Abstract
BACKGROUND: As a legacy of the large asbestos consumption until the definitive ban in 1992, Italy had to tackle a real epidemic of asbestos related diseases. The Italian National Registry of Malignant Mesotheliomas (ReNaM) is a permanent surveillance system of mesothelioma incidence, with a regional structure. Aims, assignments and territorial network of ReNaM are described, as well as data collection, recording and coding procedures. OBJECTIVES: To describe the Italian epidemiological surveillance system of mesothelioma incidence, to provide updated data about occurrence of malignant mesothelioma in Italy, and to discuss goals, attainments, and expectations of registering occupational cancer. DESIGN: Analysis of data by malignant mesothelioma incident cases surveillance system. SETTING AND PARTICIPANTS: Italy, network of regional sur-veillance system, all Italian regions. MAIN OUTCOME MEASURES: A Regional Operating Centre (COR) is currently established in all the Italian regions, actively searching incident malignant mesothelioma cases from health care institutions. Occupational history, lifestyle habits, and residential history are obtained using a standardized questionnaire, administered to the subject or to the next of kin by a trained interviewer. The extent of dataset, epide-miological parameters, and occupations involved are reported updated at 31.12.2016, and standardized incidence rates are calculated. RESULTS: At December 2016, ReNaM has collected 27,356 malignant mesothelioma cases, referring to the period of incidence between 1993 and 2015. The modalities of exposure to asbestos have been investigated for 21,387 (78%) and an occupational exposure has been defined for around 70% of defined cases (14,818). CONCLUSIONS: The Italian experience shows that epidemiological systematic surveillance of asbestos related diseases incidence has a key importance for assessing and monitoring the public health impact of occupational and/or environmental hazards, programming preventive interventions, including remediation plans and information campaigns, and supporting the efficiency of insurance and welfare system. Monitor-ing the incidence of malignant mesothelioma through a specialized cancer registry is essential to follow-up the health effects of changing modalities and extent of occupational exposures over years and of environmental contamination. Such consolidated surveillance system is recommended also for occupational cancers with low aetiological fraction.
| Translated title of the contribution | The epidemiological surveillance of malignant mesothelioma in Italy (1993-2015): Methods, findings, and research perspectives |
|---|---|
| Original language | Italian |
| Pages (from-to) | 23-30 |
| Number of pages | 8 |
| Journal | Epidemiologia e prevenzione |
| Volume | 44 |
| Issue number | 1 |
| DOIs | |
| Publication status | Published - 2020 |
ASJC Scopus subject areas
- Epidemiology
- Public Health, Environmental and Occupational Health
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La sorveglianza epidemiologica dei casi di mesotelioma maligno in Italia (1993-2015) : Metodi, risultati e prospettive di ricerca. / Marinaccio, Alessandro; Corfiati, Marisa; Binazzi, Alessandra; Di Marzio, Davide; Bonafede, Michela; Verardo, Marina; Migliore, Enrica; Gennaro, Valerio; Mensi, Carolina; Schallemberg, Gert; Mazzoleni, Guido; Fedeli, Ugo; Negro, Corrado; Romanelli, Antonio; Chellini, Elisabetta; Grappasonni, Iolanda; Pascucci, Cristiana; Madeo, Gabriella; Romeo, Elisa; Trafficante, Luana; Carrozza, Francesco; Angelillo, Italo Francesco; Cavone, Domenica; Cauzillo, Gabriella; Tallarigo, Federico; Tumino, Rosario; Melis, Massimo.
