Roberto Pasetto

The health profile of populations living in contaminated sites: SENTIERI approach.

SENTIERI project (Epidemiological Study of Residents in Italian Contaminated Sites) studied mortality in the sites of national interest for environmental remediation (National Priority Contaminated Sites—NPCSs). SENTIERI described mortality of residents in NPCSSs, and it specifically focused on causes of death for which environmental exposure is suspected or ascertained to play an etiologic role. The epidemiological evidence of the causal association was classified a priori into one of these three categories: Sufficient (S), Limited (L), and Inadequate (I). Mortality in the period 1995−2002 was studied for 63 single or grouped causes at the municipal level by computing: crude rate, standardized rate, standardized mortality ratios (SMR), and SMR adjusted for an ad hoc deprivation index. Regional populations were used as references for SMR calculations and 90% CI accompanied SMR values. The deprivation index was constructed using 2001 national census variables for the following socioeconomic domains: education, unemployment, dwelling ownership, and overcrowding. SENTIERI results will allow the priorities setting in remediation intervention so as to prevent adverse health effects from environmental exposure. This papers objective is to present the rationale, methods, advantages, and limitations underlying SENTIERI project and to describe data and resources required to apply a similar approach in other countries.

Occupational Burden of Asbestos-related Cancer in Argentina, Brazil, Colombia, and Mexico

BACKGROUND An estimate at the national level of the occupational cancer burden brought about by the industrial use of asbestos requires detailed routine information on such uses as well as on vital statistics of good quality. A causal association with asbestos exposure has been established for mesothelioma and cancers of the lung, larynx, and ovary. OBJECTIVES The aim of this study was to provide estimates of the occupational burden of asbestos-related cancer for the Latin American countries that are or have been the highest asbestos consumers in the region: Argentina, Brazil, Colombia, and Mexico. METHODS The burden of multifactorial cancers has been estimated through the approach suggested for the World Health Organization using the population attributable fraction. The following data were used: Proportion of workforce employed in each economic sector. Proportion of workers exposed to asbestos in each sector. Occupational turnover. Levels of exposure. Proportion of the population in the workforce. Relative risk for each considered disease for 1 or more levels of exposure. Data on the proportion of workers exposed to asbestos in each sector are not available for Latin American countries; therefore, data from the European CAREX database (carcinogen exposure database) were used. FINDINGS Using mortality data of the World Health Organization Health Statistics database for the year 2009 and applying the estimated values for population attributable fractions, the number of estimated deaths in 5 years for mesothelioma and for lung, larynx, and ovary cancers attributable to occupational asbestos exposures, were respectively 735, 233, 29, and 14 for Argentina; 340, 611, 68, and 43 for Brazil; 255, 97, 14, and 9 for Colombia, and 1075, 219, 18, and 22 for Mexico. CONCLUSIONS The limitations in compiling the estimates highlight the need for improvement in the quality of asbestos-related environmental and health data. Nevertheless, the figures are already usable to promote a ban on asbestos use.

Asbestos-related Diseases in Italy: Epidemiologic Evidences and Public Health Issues

Abstract Epidemiologic information about asbestos-related diseases in Italy, derived from mortality data, epidemiologic surveillance, and analytical studies, is presented. These systems evidence exposures to asbestos and relative risks for populations exposed in work environments and also in the general environment, and provide objective data to identify sources of exposure and for risk management. Limitations and perspectives of Italian studies are considered, and public health issues evaluated: the risk for migrants, social security aspects, and asbestos-related disease in the courts. Although asbestos use was banned in 1992, information and risk communication efforts should be implemented to empower affected individuals and communities and to pursue equitable allocation of resources for pnmary prevention and health surveillance.

Measures of material and social circumstances to adjust for deprivation in small-area studies of environment and health: review and perspectives

The present review describes and critically analyzes the main characteristics of deprivation indices (DIs), meant as measures of material and social circumstances at a population level, used to adjust for deprivation in small-area studies of environment and health. A systematic search strategy in the period 1990-2009 was run on PubMed/Medline and Embase databases, and 41 articles were selected. In most of the reviewed studies DIs appear to be pragmatically applied and information is not adequate to evaluate whether the use of DIs is efficient. Suggestions for the use of DIs are given foreseeing that more data on exposure, outcomes and other predictive factors will be acquired, and information will be growingly available to disentangle the complex interplay between exposure, health and deprivation.

