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Notwithstanding the ban in 1992, asbestos exposure for workers in the construction sector in Italy remains a concern. The purpose of this study is to describe the characteristics of malignant mesothelioma (MM) cases recorded by the Italian registry (ReNaM) among construction workers. Incident mesothelioma cases with a definite asbestos exposure have been analyzed. Characteristics of cases and territorial clusters of crude rates of MM in construction workers have been described, as well as the relation between asbestos use before the ban and the historical trend of workforce in the construction sector in Italy. ReNaM has collected 31,572 incident MM cases in the period from 1993 to 2018 and asbestos exposure has been assessed for 24,864 (78.2%) cases. An occupational exposure has been reported for 17,191 MM cases (69.1% of subjects with a definite asbestos exposure). Among them, 3574 had worked in the construction sector, with an increasing trend from 15.8% in the 1993–98 period to 23.9% in 2014–2018 and a ubiquitous territorial distribution. The large use of asbestos in construction sector before the ban makes probability of exposure for workers a real concern still today, particularly for those working in maintenance and removal of old buildings. There is a clear need to assess, inform, and prevent asbestos exposure in this sector.

Introduction. Malignant mesotheliomas have been observed in entertainment workers in the last decades. They have been evaluated as occupationally exposed to asbestos contained in tools used for fireproof and sound-absorbing purposes. Aim of the study. To evaluate the mortality of workers engaged in a Florentine theatre where a large quantity of asbestos was found in the '80s, put in place 20 years earlier. Methods. It is a cohort study on entertainment workers with follow-up period ranged from 1-1-1970 till 31-12-2018. Standardized Mortality Ratios (SMRs) and their 95% Confidence Intervals (95% IC) were calculated by gender and job ("manual workers" and "all other jobs"), using age and sex specific mortality rates of Tuscan population. Results. The cohort includes 826 workers (389 manual workers and 437 engaged in other jobs) engaged by the Florentine theatre between 01/01/1937 and 31/12/1990. Excesses of mortality for all causes are observed in manual workers, either males (301 cases; SMR 304,0; 95% IC 271,5-340,3) or females (86 cases; SMR 429,8; 95% IC 348,0-531,0). The group of the other workers presents deficits of mortality by all causes, cancers and cardiovascular diseases in both genders. One death for pleural cancer is observed in a manual worker. Discussion. The results are in line with previous observations in similar occupations. In the examined Florentine theatre the asbestos exposures were important only for the manual workers who worked in the technical rooms characterized by the presence of friable asbestos sprinkled and in a bad state of maintenance.

Objective To develop a short, flexible, and comprehensive tool to measure psychological distress in caregivers of malignant mesothelioma (MM) patients: the Mesothelioma Psychological Distress Tool-Caregivers version (MPDT-C). Methods Based on a systematic review of the relevant literature, aspects associated with caregiver distress were derived. Expert researchers/clinicians developed a pool of items for each identified aspect. Content validity was assessed through a multiple mixed-methods approach. A multicenter study was conducted to explore the factorial structure of the 47-item MPDT-C through Bayesian factor analysis. Results The Bayesian exploratory factor analysis revealed an underlying three-factor structure. Factors were labeled Secondary Traumatic Stress, Engagement in Caring, and Meaningful Cognitive Restructuring. All scales showed sufficient reliability and corrected item-total correlations. Females scored higher than males for Engagement in Caring. Conclusions Taking care of malignant mesothelioma patients is a stressful process that influences the caregiver's physical, emotional, and social wellbeing. Our study offers preliminary evidence in support of the adequate psychometric properties of the MPDT-C, and these should now be replicated. Results suggest that the MPDT-C is a reliable tool with which to detect the psychological distress of this traumatized population.

Although the predominant occupation origin of mesothelioma is well known, determinant factors involved in filing compensation are scarcely investigated. A linkage between incident mesothelioma cases collected by Italian mesothelioma register (ReNaM) and compensation claims and assignment by Italian national insurance Institute (INAIL) has been conducted for cases diagnosed in the period 2010-2015 and occupational exposure to asbestos. Logistic regression models and decision tree models have been used to identify demographic, diagnostic and anamnestic factors significant for filing and receiving compensation. We have included in the analyses 5019 mesothelioma cases, and among them, 3321 (66.2 %) were found in INAIL archives as mesothelioma cases who fil claims for compensation. The modalities of asbestos exposure, sector of working activities and job type are crucial factors. Furthermore, gender, age at diagnosis, area of residence have been found to be significant predictors of probability to fil claims. Relative risks to fil claims were obtained for the above determinants and conditions to maximize the probability to obtain compensation identified. Our findings demonstrate that there is a need to enforce policies for improving awareness of the occupational origin for mesothelioma cases. Stakeholders, occupational health and safety institutions can play an important role for improving the sensitization regarding the rights of compensation benefits, ensuring the equity and the effectiveness of insurance, welfare and public health systems.

BACKGROUND: The aim of this work was to evaluate the impact of the restrictions put in place to control the COVID-19 pandemic on new diagnoses of malignant mesothelioma (MM) in Italy. METHODS: Twelve of the 21 Italian malignant mesothelioma CORs (regional operating centres) participated. The study included all cases of MM with microscopic confirmation; cases without microscopic confirmation and death certificate only (DCO) were excluded. For each case, information on sex, date of birth, tumor site, morphology, and date of diagnosis was retrieved. We compared the number of incident cases in 2020 with 2019, looking at the overall picture and for four periods: pre-pandemic (January-February), first wave (March-May), low incidence (June-September), and second wave (October-December). RESULTS: A total of 604 cases were registered: 307 in 2019 and 297 in 2020. In the 2020 pre-pandemic period, the incidence was higher than in the same months in 2019 (+45%); there was no significant change during the first wave (+1%) or in the low-incidence period (-3%), while a decrease was observed during the second wave (-32%). However, the data were not homogeneous across the country: the increase in the pre-pandemic period concerned mostly the regions of northern (+61.5%) and central Italy (+43.5%); during the first wave, MM diagnoses increased in the northern (+38.5%) and central (+11.4%) regions but decreased in the southern regions (-52.9%). All these differences are compatible with random fluctuations. CONCLUSION: The COVID-19 pandemic had little or no impact on new MM diagnoses, and variations were not homogeneous throughout the country.