In: Epidemiologia e prevenzione, Vol. 44, No. 1, 2020, p. 23-30.Research output: Contribution to journal › Article › peer-review
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TY - JOUR
T1 - La sorveglianza epidemiologica dei casi di mesotelioma maligno in Italia (1993-2015)
T2 - Metodi, risultati e prospettive di ricerca
AU - Marinaccio, Alessandro
AU - Corfiati, Marisa
AU - Binazzi, Alessandra
AU - Di Marzio, Davide
AU - Bonafede, Michela
AU - Verardo, Marina
AU - Migliore, Enrica
AU - Gennaro, Valerio
AU - Mensi, Carolina
AU - Schallemberg, Gert
AU - Mazzoleni, Guido
AU - Fedeli, Ugo
AU - Negro, Corrado
AU - Romanelli, Antonio
AU - Chellini, Elisabetta
AU - Grappasonni, Iolanda
AU - Pascucci, Cristiana
AU - Madeo, Gabriella
AU - Romeo, Elisa
AU - Trafficante, Luana
AU - Carrozza, Francesco
AU - Angelillo, Italo Francesco
AU - Cavone, Domenica
AU - Cauzillo, Gabriella
AU - Tallarigo, Federico
AU - Tumino, Rosario
AU - Melis, Massimo
N1 - Funding Information: Among the ongoing national mesothelioma surveillance systems, the Italian experience has some peculiarities that must be underlined. ReNaM structure is regional with a devoted centre in each Region; Inail provides aggregate data analyses and promotes research projects. The data sources are each institution that diagnoses and treats cases; for extra-pleural MM cases, it is realistic that the net of data sources need to be enforced. The epidemiological monitoring of mesothelioma was performed in most of Countries based on cause of death statistics or population cancer registries. Italy is one of the few Countries having an active MM surveillance system, the one with the longer period of activity and the only one that assures complete territorial coverage, national standardized procedures, and centralized data processing and quality control, including non-occupational exposure qualitative assessment. Therefore, its technical tools (anamnestic questionnaire, classification and code systems for diagnosis and exposures, the network of active research of cases) could represent a model for the development of analogous experiences in other Countries. In Italy, the legislative decree No. 81/2008 points out an articulated system for the registration of occupational cancers, which has been well established for tumours with a high aetiological fraction, such as malignant mesothelioma and sinonasal cancer, but not yet for those with low aetiological fraction. The National Sinonasal Cancer Registry (Registro dei Tumori Naso-Sinusal, ReNa-TuNS), that currently covers only six regions and one autonomous province but has already started to produce aggregated statistics at national level, have a structure which is similar to ReNaM structure.21,22 The lack of a systematic research activity for cases with low aetiological fraction is due to the actual difficulties to identify the occupational aetiology. These include long latency, interactions between different causal factors (e.g., voluptuous habits, lifestyles, environmental exposures, individual susceptibility), acquisition of occupational histories and a widespread lack of information about work-related risks which may produce a low level of occupational diseases reporting. Currently, in agreement with the Regional Operative Centres, Inail is setting up a monitoring system based on the methodology already known in the literature as the OCCAM project for the identification of suspected cases and the involvement of the territorial services for the assessment of the case and the deepening of the professional aetiology with a direct interview.23 Some points of attention and critical limitations of the ReNaM activities have to be discussed preliminarily. The beginning of registration is not consistent across Italian regions and, consequently, any evaluation of the trend of MM incidence is strongly limited. The effectiveness in identifying the modalities of exposure is heterogeneous between regions and the percentage of subjects interviewed varies between 45% and 95%, depending on the available resources and knowledge. The different year of COR activities beginning and the different percentage of interviewed subjects has to be considered and it could influence the findings here presented. Furthermore, 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, the possible lack of homogeneity among practices adopted by CORs is a crucial and real issue. It often depends on the absence of prompt availability of the other informative sources necessary to verify data for completeness (e.g., hospital discharge records, archives of deaths, cancer registries). Considering that the territorial characterization of mesothelioma is very high (as a consequence of the localized exposure risks), such discrepancies denote a critical element of the national system. Currently, the update of operating guidelines of ReNaM is ongoing, with the aim of increasing uniformity in the CORs network. The absolute number of MM cases and the incidence rates have been stable in the last decade in some Countries which have banned asbestos use early.24,25 Recently, a pooled analysis of a large group of Italian asbestos-exposed