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ORIGINAL ARTICLE
Malignant mesothelioma due to non-occupational
asbestos exposure from the Italian national surveillance
system (ReNaM): epidemiology and public health issues
Alessandro Marinaccio,
1
Alessandra Binazzi,
1
Michela Bonafede,
1
Marisa Corfiati,
1
Davide Di Marzio,
1
Alberto Scarselli,
1
Marina Verardo,
2
Dario Mirabelli,
3
Valerio Gennaro,
4
Carolina Mensi,
5
Gert Schallemberg,
6
Enzo Merler,
7
Corrado Negro,
8
Antonio Romanelli,
9
Elisabetta Chellini,
10
Stefano Silvestri,
10
Mario Cocchioni,
11
Cristiana Pascucci,
11
Fabrizio Stracci,
12
Valeria Ascoli,
13
Luana Trafficante,
14
Italo Angelillo,
15
Marina Musti,
16
Domenica Cavone,
16
Gabriella Cauzillo,
17
Federico Tallarigo,
18
Rosario Tumino,
19
Massimo Melis,
20
ReNaM Working Group
For numbered affiliations see
end of article.
Correspondence to
Dr Alessandro Marinaccio,
Italian Workers’Compensation
Authority (INAIL), Department
of Occupational and
Environmental Medicine,
Epidemiology and Hygiene,
Unit of Occupational and
Environmental Epidemiology,
Italian Mesothelioma Register,
Via Stefano Gradi 55,
Rome 00143, Italy;
a.marinaccio@inail.it
Received 29 April 2014
Revised 31 October 2014
Accepted 25 November 2014
To cite: Marinaccio A,
Binazzi A, Bonafede M,
et al.Occup Environ Med
Published Online First:
[please include Day Month
Year] doi:10.1136/oemed-
2014-102297
ABSTRACT
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.
INTRODUCTION
Asbestos is a natural fibrous mineral of hydrate sili-
cates, generally classified in amphiboles (actinolite,
amosite, anthophyllite, crocidolite and tremolite) and
serpentine (chrysotile), showing different chemical
and physical properties. It has unusual characteristics
of plasticity and properties of high tensile strength,
and thermal and chemical resistance.
Recently, the International Agency for Research
on Cancer confirmed all forms of asbestos as car-
cinogenic for humans (group 1). There is sufficient
evidence that asbestos causes mesothelioma and
cancer of the lung, larynx and ovary. Positive asso-
ciations have also been observed between exposure
to all forms of asbestos cancer (malignant meso-
thelioma) and cancer of the pharynx, stomach,
What this paper adds
▸Malignant mesothelioma is a rare tumour
which can also occur after low levels of
asbestos exposure.
▸Epidemiological analytical studies have
repeatedly reported a significant risk of
mesothelioma for people exposed to asbestos
in non-occupational settings.
▸We documented that 10.2% of mesothelioma
cases are due to non-occupational exposure to
asbestos as suggested by the findings of a
large epidemiological national surveillance
system (15 845 cases and 12 065 individuals
interviewed).
▸The most significant source of risk is
cohabitation with an occupationally exposed
patient or residence near an asbestos cement
plant; asbestos exposure during leisure
activities is difficult to identify and probably
underestimated.
▸It is necessary to define policies and strategies
for increasing prevention tools and for dealing
with compensation rights for malignant
mesothelioma cases induced by
non-occupational exposure to asbestos.
Marinaccio A, et al.Occup Environ Med 2015;0:1–8. doi:10.1136/oemed-2014-102297 1
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colon and rectum.
1
Malignant mesothelioma (MM) is a tumour
arising from the serous membranes of the pleura and, less fre-
quently, of the peritoneal and pericardial cavities and from the
testis tunica vaginalis. Prognosis is poor and average survival is
9–12 months from diagnosis for pleural and even lower for
peritoneal forms.
Many western countries are currently going through an MM
epidemic, considering the extensive use of asbestos between the
1950s and the 1980s in several industrial applications and the
long latency period (around 40 years) from the beginning of
exposure. Moreover, asbestos is still extensively used in many
countries in Asia, South America, Africa and in the former
Soviet Union; at present, 125 million people have been esti-
mated to be exposed to asbestos worldwide.
