[A top-down path to promote environmental justice in a contaminated area. The experience with the community of Porto Torres (Sardinia, Italy)]. / Un percorso top-down di promozione della giustizia ambientale in un sito contaminato. L'esperienza con la comunità di Porto Torres.

Nowadays, in Italy, researchers from various disciplines and institutions are referring to environmental justice to promote health equity in relation to environmental risks and benefits. This presents an opportunity for the convergence of bottom-up and top-down perspectives, which differ in nature, to advance environmental justice at the local level. This contribution presents the experience of researchers from the Italian National Institute of Health in the contaminated area of Porto Torres (Sardinia). The experience began with the development of study activities aimed at describing the health profile of the population residing in Porto Torres. These activities embraced the requests of the local community and included interactions with local institutional and social actors. The study activities were designed with a focus on environmental justice, which requires an understanding of the local context and of its history. The contribution describes the various stages that led from the development of the study to the engagement with local institutional and social actors, communication of study results, and participation in local initiatives on environmental justice. Finally, the text proposes some considerations on how researchers from a central institution can develop and conduct study activities to promote environmental justice at the local level.

An Approach to Overcome the Limitations of Surveillance of Asbestos Related Diseases in Low- and Middle-Income Countries: What We Learned from the Sibaté Study in Colombia.

Introduction: The asbestos industry began its operations in Colombia in 1942 with the establishment of an asbestos-cement facility in Sibaté, located in the Department of Cundinamarca. Despite extensive asbestos use and production in Colombia, the country lacks a reliable epidemiological surveillance system to monitor the health effects of asbestos exposure. The Colombian health information system, known as SISPRO, did not report mesothelioma cases diagnosed in the municipality, posing a significant challenge in understanding the health impacts of asbestos exposure on the population of Sibaté. Methods: To address this issue, an active surveillance strategy was implemented in Sibaté. This strategy involved conducting door-to-door health and socioeconomic structured interviews to identify Asbestos-Related Diseases (ARDs). Validation strategies included a thorough review of medical records by a panel of physicians, and the findings were communicated to local, regional, and national authorities, as well as the general population. Results: The active surveillance strategy successfully identified a mesothelioma cluster in Sibaté, revealing the inadequacy of the existing health information system in monitoring asbestos-related diseases. The discovery of this cluster underscores the critical importance of implementing active surveillance strategies in Colombia, where governmental institutions and resources are often limited. Conclusion: The findings of this study emphasize the urgent need for Colombia to establish a reliable epidemiological surveillance system for asbestos-related diseases (ARDs). Active surveillance strategies can play a crucial role in identifying mesothelioma clusters and enhancing our understanding of the health effects of asbestos exposure in low- and middle-income countries.

Sustainability of Italian seaports located near contaminated sites: results of an exploratory analysis.

INTRODUCTION: Ports are strategic areas of economic importance, but they are also very critical contexts. Many Italian ports are included in contaminated sites of concern for remediation, with the presence of pressure factors that overload the burden capacity of local ecosystems and communities. AIM: The aim of this study is to characterize Italian seaport areas through a general theoretical path on the theme of ports-sustainability-local communities, identifying the ports located in municipalities included in contaminated sites studied by the SENTIERI Project (Epidemiological Study of Residents in Italian Contaminated Sites). Many of the selected ports, are being part of complex industrial areas, where, in addition to the port area, there are other sources of environmental contamination potentially harmful to health. RESULTS: Excesses risk were observed for mesothelioma and for respiratory diseases, pathologies for which there is epidemiological evidence of an excess of risk associated with residence in port areas. DISCUSSION: The strong environmental pressures that characterize these areas make it necessary to adopt adequate environmental and health protection measures.

[Environmental justice promotion in the Italian contaminated sites through the national epidemiological surveillance system SENTIERI]. / Il contributo di SENTIERI alla promozione della giustizia ambientale nei siti contaminati italiani.

Conceptual and operational aspects of studying and promoting environmental justice and the results from assessments on environmental justice carried out within the epidemiological surveillance SENTIERI focused on communities living close to main Italian contaminated sites are here summarized. The communities under SENTIERI surveillance often have environmental injustice conditions associated with the cumulative impact of environmental pressures due to contamination and a high socioeconomic deprivation and mortality risk. In Italy, a North-South divide gradient is present, with the worst conditions in the South&Island, where most communities affected by contaminated sites are socioeconomically deprived. The main mechanisms of development and maintenance of distributive injustice in contaminated sites are attributable to procedural injustice conditions, with marginalization and misrecognition of disadvantaged communities or subgroups in decisional processes regarding both the location and permanence of polluting industrial plants and the interventions on remediation and reduction of hazardous exposures and health-related impacts. Within SENTIERI, strategies have been developed to produce participative territorial communication plans and to strengthen the environmental health literacy of local institutional and social actors. SENTIERI contributes in promoting environmental justice through the empowerment of social capacities of local communities.

[SENTIERI - Epidemiological Study of Residents in National Priority Contaminated Sites. Sixth Report]. / SENTIERI - Studio epidemiologico nazionale dei territori e degli insediamenti esposti a rischio da inquinamento. Sesto Rapporto.

