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Objectives: descriptive evaluation of distributional justice in the epidemiological surveillance system of populations residing in Italian National priority Contaminated Sites (NPCSs) of SENTIERI project. Analysis of the feasibility of monitoring different Environmental Justice dimensions in SENTIERI., Design: descriptive study and ecological meta-analysis. SETTING AN PARTICIPANTS: residents in 298 municipalities included in 44 NPCSs in SENTIERI. Description of their level of deprivation and mortality analysis by deprivation level in the first period evaluated in SENTIERI, years 1995-2002., Main Outcome Measures: an index of multiple deprivation at municipality level DI-SENTIERI, built using 4 indicators based on variables from the Italian 2001 Census, was used to describe deprivation in communities living in NPCSs. The risk of mortality for all causes and all tumors in the pool of NPCSs municipalities by deprivation level was assessed using meta-Standardized Mortality Ratios (meta-SMRs)., Results: sixty percent of municipalities (No. 179) in NPCSs belong to the two more deprived quintiles. The socioeconomic disadvantage of communities resident in NPCS has a North-South gradient: the proportion of municipalities belonging to the two more deprived quintiles is 29% in the North, 68% in the Centre, 92% in the South. Meta-SMRs for all causes in less deprived municipalities were 98 (90%CI 95-100) in men e 101 (90%CI 97-104) in women, the values for all cancers were 99 (90%CI 94-103) in men and 100 (90%CI 95-105) in women. The corresponding estimates in more deprived municipalities were, respectively in men and women, 103 (90%CI 101- 104) and 102 (90%CI 100-104) for all causes, 104 (90%CI 102-106) and 102 (90%CI 100-104) for all cancers., Conclusions: residents in NPCSs are exposed to environmental stressors and are generally more deprived. The socioeconomic disadvantage is mostly affecting Central and Southern Italy populations. Furthermore, in these deprived communities the risk of mortality for all diseases and all cancers is higher. Populations living in NPCSs are affected by distributional injustice. To monitor the different dimensions of Environmental Justice, the DI-SENTIERI should be developed and other socioeconomic indicators implemented.

The purpose of the SENTIERI-ReNaM Project is to analyse the incidence of mesothelioma in Italian National Priority Contaminated Sites (NPCSs) in order to estimate the health impact of asbestos on resident populations, disentangling the role of occupational and environmental exposures. SENTIERI Project has provided the relevant information on geographic and demographic structure of NPCSs and on existing sources of contamination. The Italian National Mesothelioma Registry (ReNaM), that covers the whole country through its Regional Operational Centres (CORs), has made available the procedures for estimating the incidence of mesothelioma in NPCSs and for assessing occupational and environmental asbestos exposure of the individual cases. The synergy between these two epidemiological surveillance systems lay also the ground for communication programmes with the affected communities.