2
In the countries that have banned asbestos, the majority of
asbestos-related diseases are caused by occupational exposure
that occurred in the past. Nevertheless, assessment of the spread
and of the health effects of non-occupational asbestos exposure
continues to be of great public interest because it is related to
peculiar exposure circumstances like living with asbestos
workers or close to asbestos mines or manufacturing plants, or
naturally occurring asbestos fibres, or in asbestos-insulated build-
ings.
3
In the past four decades, excesses of incidence of meso-
thelioma and cancer of the lung have been reported as a
consequence of the natural presence of asbestos (or asbestos-
like) material in rural areas in Turkey,
4
Greece,
5
Corsica in
France,
6
Biancavilla (Sicily) in Italy,
7
New Caledonia,
8
China
9
and California in the USA.
10
The increased risk of cancer for
population groups resident in the vicinity of raw asbestos pro-
duction sites (mines or mills), as well as for people living close
to industrial manufacturing plants producing material contain-
ing asbestos, has been demonstrated.
11–13
In Italy, 3 748 550 tons of raw asbestos were produced up to
the 1992 ban, with a peak between 1976 and 1980 at more than
160 000 tons/year; asbestos consumption decreased in Italy
since 1980s only (around ten years later with respect to other
industrialised countries).
14
As environmental exposure related to
residence near asbestos-cement plants has been repeatedly
reported for Casale Monferrato,
15
Bari,
16
Broni
17
and La
Spezia,
18
this usage pattern may have led to sustained non-
occupational exposures. The contribution of different patterns of
non-occupational exposures is most likely underestimated, due to
their much lower level, which, however, is not negligible and is
possibly sufficient to cause disease. A permanent surveillance
system of mesothelioma incidence in Italy has been run since
2002 by the National Register of Malignant Mesotheliomas
(ReNaM, “Registro Nazionale dei Mesoteliomi”in Italian) iden-
tifying cases and assessing asbestos exposure.
19
The purpose of the present study is to present data about
non-occupationally exposed MM case currently available in the
ReNaM archive. The figure is discussed with respect to compen-
sation and welfare system efficiency for people exposed in the
past and to asbestos exposure prevention strategies for the
present.
METHODS
The epidemiological surveillance of mesothelioma incidence is
conducted in Italy by a specific register drawn up, by law, in
2002. ReNaM has a regional structure: a Regional Operating
Centre (COR) has gradually been established in all Italian
regions except the Molise region and an autonomous province
of Bolzano, covering almost the whole country (98.5% of the
Italian population). Each COR works applying the national stan-
dardised methods described in the specific guidelines.
20
They
actively search for MM cases by obtaining information from
healthcare institutions that diagnose and treat cases (especially
pathology units and lung care and chest surgery wards).
Diagnostic coding criteria have been established by means of a
grid according to three classes of decreasing level of certainty:
certain, probable and possible MM. Occupational history, life-
style and residential history are obtained using a standardised
questionnaire, administered by a trained interviewer, to the
patient or to the next of kin after informed consent expressed
by the cases or their relatives at the beginning of the interview.
CORs may consult local public health and safety agencies to
gain supplementary information on occupational and/or residen-
tial exposure. In each COR, an industrial hygienist, or a panel
of industrial hygienists, classifies and codes the exposure by
examining the information collected. Moreover, an agreement
between the Italian Workers’Compensation Authority (INAIL)
and the Italian Social Security Institute (INPS) makes it possible
to retrieve pension contributions from personal data. Therefore,
in many cases, INAIL may provide CORs with information
about occupational histories of mesothelioma cases, either as a
confirmation of information obtained directly from the patient,
or as a major information source when the interview is not
available.
Occupational exposure classification can be assigned as defin-
ite, probable or possible. Definite occupational exposure refers
to people whose work has involved the use of asbestos or mate-
rials containing asbestos. Probable occupational exposure refers
to people who have worked in a firm where asbestos was cer-
tainly used, but whose exposure cannot be documented, and
possible occupational exposure to people who have worked in
firms in an economic sector where asbestos has been used.
Further, specific codes are assigned to familial exposure (when
patients have lived with a person occupationally exposed to
asbestos), environmental (residence near a source of asbestos
pollution without work-related exposure) and leisure activities.