INTRODUCTION ADN OBJECTIVES: The Sixth Report presents the results of the "SENTIERI Project: implementation of the permanent epidemiological surveillance system of populations residing in Italian Sites of Remediation Interest", promoted and financed by the Italian Ministry of Health (Centre for Disease Control and Prevention - CCM Project 2018). The aim of this study is to update the mortality and hospitalization analyses concerning the 6,227,531 inhabitants (10.4% of the Italian population) residing in 46 contaminated sites (39 of national interest and 7 of regional interest). The sites include 316 municipalities distributed as follows: 15 in the North-East (20.3% of the investigated population); 104 in the North-West (12% of the investigated population), 32 in the Centre (12.6% of the investigated population), 165 in the South and Islands (55.5% of the investigated population). Analyses were carried out on the paediatric-adolescent (1,128,396 residents) and youth (665,284 residents) population, and a study on congenital anomalies (CA) was carried out at sites covered by congenital malformation registers. Accompanying the epidemiological assessments, site-specific socioeconomic conditions were examined and an overall estimate of excess risk for populations residing at contaminated sites was drawn up. By means of a systematic review of the scientific literature, the epidemiological evidence on causal links between sources of environmental exposure and health effects was updated to identify pathologies of a priori interest. METHODOLOGY: In the 46 sites included in the SENTIERI Project, mortality (time window: 2013-2017) and hospital admissions (time window: 2014-2018) of the general population of all ages, divided by gender, and of the paediatric-adolescent (0-1 year, 0-14 years, 0-19 years), youth (20-29 years), and overall (0-29 years) age groups, divided by gender, were analysed. In 21 sites, CA diagnosed within the first year of life were studied. Standardised mortality ratios (SMR) and hospitalization ratios (SHR) were calculated with reference to the rates in the regions to which the sites belong. The reference population was calculated net of residents in the sites. CA were studied by calculating the prevalence per 10,000 births and the ratio, multiplied by 100, between the cases observed at the site and those expected on the basis of the prevalences observed in the reference area (region or sub-regional area of belonging, according to the geographical coverage of the registry). The socioeconomic condition studied in the 46 sites is based on the convergence of three deprivation indicators with respect to the reference region: deprivation index at municipal level, deprivation index at census section level, premature mortality indicator (age range 30-69 years) for chronic non-communicable diseases. For the estimation of excess risk for the entire study population, meta-analysis of the mortality and hospitalization risk estimates for each site was carried out and the number of excess deaths estimated for the sites as a whole. The epidemiological evidence was updated through a systematic literature review (January 2009-May 2020), following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was carried out on the search engines MEDLINE, EMBASE and Web of Science; the quality of the studies included in the review was assessed using the AMSTAR 2 checklist for systematic reviews and the NewCastle-Ottawa Scale for observational studies in the case of cohort and case-control studies and a modified version thereof for ecological and cross-sectional studies. The update was based on the selection of 14 systematic reviews, 15 primary studies, 6 monographs/reports from international scientific organisations on health effects due to the presence of environmental exposure sources. RESULTS: Mortality. The a priori causes of interest that occur most frequently in excess are, in descending order: malignant lung cancer, malignant mesothelioma of the pleura, malignant bladder cancer, respiratory diseases, non-Hodgkin lymphomas, malignant liver cancer, all malignant tumours, malignant colorectal cancer, malignant stomach cancer, total mesotheliomas, malignant breast cancer, and asbestosis. Hospitalization. The a priori causes of interest that occur most frequently in excess are represented in descending order by: respiratory diseases, malignant lung cancer, malignant tumours of the pleura, malignant bladder cancer, malignant breast cancer, malignant liver cancer, asthma, malignant colorectal cancer, all malignant tumours, malignant stomach cancer, non-Hodgkin's lymphomas, acute respiratory diseases, leukaemias. The differences observed between mortality and hospitalization can be attributed to the intrinsic characteristics of the diseases (higher or lower lethality, gender differences in incidence), lifestyles, and occupational phenomena. Age classes. Excesses of general mortality were observed in the first year of life at the Manfredonia, Basso Bacino Fiume Chienti, Litorale Domizio Flegreo and Agro Aversano sites; in the 0-1 year and 0-19 year age groups at Casale Monferrato; in the paediatric age group at Serravalle Scrivia and at the Trento Nord site; in the 0-19 year age group at Sassuolo Scandiano; in the young age group (0-29 years) at the two municipalities of Cerchiara and Cassano (Crotone-Cassano-Cerchiara site). With regard to hospitalization due to natural causes, risk excesses in both genders are found in the first year of life in 35% of the sites (Porto Torres industrial areas, Bari-Fibronit, Basso bacino fiume Chienti, Bolzano, Crotone-Cassano-Cerchiara, Cerro al Lambro, Bologna ETR large repair workshop, Gela, Manfredonia, Massa Carrara, Pioltello Rodano, Pitelli, Priolo, Sesto San Giovanni, Trento Nord, and Trieste). These same sites, with the addition of Casale Monferrato, Cengio e Saliceto, Serravalle Scrivia, and Sulcis-Iglesiente-Guspinese (total: 43% of sites), show excesses for all natural causes, in both genders, even in the paediatric-adolescent age group (0-19 years). Among young adults (20-29 years), the analyses show excesses of hospitalization for all natural causes in both genders in the Bolzano, Crotone-Cassano-Cerchiara, Gela, Manfredonia, Pitelli, Priolo, and