The purpose of SENTIERI-ReNaM Project is to describe mesothelioma incidence in the Italian National Priority Contaminated Sites (NPCSs). The present report deals with 39 NPCSs (20 in Northern Italy, 8 in Central Italy and 11 in Southern Italy). Asbestos is specifically mentioned in the regulatory acts of recognition for 10 NPCSs and it is the only agent that has determined environmental contamination in 3 of them (Casale Monferrato, Broni, and Bari). The timeframe of the study is 2000-2011 for 34 out of 39 sites. The corresponding reference periods for the sites of Latium, Campania, Umbria, and Bolzano Province are, respectively, 2001-2011, 2005-2011, and 2006-2011. Standardized Incidence Ratios (SIRs) for mesothelioma, with their corresponding 90% Confidence Intervals, have been estimated for all sites. The interpretation of the study findings has been based on anamnestic information made available by the Italian National Mesothelioma Registry (ReNaM), and completed thanks to knowledge derived from the international scientific literature. In men, mesothelioma incidence has shown excesses in 27/39 sites and defects in the remaining 12; in women, excesses have been reported in 20 sites, defects in 15, and no cases have been detected in the remaining 4 sites. The highest annual incidence rates have been observed in the sites characterized only by the presence of asbestos- cement factories (Broni and Casale Monferrato): respectively, 98.0 and 68.6 per 100,000 per year in men, 72.1 and 45.8 in women. Besides these two sites, the highest rates have been observed in the sites with naval shipyards: 13.2 in men and 2.5 in women. Excesses of mesothelioma incidence have been confirmed (with respect to previous observations) in the sites of Broni, Casale Monferrato, Balangero, and in the coastal areas of Trieste, La Spezia, Venice, and Leghorn. Balangero has been the major European chrysotile quarry, while the other sites are characterized by the presence of naval shipyards with demonstrated use of asbestos before it was banned in 1992. An excess of mesothelioma incidence has also been confirmed in the site of Biancavilla, characterized by the presence of the fluoro-edenite fibrous amphibole, classified as carcinogenic to humans by the International Agency for Research on Cancer (IARC). An increased incidence of mesothelioma was also observed in the areas where no direct use of asbestos had previously been documented, like Cengio and Saliceto (chemical industry), Falconara on Sea (oil refinery), and Litorale Domizio Flegreo and Agro Aversano (a large area including multiple hazardous waste dumping sites). These findings show that a relevant proportion of Italian mesothelioma cases is concentrated in NPCSs. About 1,500 extra cases of mesothelioma have been estimated in the overall series of 39 sites (2000-2011), corresponding to 125 extra cases per year. The excess has concerned the sites with manufacture of asbestos-cement products, but also the areas with asbestos quarries, naval shipyards, illegal hazardous waste dumping sites with asbestos-containing materials, petrochemical industries, refineries and steel plants. In some sites, particularly Casale Monferrato and Broni, analytical epidemiological studies have shown the causal role of not only occupational, but also environmental exposures, with special reference to paving of gardens and courtyards with asbestos-cement industry by-products. The main novelty generated by the collaborative SENTIERI-ReNaM Project concerns the detection of significant mesothelioma excesses not only in sites where asbestos is explicitly reported as a source of contamination, but also in a number of areas defined "of national interest" for environmental cleanup due to other sources of pollution. This confirms that the range of economic activities and working and living environments affected by asbestos exposure is very wide and it is not restricted to the industrial sectors characterized by the direct use of this material.

The integration of current data sources is now a practice widely used in epidemiology, especially in the environmental field. To better describe the health profile of populations residing in proximity to areas characterized by a "strong environmental pressure", the combined use of multiple indicators (i.e., mortality, hospitalization, cancer incidence) is recommended. To choose an indicator is complex, as indicators should be contextualized and they need to be related to the several issues involved in the studied pathology. This chapter explores the general considerations that are to be addressed both at the time of the study design, during the selection of outcomes and of the proper data sources, and at the time of the discussion of the results, when different and complementary data are compared. A special focus is devoted to the case of mesothelioma.

SENTIERI-ReNaM Project analysed the incidence of malignant mesothelioma (MM) for the period 2000-2011 in 39 National Priority Contaminated Sites (NPCSs), and assessed the overall impact of mesothelioma in different types of NPCSs. In the study period, 2,683 incident cases of malignant mesothelioma were recorded: 1,998 males (74.5%), 685 females (25.5%). Excluding cases with non attributable exposure and those non interviewed, exposure was identified in 1,926 cases (70% of all cases): 1,541 males (occupational exposure: 1,414; environmental exposure: 82), 385 females (occupational exposure: 103; environmental exposure: 141). Women experienced mainly environmental and domestic exposures to asbestos. Standard Incidence Ratio (SIR) excesses were observed in men in 27 out of 39 NPCSs and defects in the remaining 12; in women, 20 NPCSs showed SIR excesses, defects in 15; in 4 NPCSs no MM cases occurred among female population. The highest rates were found in NPCSs with asbestos-cement plants (Broni and Casale Monferrato), respectively, 98 per 100,000 per year and 68.6 in men, 72.1 and 45.8 in women. Excluding these two sites, the highest incidence rates were found in the group with harbours and shipyards, where the rates were, respectively, 13.2 among men and 2.5 among women. The results of this report will be communicated to national and local institutions, as well as to NPCSs resident populations.

