). RESULTS: the mortality curve strongly rises from 1970 and seems to be smoothed in the last years. Mortality caused by mesothelioma and incident cases with certain diagnosis are overlapping, as are mortality due to pleural cancer other than mesothelioma and mesothelioma incidence with uncertain diagnosis (probable/possible). CONCLUSIONS: this epidemiological analysis of deaths encoded as pleural tumour suggests to carefully investigate space-temporal distribution before excluding they could be mesotheliomas. Some new lights have been thrown on the statistical behaviour of mesothelioma mortality.

[SENTIERI-ReNaM: Rationale and objectives]. / SENTIERI-ReNaM: Razionale e obiettivi.

The purpose of the SENTIERI-ReNaM Project is to analyse the incidence of mesothelioma in Italian National Priority Contaminated Sites (NPCSs) in order to estimate the health impact of asbestos on resident populations, disentangling the role of occupational and environmental exposures. SENTIERI Project has provided the relevant information on geographic and demographic structure of NPCSs and on existing sources of contamination. The Italian National Mesothelioma Registry (ReNaM), that covers the whole country through its Regional Operational Centres (CORs), has made available the procedures for estimating the incidence of mesothelioma in NPCSs and for assessing occupational and environmental asbestos exposure of the individual cases. The synergy between these two epidemiological surveillance systems lay also the ground for communication programmes with the affected communities.

[SENTIERI-ReNaM: Materials and methods]. / SENTIERI-ReNaM: Materiali e metodi.

In the framework of SENTIERI Project, this study is aimed to identify excess risks of malignant mesothelioma (MM) in Italian National Priority Contaminated Sites (NPCSs) included in the national environmental remediation programme and to discuss the results by means of data available from the Italian National Mesothelioma Registry (ReNaM). Re- NaM has a regional structure with Regional Operational Centres (CORs) in charge of identifying mesothelioma incident cases and defining the asbestos exposure modalities thought an individual questionnaire. Starting from the 44 NPCSs selected in SENTIERI Project, we excluded Calabria and Sardinia Regions from the analyses (3 NPCSs). Furthermore, for 2 sites (Emarese in Valle d'Aosta and Tito in Basilicata) no incident MM cases have been detected in the considered period. Incident cases of MM and Standardized Incidence Ratios (SIR), with corresponding 90% confidence intervals, have been estimated in each NPCS, for both gender, in the period 2000-2011. Age-standardized rates of Italian geographical macro-areas (North- East, North-West, Centre, South and Islands) have been used to estimate expected cases. For every analyzed site, the occupational and non-occupational asbestos exposure modalities are discussed.

[SENTIERI-ReNaM: Burden of disease from mesothelioma in national priority contaminated sites in Italy]. / SENTIERI-ReNaM: Valutazione globale del carico di mesotelioma.

BACKGROUND: in Italy, National Priority Contaminated Sites (NPCSs) are defined as of concern for remediation; most of them are sites with a long-lasting industrial activity. OBJECTIVE: the study aims to estimate the burden of disease from mesothelioma in NPCSs. DESIGN: mesothelioma incidence in the period 2000-2011 was estimated for the populations residing in the 39 Italian NPCSs. Data were taken from the Italian National Mesothelioma Registry (ReNaM). NPCSs were ranked into risk groups (RGs) on the basis of the presence of the following asbestos-exposing activities: 1. asbestos-cement plants; 2. asbestos mines; 3. harbours with shipyards; 4. illegal dumping sites containing asbestos; 5. petrochemicals and/or refineries, and/or steel plants; 6. chemical plants and/or landfills without explicit mention of asbestos. For the population residing in each NPCS, crude rates per 100,000 per year and number of observed minus expected cases (Obs-Exp) by gender were computed. Expected cases were calculated using the age-class rates of a reference population (the geographical macroarea of every NPCS). For every RG, the meta-analytic estimate of the attributable proportion (AP), i.e., the proportion of cases attributable to the local context, was computed, being the AP for each NPCS expressed as (Obs-Exp/Obs) x100. RESULTS: the total number of mesothelioma cases estimated in the considered period of 12 years is 2,741 (2,048 males, 693 females). The total number of Obs-Exp cases was 1,531 (1,178 in males, 353 in females). In males, crude rate ranges from 71.5 in the RG1 to 3.0 in RG4, while in females it ranges from 48.4 in RG1 to 0.6 in RG4. In males, AP in RGs from 1 to 3 is over 65%, in RG4 is 59%, in RG5 is 30%, in RG6 is -14%. AP in females gradually drops from 95% in RG1 to -64% in RG6. CONCLUSIONS: the burden of mesothelioma in populations residing in NPCSs is high, with an AP gradient consistent with the a priori RG. This burden impacts on females in a different way: rates are lower than male ones; AP is similar to male ones in the RGs 1 and 3.