Smoke-free policies are effective in preventing secondhand smoke (SHS) exposure, but their adoption at home remains largely voluntary. This study aimed to quantify SHS exposure in homes with residents who smoke in Europe according to households’ characteristics, tobacco consumption habits, and national contextual factors. Cross-sectional study (March 2017–September 2018) based on measurements of air nicotine inside 162 homes with residents who smoke from nine European countries. We installed passive samplers for seven consecutive days to monitor nicotine concentrations. Through self-administered questionnaires, we collected sociodemographic information and the number of individuals who smoke, smoking rules, frequency, location, and quantity of tobacco use in households. Country-level factors included the overall score in the Tobacco Control Scale 2016, the smoking prevalence, and self-reported SHS exposure prevalence. Nicotine concentrations were analyzed as continuous and dichotomous variables, categorized based on the limit of quantification of 0.02 μg/m3. Overall, median nicotine concentration was 0.85 μg/m3 (interquartile range (IQR):0.15–4.42), and there was nicotine presence in 93% of homes. Participants reported that smoking was not permitted in approximately 20% of households, 40% had two or more residents who smoked, and in 79% residents had smoked inside during the week of sampling. We found higher nicotine concentrations in homes: with smell of tobacco smoke inside (1.45 μg/m3 IQR: 0.32–6.34), where smoking was allowed (1.60 μg/m3 IQR: 0.68–7.63), with two or more residents who smoked (2.42 μg/m3 IQR: 0.58–11.0), with more than 40 cigarettes smoked (2.92 μg/m3 IQR: 0.97–10.61), and where two or more residents smoked inside (4.02 μg/m3 IQR: 1.58–11.74). Household nicotine concentrations were significantly higher in countries with higher national smoking prevalence and self-reported SHS exposure prevalence (p < 0.05). SHS concentrations in homes with individuals who smoke were approximately twenty times higher in homes that allowed smoking compared to those reporting smoke-free household rules. Evidence-based interventions promoting smoke-free homes should be implemented in combination with strengthening other MPOWER measures. This project has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 681040. The work of SG was partially supported by the Italian League Against Cancer (LILT, Milan). EF is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR319) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.

This Catalogue is a collection of information on the use of raw asbestos and asbestos-containing materials used in several industries and occupational activities, with particular attention to the situation of Tuscany, a region of Central Italy. The work was developed at the Institute for Cancer Research, Prevention and Clinical Network (ISPRO) of Florence, where epidemiologic research and surveillance activities have been developing since 1988 and where the coordination and evaluation of the regional health surveillance programme provided to past asbestos workers started in 2016 and is still ongoing. The Catalogue aims at being a working tool for all health professionals engaged in examining and classifying the occupational asbestos exposures of subjects both affected by diseases that could be associated to this carcinogen and examined within the regional health surveillance programme. It is necessary for the health personnel engaged in the above-mentioned activities to know or to have the possibility to find exact and detailed data on asbestos exposure by occupational sector. These data are briefly described in the 29 factsheets this Catalogue consists of. In each factsheet, the presence and every use of asbestos are described, with reference to a precise occupational sector. Several occupational sectors can be considered together because of analogies on asbestos exposure. Occupations are considered on the basis of existing evidence on the use of raw asbestos or asbestos-containing materials (as semi-finished or finished products or as auxiliary materials in production processes). Besides the presence and use of asbestos, a description of the possible exposures of workers is reported. Sources of information were scientific and grey literature as well as the 7,187 occupational histories of mesothelioma registered by the specific Tuscan registry. Some factsheets have been revised and enhanced by Italian experts on the asbestos exposure with a specific competence in the examined sectors. Each factsheet includes also questions to be addressed to workers in order to examine in depth their possible asbestos exposure. For those who would like to expand their knowledge on this topic, references are reported both at the end of each factsheet and at the end of the volume. In all industrialized countries, also in those which have not already banned asbestos use, a decrease in the use of this material and in the relative exposure have been observing since the end of the Seventies, few years after the general consensus within the scientific community on asbestos carcinogenicity. This decreasing trend has been becoming greater and greater since the end of the Eighties, when more restrictive regulations have been approved and applied, especially in occupational settings. Nevertheless, nowadays asbestos-related diseases are still diagnosed due to past exposures, although during next decade a decreasing incidence of malignant mesothelioma - the cancer most specifically related to this carcinogen and characterized by a very bad prognosis and the longest latency - could be observed. Particular attention will be paid to jobs regarding renovation of old buildings containing asbestos and to decontamination activities. In conclusion, this Catalogue is a working tool - although it is not exhaustive and could be upgraded with new information - for all professionals engaged in asbestos risk prevention activities as health personnel, personnel of insurance companies, employers, and employee representatives.

IntroductionExposure to asbestos increases the risk of lung cancer and mesothelioma. Few studies quantified the premature occurrence of these diseases in asbestos-exposed workers. Focus on premature disease onset (rate advancement or acceleration) can be useful in risk communication and for the evaluation of exposure impact. We estimated rate advancement for total mortality, lung cancer and pleural mesothelioma deaths, by classes of cumulative asbestos exposure in a pooled cohort of asbestos cement (AC) workers in Italy.MethodThe cohort study included 12 578 workers from 21 cohorts, with 6626 deaths in total, 858 deaths from lung cancer and 394 from pleural malignant neoplasm (MN). Rate advancement was estimated by fitting a competitive mortality Weibull model to the hazard of death over time since first exposure (TSFE).ResultAcceleration time (AT) was estimated at different TSFE values. The highest level of cumulative exposure compared with the lowest, for pleural MN AT was 16.9 (95% CI 14.9 to 19.2) and 33.8 (95% CI 29.8 to 38.4) years at TSFE of 20 and 40 years, respectively. For lung cancer, it was 13.3 (95% CI 12.0 to 14.7) and 26.6 (95% CI 23.9 to 29.4) years, respectively. As for total mortality, AT was 3.35 (95% CI 2.98 to 3.71) years at 20 years TSFE, and 6.70 (95% CI 5.95 to 7.41) at 40 years TSFE.ConclusionThe current study observed marked rate advancement after asbestos exposure for lung cancer and pleural mesothelioma, as well as for total mortality.