Cancer incidence in Italian contaminated sites

INTRODUCTION The incidence of cancer among residents in sites contaminated by pollutants with a possible health impact is not adequately studied. In Italy, SENTIERI Project (Epidemiological study of residents in National Priority Contaminated Sites, NPCSs) was implemented to study major health outcomes for residents in 44 NPCSs. METHODS The Italian Association of Cancer Registries (AIRTUM) records cancer incidence in 23 NPCSs. For each NPCSs, the incidence of all malignant cancers combined and 35 cancer sites (coded according to ICD-10), was analysed (1996-2005). The observed cases were compared to the expected based on age (5-year period,18 classes), gender, calendar period (1996-2000; 2001-2005), geographical area (North-Centre and Centre-South) and cancer sites specific rates. Standardized Incidence Ratios (SIR) with 90% Confidence Intervals were computed. RESULTS In both genders an excess was observed for overall cancer incidence (9% in men and 7% in women) as well as for specific cancer sites (colon and rectum, liver, gallblad-der, pancreas, lung, skin melanoma, bladder and Non Hodgkin lymphoma). Deficits were observed for gastric cancer in both genders, chronic lymphoid leukemia (men), malignant thyroid neoplasms, corpus uteri and connective and soft-tissue tumours and sarcomas (women). DISCUSSION This report is, to our knowledge, the first one on cancer risk of residents in NPCSs. The study, although not aiming to estimate the cancer burden attributable to the environment as compared to occupation or life-style, supports the credibility of an etiologic role of environmental exposures in contaminated sites. Ongoing analyses focus on the interpretation of risk factors for excesses of specific cancer types overall and in specific NPCSs in relation to the presence of carcinogenic pollutants.

Malignant mesothelioma in Rome and Latium Region, 1993-2001

Aims and background Epidemiological studies on malignant mesothelioma have provided evidence on the etiologic role of occupational asbestos exposure and, to some extent, domestic and residential exposures. Less attention has been given to the occurrence of mesothelioma in urban areas where large quantities of asbestos have been employed in the past. The purpose of the study was to investigate the occurrence of mesothelioma in patients living in the urban area of Rome and in other parts of the Latium Region and the patterns of asbestos exposure. Methods and study design A pathology-based, malignant mesothelioma archive operating in Rome, Italy, was the source of cases. Included in the survey were cases resident in Latium and diagnosed in the period January 1, 1993, through December 31, 2001. Information on asbestos exposure was derived from interviews to the patient or his/her next of kin and from available medical records. Results The case series included: 114 males and 53 females; total, 167. Information on asbestos exposure was available for 138 cases (83%). Occupational exposure was ascertained or suspected for 33% of cases resident in Rome and 63% of those resident in other municipalities of Latium. Sex ratio was 1.6 in Rome and 3.3 in Latium. Conclusions The high prevalence of women among mesothelioma cases and lower proportion of occupational exposure in Rome versus the other municipalities of Latium suggest a possible role of environmental asbestos exposure in the urban area.

International scientific cooperation on asbestos-related disease prevention in Latin America.