Sulcis-Iglesiente-Guspinese sites. Among young women only, excesses for all natural causes are also found in Brescia Caffaro, Brindisi, Broni, Casale Monferrato, Crotone-Cassano-Cerchiara, Falconara Marittima, Fidenza, and Massa Carrara. Congenital anomalies. In the 21 sites investigated for CA, 10,126 cases of CA, validated by participating registers, were analysed out of 304,620 resident births. Genital CA is the subgroup for which the greatest number of excesses was observed (in 6 out of 21 sites). The available evidence does not allow a causal link to be established between the excesses observed for specific subgroups of ACs and exposure to industrial sources, but the results suggest further action. The interpretation of the results appears, in fact, particularly complex as the scientific literature on the association between exposure to industrial sources and AC is very limited. Socioeconomic status. The sites in which the indicators converge to show the presence of fragility are: Litorale Vesuviano area, Val Basento industrial areas, Basso Bacino fiume Chienti, Biancavilla, Crotone-Cassano-Cerchiara, Litorale Domizio Flegreo and Agro Aversano, Livorno, Massa Carrara, Trieste. Global impact. Over the period 2013-2017, an estimated 8,342 excess deaths (CI90% 1,875-14,809) or approximately 1,668 excess cases/year, 4,353 excess deaths among males (CI90% 334-8,372) and 3,989 among females (CI90% -1,122;9,101). The pooled excess risk of general mortality is 2% in both genders (pooled SMR 1.02; CI90% 1.00-1.04). The proportion of excess deaths to total observed deaths is almost constant over time, rising from 2.5% in 1995-2002 to 2.6% in 2013-2017. The number of deaths in absolute value is also very similar between the periods analysed. Deaths from all malignant tumours contribute the most by accounting for 56% of the observed excesses, the excess risk of mortality from malignant tumours across all sites, compared to the reference populations, is 4% in the male population (pooled SMR 1.04; CI90% 1.01-1.06) and 3% among the female population (pooled SMR 1.03; CI90% 1.01-1.05). Hospitalization (2014-2018) in the 46 sites as a whole was in excess of 3% for all causes, in both genders, for all major disease groups (males: SHR pooled 1.03; CI90% 1.01-1.04 - females: SHR pooled 1.03; CI90% 1.01-1.05). The results for the pooled estimates at the 46 sites on the general population, both with regard to mortality and hospitalization, are consistent in indicating excess risk in both genders for all the diseases considered and, in particular, for all malignancies. A total of 1,409 paediatric-adolescent deaths and 999 young adult deaths were observed, and the pooled analysis of mortality across the 46 sites showed no critical issues, with pooled estimates for all causes, perinatal morbid conditions and all malignancies falling short of expectations. The analysis of hospitalizations, on the other hand, showed an excess risk of 8% (males: SHR pooled 1.08; CI90% 1.03-1.13 - females: SHR pooled 1.08; CI90% 1.03-1.14) for all causes in the first year of life, and in paediatric-adolescent and juvenile age of 3-4% among males (age 0-19 years: SHR pooled 1.04; CI90% 1.02-1.06 - age 20-29 years: SHR pooled 1.03; CI90% 1.00-1.05) and 5% among females (in both age groups; SHR pooled 1.05; CI90% 1.02-1.08). The pooled analysis of mortality for the a priori identified diseases reported excesses for specific diseases in the group of sites with sources of exposure associated with them. Mortality from total mesotheliomas is three times higher at sites with asbestos present (males:pooled SMR 3.02; CI90% 2.18-3.87 - females: pooled SMR 3.61; CI90% 2.33-4.88) and that from pleural mesotheliomas more than two times higher at the group of sites with asbestos and port areas (males: pooled SMR 2.47; CI90% 1.94-3.00 - females: pooled SMR 2.43; CI90% 1.67-3.19). Lung cancer was in excess by 6% among males (pooled SMR 1.06; CI90% 1.03-1.10) and 7% among females (pooled SMR 1.07; CI90% 1.00-1.13). In addition, there are excess mortalities for colorectal cancer at sites with chemical plants, by 4 % among males (SMR pooled 1.04; CI90% 1.01-1.08) and 3 % among females (SMR pooled 1.03; CI90% 1.00-1.07) and for bladder cancer among the male population of sites with landfills (+6 %: SMR pooled 1.06; CI90% 1.02-1.11). Among the diseases of a priori interest, stomach and soft tissue cancers are at fault as a cause of death among all the sites considered. LITERATURE REVIEW: The update of the epidemiological evidence underlying the Sixth SENTIERI Report has highlighted in the general population a possible association, previously undiscovered, between certain diseases and residence near petrochemical and steel plants, landfills, coal mines and asbestos sources. CONCLUSIONS AND PERSPECTIVES: Despite the fact that this is an ecological study, and the excesses of pathologies with multifactorial aetiology can never be mechanically attributed solely to the environmental pressure factors that exist or existed in the areas studied, the ability to identify the excesses found in the contaminated sites investigated by the SENTIERI Project confirms the validity of this method of assessing the site-specific health profile, based on the use of epidemiological evidence to identify pathologies of interest a priori. In interpreting the data and lending robustness to what has been observed, comparison with the results obtained in previous Reports is essential. The global estimates give an overall picture that shows excess mortality and hospitalization in these populations compared to the rest of the population, and show how, for specific pathologies, comparable effects are produced at sites with similar contamination characteristics. The themes developed in the in-depth chapters broaden the vision and understanding of the complex interactions between environment and health, describe the possibilities offered by new ways of communicating the results, and confirm the modernity of a Project that began way back in 2006, and that could be grafted onto the objectives of the National Recovery and Resilience Plan within the framework of the Operational Programme Health, Environment, Biodiversity and Climate.