Modalities of exposure are assigned with an exclusive and hier-
archical methodology: cases defined as ‘familial exposure’had
no occupational exposure, whereas cases having ‘environmental
exposure’had neither familial nor occupational exposure.
Finally, cases classified as due to ‘leisure activities exposure’had
no other relevant circumstances of exposure. The data collected
by each COR are then periodically sent to ReNaM and stored in
a centralised database. All procedures and systems of classifica-
tions and codes are more extensively described in the aforemen-
tioned guidelines.
To date, ReNaM has collected cases with a diagnosis of MM
in the period 1993–2008; the collection and analyses of data
for the period of incidence 2009–2012 are ongoing. Italian
regions did not contribute homogenously during this period:
Piedmont, Veneto, Tuscany and Apulia produced incidence
regional data starting from 1993, Basilicata from 1995, Liguria,
Emilia-Romagna and Marche from 1996, Sicily from 1998,
Lombardy, Friuli-Venezia Giulia and Valle D’Aosta from 2000,
Campania from 2001 and Umbria from 2006. The data from
Calabria and Sardinia cannot be considered complete with
regard to the incidence of the disease. Finally, Trentino
Alto-Adige only collected data for the province of Trento (half
of the resident people and territorial extension of the Region).
The province of Bolzano and Molise region have still not con-
tributed to the network. Standardised incidence rates have been
calculated with the direct method for the territorial coverage of
incidence data and with population at the national census at
2001 used as the denominator and for age standardisation. The
exposure data analyses pertain to the whole ReNaM database
2 Marinaccio A, et al.Occup Environ Med 2015;0:1–8. doi:10.1136/oemed-2014-102297
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including data from regions with incomplete incidence figures.
All statistical analyses were carried out with the SPSS software
(V.21.0).
RESULTS
In the period between 1993 and 2008, a list of 15 845 cases of
MM were identified. The pleural site was reported in 93%
(14 736 cases), while peritoneal cases accounted for 6.4% of the
total number (1017 cases); pericardial and testicular cases
accounted for 0.3% (41 and 51 cases, respectively). The male/
female ratio was 2.6 among pleural cases, and 1.4 and 1.9 among
peritoneal and pericardial ones, respectively. The mean age at
diagnosis was 68.3 years (SD±10.6) in men and 69.8 (SD
±11.6) in women. People aged less than 45 years were rare,
accounting for 2.4% of all recorded MM cases. The standardised
incidence rate for pleural mesothelioma (certain, probable and
possible) in 2008 was 3.84 cases per 100 000 inhabitants for
men and 1.45 for women; 0.26 and 0.12, respectively, for the
peritoneal site and less than 1 case per million inhabitants for
pericardial and tunica vaginalis testis forms. The modalities of
exposure to asbestos fibres were investigated for 12 065 (76.1%)
of the 15 845 cases collected. This percentage was not constant
geographically and showed great variability (higher than 90% in
Lombardy, Tuscany, Apulia, Umbria and the province of Trento;
lower than 50% in Sicily, Campania and Calabria). For 8367
cases (69.3% of the 12 065 cases for which the exposure defin-
ition is available), the modalities of asbestos exposure were classi-
fied as occupational (definite, probable, possible); for 2466 cases
(20.4%), we found no asbestos exposure.
19
The list of cases defined as non-occupationally exposed
includes 1232 individuals. We found 530 (4.4%) MM cases
with familial exposure (they have lived with a person who was
occupationally exposed), 514 MM cases (4.3%) with environ-
mental exposure to asbestos (they lived near sources of asbestos
pollution and have not been occupationally exposed) and 188
(1.6%) with exposure due to hobby-related or leisure activities.
The proportion of MM cases due to non-occupational asbestos
exposure (familial, environmental or related to leisure activities)
was 10.2% at the national level with significant territorial vari-
ability and the highest values in Piedmont (24.4%), Trento
autonomous province (15.6%), Puglia (14.4%) and Veneto
(13.5%). The female/male ratio was 2.3:1 for the whole popula-
tion with non-occupational exposure, but it reached the value of
5.9:1 focusing on MM cases with exclusively familial modalities
of exposure.