[SENTIERI-ReNaM: Results]. / SENTIERI-ReNaM: Risultati.

Mesothelioma incidence has been analyzed in National Priority Contaminated Sites (NPCSs) to estimate the health impact of asbestos exposure on resident people. The burden of professional and environmental exposures has been identified through data of the Regional Operational Centres (CORs), made available by the Italian National Mesothelioma Registry (ReNaM). An excess of mesothelioma incidence is confirmed in sites with a known past history of direct use of asbestos, such as Balangero, Casale Monferrato, Broni, Bari-Fibronit, and in coastal areas, where shipyards, harbours and other industries that involved a wide use of asbestos are represented (e.g., Trieste, La Spezia, Venice, and Leghorn). An excess of mesothelioma has been observed in settings where the asbestos is not mentioned as contaminant in the decree that included these sites among NPCSs, such as Cengio and Saliceto in Northern Italy; Falconara Marittima and the Bacino Idrografico Fiume Sacco in the Central Italy; the Litorale Domizio Flegreo and Agro Aversano, Milazzo, and Gela in the Southern Italy. Observed excess in the various NPCSs confirms the large-scale occurrence in contaminated Italian sites of a significant amount of total mesothelioma cases observed at national level. The analysis of occupational risk in epidemiological studies with an ecological design helps in defining the contribution of different factors to the overall risk.

[SENTIERI-ReNaM: Discussion and concluding remarks]. / SENTIERI-ReNaM: Discussione e considerazioni conclusive.

SENTIERI-ReNaM Project analysed the incidence of malignant mesothelioma (MM) for the period 2000-2011 in 39 National Priority Contaminated Sites (NPCSs), and assessed the overall impact of mesothelioma in different types of NPCSs. In the study period, 2,683 incident cases of malignant mesothelioma were recorded: 1,998 males (74.5%), 685 females (25.5%). Excluding cases with non attributable exposure and those non interviewed, exposure was identified in 1,926 cases (70% of all cases): 1,541 males (occupational exposure: 1,414; environmental exposure: 82), 385 females (occupational exposure: 103; environmental exposure: 141). Women experienced mainly environmental and domestic exposures to asbestos. Standard Incidence Ratio (SIR) excesses were observed in men in 27 out of 39 NPCSs and defects in the remaining 12; in women, 20 NPCSs showed SIR excesses, defects in 15; in 4 NPCSs no MM cases occurred among female population. The highest rates were found in NPCSs with asbestos-cement plants (Broni and Casale Monferrato), respectively, 98 per 100,000 per year and 68.6 in men, 72.1 and 45.8 in women. Excluding these two sites, the highest incidence rates were found in the group with harbours and shipyards, where the rates were, respectively, 13.2 among men and 2.5 among women. The results of this report will be communicated to national and local institutions, as well as to NPCSs resident populations.

Epidemiological patterns of asbestos exposure and spatial clusters of incident cases of malignant mesothelioma from the Italian national registry.