[Methodological approaches to evaluate the over-time mortality in SENTIERI epidemiological surveillance system: a focus on cohort analyses]. / Approcci metodologici per valutare l'andamento della mortalità nel lungo periodo nel sistema di sorveglianza SENTIERI: focus sull'analisi di coorte.

The SENTIERI Project analyses the health profile of the populations residing in Italian national priority contaminated sites in specific calendar periods using a cross-sectional approach. An aspect that has not been evaluated so far is the analysis over a long period, for understanding the changes in health profiles over time and studying them also in function of the changes occurred in the territories. This article studies temporal trends by birth cohort and calendar period for overall mortality and lung cancer mortality from 1980 to 2018, separately for men and women, for three sites: Priolo (Sicily Region, Southern Italy), Pitelli (Liguria Region, Northern Italy), and Terni-Papigno (Umbria Region, Central Italy). A method for selecting the temporal model that best fits the data is then proposed. General mortality presents complex temporal profiles when considering cumulative risks, and usually the most important temporal axis is the birth cohort for cumulative SMRs (i.e., after adjusting for trends in the reference population). For lung cancer, the most important time axis is the birth cohort and the age-cohort model is the most appropriate, in particular for men of Priolo and Terni.

[The concept map of SENTIERI Project: a communication interactive digital tool of the national epidemiological surveillance system of Italian contaminated sites]. / La mappa concettuale: uno strumento digitale interattivo per la comunicazione del sistema di sorveglianza epidemiologica SENTIERI nei siti contaminati.

This paper describes the development and the envisioned use of concept maps in the framework of the SENTIERI communication strategies as an information and scientific communication tool applied to epidemiological surveillance in contaminated sites. The concept map of SENTIERI 2019-2022 was designed and implemented to foster access to complex scientific information ensuring usability of the contents and communication with the various stakeholders. The concept map aims to promote environmental health literacy in contaminated sites. The methodology adopted to create the map includes the following phases: 1. choice of a dynamic focus question; 2. selection of the representative terms of the addressed topics; 3. elaboration of the glossary of the selected terms; 4. representation of the links among the selected terms; 5. identification of the significant propositions that make explicit the meaning of each link. Online access to the map is guaranteed by the Mindomo software. The use of the concept map promotes active learning of the topics that characterize SENTIERI 2019-2022 through knowledge paths chosen because of the specific interests and learning purposes. The concept map derives from the integration of specific approaches of the epidemiological discipline with those of the social sciences and offers the possibility of developing site-specific maps through the interactions with local actors and the integration of elements related to emerging problems as well as institutional and local interests.

[Global evaluation of the mortality and hospitalization in the Italian contaminated sites included in the SENTIERI project]. / Stime globali della mortalità e ospedalizzazione nei siti contaminati italiani inclusi nel progetto SENTIERI.

Since 2006, epidemiological surveillance of populations living in Italian contaminated sites has been ongoing (SENTIERI Project). Updated global estimates of mortality (2013-2017) and hospitalization (2014-2018) are reported. The excess deaths (observed-expected) for the main groups of diseases were calculated for all the 46 sites together. Through a random-effect meta-analysis of the standardized mortality and hospitalization rates (SMR/SHR), the pooled SMR/SHR for all the sites and their groupings were estimated. In the 46 sites, 8,342 exceeding deaths (1,668/year) were estimated, 4,353 in males and 3,989 in females, resulting in an excess risk of 2% in both genders. The risk of hospitalization for all causes was in excess of 3%. These excesses are mainly attributable to malignant tumours. In subgroups of sites, exceeding SMRs were observed for all mesotheliomas and pleural mesotheliomas, lung and colorectal cancers in both genders. SHR for all causes were observed in excess in the first year of life (+8%), in the group 0-19 and 20-29 years (+3-5%); no excesses of mortality were observed in the group 0-29 years.

Health in contaminated sites: the contribution of epidemiological surveillance to the detection of causal links. Commentary.

The search for cause-effect relationships is a central aspect of epidemiological surveillance programs applied to populations living close to contaminated sites. Here are described needs for assessing causality in using different epidemiological study designs in association with the aim of promoting environmental public health, where uncertainties should be considered under a precautionary driven approach.

Distributive justice in environmental health hazards from industrial contamination: A systematic review of national and near-national assessments of social inequalities.

Communities where polluting human activities are sited often show disadvantage in terms of social and economic variables. Environmental distributive justice studies seek to identify common characteristics in exposed populations and highlight the presence of environmental inequalities. We have conducted a review of the existing literature about justice in the distribution of health hazards from industrial pollution. We included papers investigating associations between social disadvantage and contamination through assessments at national or macro-area level. From each study we extracted: indicators for the social determinants of exposed communities (classified according to PROGRESS-plus categories); definition and measurement of environmental hazard (as either proximity to contamination sources, exposure to emissions or health impacts from pollutants); study design and methods; significant results. We retrieved 45 eligible articles. Most publications were from USA and had a nationwide scope with data at municipal/sub-municipal scale. Socioeconomic position and race/ethnicity were the social determinants most often explored, followed by occupation and education; air pollution was the commonest sort of contamination, while proximity prevailed as measurement of hazard. All papers found significant associations between social dimensions and health hazard from industrial contamination: the majority of associations supported an increased burden on vulnerable categories, especially ethnic minorities and unemployed - however, several relationships were found in the opposite direction or in both ways, particularly with wealth and education, reflecting a mixed reality where potential discrimination in siting decisions coexists with socioeconomic benefits for nearby communities due to industrial development. Assessments of environmental distributive justice are lacking in most countries and those that are conducted show vast methodological heterogeneity. We recommend consistency in models and indicators, the inclusion of female-led households among indicators of social disadvantage, and the adoption of a small scale to elicit significant findings and provide meaningful policy action.

Mortality temporal trends and cancer incidence profiles of residents in the petrochemical industrially contaminated town of Gela (Sicily, Italy).