Table 1 shows the demographic, diagnostic and personal
history characteristics of the 1232 MM cases with non-
occupational exposure to asbestos. As an individual may have
had multiple exposure, 1427 causally relevant exposures were
registered for the 1232 cases included in the analysis. Table 2
describes these 1427 modalities of exposures in detail. For the
530 cases classified as having familial aetiology, we considered
only familial exposure circumstances, ignoring environmental
exposures, if any. This choice is consistent with recent simula-
tions of low-level exposed workers that show asbestos levels com-
mensurate with background concentrations in those exposed
domestically.
21
In table 3, occupationally and non-occupationally exposed MM
cases are compared with respect to selected epidemiological para-
meters. A statistically significant difference in mean age at diagno-
sis was found between occupationally and non-occupationally
exposed cases (68.1 vs 67.2 years, p<0.01) and in non-
occupationally exposed cases by gender (66 vs 68 years for men
and women, respectively, p<0.05). The values range from
69.3 years (SD±11.01) for leisure exposed to 67.5 (SD±11.8) for
familial and 66.1 (SD±13.6) for environmental, with a statistically
significant difference by gender in familial cases (p<0.0001):
68 (SD±11.5) in women versus 63 (SD±12.6) years in men.
Mean age at first exposure was lower among those with non-
occupational exposure compared to the occupational cases (18.5
vs 22.5 years, p<0.0001). Latency time, defined as the time elap-
sing between the beginning of asbestos exposure and MM diagno-
sis, shows higher median values overall for non-occupational
exposure than occupational exposure (46 years, SD±12): 51 years
(SD±14) in familial exposures (although lower in women,
49.5 years, than in men, 55 years) and 49 years (SD±16) in envir-
onmental exposures (again lower in women, 47 years, than in
men, 53 years). Conversely, in leisure activities, the median latency
times is 43.5 years, significantly different by gender (48 vs
37 years, respectively, for men and women, p<0.001).
Figure 1 shows the geographical distribution of MM cases
due to familial, environmental and leisure activities collected by
Table 1 MM cases (N, %) collected by the National
Mesothelioma Register (ReNaM) due to familial, environmental and
leisure activity exposure by gender, age, anatomical site, period of
diagnosis, level of diagnostic certainty, morphology and modalities
of interview (Italy, 1993–2008)
Men Women
N Per cent N Per cent
Exposure modalities
Familial 77 20.6 453 52.8
Environmental 217 58.0 297 34.6
Leisure activities 80 21.4 108 12.6
Pleural 348 93.0 801 93.4
Anatomical sites
Peritoneum 23 6.1 56 6.5
Pericardium 0 0.0 1 0.1
Tunica vaginalis of the testis 3 0.8 ––
Age classes
0–44 24 6.4 36 4.2
45–64 147 39.3 276 32.2
65–74 93 24.9 274 31.9
+75 110 29.4 272 31.7
1993–1996 42 11.2 62 7.2
1997–2000 86 23.0 172 20.0
Period of diagnosis
2001–2004 125 33.4 327 38.1
2005–2008 121 32.4 297 34.6
Diagnostic certainty
MM certain 318 85.0 700 81.6
MM probable or possible 56 15.0 158 18.4
Morphology
Epithelioid 226 60.4 523 61.0
Fibrous 40 10.7 50 5.8
Biphasic 46 12.3 93 10.8
MM NOS 36 9.6 107 12.5
Not available 26 7.0 85 9.9
Exposure detection
Direct interview 200 53.5 392 45.7
Indirect interview 173 46.3 464 54.1
No interview, other information source 1 0.3 2 0.2
Overall 374 100.0 858 100.0
MM, malignant mesothelioma; NOS, not otherwise specified.
