The Epidemiological Surveillance of Mesothelioma Mortality in Italy as a Tool for the Prevention of Asbestos Exposure

Our plain-English summary of The Epidemiological Surveillance of Mesothelioma Mortality in Italy as a Tool for the Prevention of Asbestos Exposure, by L. Fazzo, G. Minelli, M. De Santis, et al (International Journal of Environmental Research and Public Health, 2023).

The study

• Authors: L. Fazzo, G. Minelli, M. De Santis, E. Ceccarelli, I. Iavarone, A. Zona
• Journal: International Journal of Environmental Research and Public Health
• Published: 2023;20(11)
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

As part of a surveillance plan active since the early 1990s, this study evaluates malignant mesothelioma (MM) mortality for the time-window 2010-2019 in Italy, a country that banned asbestos in 1992. National and regional mortality rates for MM, and municipal standardized mortality ratios (all mesotheliomas, pleural (MPM) and peritoneal (MPeM)), by gender and age group were calculated. A municipal clustering analysis was also performed. There were 15,446 deaths from MM (11,161 males, 3.8 × 100,000; 4285 females, 1.1 × 100,000), of which 12,496 were MPM and 661 were MPeM. In the study period, 266 people ≤50 years died from MM. A slightly decreasing rate among males since 2014 was observed. The areas at major risk hosted asbestos-cement plants, asbestos mines (chrysotile in Balangero), shipyards, petrochemical and chemical plants, and refineries. Female mortality excesses particularly were found in municipalities with a fluoro-edenite-contaminated mine (Biancavilla) and textile facilities. Excesses were also found in a region with the presence of natural asbestos fibres and in males living in two small islands. The Italian National Prevention Plan stated recommendations to eliminate asbestos exposures and to implement health surveillance and healthcare for people exposed to asbestos.

In plain English

This study belongs to Italy's mesothelioma mortality surveillance, active since the early 1990s. It used the national death register to compare malignant mesothelioma deaths in 2010–2019 across regions and Italy's 7903 municipalities. It did not measure anyone's individual asbestos exposure. There were 15,446 deaths: 11,161 males (age-standardized rate 3.82 per 100,000, 90% confidence interval 3.76–3.88) and 4285 females (1.10 per 100,000, 1.07–1.13). Of these, 12,496 were pleural and 661 peritoneal mesothelioma. Male mortality fell slightly from 2014. Rates were higher in the north. For all mesothelioma, statistically significant excesses based on at least five deaths appeared in 170 municipalities for males and 56 for females. Male clusters lay near known asbestos sources such as shipbuilding harbours, refineries, petrochemical and steel plants, and former asbestos-cement plants. Three areas had clusters among females only. Two had non-asbestos textile facilities; the third, Biancavilla, had documented natural fluoro-edenite fibres. Of 266 deaths at age 50 or younger, Casale Monferrato showed a significant local excess. The authors concluded that asbestos remains a health problem in Italy after its 1992 ban.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: National mortality surveillance study using death-register data. It calculated age-standardized rates (direct method, European population 2013 as reference) and municipal standardized mortality ratios (SMRs), both with 90% confidence intervals. It also ran a spatial cluster analysis (p less than 0.10).
• Who was studied: All deaths from malignant mesothelioma in Italy, 2010–2019, recorded in the National Register of Causes of Death. They were analysed nationally, for the 21 regions and autonomous provinces, and for each of the 7903 municipalities.
• Exposure: No individual exposure was measured. The authors linked high-mortality areas to known or suspected asbestos sources: shipbuilding harbours, petrochemical plants and refineries, steel plants, chemical facilities and former asbestos-cement plants. For females they named non-asbestos textile facilities and naturally occurring fluoro-edenite fibres (Biancavilla).
• Main results:
  • 15,446 people died from malignant mesothelioma in 2010–2019: 11,161 males and 4285 females
  • Males, all mesothelioma: age-standardized rate 3.82 per 100,000 inhabitants (90% confidence interval 3.76–3.88)
  • Females, all mesothelioma: age-standardized rate 1.10 per 100,000 inhabitants (90% confidence interval 1.07–1.13)
  • Most deaths were from pleural mesothelioma (81% in males, 79% in females). In total there were 12,496 pleural and 661 peritoneal mesothelioma deaths.
  • The male-to-female rate ratio was 3.5 for all mesothelioma and 2.0 for peritoneal mesothelioma
  • Male mortality decreased slightly from 2014; female mortality peaked in 2018
  • Regional rates showed a north–south gradient in both sexes
  • For all mesothelioma, statistically significant excess SMRs based on at least five cases were found in 170 municipalities for males and 56 for females
  • Significant peritoneal mesothelioma clusters were found in three areas for males (Casale Monferrato, Monfalcone, Torre Annunziata) and two for females (Grugliasco, with textile facilities, and Biancavilla, with a fluoro-edenite mine)
  • Three areas had significant clusters of all and pleural mesothelioma in females only
  • Two of these female-only cluster areas, Sarnico and Grugliasco, host non-asbestos textile facilities. The third, Biancavilla, has documented naturally occurring fluoro-edenitic fibres.
  • 266 people aged 50 or younger died from mesothelioma: 176 males (0.12 per 100,000) and 90 females (0.05 per 100,000)
  • 212 of the 7903 Italian municipalities had at least one mesothelioma death at age 50 or younger
  • Among people aged 50 or younger, significant regional excesses were found in Piedmont (SMR 200, 90% CI 127–313; 35 deaths) and Lombardy (SMR 153, 90% CI 108–215; 65 deaths)
  • Among people aged 50 or younger (males and females combined), Casale Monferrato had a statistically significant excess (SMR 2878.8, 90% CI 1622.1–5109.0). Naples (SMR 170.8, 90% CI 83.2–351) and Milan (SMR 114.5, 90% CI 68.4–191.5) had non-significant excesses.
• The authors' conclusion: The authors concluded that asbestos is still a health problem in Italy after the 1992 ban, with only a slight recent decrease. In their view, the excess risks in people under 50 and in females point to non-occupational exposures.
• Limitations the authors state:
  • 12–13% of mesothelioma deaths were recorded at unspecified sites, so pleural mesothelioma may be underestimated
  • Few deaths at age 50 or younger made the trend in that age group hard to interpret
  • Mortality data have limitations compared with incidence (new-case) data
  • The cluster analysis is less specific than the SMR analysis

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Asbestos Exposure, standardized mortality ratio (SMR), Asbestos-Cement, Chrysotile, fluoro-edenite, Biancavilla.

Related studies

• Epidemiological surveillance of mesothelioma mortality in Italy — L. Fazzo, G. Minelli, et al. (2018)
• Burden of Mortality from Asbestos-Related Diseases in Italy — L. Fazzo, A. Binazzi, et al. (2021)
• Translation, Cultural Adaptation, and Content Validation of a Pleural Mesothelioma Questionnaire to Portuguese Context - A Key Tool for Epidemiological Surveillance — C. Santos, E. Sacadura-Leite, et al. (2024)
• Pleural mesothelioma mortality and asbestos exposure mapping in Italy — L. Fazzo, M. De Santis, et al. (2012)
• Peritoneal mesothelioma mortality in Italy: Spatial analysis and search for asbestos exposure sources — A. Zona, L. Fazzo, et al. (2019)
• Mortality rates from asbestos-related diseases in Italy during the first year of the COVID-19 pandemic — L. Fazzo, E. Grande, et al. (2023)

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