The International Labour Organization-World Health Organization Outline for the Development of National Programmes for Elimination of asbestos-related diseases recommends the “Enhancement of international cooperation to stimulate the transfer of know-how on alternatives to asbestos and the best practices for prevention of asbestos-related diseases” as a strategic action to be developed at national level. In this framework, the Italian National Asbestos project (www.iss.it/amianto), financed by the Ministry of Health within the Italian Asbestos National Plan, aims to develop collaborations on diverse asbestos-related research, training and dissemination activities in countries where asbestos use is still permitted or has been recently banned, with a particular attention to Latin American countries. This viewpoint focuses on asbestos consumption and epidemiologic studies in Argentina, Brazil, Colombia, and Mexico. In the second half of the 20th century, Latin America was one of the regions in the world in which the global asbestos industry displaced local industrial mining, production, and trade of asbestos. These activities also are currently maintained by the domestic industry and a widespread use of asbestos is still present in many Latin American countries. Consumption in Latin America was initially supported by the import of both asbestos fibers and asbestoscontaining products, mostly from Canada and the United States and by asbestos cement production mostly concentrated by the multinational Eternit group. Between 1960 and 1980, major consumption was concentrated in Brazil, Mexico, Colombia, and Argentina. Consumption in Latin America peaked in 1980 with 356,033 tons used, half of which was consumed by Brazil (Table 1). The latter maintained the position as the dominant asbestos

Lung Cancer Mortality in a Cohort of Workers in a Petrochemical Plant: Occupational or Residential Risk?

Abstract The purpose of the present study is to examine the role of environmental (non occupational) exposures in lung cancer risk among petrochemical workers at a large petrochemical plant built on the Sicilian coast in the immediate vicinity of the town of Gela, Italy in 1960. The cohort included workers employed in the Gela petrochemical plant in 1960–1993. We looked at mortality rates for the period 1960–2002. An internal comparison was performed between two categories of workers with different likelihood of residence in Gela during the period of employment. The rate ratio of mortality from lung cancer comparing “probable residents” with “possible non residents,” adjusted for age, calendar period, and job classification (only blue collar, only white collar and both), was 1.66 (90% Confidence Interval 1.07–2.58). Although the informationr.:collected is quite sparse and no inferences can be made about risk sources, the results show a possible excess of residential/ environmental risk from lung cancer mortality for those workers more likely to have been residents in Gela.

Mortality and morbidity study of petrochemical employees in a polluted site

BackgroundThe area of Gela was included among the 57 Italian polluted sites of national interest for environmental remediation because of its widespread contamination from a petrochemical complex. The present study investigates mortality and morbidity of the cohort of Gela petrochemical workers with the aim of disentangling occupational from residential risk.MethodsMortality was assessed for 5,627 men hired from 1960, year of the plant start-up, to 1993; it was followed up for vital status in the period 1960–2002. Morbidity was analysed for 5,431 workers neither dead nor lost to follow-up from 1960 to 2001 and was based on Hospital Discharge Records in the period 2001–2006. The work experience was classified in terms of job categories such as blue collars, white collars, and both – workers who shifted from blue to white collar (95%) or vice versa. An ad hoc mobility model was applied to define qualitative categories of residence in Gela, as residents and commuters. Standardized Mortality Ratios (SMRs) and Mortality Rate Ratios (MRRs) were computed, the latter by using a Poisson regression model. Morbidity was analyzed in terms of Hospital Discharge Odds Ratios (HDORs) through a logistic regression model. While performing the internal comparisons, white collars was the reference category for the job analysis, and commuters was the reference category for the residential analysis.ResultsIn the light of epidemiological evidence about health risk from petrochemical industries in both occupational and environmental settings, and/or on the basis of information about occupational and residential contamination and health risk in the area of Gela, noteworthy results are shown for lung cancer [MRR: 2.11 (CI 90%; 0.96-4.63) in blue collars; 1.71 (1.09-2.69) in residents], respiratory diseases [HDOR: 2.0 (1.0-3.0) in blue collars; 1.4 (0.96-2.06) in residents] and genitourinary diseases [HDOR: 1.34 (1.06-1.68) in blue collars; 1.23 (1.04-1.45) in residents].ConclusionsThe results support a role of the exposures in the occupational and residential settings, the latter due to the local ascertained contamination, in affecting the workers’ health. These results underline the urgent need of water, soil, air and food-chain monitoring programs, to discover active sources of exposure and consequently define public health interventions.

Urban Mesothelioma: Is There an Emerging Risk of Asbestos in Place?