Marinaccio A, et al.Occup Environ Med 2015;0:1–8. doi:10.1136/oemed-2014-102297 3
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ReNaM in the Italian territory. The map makes it possible to
identify the areas of asbestos pollution contamination due to the
presence of asbestos-cement industry plants (Casale Monferrato,
Broni and Bari), areas of shipbuilding and repair (Monfalcone,
Trieste, La Spezia, Genova, Castellamare di Stabia, Livorno and
Taranto) and areas of environmental exposure in Biancavilla
Table 2 Modalities of exposure of malignant mesothelioma (MM) cases (N, %) collected by the National Mesothelioma Register (ReNaM)
disentangled by familial, environmental or leisure activity exposure categories and gender (Italy, 1993–2008)
Men Women
Number of exposures* Per cent Number of exposures* Per cent
Familial: cohabitation with (530 MM cases)
Parents 74 74.0 138 23.9
Husband/wife 3 3.0 354 61.4
Son/daughter 5 5.0 27 4.7
Other cohabitants 18 18.0 58 10.1
Overall 100 100 577 100
Environmental: residence near (514 MM cases)
Asbestos cement plant 103 43.6 144 44.6
Railways 18 7.6 22 6.8
Rail stock building, repair and demolition plant 10 4.2 7 2.2
Docks 8 3.4 6 1.9
Shipbuilding and repair 8 3.4 7 2.2
Steel industry plants 2 0.8 12 3.7
Chemical or petrochemical plants 7 3.0 8 2.5
Mines or mills 7 3.0 9 2.8
Others 73 30.9 108 33.4
Overall 236 100 323 100
Use of asbestos materials containing asbestos†29 34.5 92 80.7
Home masonry 25 29.8 3 2.6
Thermal insulation at home 9 10.7 2 1.8
Leisure activities (188 MM cases)
Plumbing or electric repair at home 2 2.4 2 1.8
Car repair 4 4.8 –
Other activities 15 17.9 15 13.2
Overall 84 100 114 100
*The number of exposures exceeds the number of mesothelioma cases due to the possibility of multiple exposures for a single case.
†Including exposures due to the presence of asbestos in objects not used in a working context (eg, ironing boards, rural tool sheds).
Table 3 Mean age at diagnosis.
Number Years (SD) p Value
Mean age at diagnosis
Occupational exposure 8367 68.1 (±10) Ref
Non-occupational exposure 1232 67.2 (±12.3) <0.01
Familial 530 67.5 (±11.8) 0.161
Environmental 514 66.1 (±13.6) <0.001
Leisure activities 188 69.3 (±11.01) 0.108
Mean age at first exposure
Occupational exposure 8367 22.5 (±8.3) Ref
Non-occupational exposure 1232 18.5 (±15.6) <0.001
Familial 530 17 (±14.3) <0.001
Environmental 514 17 (±16.2) <0.001
Leisure activities 188 27 (±14.5) <0.001
Median latency
Occupational exposure 8367 46 (±12) Ref
Non-occupational exposure 1232 49 (±15) <0.001
Familial 530 51 (±14) <0.001
Environmental 514 49.5 (±16) <0.001
Leisure activities 188 43 (±14.1) <0.01
Mean age at first exposure and median latency period of malignant mesothelioma cases collected by the National Mesothelioma Register (ReNaM) by modalities of exposure (Italy,
1993–2008).
4 Marinaccio A, et al.Occup Environ Med 2015;0:1–8. doi:10.1136/oemed-2014-102297
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(Sicily) due to the local presence of fluoroedenite (an amphibole
asbestiform mineral), a contaminating material massively used
for construction and road paving in the area.
DISCUSSION
MM is a major public health issue considering the increasing
incidence in many countries; the still complex and difficult
Figure 1 Geographical distribution of malignant mesothelioma (MM) cases due to environmental, familial, leisure activities collected by the
National Mesothelioma Register (ReNaM) by municipalities of residence at diagnosis. Italy, 1993–2008. Labels and circle graphs are reported for
municipalities with at least six MM cases with environmental (E, in green) or familial (F, in red) or leisure activities-related (L, in blue) exposure to
asbestos. Selected municipalities are Casale Monferrato (92 MM cases due to environmental exposure in the period, 68 due to familial exposure,
4 leisure activities-related exposure), Torino (37, 25, 7), Collegno (7, 4, 0) in Piedmont; Genova (6, 32, 16), La Spezia (4, 9, 2) in Liguria; Milano
(18, 3, 18), Broni (26, 7, 0), Stradella (9, 2, 4) in Lombardy; Padova (12, 7, 2), Venezia (4, 14, 0) in Veneto; Trieste (0, 9, 0), Monfalcone (1, 7,
0) in Friuli-Venezia Giulia; Reggio Emilia (1, 9, 1), Bologna (4, 2, 1), Parma (4, 4, 1), Ravenna (2, 5, 1) in Emilia-Romagna; Livorno (1, 5, 0) in
Tuscany; Roma (4, 4, 1) in Lazio; Bari (42, 3, 1), Taranto (13, 5, 1) in Apulia; Biancavilla (7, 0, 0) in Sicily.