OBJECTIVE: In 2000, a vast area in Gela (Sicily, Italy) was defined as a national priority contaminated site due to pollution from a petrochemical complex. This study is aimed at addressing the influence of the petrochemical complex on the health profile of residents in Gela. METHODS: Trend analysis by gender was performed for mortality for all diseases and malignant cancers, in the period 1980-2014 for residents in the municipality of Gela, by directly standardized rates and Joinpoint regressions, using, as a reference population, people resident in the Sicily region. SMRs were computed for 5-year periods in the same timespan. Since the beginning of the period analyzed, the share of population of Gela represents 1.5% of total residents in Sicily. Cancer incidence was analyzed for the period 2007-2012 applying a hierarchical Bayesian model to estimate Standardized Incidence Ratios (SIR). Ranks of these ratios were computed to highlight the most incident diseases affecting the population. Malignant neoplasms of lung, stomach and colon were selected because of a priori interest, as they are associated, in etiological terms, with the main contaminants found in the area. Malignant neoplasms of liver, pancreas and larynx were selected as "control diseases" since they share the same main risk factors (smoke and alcohol consumption) of neoplasms of a priori interest, but are not associated with the priority index contaminants identified in Gela. RESULTS: Mortality rates for all causes combined in both genders in Gela decreased over time, but they were higher than those of the whole Sicilian population. The trend of mortality rates due to all malignant cancers increased in men, especially from 1980 to 1987. This result was confirmed by the Joinpoint regression (annual percentage change (APC) 9.8). SMRs analysis showed significant excesses in mortality due to all diseases for both genders compared to the reference population. Other excesses were observed for mortality due to malignant cancers in men and for circulatory diseases in women. The trend for cancers in women in Gela increased from the mid-nineties but less than in men. SIR estimates were higher than 1 for all the diseases analyzed and in both sexes, and their ranks highlighted that cancer sites of a priori interest hold higher positions than "control diseases", although credibility intervals overlapped. CONCLUSIONS: Results highlight that the health profile of residents in Gela is worse than the one of the reference population. Moreover, cancer incidence is in excess in all the sites analyzed and mortality due to all cancers combined has a trend compatible with a cumulative impact due to petrochemical contamination.

Exploring methods for the assessment of temporal trends in mortality and hospitalization in Italian industrially contaminated sites.

INTRODUCTION: The Italian contaminated sites of interest for remediation are monitored by SENTIERI, an epidemiological surveillance system describing the health status of populations living nearby these sites. There is an increasing concern on how to assess temporal changes in the health status of these populations. METHODS: A sequence of three statistical techniques was adopted to analyse temporal trends of mortality and hospitalization, by using different indicators and reference populations, in a sample of 36 sites with industrial sources of contamination monitored by SENTIERI. RESULTS: Positive temporal trends in health risks are detected reflecting mainly long term effects of industrial activities. The adopted methodology identifies multiple factors influencing the temporal patterns: type of health outcomes, type of disease, and its link with gender and type of emission sources. CONCLUSIONS: Reliable methods to assess health profile changes in local populations attributable to contaminations are key elements to measure the impact of remediation activities.

Where are the landfilled zones? Use of historical geographic information and local spatial knowledge to determine the location of underground asbestos contamination in Sibaté (Colombia).

INTRODUCTION: Sibaté is a municipality located in the central region of Colombia, where the first asbestos-cement facility of the country has been in operation since 1942. Both a malignant pleural mesothelioma cluster and landfilled zones with the presence of an underground friable asbestos layer have been identified in Sibaté. There is still limited knowledge regarding the history of the construction of landfilled zones, and what kinds of materials were deposited. The current study aims to improve our understanding of the history and characteristics of the landfilled zones present in Sibaté. METHODS: Two participatory workshops with inhabitants of Sibaté were conducted to determine when the landfilled zones were built and their location. Information collected in participatory workshops was crossed with both topographic maps and aerial photographs, giving special attention to zones within the urban area of the municipality that in the past were inundated with water from El Muña Reservoir. An opportunistic soil sampling campaign was conducted in suspected landfilled zones that had not been previously sampled, during the replacement of pipelines of the drainage system ordered by the municipality. RESULTS: The analysis of historical topographic maps, combined with the interpretation of aerial photographs, confirmed the disposal of residues in areas that were previously inundated with water from El Muña Reservoir, creating landfilled zones in the urban area of Sibaté. On top of these landfilled zones, a football stadium and a football field with an athletic track were built. The location of landfilled zones identified using geographic analysis was similar to the location identified analyzing maps constructed by inhabitants of Sibaté in participatory workshops. The four soil samples collected during an opportunistic sampling campaign confirmed the presence in new locations of the underground friable asbestos layer discovered in previous studies. DISCUSSION: Based on the extension of the landfilled zones, the presence of friable asbestos in these areas, and the close proximity to a school and residential dwellings, there could have been major dispersion events of asbestos fibers in the urban area of Sibaté during the disposal of residue materials and the construction of the landfilled zones. Thus, important asbestos exposures may have occurred among residents of Sibaté, which is aggravated by the fact that during those years, more than 50% of the population of Sibaté was 25 years old or younger. Although the results of the current study improved our understanding of the processes and chronology associated with the landfilled zones, the uncertainty regarding their exact location remains significant. It is important to continue investigating the adverse health effects resulting from this potential asbestos exposure source.

[Environmental justice promotion in industrially contaminated sites]. / Promozione della giustizia ambientale nei siti industriali contaminati.

The communities residing close to industrially contaminated sites are often affected by several fragilities, particularly of a socioeconomic nature. The disadvantaged conditions have often resulted from their marginalization in the decision-making related to the industrialization processes and may persist even when action is taken to limit the harmful consequences for the natural and social environment. Exposure to contaminants and the resulting health risks often regard socioeconomic deprived communities or the most disadvantaged subgroups, generating conditions of environmental injustice. This paper reports the results of a multidisciplinary reflection focusing on the Italian context. It describes how the national epidemiological surveillance system of communities residing close to industrially contaminated sites (named SENTIERI) and local epidemiological surveillance systems can be implemented to document local conditions of distributive injustice (inequalities in harmful exposures and consequent health risks). Furthermore, it analyses the mechanisms for generating and maintaining marginalities that prevent local communities from participating in decision-making processes (procedural injustice). Finally, after having identified and described the dimensions of community capacity, which concern both to the understanding of the adverse effects of environmental contamination and to the capability of promoting interventions against environmental injustices, it proposes an environmental justice promotion approach that starts from mapping the dimensions of community capacity as a premise to the identification of interventions for community empowerment.