worker cohorts (43 evaluated cohorts including 51,081 subjects) has provided evidence of a flattening of pleural MM mortality risk after long time since first exposure (around 40 years).26 However, asbestos has been widely used in building materials, either in industrial or residential settings, and remains mostly in-place, representing a health hazard for workers engaged in their maintenance and abatement, as well as for unaware population groups.27 According to ReNaM data, most of occupational exposures occurred in the construction sector and about 10% of all the registered cases recognized a defined exposure in non-occupational settings. The evolution in the patterns of exposures, with a decreasing weight – in the recent case list – of subjects which have suffered a significant exposure in activities traditionally recognized with a well-known asbestos exposure as “asbestos-cement plants”, “shipbuilding” and “railways maintenance”, is a real concern. The analyses of sectors of exposure for MM cases cannot be conclusive regarding the trend in exposure, considering the absence of exposed people trend evaluation and must be verified by analytical studies, which have to include a historical reconstruction of exposed workers by sector. It is necessary to raise public awareness about the great variety of industrial and non-industrial sectors involved in asbestos exposure, not only for a direct use of the material, but for its presence in the industrial cycles or in the workplaces. It is reasonable to assume that the systematic dissemination of epidemiological surveillance findings plays a crucial role in this field. The research activity of ReNaM group, supported by In- ail, by regions and, in part, by research projects co-financed by CCM (Centre for Diseases Prevention and Control of the Italian National Ministry of Health), provided a number of scientific contributions, as documented by papers published in national and international journals over years. The joint analysis of ReNaM data, mortality statistics, and asbestos consumption before the ban allowed to forecast mesothelioma mortality predicting a peak around 2015-2020.28 A recent study performing a historical reconstruction of pleural mesothelioma mortality since 1970 actually confirmed these predictions29 and ReNaM incidence data allow to consider the epidemic curve at his peak at the present. The analysis of economic activities involved in asbestos exposure identified by ReNaM of uncommon occupational exposures and the characterization of spatial clusters of incident cases by source of exposure provided epidemiological data on the spatial and temporal distribution of risk among different population groups.30The characteristics and the extent of non-occupational exposure (mainly environmental and familial exposures) have been estimated around 10% of cases, mainly due to the residence near asbestos-cement plants and to the cohabitation with occupationally exposed subjects.31 The record linkage between ReNaM and Inail administrative archives allowed to highlight the problem of underreporting of malignant mesothelioma to the insurance institution.32 In the framework of a collaboration with the Italian National Health Institute (Istituto superiore di sanità, ISS), an extensive analysis of MM incidence in Italian national priority contaminated sites (NPCSs) has been recently performed, showing an overall excess of 1,531 cases in that areas.33 Based on ReNaM data, an econometric analysis estimated medical care costs and insurance and compensation costs of 33,000 and 25,000 euros per mesothelioma case, respectively, but a cost of 200,000 euros per patient for productivity loss, representing most of the indirect costs of disease.34 The permanent national surveillance system will be essential to confirm the start and to monitor the slope of the decreasing incidence expected in the next years as well as any possible changes in disease features and exposure modalities. Furthermore, actually the extent of workers currently exposed to relevant air concentrations of asbestos fibres in the removal or disposal of asbestos containing materials is relevant.35 Recently, there has been a scientific debate about the so-called “third wave” of mesothelioma occurrence, evidencing the lack of available evidences.36 The present findings and previously published analyses documented as 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 nonoccupational exposure to asbestos needs to be carefully undertaken from the economic, ethical, and insurance points of view. Recently, in Italy, a special fund for asbestos victims (without any occupational exposure) has been implemented. Finally, the crucial role of epidemiological findings to support and stimulate the reliability and effectiveness of the insurance system must be evidenced. Even if ReNaM has only an epidemiological purpose, the information provided could assist in the process of attribution of causation and implement reporting and compensation practices. Publisher Copyright: © 2020, Inferenze Scarl. All rights reserved. Copyright: Copyright 2020 Elsevier B.V., All rights reserved.