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diagnosis, staging and treatment; the poor prognosis, which is
not improving, and the implications for welfare and insurance
systems due to the occupational origin for many patients. The
close relationship with asbestos exposure has been demonstrated
by a large amount of data, although the recognition of patho-
genetic mechanisms is still incomplete. All forms of asbestos
cause mesothelioma, prevalently of the pleura but also of the
serous membranes of the peritoneum, lung, ovary and larynx
cancers. A positive association has been reported for cancers of
the colon and rectum, stomach and pharynx.
1
Asbestos has been
banned in many industrialised countries but is still mined and
used in a large part of the world.
22
As a legacy of the massive
use of asbestos, Italy is today one of the countries most involved
in the monitoring, surveillance and control of asbestos-related
diseases.
23
Similar experiences to the Italian mesothelioma inci-
dence surveillance system, with regard to methods and exten-
sion, are scarce and, to the best of our knowledge, currently
ongoing only in France
24
and Australia.
25
Critical limitations of the ReNaM data set have to be discussed
preliminarily. Some regions of the Italian network were collecting
incidence cases even before the beginning of the national register
in 1993, but others started later or are not yet participating. Any
evaluation of the trend of MM incidence is therefore strongly
limited. The ability/effectiveness to identify the modalities of
exposure is not fully consistent between regions and the percent-
age of patients interviewed varies between 45% and 95%
depending on the available resources and knowledge. COR’s
activities began not at the same year, as started in Methods, and
this could influence incidence and asbestos exposure findings.
Although the coding and classifying systems (for diagnosis and
exposure) such as the questionnaire for the anamnestic survey
and the operative procedure are nationally established, neverthe-
less the possible lack of homogeneity among CORs in the prac-
tice is a crucial and real issue. The identification and assessment
of the different asbestos exposure modalities actually represents a
key factor of the ReNaM register that can help in defining the
strategies to prevent the health risks/effects for the population
and to guarantee a proper welfare protection. At present in Italy,
the issue of insurance and welfare protection for mesothelioma
cases due to non-occupational exposure to asbestos is under
debate. Different modalities of non-occupational exposure to
asbestos pose different concerns with respect to the welfare pro-
tection framework.
Environmental exposure from naturally occurring asbestos
contamination of the soil has been documented in Turkey,
where mesothelioma epidemics due to the presence of tremolite,
chrysotile and erionite, belonging to the zeolite family, have
been proved.
26
In Greece, a high frequency of pleural calcifica-
tion was found in patients living in places where no industrial
use of asbestos was documented in the past, but tremolite fibres
have been found in the soil used to make whitewash that was
commonly applied to homes in the affected areas.
27
Natural
contamination of the soil with tremolite fibres has also been
detected in Cyprus
28
and Corsica,
6
as evidenced by occurrences
of asbestos-related diseases without any asbestos use for indus-
trial applications. Similarly, cases of pleural mesothelioma in
New Caledonia have been signalled due to the use of a white-
wash material primarily containing tremolite fibres,
29
and in
Chinese rural areas they appear to be related to the presence of
crocidolite outcrops.
9
Cases of mesothelioma have been found
in the town of Libby (Montana, USA), close to which there
operated the world’s largest vermiculite mine, vermiculite being
extensively used in the surrounding residential zone,
11
and in
the township of Wittenoom (Western Australia), where a
crocidolite mine was active from 1943 to 1966 with extensive
use of the tailings to pave roads, footpaths and school play-
grounds.
30
In Italy, three MM cases due to tremolite pollution
in a rural area of Basilicata have been signalled,
31
while in the
area of Biancavilla Etnea (Sicily) an excess of mortality due to
pleural tumours has been observed and subsequent analyses
have confirmed the causal role of a mine in the neighbourhood
extracting a fluoroedenite-contaminated material massively used
for construction and road paving.
7
The risk of mesothelioma
associated with local industrial sources was clearly demonstrated
for the neighbouring populations.
32 33
The spatial variation in
the mesothelioma risk in an area highly polluted by the
asbestos-cement plant in Casale Monferrato has been discussed,
adjusting for occupational and domestic exposures, highlighting
the fact that the effect on the general population of pollution
from industrial sources decreases with increasing distance from
the factory.