The challenges of applying an Activity-Based Sampling methodology to estimate the cancer risk associated with asbestos contaminated landfilled zones.

Inhabitants of Sibaté (Colombia) report that between approximately 1975 and 1985 asbestos-containing materials (ACM) were dumped at different locations in the urban area of the municipality. Starting in around 1986, the dumping of materials resulted in landfilled zones, on top of which different facilities were then constructed. In a previous study, an underground friable asbestos layer was discovered in these landfilled zones. However, potential exposure to asbestos on the surface of landfilled zones in Sibaté has not been determined. In the current study, the U.S. EPA Activity-Based Sampling (ABS) methodology was adapted and applied in three scenarios located on potential landfilled areas in Sibaté, to estimate the current risk of exposure to asbestos through inhalation, and the resulting excess lifetime cancer risk (ELCR). For this purpose, generic ABS in a football stadium, and specific ABS in both a public playground and a school courtyard were conducted. Personal, area and blank samples were collected and analyzed using phase contrast microscopy (PCM) and transmission electron microscopy (TEM) following NIOSH 7400 and ISO 13794 methods, respectively. Exposure point concentrations were determined and compared against the action level for asbestos in air (ALAA), and were also used to calculate the ELCR of each scenario. A total of 25 airborne asbestos samples were collected, and 22 of these (12 personal samples, 7 area samples and 3 blank samples) were analyzed using PCM. Eighteen of these samples (12 personal, 3 area samples and 3 blank samples) were analyzed using TEM. The total asbestos structures concentration of personal samples ranged from non-detected to 0.326 S/cc (i.e., total asbestos structures counts ranged from 0 to 12). All samples had PCM-Equivalent asbestos structures concentrations below analytical sensitivity. Of the 22 samples analyzed, 18 were overloaded with particles. Although chrysotile and actinolite were identified in some personal samples, suggesting a potential risk of asbestos exposure, the ELCR was at U.S. EPA acceptable risk levels. Since the ABS methodology was applied in a limited number of scenarios and a small number of samples were collected, these results should be interpreted with caution and additional sampling campaigns are required to fully understand the risk of asbestos exposure in Sibaté. Methodological and analytical challenges encountered in the current study are discussed in detail, which could inform future ABS studies, not only in Sibaté, but also in other areas with asbestos-contaminated soils.

Industrial contaminated sites and health: results of a European survey.

BACKGROUND: industrially contaminated sites (ICSs) have been recognised as a major public health concern since they involve exposure to multiple environmental stressors, normally distributed unevenly within population. The COST Action on Industrially Contaminated Sites and Health Network (ICSHNet) comprises a European network of experts and institutions to clarify needs and priorities for better characterising the impact on environment and health of ICS. OBJECTIVES: evaluate the availability of information and studies concerning selected ICSs in participating Countries within the ICSHNet, with particular consideration on the accessibility to environmental, health and demographic data, and research and assessment tools. METHODS: to evaluate the availability of data, an Action Questionnaire (AQ) was developed based on previous questionnaires used in different European projects and on expert consultation. The AQ, with 84 items organised in eight sections, was adapted to an on-line version using the software LimeSurvey. The survey was sent to 47 participants within the ICSHNet, to report over a list of 99 ICSs previously identified. RESULTS: information was gathered from 81 sites out of the initially selected 99, reported by 45 participants from 27 Countries (82% of Countries in the ICSHNet). The predominant polluting activities were waste disposal (46%) and chemical industries (37%), affecting all environmental media, but more extensively surface and groundwater (70%) and soil (68%). Main categories of contaminants affecting different media were heavy metals and chlorinated hydrocarbons, but also BTEX (benzene, toluene, ethylbenzene, and xylene) and ambient air pollutants (e.g., particulate matter, SOx). Human health risk assessment was the most prevalent methodological approach for characterising impacts on health (32%), followed by epidemiological studies (26%), and health impact assessment (12%). The low reporting, both referring to data availability or methodologies, could be due to absence of data, or to the fact that the reporting person (many of them from the public health sector) did not know how to reach the environmental information. CONCLUSIONS: survey findings suggest that improving the collection and access to specific environmental, health and demographic data related to ICSs is crucial to meet the methodological requirement to better analyse the health impact of ICSs.

Human biomonitoring as a tool for exposure assessment in industrially contaminated sites (ICSs). Lessons learned within the ICS and Health European Network.