Mezei et al's letter (1) is an opportunity to provide more details about our study on pericardial and tunica vaginalis testis (TVT) mesothelioma (2), which is based on the Italian national mesothelioma registry (ReNaM): a surveillance system on mesothelioma, with individual asbestos exposure assessment. Incidence of pericardial mesothelioma has been estimated around 0.5 and 0.2 cases per 10 million person-years in men and women, respectively, and around 1 case for TVT mesothelioma. ReNaM collected 138 cases thanks to its long period of observation (1993-2015) and national coverage. Conducting a population-based case-control study with incidence-density sampling of controls across Italy and over a 23 year time-span should have been planned in 1993 and would have been beyond feasibility and ReNaM scope. We rather exploited two existing series of controls (3). The resulting incomplete time- and spatial matching of cases and controls is a limitation of our study and has been acknowledged in our article. The analysis of case-control studies can nevertheless be accomplished in logistic models accounting for the variables of interest, in both individually and frequency matched studies (4). Furthermore, analyses restricted to (i) regions with enrolled controls, (ii) cases with definite diagnosis, (iii) incidence period 2000-2015, and (iv) subjects born before 1950 have been provided in the manuscript, confirming the strength of the association with asbestos exposure (supplemental material tables S4-7). Following Mezei et al's suggestion, we performed further sensitivity analyses by restriction to regions with controls and fitting conditional regression models using risk-sets made of combinations of age and year of birth categories (5-year classes for both). We confirmed positive associations with occupational exposure to asbestos of pericardial mesothelioma, with odds ratios (OR) (adjusted for region) of 9.16 among women [95% confidence interval (CI) 0.56-150] and 5.63 (95% CI 1.02-31.0) among men; for TVT mesothelioma the OR was 7.70 (95% CI 2.89-20.5). Using risk sets of age categories and introducing year of birth (5-year categories) as a covariate (dummy variables) the OR were similar: OR (adjusted for region) of 9.17 among women (95% CI 0.56-150) and 5.76 (95% CI 1.07-31.0) among men; for TVT the OR was 9.86 (95% CI 3.46-28.1). Possible bias from incomplete geographical overlap between cases and controls has been addressed in the paper (table S4) and above. In spatially restricted analyses, OR were larger than in those including cases from the whole country, indicating that bias was towards the null. Mezei et al further noted that "the regional distribution of controls is different from that of person-time observed". This objection is not relevant because the above analyses were adjusted by region. Our controls were provided by a population-based study on pleural mesothelioma (called MISEM) and a hospital-based study on cholangiocarcinoma (called CARA). In MISEM, the response rate was 48.4%, a low but not unexpected rate as participation among population controls is usually lower and has been declining over time (5). It is important to underline that ReNaM applied the same questionnaire that was used for interviews and carried out the same exposure assessment as both MISEM and CARA. As repeatedly stated in ReNaM papers (6-7), each regional operating center assesses asbestos exposure based on the individual questionnaire, other available information, and knowledge of local industries. Occupational exposure to asbestos is classified as definite, probable or possible. Occupational exposure is (i) definite when the subject`s work was reported or otherwise known to have involved the use of asbestos or asbestos-containing materials (MCA); (ii) probable when subjects worked in factories where asbestos or MCA were used, but their personal exposure could not be documented; and (iii) possible when they were employed in industrial activities known to entail the use of asbestos or MCA. Hence, the definite and probable categories are closer to one another and were combined in our analyses. In any case, restricting analyses to subjects with definite occupational exposure and using each set of controls separately, as suggested by Mezei et al, yielded elevated OR for TVT and pericardial mesothelioma among men using both the above described modelling strategies; the OR could not be calculated for women. There were 70 (25 pericardial and 45 TVT) occupationally exposed mesothelioma cases. In population-based studies, analyses by occupation are limited by the low prevalence of most specific jobs. As briefly reported in our paper, for purely descriptive purposes, the industrial activity of exposure (cases may have multiple exposures), were construction (22 exposures, 7 and 15 for pericardial and TVT mesotheliomas, respectively), steel mills and other metal working industries (4 and 11), textile industries (2 and 3), and agriculture (2 and 5); other sectors had lower exposure frequencies. The absence of industries like asbestos-cement production, shipbuilding and railway carriages production/repair should not be surprising and had already been observed (7). In the Italian multicenter cohort study of asbestos workers (8), given the person-years of observation accrued by workers employed in these industries and gender- and site-specific crude incidence rates, approximately 0.1 case of pericardial and 0.2 of TVT mesothelioma would have been expected from 1970 to 2010. Even increasing ten-fold such figures to account for higher occupational risks among these workers would not change much. Asbestos exposure in agriculture has been repeatedly discussed in ReNaM reports (9: pages 70, 73, 128, 164 and 205). Exposure opportunities included the presence of asbestos in wine production, reuse of hessian bags previously containing asbestos, or construction and maintenance of rural buildings. Similarly, mesothelioma cases and agricultural workers exposed to asbestos have been noted in France (10). In conclusion, the additional analyses we performed according to Mezei et al's suggestions confirm the association between asbestos exposure and pericardial and TVT mesothelioma, supporting the causal role of asbestos for all mesotheliomas. ReNaM`s continuing surveillance system with national coverage is a precious platform for launching analytical studies on pleural and extra pleural mesothelioma. References 1. Mezei G, Chang ET, Mowat FS, Moolgavkar SH. Comments on a recent case-control study of malignant mesothelioma of the pericardium and the tunica vaginalis testis Scand J Work Environ Health. 2021;47(1):85-86. https://doi.org/10.5271/3909 2. Marinaccio A, Consonni D, Mensi C, Mirabelli D, Migliore E, Magnani C et al.; ReNaM Working Group. Association between asbestos exposure and pericardial and tunica vaginalis testis malignant mesothelioma: a case-control study and epidemiological remarks. Scand J Work Environ Health. 2020;46(6):609-617. https://doi.org/10.5271/sjweh.3895. 3. Greenland S. Control-initiated case-control studies. Int J Epidemiol 1985 Mar;14(1):130-4. https://doi.org/10.1093/ije/14.1.130. 4. Pearce N. Analysis of matched case-control studies. BMJ 2016 Feb;352:i969. https://doi.org/10.1136/bmj.i969. 5. Bigert C, Gustavsson P, Straif K, Pesch B, Bruning T, Kendzia B et al. Lung cancer risk among cooks when accounting for tobacco smoking: a pooled analysis of case-control studies from Europe, Canada, New Zealand, and China. J Occup Environ Med 2015 Feb;57(2):202-9. https://doi.org/10.1097/JOM.0000000000000337. 6. Marinaccio A, Binazzi A, Marzio DD, Scarselli A, Verardo M, Mirabelli D et al.; ReNaM Working Group. Pleural malignant mesothelioma epidemic: incidence, modalities of asbestos exposure and occupations involved from the Italian National Register. Int J Cancer 2012 May;130(9):2146-54. https://doi.org/10.1002/ijc.26229. 7. Marinaccio A, Binazzi A, Di Marzio D, Scarselli A, Verardo M, Mirabelli D et al. Incidence of extrapleural malignant mesothelioma and asbestos exposure, from the Italian national register. Occup Environ Med 2010 Nov;67(11):760-5. https://doi.org/10.1136/oem.2009.051466. 8. Ferrante D, Chellini E, Merler E, Pavone V, Silvestri S, Miligi L et al.; the working group. Italian pool of asbestos workers cohorts: mortality trends of asbestos-related neoplasms after long time since first exposure. Occup Environ Med 2017 Dec;74(12):887-98. https://doi.org/10.1136/oemed-2016-104100. 9. ReNaM VI Report. Available from: https://www.inail.it/cs/internet/docs/alg-pubbl-registro-nazionale-mesoteliomi-6-rapporto.pdf. Italian 10. Marant Micallef C, Shield KD, Vignat J, Baldi I, Charbotel B, Fervers B et al. Cancers in France in 2015 attributable to occupational exposures. Int J Hyg Environ Health 2019 Jan;222(1):22-9. https://doi.org/10.1016/j.ijheh.2018.07.015.