34
Mesothelioma cases due to cohabitation with
exposed people have been attributed to soiled work clothes
brought home. An Italian cohort study of wives of Casale
Monferrato asbestos-cement factory workers showed a large
excess of pleural mesothelioma (standardised mortality ratio,
SMR=18.00, 21 observed vs 1.2 expected).
35
Evidence is also
accumulating about passive asbestos exposure in asbestos-
containing buildings, such as public offices or schools, where
the people involved have no awareness of direct physical contact
with asbestos-containing material.
36
Estimates of the proportion of individuals non-occupationally
exposed to asbestos, as well as of the relative contribution of non-
occupational and occupational exposures to incidence, are rarely
available,
37
although analyses of the incident trend for MM cases
for different categories of exposure are reported.
38
Our study pro-
vides a reliable estimation of 10% (1232 cases) for MM cases due
to non-occupational asbestos exposure based on more than
15 845 detected cases, of which 12 065 were individually inter-
viewed. This estimate is strongly related to specific Italian patterns
of exposure. The distribution of modalities of exposure shows that
familial exposure is the most frequent in non-occupationally
exposed cases, although it has to be considered that asbestos
exposure during leisure activities is difficult to identify and prob-
ably underestimated. Residence near asbestos cement plants is
largely predominant in the environmentally exposed patients.
However, the analytical description of living conditions (historical
residence) and habits (leisure time and hobby activities) involved
in the risk of asbestos exposure remains of great value for primary
prevention and public health policies.
The design of our study (an incidence surveillance system),
the possible presence of competitive causes of death and the
limited period of observation prevent statistical inferences on
the association between exposure and time to event (age or
latency).
39 40
Non-occupational exposure exhibits some dis-
tinctive features that deserve special attention. One is that the
individuals involved were especially likely to be unaware of
their exposure or of the associated hazard, as in the case of
people living around industrial sources of asbestos pollution
and/or with asbestos workers. Another one is the considerably
younger age at the start of exposure, which provides the
opportunity for accruing a longer duration of exposure and
latency.
Accordingtoourfindings, asbestos pollution outside the
workplaces significantly contributes to the burden of asbestos-
related diseases. The evaluation of a framework for dealing
with compensation rights for MM cases induced by non-
occupational exposure to asbestos needs to be carefully under-
taken from the economic, ethical and insurance points of view.
6 Marinaccio A, et al.Occup Environ Med 2015;0:1–8. doi:10.1136/oemed-2014-102297
Environment
group.bmj.com on June 9, 2015 - Published by http://oem.bmj.com/Downloaded from
Finally, the identification of an environmental source of con-
tamination, by means of a specialised surveillance system for
MM incidence inclusive of individual exposure assessment,
remains an important tool for primary prevention of risks.
Author affiliations
1
Italian Workers’Compensation Authority (INAIL), Department of Occupational and
Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and
Environmental Epidemiology, Italian Mesothelioma Register, Rome, Italy
2
Valle d’Aosta Health Local Unit, Regional Operating Centre of Valle d’Aosta (COR
Valle d’Aosta), Aosta, Italy
3
COR Piedmont, Unit of Cancer Prevention, University of Turin and CPO-Piemonte,
Torino, Italy
4
COR Liguria, UO Epidemiology, IRCCS Azienda Ospedaliera Universitaria San
Martino, National Cancer Research Institute (IST), Genova, Italy
5
COR Lombardy, Department of Preventive Medicine, Fondazione IRCCS Ca’Granda,
Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
6
COR Province of Trento, Provincial Unit of Health, Hygiene and Occupational
Medicine, Trento, Italy
7
COR Veneto, Occupational Health Unit, Department of Prevention, Padua, Italy
8
Clinical Unit of Occupational Medicine, COR Friuli-Venezia Giulia, University of
Trieste—Trieste General Hospitals, Trieste, Italy
9
COR Emilia-Romagna, Health Local Unit, Public Health Department, Reggio Emilia,
Italy
10
Unit of Environmental and Occupational Epidemiology, COR Tuscany, Cancer
Prevention and Research Institute, Florence, Italy
11
Environmental and Health Sciences Department, COR Marche, University of
Camerino, Hygiene, Camerino, Italy
12
Department of Hygiene and Public Health, COR Umbria, University of Perugia,
Perugia, Italy
13
Department of Experimental Medicine, COR Lazio, University La Sapienza, Rome,
Italy
14
COR Abruzzo, Health Local Unit, Occupational Medicine Unit, Pescara, Italy
15
Department of Experimental Medicine, COR Campania, Second University of
Naples, Naples, Italy
16
Department of Internal Medicine and Public Medicine, Section of Occupational
Medicine ‘‘B.Ramazzini’’, COR Puglia, University of Bari, Bari, Italy
17
COR Basilicata, Epidemiologic Regional Centre, Potenza, Italy
18
COR Calabria, Public Health Unit, Crotone, Italy
19
Ragusa Cancer Register Unit, COR Sicily, ‘Civile—M.P. Arezzo’Hospital, Ragusa,
Italy
20
COR Sardegna, Regional Epidemiological Centre, Cagliari, Italy
Acknowledgements The Italian National Mesothelioma Register (ReNaM) is a
collaborative network of institutions. The authors thank all COR persons involved in
identification and exposure assessment and Massimo Nesti for his precious work in
promoting and improving ReNaM.