Background: in Italy, National Priority Contaminated Sites (NPCSs) are defined as of concern for remediation; most of them are sites with a long-lasting industrial activity., Objective: the study aims to estimate the burden of disease from mesothelioma in NPCSs., Design: mesothelioma incidence in the period 2000-2011 was estimated for the populations residing in the 39 Italian NPCSs. Data were taken from the Italian National Mesothelioma Registry (ReNaM). NPCSs were ranked into risk groups (RGs) on the basis of the presence of the following asbestos-exposing activities: 1. asbestos-cement plants; 2. asbestos mines; 3. harbours with shipyards; 4. illegal dumping sites containing asbestos; 5. petrochemicals and/or refineries, and/or steel plants; 6. chemical plants and/or landfills without explicit mention of asbestos. For the population residing in each NPCS, crude rates per 100,000 per year and number of observed minus expected cases (Obs-Exp) by gender were computed. Expected cases were calculated using the age-class rates of a reference population (the geographical macroarea of every NPCS). For every RG, the meta-analytic estimate of the attributable proportion (AP), i.e., the proportion of cases attributable to the local context, was computed, being the AP for each NPCS expressed as (Obs-Exp/Obs) x100., Results: the total number of mesothelioma cases estimated in the considered period of 12 years is 2,741 (2,048 males, 693 females). The total number of Obs-Exp cases was 1,531 (1,178 in males, 353 in females). In males, crude rate ranges from 71.5 in the RG1 to 3.0 in RG4, while in females it ranges from 48.4 in RG1 to 0.6 in RG4. In males, AP in RGs from 1 to 3 is over 65%, in RG4 is 59%, in RG5 is 30%, in RG6 is -14%. AP in females gradually drops from 95% in RG1 to -64% in RG6., Conclusions: the burden of mesothelioma in populations residing in NPCSs is high, with an AP gradient consistent with the a priori RG. This burden impacts on females in a different way: rates are lower than male ones; AP is similar to male ones in the RGs 1 and 3.

In the framework of SENTIERI Project, this study is aimed to identify excess risks of malignant mesothelioma (MM) in Italian National Priority Contaminated Sites (NPCSs) included in the national environmental remediation programme and to discuss the results by means of data available from the Italian National Mesothelioma Registry (ReNaM). Re- NaM has a regional structure with Regional Operational Centres (CORs) in charge of identifying mesothelioma incident cases and defining the asbestos exposure modalities thought an individual questionnaire. Starting from the 44 NPCSs selected in SENTIERI Project, we excluded Calabria and Sardinia Regions from the analyses (3 NPCSs). Furthermore, for 2 sites (Emarese in Valle d'Aosta and Tito in Basilicata) no incident MM cases have been detected in the considered period. Incident cases of MM and Standardized Incidence Ratios (SIR), with corresponding 90% confidence intervals, have been estimated in each NPCS, for both gender, in the period 2000-2011. Age-standardized rates of Italian geographical macro-areas (North- East, North-West, Centre, South and Islands) have been used to estimate expected cases. For every analyzed site, the occupational and non-occupational asbestos exposure modalities are discussed.

Mesothelioma incidence has been analyzed in National Priority Contaminated Sites (NPCSs) to estimate the health impact of asbestos exposure on resident people. The burden of professional and environmental exposures has been identified through data of the Regional Operational Centres (CORs), made available by the Italian National Mesothelioma Registry (ReNaM). An excess of mesothelioma incidence is confirmed in sites with a known past history of direct use of asbestos, such as Balangero, Casale Monferrato, Broni, Bari-Fibronit, and in coastal areas, where shipyards, harbours and other industries that involved a wide use of asbestos are represented (e.g., Trieste, La Spezia, Venice, and Leghorn). An excess of mesothelioma has been observed in settings where the asbestos is not mentioned as contaminant in the decree that included these sites among NPCSs, such as Cengio and Saliceto in Northern Italy; Falconara Marittima and the Bacino Idrografico Fiume Sacco in the Central Italy; the Litorale Domizio Flegreo and Agro Aversano, Milazzo, and Gela in the Southern Italy. Observed excess in the various NPCSs confirms the large-scale occurrence in contaminated Italian sites of a significant amount of total mesothelioma cases observed at national level. The analysis of occupational risk in epidemiological studies with an ecological design helps in defining the contribution of different factors to the overall risk.