to examine the progress of the remediation and disposal of asbestos containing materials (ACMs) in Tuscany Region (Central Italy), the relative workforce employed, and how these activities are framed and reflected in the Italian panorama.descriptive study on the asbestos removal process in Tuscany.Reports drawn up according to article No. 9 of Law No. 257/92 received by the Tuscany Region from 1993 to 2019. The on-line submission of the reports has been available since 2011.quantities and characteristics of used or removed ACMs by compact and friable matrix, the ones transferred to temporary storage and/or landfill plants during 1995-2019; number of employees engaged in activities with asbestos presence, by type and duration of activity during 2015-2019.from 1993 to 2019, the Tuscany Region received a total of 5,284 reports. From 1995 to 2019, a total of 423,487 tons of ACMs were removed in Tuscany, 402,897 in a compact matrix and 20,590 in a friable matrix. Over the past five years, the workers employed in these activities were on average 1,500, with around 182,000 hours per year in contact with ACMs.Reports article No. 9 are an essential tool to monitor and evaluate the impact of political choices to incentivize the process of ACM removal, which is still proceeding too slowly: still 3/4 of installed ACMs remain in place 28 years after the ban. Furthermore, Reports article No. 9 are a source to identify workers who are potentially exposed to lower doses than in the past; they can be included in epidemiological cohort studies as well as in health surveillance programmes of past asbestos workers, an essential assistance level of collective prevention.

to define the most frequent health pathways of cases affected by malignant pleural mesothelioma according to those suggested and evaluated by the most recent specific guidelines.epidemiological descriptive study.100 cases histologically or cytologically well defined during 2015-2017 are extracted from the archive of two Regional Mesothelioma Registries: in Tuscany Region (Central Italy) they are randomly extracted, while in Lombardy Region (Northern Italy) cases treated by a highly-specialized health centre are collected.frequency of the diagnostic and therapeutic procedures; development and application of the checklist with evaluation of the duration of some phases of the predefined pathway.all hospital medical records were collected only for 34 cases in Tuscany and 20 cases in Lombardy. The health examinations were supplied according to each case's health condition and it was not possible to define one or more structured and standardized pathways. The pre-diagnostic phase has a variable duration according to the initial health condition of the patient, also for his/her comorbidity, and to the hospital where he/she was hospitalized at first. The examinations in outpatient services (medical examinations, blood chemistry tests and radiological examinations) are several, but they are specially requested during the pre-diagnostic phase and during the period of chemotherapy. The checklist applied to a subset of Tuscan cases shows a large variation of the length of the pre-diagnostic phase (6-330 days), of the time interval between diagnosis and reporting to mesothelioma registry (1-200 days), and of the survival time (8 days - alive at 31.12.2019).to obtain the best health pathways for malignant pleural mesotheliomas, it is necessary a strong network among the health regional services with a clinical multiprofessional coordination located in hospitals characterized by a long experience on these cases, and with an active regional monitoring on all clinical, psychological, epidemiological, and legal aspects of the pathway. The regional mesothelioma registries could give a high contribution thanks to their epidemiological skills which are necessary for the monitoring.

to evaluate the health impact of the emissions of two waste incinerators located in the same area in Pietrasanta (Tuscany Region, Central Italy) at the border with the municipality of Camaiore, especially for diseases suggested in previous studies to be related to those emissions.epidemiological geographic study.the study population was defined on the basis of residence in the two municipalities and in the areas characterized by Particulate Matter with diameter equal or less than 2.5 µm (PM2.5) and poli-chloro-dibenzo-dioxin / poli-chloro-dibenzo-furans (PCDD/F) pollution defined with a dispersion model. From the resident population, for each cancer case it was sampled a control, matched to case by gender and age at case's diagnosis, and for each premature and low-weight newborn a control matched was sampled by year of birth, gender, and mother's residence.standardized (standard: European population) mortality and hospitalization rates in the residents of the two municipalities were calculated for liver, larynx, lung cancer, soft tissue sarcoma (STM), non-Hodgkin lymphoma (NHL), multiple myeloma, leukaemia, flu-excluded respiratory diseases, and circulatory diseases. The risk related to each PM2.5 and PCDD/F pollution level from the old incinerator for cancer and from the new plant for reproductive outcomes was analysed using logistic conditional regression model adjusted by gender and age.the mortality and hospitalization rates observed in the study area are similar to those calculated for the Versilia area excluded the two municipalities under study. There is a higher case distribution in the higher pollution levels, with significant increases in the highest level: • liver cancer: PM2.5 OR 2.3 (95%CI 1.5-3.6); PCDD/F OR 4.4 (95%CI 2.8-7.0); • larynx cancer: PCDD/F OR 3.2 (95%CI 1.5-6.7); • lung cancer: PCDD/F OR 1.5 (95%CI 1.1-2.0); • NHL: PCDD/F OR 8.5 (95%CI 3.1-23.5); • leukaemia: PCDD/F OR 4.1 (95%CI 1.8-9.3). The risks estimated for STM, although non significant, are consistent with those obtained in previous studies undertaken in areas characterized by dioxin pollution. There is a deficit of premature births in the area under study compared to the regional area, and no differences are observed among the different pollution areas.it cannot be excluded that the emissions from the old incinerator had a health impact on the population living in the neighbourhood. Nevertheless, it is possible that other risk factors (occupations and life styles) could have had a role on the obtained results. Better estimates could be obtained also taking into consideration the residential histories of the subjects under study.