Collaborators ReNaM Working Group members are: Detragiache E (COR Valle
d’Aosta); Merletti F, Gangemi M, Stura A, Brentisci C, Cammarieri Diglio G,
Macerata V, Gilardetti M (COR Piemonte); Benfatto L, Bianchelli M, Mazzucco G
(COR Liguria); Consonni D, Pesatori AC, Riboldi L (COR Lombardia); Bressan V,
Gioffrè F, Ballarin MN (COR Veneto); Chermaz C, De Michieli P (COR Friuli-Venezia
Giulia); Mangone L, Storchi C, Sala O (COR Emilia-Romagna); Badiali AM, Cacciarini
V, Giovannetti L, Martini A (COR Toscana); Pascucci C, Calisti R (COR Marche);
La Rosa F, D’Alo’D, Petrucci MS (COR Umbria); Davoli M, Forastiere F, Cavariani F,
Romeo E, Ancona L (COR Lazio); Di Giammarco A (COR Abruzzo); Menegozzo S,
Canfora ML, Santoro M, Viscardi F, Brangi A, Cozza V (COR Campania); Baldassarre
A (COR Puglia); Lio SG (COR Calabria);, Nicita C, Dardanoni G, Scondotto S
(COR Sicilia); Nieddu V, Pergola M, Stecchi S (COR Sardegna).
Contributors AM designed the study, performed statistical analyses, interpreted
the data and drafted the manuscript. AB, MB, MCor, DDM and AS participated in
interpreting the data and in revising the manuscript. MV, DM, VG, CM, GS, EM,
CN, AR, EC, SS, MCoc, FS, VA, LT, IA, MMu, DC, GC, FT, RT, MMe and CP
collected data, defined asbestos exposure and participated in revising the
manuscript.
Funding This research was supported and funded by the Italian Ministry of Health,
Diseases Control Center (CCM), project n. 24/12 and by Italian Workers’
Compensation Authority (INAIL), triennial research plan 2013–2015 ratified by the
INAIL scientific committee, programme P1, research line L1. The units of
epidemiology or occupational health hosting the Regional Operating Centres belong
to the National Health Service and are financed by their health authorities.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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issues
(ReNaM): epidemiology and public health
the Italian national surveillance system
non-occupational asbestos exposure from
Malignant mesothelioma due to
Massimo Melis
Cavone, Gabriella Cauzillo, Federico Tallarigo, Rosario Tumino and
Ascoli, Luana Trafficante, Italo Angelillo, Marina Musti, Domenica
Silvestri, Mario Cocchioni, Cristiana Pascucci, Fabrizio Stracci, Valeria
Merler, Corrado Negro, Antonio Romanelli, Elisabetta Chellini, Stefano
Mirabelli, Valerio Gennaro, Carolina Mensi, Gert Schallemberg, Enzo
Corfiati, Davide Di Marzio, Alberto Scarselli, Marina Verardo, Dario
Alessandro Marinaccio, Alessandra Binazzi, Michela Bonafede, Marisa
published online June 4, 2015Occup Environ Med
http://oem.bmj.com/content/early/2015/06/04/oemed-2014-102297
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