BACKGROUND: the mixed and complex nature of industrially contaminated sites (ICSs) leads to heterogeneity in exposure and health risk of residents living nearby. Health, environment, and social aspects are strongly interconnected in ICSs, and local communities are often concerned about potential health impact and needs for remediation. The use of human biomonitoring (HBM) for impact assessment of environmental exposure is increasing in Europe. The COST Action IS1408 on Industrially Contaminated Sites and Health Network (ICSHNet) decided to reflect on the potential and limitations of HBM to assess exposure and early health effects associated with living near ICSs. OBJECTIVES: to discuss challenges and lessons learned for addressing environmental health impact near ICSs with HBM in order to identify needs and priorities for HBM guidelines in European ICSs. METHODS: based on the experience of the ICSHNet research team, six case studies from different European regions that applied HBM at ICSs were selected. The case studies were systematically compared distinguishing four phases: the preparatory phase; study design; study results; the impact of the results at scientific, societal, and political levels. RESULTS: all six case studies identified opportunities and challenges for applying HBM in ICS studies. A smart choice of (a combination of) sample matrices for biomarker analysis produced information about relevant time-windows of exposure which matched with the activities of the ICSs. Combining biomarkers of exposure with biomarkers of (early) biological effects, data from questionnaires or environmental data enabled fine-tuning of the results and allowed for more targeted remediating actions aimed to reduce exposure. Open and transparent communication of study results with contextual information and involvement of local stakeholders throughout the study helped to build confidence in the study results, gained support for remediating actions, and facilitated sharing of responsibilities. Using HBM in these ICS studies helped in setting priorities in policy actions and in further research. Limitations were the size of the study population, difficulties in recruiting vulnerable target populations, availability of validated biomarkers, and coping with exposure to mixtures of chemicals. CONCLUSIONS: based on the identified positive experiences and challenges, the paper concludes with formulating recommendations for a European protocol and guidance document for HBM in ICS. This could advance the use of HBM in local environmental health policy development and evaluation of exposure levels, and promote coordination and collaboration between researchers and risk managers.

[SENTIERI: Epidemiological Study of Residents in National Priority Contaminated Sites. Fifth Report]. / SENTIERI: Studio epidemiologico nazionale dei territori e degli insediamenti esposti a rischio da inquinamento. Quinto Rapporto.

INTRODUCTION AND OBJECTIVES: This volume provides an update of the health status of the populations living in the National Priority Contaminated Sites (NPCSs) included in the SENTIERI Project. This update is part of an epidemiological surveillance programme carried out in NPCSs, promoted by the Italian Ministry of Health as a further step of a project started in 2006, when the health status of residents in contaminated sites was first addressed within the National Strategic Program "Environment and Health". The Report focuses on five health outcomes: mortality, cancer incidence, hospital discharges, congenital anomalies, and children, adolescents and young adults' health. A key element of SENTIERI project is the a priori evaluation of the epidemiological evidence of a causal association between the considered cause of disease and the exposure. When an a priori evidence is identified, it is given a greater importance in the comment of the study findings. METHODS: The present update of the SENTIERI Project concerns 45 NPCSs including in all 319 Italian Municipalities (out of over 8,000 Municipalities), with an overall population of 5,900,000 inhabitants at the 2011 Italian Census. Standardized Mortality Ratios (SMRs) and Standardized Hospitalization Ratios (SHRs), referring to a time window of 2006-2013, were computed for all the 45 NPCSs, using as a reference the corresponding mortality and hospitalization rates of the Regions where each NCPS is located. Standardized Incidence Ratios (SIRs) were computed by the Italian Association of Cancer Registries (AIRTUM) for the 22 NPCSs served by a Cancer Registry. AIRTUM covers about 56% of Italy, with partly different time-windows. SIRs have been estimated using as reference population the 4 macroareas in which Italy is divided (North-West, North-East, Centre, South). Prevalence of congenital anomalies was computed for 15 NPCSs. RESULTS: An all-cause excess of 5,267 and 6,725 deaths was observed, respectively, in men and women; the cancer death excess was of 3,375 in men and 1,910 in women. It was estimated an excess of cancer incidence of 1,220 case in men and 1,425 in women over a five-year time window. With regard to the diseases with an a priori environmental aetiological validity, an excess for malignant mesothelioma, lung, colon, and gastric cancer, and for non-malignant respiratory diseases was observed. Cancer excess mainly affected NPCSs with presence of chemical and petrochemical plants, oil refineries, and dumping hazardous wastes. An excess of non-malignant respiratory disease was also detected in NPCSs in which steel industries and thermoelectric plants were present. An excess of mesothelioma was observed in NPCSs characterized by presence of asbestos and fluoro-edenite; it was also observed where the presence of asbestos was not reported in the legislative national decrees which define the NPCS areas. It is worth noting that, even if the presence of asbestos is not reported in many NPCSs legislative decrees, petrochemical plants and steel industries, for instance, are often characterized by the presence of a large amount of this mineral that, in the past, was extensively used as an insulating material. For the first time, the present Report includes a focus on the health status of children and adolescents (1,160,000 subjects, aged 0-19 years), and young adults (660,000 subjects, aged 20-29 years). Among infants (0-1 year), an excess of 7,000 hospitalizations was observed, 2,000 of which due to conditions of perinatal origin. In the age class 0-14, an excess of 22,000 hospitalizations for all causes was observed; 4,000 of them were due to acute respiratory diseases, and 2,000 to asthma. Data on cancer incidence for subjects aged 0-24 years were derived from general population cancer registries for twenty NPCSs, and from children cancer registries (age group: 0-19 years) for six NPCSs; 666 cases where diagnosed in the age group 0-24 years, corresponding to an excess of 9%. The main contributions to this excess are from soft tissue sarcomas in children (aged 0-14 years), acute myeloid leukaemia in children (aged 0-14 years) and in the age group 0-29 years, non-Hodgkin lymphoma and testicular cancer in young adults (aged 20-29 years). In seven out of 15 NPCSs, an excess prevalence rate of overall congenital anomalies at birth was observed. Congenital anomalies excesses included the following sites: genital organs, heart, limbs, nervous system, digestive system, and urinary system. CONCLUSIONS: The main findings of SENTIERI Project have been the detection of excesses for the diseases which showed an a priori epidemiological evidence of a causal association with the environmental exposures specific for each considered NPCS. These observations are valuable within public health, because they contribute to priority health promotion activities. Looking ahead, the health benefits of an improved environmental quality might be appreciated in terms of reduction of the occurrence of adverse health effects attributable to each Site major pollutant agents. Due to the methodological approach of the present study, it was not possible to adjust for several confounding factors reported to be risk factors for the studied diseases (e.g., smoking, alcohol consumption, obesity). Even if excesses of mortality, hospitalization, cancer incidence, and prevalence of congenital anomalies were found in several NPCSs, the study design and the multifactorial aetiology of the considered diseases do not permit, for all of them, to draw conclusions in terms of causal links with environmental contamination. Moreover, it must be taken into consideration that economic factors and the availability of health services may also play a relevant role in a diseases outcome. A few observations regarding some methodological limitations of SENTIERI Project should be made. There is not a uniform environmental characterisation of the studied NPCSs in term of quality and detection of the pollutants, because this information is present in different databases which at present are not adequately connected. Moreover, the recognition of a contaminated site as a National Priority Site is based on soil and groundwater pollution, and the available information on air quality is currently sparse and not homogenous. Another limitation, in term of statistical power, is the small population size of many NPCSs and the low frequency of several health outcomes. A special caution must be paid in data interpretation when considering the correspondence between the contaminated areas and the municipality boundaries, as they do not always coincide perfectly: in some cases, a small municipality with a large industrial site, while in other settings only a part of the municipality is exposed to the sources of pollution. Furthermore, all available health information systems are currently accessible at municipality level. The real breakthrough is essentially comprised of the development and fostering of a networking system involving all local health authorities and regional environmental protection agencies operating in the areas under study. The possibility to integrate the geographic approach of SENTIERI Project with a set of ad hoc analytic epidemiological investigations, such as residential cohort studies, case control studies, children health surveys, biomonitoring surveys, and with socioepidemiological studies, might greatly contribute to the identification of health priorities for environmental remediation activities. Finally, as discussed in the last section of the report, there is a need to adopt, in each NPCS, a two-way oriented communication plan involving public health authorities, scientific community, and resident population, taking into account that the history, the cultural frame and the network of relationships specific of each local context play a major role in the risk perception perspective.