in Italy and Tuscany the resident population agedgt; 99 reached its all-time high in 2015. Respiratory diseases in men and ischemic heart diseases in women were the leading causes of death for Italian centenarians in 2015. The aim of this study is to describe the mortality of Tuscan centenarians by cause.population-based observational study using current health data, extracted from the Tuscan Regional Mortality Register. Main outcome measures are: proportional mortality and annual mortality trend at agegt;99, age-specific mortality rates (85-89; 90-94; 95-99,gt;99).at agegt;99 ischemic heart diseases, cerebrovascular diseases and respiratory diseases are among the top 5 causes of death as in the less elderly age, the relative frequency of tumors decreases and that of the ill-defined causes increases. If ill-defined and ischemic heart diseases are separated, the first cause of death is cerebrovascular diseases in males and senility in females. In the period 2002-2015 at agegt;99 all-cause mortality fell on average every year by -0.15% for males and -0.14% for females, mortality due to arteriosclerosis decreases -10% (males) and -12% (females) every year, due to cardiac arrest and other non-specific cardiopathies -5% (males) and -7% (females) and due to cerebrovascular diseases -3% (females). Mortality due to senility increases +6% per year in women.in Tuscany the first cause of death is different by gender (cerebrovascular diseases in males and senility in females) and differs from what has been observed nationally. In the 2000s, mortality from cardiovascular diseases without diagnostic significance decreased in Tuscan centenarians and that from senility increased.

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.

The identification and monitoring of occupational cancer is an important aspect of occupational health protection. The Italian law on the protection of workers (D. Leg. 81/2008) includes different cancer monitoring systems for high and low etiologic fraction tumors. Record linkage between cancer registries and administrative data is a convenient procedure for occupational cancer monitoring. We aim to: (i) Create a list of industries with asbestos exposure and (ii) identify cancer cases who worked in these industries. The Italian National Mesothelioma Registry (ReNaM) includes information on occupational asbestos exposure of malignant mesothelioma (MM) cases. We developed using data from seven Italian regions a methodology for listing the industries with potential exposure to asbestos linking ReNaM to Italian National Social Security Institute (INPS) data. The methodology is iterative and adjusts for imprecision and inaccuracy in reporting firm names at interview. The list of asbestos exposing firms was applied to the list of cancer cases (all types associated or possibly associated with asbestos according to International Agency for Research on Cancer (IARC) monograph 100C) in two Italian regions for the indication of possible asbestos exposure. Eighteen percent of the cancer cases showed at least one work period in firms potentially exposing to asbestos, 48% of which in regions different from where the cases lived at diagnosis. The methodology offers support for the preliminary screening of asbestos exposing firms in the occupational history of cancer cases.

changing of life expectancy at birth (LE) over time is an important indicator of welfare and healthcare infrastructure of a Country.to evaluate the impact of age and cause-specific mortality on the change in LE in the Tuscany Region (Central Italy).the decomposition of LE gain was realized with Pollard's method, using Epidat software.mortality data relative to residents that died during the period 1987-2015 were provided by the Tuscan Regional Mortality Registry. The analyzed causes of death were cardiovascular (CVS), respiratory (RESP), infective (INF) diseases and cancer (TUM).changing of LE expressed in years in relation to cause and age-specific mortality.the overall LE gain was 6.5 years for males and 4.3 years for females, the major gain was observed in the age groups 65-89 years (for females 75-89 years) and1 year. The highest gain (2.6 years) was attributable to the reduction of mortality for CVS, followed by TUM (males: 1.42 vs females: 0.83) and RESP (males: 0.4 vs females: 0.1). The causes responsible for the loss of LE were INF (females: -0.16 vs males: -0.07) and lung cancer in females (-0.13).the prompt treatment of acute CVS events and prevention (both primary and secondary) are responsible for the gain in LE. The reduction of mortality for TUM can be attributed to the evolution of diagnostic-therapeutic possibilities, but also to the implementation of the cancer screening programmes. Lung cancer was responsible for the loss of LE in Tuscan females; the targeted anti-smoke campaigns should, therefore, be intensified. The INF comported the loss of LE; explainable by diffusion of multi-drug resistant bacteria. The programmes of Hospital Infection Control and Antimicrobial Stewardship should be potentiated to contain the phenomenon.

Introduction The epidemiologic transition describes the reduction of mortality for infectious diseases (ID), followed by an increase in prevalence of non-communicable diseases. During recent years the situation has changed; an increase in mortality for sepsis was observed. Italy is amongst the countries with the highest prevalence of microorganisms resistant to antimicrobial therapy in Europe. The aim of the present work was to evaluate the impact of mortality for ID on life expectancy (LE) in the Tuscany region(Italy). Methods Mortality data relative to residents that died during the period 2000/2002- 2013/2015 were provided by the Tuscan Regional Mortality Registry. At first the analysis was performed for whole territory, then for geographic area (Nord-Est:NE, Centrum:C, South-East:SE). The analysis was realized with software Epidat,using the Pollard's method of decomposition of variations in LE for age and cause of death. Results The overall gain in LE was 2.9 years for males and 2.6 years for females. The increase in mortality for ID was responsible for the loss of 0.11 years of LE for males vs. 0.16 years for females. The loss was observed in males aged 45-89, for females from 69 years onwards, with the highest loss between 79-89 years. After analysis for area, geographical differences emerged, for both males and females the highest loss of LE was observed for NE (-0.23 years vs.-0.19), followed by C (-0.15 years vs. -0.16) and SE (-0.12 vs. -0.11). Conclusions The result can be partially explained by the transition from ICD-9 to ICD-10 (in 2010), which improved the sensitivity of codification, but also by diffusion of pathogens resistant to antimicrobial therapy. The highest impact of ID was observed in elderly, probably due to the existence of predisposing clinical condition. The ID deserve major attention; the programmes of hospital infection control and antimicrobial stewardship have to be potentiated in order to contain the phenomenon. Key messages During the study period an increase in mortality for infectious diseases comported the loss in terms of LE years. The growing diffusion of microorganisms resistent to antimicrobial therapy could have contributed to the higher mortality rates observed during the last period.

Objectives: The aim of this research was to examine socioeconomic disparities in quitting smoking and the association between socioeconomic status (SES) and steps in the smoking cessation pathway.M...

In an area characterized by the presence of a plant that recycles and refines precious metals the study aims to evaluate the exposure to the plant emissions of the residents in the neighbourhood using human urinary biomarkers, in comparison with those obtained in a reference and in an urban area and with the data concerning dispersions of plant emissions obtained through a specific diffusional model. 153 subjects in the study area, 95 in the urban area and 55 in the reference area, aged 18–60 years, answered to a self-administered questionnaire and collected their 24-h urine. Urinary concentrations of antimony, silver, cadmium, cobalt, chromium, mercury, nickel, platinum, creatinine, and the porphyrin patterns were detected. The results for the 3 areas were compared using parametric and non-parametric tests. Significant higher concentrations of mercury, cadmium, silver and nickel are observed in the study area in comparison with the reference area, but no differential distribution was observed by different levels of environmental pollution defined by the study's diffusion model, and no correlation was found between the concentrations of altered urinary porphyrin and metals. Life styles being equal, residents in the study area as well as residents in the urban area have high urinary levels of mercury, silver and nickel in comparison with the reference area, suggesting common environmental pressures probably related to diffuse gold processing activities, suggesting common environmental pressures. The excess of cadmium only in the study area suggests a role played by exposure to plant emissions, even if a differential distribution was not observed by different levels of environmental pollution.