Dear Sir, The causal relationship between malignant mesothelioma and asbestos has been known for a long time, whereas proof for other causal associations (e.g., SV40) is absent, limited or incomplete.1 There is strong evidence of increased risk following occupational exposure and, to some extent, environmental exposure, usually from industrial point sources or household contact2 and asbestos-contaminated soil.3 The dimension of excess risk at levels of exposure encountered in urban areas is almost unknown. The existence of an “urban factor” associated with mesothelioma has been debated in this journal.4–6 While occupational exposures to asbestos in most industrialized countries have been discontinued or severely reduced, public health attention has turned to the risks in other settings characterized by average low-level exposures that may also include high concentrations for relatively short time periods.7 Concern has focused on past construction practices that extensively used asbestos, much of which still remains in buildings and can deteriorate. Potential health hazards exist not only among persons engaged in repair, renovation and demolition activities but also among dwellers. The occurrence of mesothelioma cases associated with exposures to asbestos “in place” (the so called third wave of the impact of asbestos-induced disease) had already been predicted in the early 1990s.8 To assess the risk of exposure to asbestos in place, the urban context of cities with neither shipyard facilities nor industries that manufacture asbestos products or use this material could represent an ideal point of observation. We have undertaken a survey on the occurrence of malignant mesothelioma in Rome (a nonindustrial urban context) and surrounding municipalities of the Latium region.9 For 167 cyto-/histologically confirmed cases in the period 1993– 2001, the following information was available: residence at diagnosis, asbestos exposure history [ascertained by a standard questionnaire or medical records and classified as occupational (certain, probable or possible), domestic, environmental, hobby-related, unknown (available information does not reveal exposure) and unclassifiable (unavailable information)].10 Some of the findings in relation to cases with either occupational or unknown exposure address the criticism raised by Jockel6 with regard to the report by Hemminki and Li.4 The contrast between cases resident inside vs. outside Rome showed (i) a lower percentage of occupational exposures [33.0% (27 males, 4 females) vs. 63.0% (43 males, 3 females)]; (ii) a higher proportion of unknown exposures [43.6% (21 males, 20 females) vs. 15.1% (8 males, 3 females)]; (iii) a lower male-to-female ratio for pleural mesothelioma [1.4, 95% confidence interval (CI) 1.07–1.91 vs. 3.8, 95% CI 2.79 – 4.98], also confirmed by mortality data (1.4, 95% CI 1.19 –1.72 vs. 2.1, 95% CI 1.70 –2.62). A low prevalence of occupational exposure (one-third confined to construction works) in Rome compared to outside Rome is consistent with the absence in the city of large industries that manufacture/use asbestos products. As well, a high prevalence of occupational exposure outside the city is consistent with the presence in the surrounding region of a merchant navy harbor,11 asbestos cement industry and small/mid-sized or large industrial areas where asbestos is used extensively.12 By contrast, a higher proportion of unknown exposures in Rome compared to outside Rome is not plausible; this category does not comprise “any exposure”, as for plumbers or welders (occupations that are considered “possibly” asbestos-related), and includes almost an equal number of males and females involved in non-asbestos-related jobs, e.g., white-collar workers, salespersons, teachers and housewives. Among cases resident in Rome, we observed an apparent excess of women with no appreciable occupational asbestos exposure. From these observations, we infer that there might be an urban hazard concerning asbestos linked to exposures in place. Asbestos was used extensively in buildings in Rome between the 1960s and early 1970s; sprayed amosite and crysotile were employed, especially in public administration buildings and offices.13 A further argument in favor of our hypothesis is that standardized mortality rates from malignant pleural neoplasm (a proxy of mesothelioma incidence)14 are higher in Rome compared to pooled Latium municipalities (men, 0.95 and 0.79 per 100,000; women, 0.59 and 0.39 per 100,000, respectively; years 1980 –1997). A specific risk of mesothelioma for women in settings characterized by environmental fiber exposure has been suggested.15 In conclusion, the following considerations appear to be warranted. Questionnaires that document asbestos exposure should be revised to cope with evolving patterns of exposure. The tool of estimating exposure by history alone is inadequately sensitive to allow assessment of the proportion of cases