Health inequalities: a Research Positioning Exercise at the National Institute of Health, Italy.

BACKGROUND: The Italian National Institute of Health (Istituto Superiore di Sanità, ISS) considers health inequalities (HI) an important area of activity. As the scientific and technical body of the Ministry of Health and the National Health Service, ISS may play a key role to reduce HI. In order to enable ISS in addressing the new and crucial HI challenge, a Research Positioning Exercise was designed and implemented. METHODS: The Exercise included: (i) workshop to strengthen the institutional interest in the field of HI; (ii) review and analysis of ISS publications (years 2000-2017) to identify HI research topics; (iii) survey among ISS researchers regarding main research challenges to address HI in the coming years; and (iv) analysis of input on research challenges from HI international experts. RESULTS: The results of this Exercise suggest that the following points should be included in the future ISS agenda planning: (i) themes which ISS should continue working on (e.g. migrants/vulnerable groups); (ii) themes to be improved: (a) relationship between social determinants and mechanism of HI generation and (b) relationship between risk factors exposure and social determinants; and (iii) new themes to be addressed: (a) mechanisms underlying the resilience observed in Italy; (b) new socioeconomic indicators for HI monitoring; and (c) evidence-based policies aimed at reducing HI. CONCLUSION: Findings of this Exercise show that ISS researchers identified relevant areas, addressing inequalities in addressing the health. Because of ISS structural peculiarity that includes multidisciplinary expertise, the ISS could provide a significant contribution to HI research challenges and knowledge gaps.

An asbestos contaminated town in the vicinity of an asbestos-cement facility: The case study of Sibaté, Colombia.

INTRODUCTION: The asbestos industry began operations in Colombia in 1942, with an asbestos-cement facility located in the municipality of Sibaté. In recent years residents from Sibaté have been complaining about what they consider is an unusually large number of people diagnosed with asbestos-related diseases in the town. A study to analyze the situation of Sibaté started in 2015, to verify if the number of asbestos related diseases being diagnosed were higher than expected, and to identify potential asbestos exposure sources in the town. METHODS: A health and socioeconomic survey was implemented door-to-door to identify potential asbestos-related diseases. Several self-reported mesothelioma cases were identified, and for confirmation purposes, copies of the medical record with the histopathology report were obtained. A panel of six physicians analyzed the medical records. Information of validated cases was used to estimate the male and female age-adjusted incidence rate for Sibaté. Based on reports of the existence of potential asbestos-contaminated landfills, topographic maps, a digital elevation model, and current satellite images were crossed using a geographic information system to identify potential landfilled areas, and soils samples were collected in some of these areas. RESULTS: A total of 355 surveys were completed, and 29 self-reported mesothelioma cases were identified. Twenty-five of these cases have been persons who had lived at some moment of their lives in Sibaté. It was possible to obtain copies of the medical diagnosis for 17 cases. Of these, the panel of physicians classified 15 cases as certain pleural mesothelioma, one as probable, and one as not mesothelioma. Based on this information, the estimated age-adjusted incidence rate of mesothelioma in Sibaté was 3.1 × 105 persons-year for males and 1.6 × 105 persons-year for females. These rates are high in comparison to those reported in other cities, regions, and countries of the world. Using geographic information systems, landfilled zones in the urban area of Sibaté were identified, on top of which a school and different sports facilities were built. The analysis of four soil samples collected in landfilled zones, confirmed the existence of an underground layer of friable and non-friable asbestos. CONCLUSION: The collected evidence suggests the presence of a malignant pleural mesothelioma cluster in Sibaté.