PY - 2020
Y1 - 2020
N2 - BACKGROUND: As a legacy of the large asbestos consumption until the definitive ban in 1992, Italy had to tackle a real epidemic of asbestos related diseases. The Italian National Registry of Malignant Mesotheliomas (ReNaM) is a permanent surveillance system of mesothelioma incidence, with a regional structure. Aims, assignments and territorial network of ReNaM are described, as well as data collection, recording and coding procedures. OBJECTIVES: To describe the Italian epidemiological surveillance system of mesothelioma incidence, to provide updated data about occurrence of malignant mesothelioma in Italy, and to discuss goals, attainments, and expectations of registering occupational cancer. DESIGN: Analysis of data by malignant mesothelioma incident cases surveillance system. SETTING AND PARTICIPANTS: Italy, network of regional sur-veillance system, all Italian regions. MAIN OUTCOME MEASURES: A Regional Operating Centre (COR) is currently established in all the Italian regions, actively searching incident malignant mesothelioma cases from health care institutions. Occupational history, lifestyle habits, and residential history are obtained using a standardized questionnaire, administered to the subject or to the next of kin by a trained interviewer. The extent of dataset, epide-miological parameters, and occupations involved are reported updated at 31.12.2016, and standardized incidence rates are calculated. RESULTS: At December 2016, ReNaM has collected 27,356 malignant mesothelioma cases, referring to the period of incidence between 1993 and 2015. The modalities of exposure to asbestos have been investigated for 21,387 (78%) and an occupational exposure has been defined for around 70% of defined cases (14,818). CONCLUSIONS: The Italian experience shows that epidemiological systematic surveillance of asbestos related diseases incidence has a key importance for assessing and monitoring the public health impact of occupational and/or environmental hazards, programming preventive interventions, including remediation plans and information campaigns, and supporting the efficiency of insurance and welfare system. Monitor-ing the incidence of malignant mesothelioma through a specialized cancer registry is essential to follow-up the health effects of changing modalities and extent of occupational exposures over years and of environmental contamination. Such consolidated surveillance system is recommended also for occupational cancers with low aetiological fraction.
AB - BACKGROUND: As a legacy of the large asbestos consumption until the definitive ban in 1992, Italy had to tackle a real epidemic of asbestos related diseases. The Italian National Registry of Malignant Mesotheliomas (ReNaM) is a permanent surveillance system of mesothelioma incidence, with a regional structure. Aims, assignments and territorial network of ReNaM are described, as well as data collection, recording and coding procedures. OBJECTIVES: To describe the Italian epidemiological surveillance system of mesothelioma incidence, to provide updated data about occurrence of malignant mesothelioma in Italy, and to discuss goals, attainments, and expectations of registering occupational cancer. DESIGN: Analysis of data by malignant mesothelioma incident cases surveillance system. SETTING AND PARTICIPANTS: Italy, network of regional sur-veillance system, all Italian regions. MAIN OUTCOME MEASURES: A Regional Operating Centre (COR) is currently established in all the Italian regions, actively searching incident malignant mesothelioma cases from health care institutions. Occupational history, lifestyle habits, and residential history are obtained using a standardized questionnaire, administered to the subject or to the next of kin by a trained interviewer. The extent of dataset, epide-miological parameters, and occupations involved are reported updated at 31.12.2016, and standardized incidence rates are calculated. RESULTS: At December 2016, ReNaM has collected 27,356 malignant mesothelioma cases, referring to the period of incidence between 1993 and 2015. The modalities of exposure to asbestos have been investigated for 21,387 (78%) and an occupational exposure has been defined for around 70% of defined cases (14,818). CONCLUSIONS: The Italian experience shows that epidemiological systematic surveillance of asbestos related diseases incidence has a key importance for assessing and monitoring the public health impact of occupational and/or environmental hazards, programming preventive interventions, including remediation plans and information campaigns, and supporting the efficiency of insurance and welfare system. Monitor-ing the incidence of malignant mesothelioma through a specialized cancer registry is essential to follow-up the health effects of changing modalities and extent of occupational exposures over years and of environmental contamination. Such consolidated surveillance system is recommended also for occupational cancers with low aetiological fraction.
KW - Asbestos
KW - Epidemiological surveillance system
KW - Italy
KW - Mesothelioma
UR - http://www.scopus.com/inward/record.url?scp=85084379274&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85084379274&partnerID=8YFLogxK
U2 - 10.19191/EP20.1.P023.014
DO - 10.19191/EP20.1.P023.014
M3 - Articolo
C2 - 32374111
AN - SCOPUS:85084379274
VL - 44
SP - 23
EP - 30
JO - Epidemiologia e prevenzione
JF - Epidemiologia e prevenzione
SN - 1120-9763
IS - 1
ER -