Introduction Changing of life expectancy at birth (LE) over time reflects variations of mortality rates of a certain population. Italy is amongst the countries with the highest LE, Tuscany ranks fifth at the national level. The aim of the present work was to evaluate the impact of various causes of death in different age groups on the change in LE in the Tuscany region (Italy) during period 1987-2015. Material and methods Mortality data relative to residents that died during the period between 1987/1989 and 2013/2015 were provided by the Tuscan Regional Mortality Registry. The causes of death taken into consideration were cardiovascular (CVS), respiratory (RESP) and infective (INF) diseases and cancer (TUM). The decomposition of LE gain was realized with software Epidat, using the Pollard’s method. Results The overall LE gain during the period between two three-years periods was 6.7 years for males, with a major gain between 65-89, and 4.5 years for females, mainly improved between 75-89, Conclusions During the study period (1987-2015) the gain in LE was major for males. To the reduction of mortality for CVS have contributed to the tempestuous treatment of acute CVS events and secondary CVS prevention. For TUM the result is attributable to the adherence of population to oncologic screening programmes. The excess of mortality for INF that lead to the loss of LE can be attributed to the passage from ICD-9 to ICD-10 in 2003 (higher sensibility of ICD-10) and to the diffusion of multi-drug resistant bacteria, which lead to elevated mortality in these years. Key messages The gain in LE during the period the 1987-2015 was higher in males. The major contribution to gain in LE was due to a reduction of mortality for CVS diseases.

Background Multiple sclerosis (MS) is the immune-mediated inflammatory disease affecting myelinated axons of the central nervous system with enormous socio-economic impact. The aim of this study was to analyze mortality trends for MS in Italy. Methods The mortality data relative to period 1980-2015 were provided by Italian Institute of Statistics, data were aggregated in 5 intervals (1980-1986; 1987-1993; 1994-2000; 2001-2008; 2008-2015). The Age-Standardized mortality Rates (SR) with respective 95% confidence intervals (95%CI) were calculated (using the European standard 2013) in order to evaluate the mortality trends (in confrontation to the initial period) and Standardized Mortality Ratios (SMR), in order to confront mortality in 5 major geographic areas: North-East (NE), North-West (NW), Central Italy (CI), South Italy (SI) and Islands (I). Results During the study period 4959 deaths for males and 7433 for females were observed. The SRs were significantly higher for females (0.71;95%CI:0.70-0.73 vs. 0.56; 95%CI:0.54-0.57). Significantly higher SMR were observed for both sexes in I (M:123.3 vs F:112.7), for females also in NE (106.5) and NW (115.8). Significantly lower SMR for both sexes were observed in SI (M:88.8; F:71.4) and for males in CI (90.9). The observed SRs during the five intervals for males were: 0.65(95%CI 0.60-0.69); 0.52 (95%CI 0.49-0.56); 0.46 (95%CI 0.43-0.49); 0.53 (95%CI 0.49-0.56); 0.59 (95%CI 0.56-0.62); and for females: 0.69 (0.65-0.73); 0.69 (0.65-0.73); 0.61 (0.58-0.65); 0.68 (0.65-0.72); 0.81(0.77-0.84); respectively. An initial decrease of SRs was observed for males until 2001-2007 in confrontation to the initial period (p < 0.05). For females significant increase of SRs was observed in 2008-2015 (p < 0.05). Conclusions An increase of mortality for MS, observed for females, especially after 2000 may reflect the raising prevalence of MS in Italy. Important geographical differences were observed for five main areas. Key messages During the study period an increase of mortality for MS was observed for females. Important differences were observed between five main Italian geographic areas.

MPM is one of the most serious professional cancer with a high frequency in subjects previously exposed to asbestos. Several trials have been made or are ongoing to define an effective therapy to allow a longer survival and to reduce its burdensome management by the health systems. The few MPM Care Pathways (CP), which have been suggested by groups of experts of scientific community, are only a list of practicable interventions without the structure of a pathway so the aims of this paper are the declination of possible cases of a MPM CP and the quantification of the costs using a regional consensus CP, verifying its application. The diagnostic and therapeutic procedures of the regional CP were defined starting to a sample of 34 patients treated in public regional hospitals for MPM, diagnosed in 2015, and having.at least a one year follow up. The costs were attributed using the regional price list for outpatient health activities and the DRG for hospitalized activities. The formed cost accounting model was applied in order to calculate the cost for the public regional administration. Last, the obtained results were discussed with surgical thoracic surgeons of the three regional university hospitals. The developed cost accounting model has identified three cases of a MPM CP. They present a common diagnostic phase (7.246,90€) following by three possible treatments, differently combinable between them: surgery (10.808,00€), chemotherapy (164,00€ + drug cost for access) and observation (41,00€). The cost will be due to the specific combination of the three treatments plus the diagnostic phase, predictable according to patient’s age and staging, which can afford each patient affected by MPM. The contribution of the cost accounting model applied to the consensus regional CP for MPM allows to assess the care’s appropriateness of the cases actually treated. It could be used also for CPs of other diseases and as a method for institutional financing of the route. Key messages Relevance of a shared Care Pathway realisation for a rare, highly letal and complex professional disease. An accurate and scientific costs analysis model to a C is an innovation.

to estimate the number of deaths from noncommunicable chronic diseases (NCD) attributable to behavioural risk factors (tobacco smoking, unhealthy nutrition, physical inactivity, overweight, and excessive alcohol use) in 2016 for Italy and for the Italian regions.descriptive study.mortality data were obtained by the Italian National Institute of Statistics. Causes of deaths from NCD associated with the five RFs were selected. Italian attributable fractions were obtained by the 2016 estimates of the Global Burden of Disease Study and applied to the mortality data. Regional prevalence of risk factors was obtained by the national surveillance system PASSI for the years 2013-2016.absolute number of attributable deaths, joint attributable fraction, proportion of total deaths attributable to RFs (MAprop).about 191,000 out of 614,307 deaths occurred in Italy in 2016 were attributable to combined RFs (about 37% in males; 26% in women). Joint MAprop was between 33% in men (24% in women) from Val d'Aosta and 40% in men (31% in women) from Campania. In Italy, 17% and 6% of the total amount of deaths were attributable to smoking in men and women, respectively; 6% and 3% to alcohol abuse; 7% and 8% to overweight; 13% and 12% to dietary RFs, and 2% and 3% to low physical activity. The higher proportion of attributable deaths by age-group was recorded in people aged 40-59 years (43% in men; 28% in women). Regional differences in attributable deaths are confirmed by regional RF prevalence recorded by the PASSI surveillance system for the years 2013-2016.these are the first estimates of the number of deaths due to NCDs attributable to behavioural RFs estimated for each region and for Italy as a whole. Effective primary prevention policies should be reinforced, since these RFs are potentially modifiable.