BACKGROUND: Previous ecological spatial studies of malignant mesothelioma cases, mostly based on mortality data, lack reliable data on individual exposure to asbestos, thus failing to assess the contribution of different occupational and environmental sources in the determination of risk excess in specific areas. This study aims to identify territorial clusters of malignant mesothelioma through a Bayesian spatial analysis and to characterize them by the integrated use of asbestos exposure information retrieved from the Italian national mesothelioma registry (ReNaM). METHODS: In the period 1993 to 2008, 15,322 incident cases of all-site malignant mesothelioma were recorded and 11,852 occupational, residential and familial histories were obtained by individual interviews. Observed cases were assigned to the municipality of residence at the time of diagnosis and compared to those expected based on the age-specific rates of the respective geographical area. A spatial cluster analysis was performed for each area applying a Bayesian hierarchical model. Information about modalities and economic sectors of asbestos exposure was analyzed for each cluster. RESULTS: Thirty-two clusters of malignant mesothelioma were identified and characterized using the exposure data. Asbestos cement manufacturing industries and shipbuilding and repair facilities represented the main sources of asbestos exposure, but a major contribution to asbestos exposure was also provided by sectors with no direct use of asbestos, such as non-asbestos textile industries, metal engineering and construction. A high proportion of cases with environmental exposure was found in clusters where asbestos cement plants were located or a natural source of asbestos (or asbestos-like) fibers was identifiable. Differences in type and sources of exposure can also explain the varying percentage of cases occurring in women among clusters. CONCLUSIONS: Our study demonstrates shared exposure patterns in territorial clusters of malignant mesothelioma due to single or multiple industrial sources, with major implications for public health policies, health surveillance, compensation procedures and site remediation programs.

Malignant mesothelioma due to non-occupational asbestos exposure from the Italian national surveillance system (ReNaM): epidemiology and public health issues.

INTRODUCTION: Italy produced and imported a large amount of raw asbestos, up to the ban in 1992, with a peak in the period between 1976 and 1980 at about 160,000 tons/year. The National Register of Mesotheliomas (ReNaM, "Registro Nazionale dei Mesoteliomi" in Italian), a surveillance system of mesothelioma incidence, has been active since 2002, operating through a regional structure. METHODS: The Operating Regional Center (COR) actively researches cases and defines asbestos exposure on the basis of national guidelines. Diagnostic, demographic and exposure characteristics of non-occupationally exposed cases are analysed and described with respect to occupationally exposed cases. RESULTS: Standardised incidence rates for pleural mesothelioma in 2008 were 3.84 (per 100,000) for men and 1.45 for women, respectively. Among the 15,845 mesothelioma cases registered between 1993 and 2008, exposure to asbestos fibres was investigated for 12,065 individuals (76.1%), identifying 530 (4.4%) with familial exposure (they lived with an occupationally exposed cohabitant), 514 (4.3%) with environmental exposure to asbestos (they lived near sources of asbestos pollution and were never occupationally exposed) and 188 (1.6%) exposed through hobby-related or other leisure activities. Clusters of cases due to environmental exposure are mainly related to the presence of asbestos-cement industry plants (Casale Monferrato, Broni, Bari), to shipbuilding and repair activities (Monfalcone, Trieste, La Spezia, Genova) and soil contamination (Biancavilla in Sicily). CONCLUSIONS: Asbestos pollution outside the workplace contributes significantly to the burden of asbestos-related diseases, suggesting the need to prevent exposures and to discuss how to deal with compensation rights for malignant mesothelioma cases induced by non-occupational exposure to asbestos.

[Active research, registration, and prevention of tumors of professional origin]. / Ricerca attiva, registrazione e prevenzione dei tumori di origine professionale.

Occupational cancer is an important public health concern in Italy and in many industrialized countries. The difficulties in monitoring and the complexity in retrieving occupational cancer cases have required the enrolment of a national epidemiologic sureveillance system at national scale with active search methods. A structured system for the registration of occupational cancer cases is normed by the Decree No. 81/2008, that accounts for the previous legislative procedures and experiences. Research activities and prevention of occupational cancer should be integrated with insurance policies to the purpose of an efficient protection of workers health.