Our aim was to provide a systematic review of studies on the burden of disease due to second-hand smoke (SHS) exposure, reviewing methods, exposure assessment, diseases causally linked to SHS, health outcomes, and estimates available to date. A literature review of studies on the burden of disease from SHS exposure, available in PubMed and SCOPUS, published 2007–2018 in English language, was carried out following the PRISMA recommendations. Overall, 588 studies were first identified, and 94 were eligible. Seventy-two studies were included in the systematic review. Most of them were based on the comparative risk assessment approach, assessing SHS exposure using mainly surveys on exposure at home/workplaces. Diseases more frequently studied were: lung cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, asthma and breast cancer in adults; lower respiratory tract infection, otitis media, asthma, sudden infant death syndrome and low birth weight in children. The SHS exposure assessment and the reported population attributable fractions (PAF) were largely heterogeneous. As an example, the PAF from lung cancer varied between 0.6% and 20.5%. Moreover, PAF were estimated applying relative risks and SHS exposures with no consistent definitions or with different age classes. The research gap on the SHS exposure burden is shrinking. However, estimates are not yet available for a number of countries, particularly the Middle Eastern and African countries, and not all diseases with the strongest evidence of causation, such as sudden infant death syndrome, have been explored. Moreover, in some cases the applied methodology revealed relatively low quality of data. info:eu-repo/semantics/acceptedVersion

Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017. The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%. The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home.

The current study examined symptoms of irritation reported by non-smokers passively exposed to e-cigarette aerosols and their timing and association with the concentrations of volatile organic compounds (VOCs) produced.40 healthy non-smoking adults were exposed to e-cigarette aerosols for 30 min in a 35 m20 males and 20 females, with a mean age of 24.6 years (SD = 4.3) and exhaled CO 7 ppm participated. PM concentrations in both experimental sessions were higher than the Control (p 0.001). The most commonly reported symptoms were burning, dryness, sore throat, cough, breathlessness and headache. During both experimental sessions, ocular, nasal, throat-respiratory symptoms and general complaints increased significantly (p 0.05). Ocular and nasal symptoms returned to baseline by tA 30-min exposure to SHA provoked symptoms of sensory irritation and general complaints that lasted up to 30 min after the exposure and were positively associated with the concentrations of the VOC mixture emitted.

Introduction Aim: After the classification of second-hand smoke (SHS) as a known human pulmonary carcinogen by International Agency for Research on Cancer, most Countries of the European Union (EU) introduced smoking ban at workplaces and public places. Main aim of this study was to study trend of SHS exposure at work, 2006-2014. Material and Methods Figures were collected in four cross-sectional surveys representative of population of each EU Country. Surveys were conducted in 2006, 2010, 2012, 2014 (Eurobarometer 66.2, 72.3, 77.1, 82.4) in all 28 EU Countries. The question on SHS exposure at work was recorded in both smokers and non-smokers: “How long are you exposed to tobacco smoke at your workplace?” Possible answers were: 5 hours a day; Never or almost never; don’t know, In the 2012 and 2014 surveys a new category was added: “occasionally exposed”. Results Prevalence of exposure to SHS at work decreased by around 70% from 2006 to 2014. The drop was recorded since 2010 for exposures for ≥1 hour per day, whereas the exposure to

Asbestos-related diseases are characterized by a long latency time since exposure. This accounts for a health surveillance programme addressed to asbestos workers to be performed for decades after the cessation of occupational exposure. We describe the health surveillance programme for former asbestos-exposed workers in Tuscany Region (Central Italy), with particular attention to organization and related critical issues. The Deliberation of the Regional Administration of Tuscany (No. 396/2016) supports the programme, defined by a regional group of experts, and defines the public health services where the programme has to be implemented. The programme activities are classified in two levels: a first level for a basic health evaluation and a second level for in-depth analyses. The former asbestos workers, aged less than 80 years and with cessation of occupational asbestos exposure in the last 30 years, that might be included free of charge in the programme are about 5.600. The funds assigned to develop the programme from 2016 to 2024 were 2,044,808 euros. The Regional Administration of Tuscany decided to offer and guarantee a homogeneous programme in the whole region. The identification of a specific public health programme and the cooperation of social stakeholders, defined with specific regional agreements, might facilitate to overcome the problems which are still open, such as a broaden invitation to adhere to the programme, an extended knowledge on the service, and the application of a similar health programme for still-working former asbestos workers.

Smoking cessation is the key cancer and cardiovascular disease (CVD) prevention action for smokers; however, smokers can still benefit from earlier diagnosis. This study aims to investigate behaviours towards cancer and CVD prevention by smoking habits in Italy. The study relies on data from a large Italian population-based survey carried out in 2013 on a sample of 119 073 individuals. We studied the relationship between smoking habits and the participation in cancer (cervical, breast and colorectal) screening programmes, or CVD prevention (performing cholesterol, blood pressure and glycaemia exams) using a multilevel logistic regression model. Only 11.4, 40.1 and 8.0% of the subsamples attended cervical, breast and colorectal cancer screening, respectively, whereas CVD prevention registered higher attendance: 83.3, 66.4 and 58.1%, respectively, for cholesterol, blood pressure and glycaemia. Smokers were less likely to undergo Pap smear compared with nonsmokers [odds ratio (OR): 0.70; 95% confidence interval (CI): 0.57-0.87], whereas former smokers showed a higher attendance for breast and colorectal cancer screening (OR: 1.25; 95% CI: 1.14-1.37 for breast, OR: 1.21; 95% CI: 1.07-1.38 for colorectal cancer). Former smokers were also more likely to perform CVD prevention. Moreover, CVD prevention was inversely related to smoking (OR: 0.84; 95% CI: 0.74-0.96 for cholesterol; OR: 0.86; 95% CI: 0.79-0.93 for blood pressure; OR: 0.61; 95% CI: 0.54-0.69 for glycaemia). Particular attention should be paid to involve smokers in prevention checks. Research aimed at understanding smokers' pessimistic attitudes, which may determine smokers' prevention avoidance, and at improving smokers' engagement with prevention is needed and may help increase the reach of supported smoking-cessation programmes.

Finkelstein1 invited physicians and researchers interested in mesothelioma to investigate on past usage of talcum powders by affected people. In Italy, asbestos contamination in talc for industrial use has been documented,2 and, as he underlines tremolite contamination at low levels of cosmetic and pharmaceutical talc has been reported in USA by Blount3 and Gordon and colleagues.4 In the Italian National Mesothelioma Register (ReNaM), the analysis of intensive exposure to talc has been evaluated with respect to occupational and environmental history. The catalogue of possible asbestos exposure circumstances (a tool for the interviewers) reports the potential presence of industrial talcs in quarries or mines working activities, in leather tanning and in rubber industries. The use of intensive cosmetic talc for personal use is evaluated by means of a structured questionnaire,5 as reported in the ReNaM guidelines (see https://www.inail.it/cs/internet/docs/all-linee-guida-renam.pdf%3Fsection=attivita, p82, p98, in Italian). In our paper regarding gender differences in mesothelioma epidemiology,6 we have presented figures referring to 21 463 MM cases detected by ReNaM with a diagnosis between 1993 and 2012. Among female case list (6087 cases), 4374 cases (71.9%) have been interviewed for defining exposure. During the interview, 30 MM female cases referred an intensive use of talc in the context of occupational or life habits. For five of them, the regional centre has identified an exposure to asbestos due to intensive talc use, classifying such modality of exposure as ‘leisure activities’ (see ReNaM guidelines5). For the remaining 25 cases, an occupational exposure to asbestos in other working (or familiar or environmental) circumstances has been identified and coded. Registry data such as those provided by ReNaM cannot provide estimates of the mesothelioma risk associated with any particular exposure circumstance. We plan to include talc exposure at work and cosmetic talc usage in the analyses of a case–control study on pleural mesothelioma currently under way. A specific survey to compare and discuss how the modalities of exposure to talc have been evaluated in patients with mesothelioma in countries where epidemiological surveillance systems are active could improve knowledge and support prevention policies.

Asbestos-related diseases usually have a long latency since first exposure and this legitimates a health surveillance programme addressed to asbestos workers after the cessation of their occupational exposure. After a brief history of health surveillance initiatives performed in Italy as well as in other countries, we describe a regional programme for former asbestos-exposed workers, focusing on organizational features. A regional group of experts defined its operational and economical aspects. The Regional Council supported the whole programme, making it free of charge for all subjects who fulfil the predefined enrolment criteria (being resident in the region, being younger than 80 years old with cessation of occupational asbestos exposure within the last 30 years). The programme activities are classified in two levels: a first level for a basic health evaluation and a second level for in-depth analyses. In order to guarantee an homogeneous delivery in the whole region, the programme has to be performed by public health services with a quality control of activities. The involvement of specific public health services and the cooperation of social stakeholders are expected to play a major role in overcoming still open critical issues, such as the lack of programme existence awareness and adhesion, the correct stratification of subjects for the follow-up, and the real homogeneous delivery of the health surveillance in whole region.

Chronic silica exposure has been associated to cancer and silicosis. Furthermore, the induction of oxidative stress and the generation of reactive oxygen species have been indicated to play a main role in the carcinogenicity of respirable silica. Therefore, we conducted a cross-sectional study to evaluate the prevalence of 3-(2-deoxy-β-D-erythro-pentafuranosyl)pyrimido[1,2-α]purin-10(3H)-one deoxyguanosine (M 1 dG) adducts, a biomarker of oxidative stress and peroxidation of lipids, in the nasal epithelium of 135 silica-exposed workers, employed in pottery, ceramic and marble manufacturing plants as well as in a stone quarry, in respect to 118 controls living in Tuscany region, Italy. The M 1 dG generation was measured by the 32 P-postlabelling assay. Significant higher levels of M 1 dG adducts per 10 8 normal nucleotides were observed in the nasal epithelium of smokers, 77.9 ± 9.8 (SE), and in those of former smokers, 80.7 ± 9.7 (SE), as compared to non-smokers, 57.1 ± 6.2 (SE), P = 0.001 and P = 0.004, respectively. Significant increments of M 1 dG adducts were found in the nasal epithelium of workers that handle artificial marble conglomerates, 184 ± 36.4 (SE), and in those of quarry workers, 120 ± 34.7 (SE), with respect to controls, 50.6 ± 2.7 (SE), P = 0.014 and P

to evaluate mortality in immigrants dwelling in Tuscany Region (Central Italy) compared to mortality data relating to the Italian population residing in the same region.cross-sectional descriptive mortality study relying on a unique data source, i.e., the Regional Mortality Registry of Tuscany, for the period 1997-2013.in the analysis, immigrants residing in Tuscany were included; Italian residing in the same region were the comparison population. Immigrants were divided into two categories: immigrants from Countries at High Migration Rates (CHMRs) and immigrants from Developed Countries (DCs).proportional general and cause-specific mortality by age and gender for the period 1997-2013; trends of standardized truncated (age 20-64) mortality rates for the Italian population, and for immigrants from CHMRs and from DCs for the period 2002-2013; standardized mortality ratios (SMRs) in people from CHMRs with confidence interval at 95% (95%CI) for all causes and cause-specific mortality.during 1997-2013, 4,681 deaths were recorded among immigrants, 3,005 of which were in immigrants from a CHMR. Both cause-specific and general mortality trends in Italians and in immigrants from DCs are lowering, while general mortality of immigrants from CHMRs seems to have risen in the last 5 years. Mortality of people from CHMRs for all causes, cardiovascular causes, and cancer is permanently lower than Italian population's mortality in the examined period, but the gap seems to progressively reduce. On the other hand, child mortality among immigrants from CHMRs, despite a declining trend, is consistently higher than Italian population's mortality. Following the SMR analysis, the only exceeding cause of mortality in people from CHMRs - compared to the Italian population - is homicide among men (SMR: 3.46; 95%CI 1.55-5.59).this study updates our knowledge on immigrants' mortality - and, indirectly, on their health status - in Tuscany. The gap between mortality of Italians and immigrants from CHMRs is reducing: this could be partially explained by a successful ongoing integration process. For future analyses, it would be important to obtain more complete data relative to non-resident immigrants' mortality, as their number is constantly increasing.

"Non-communicable diseases cause more than 80% of deaths in europe and, among these, 20% are caused by cancer. Modifiable lifestyle factors considered in the italian national programme "Guadagnare salute" (Gaining health), such as tobacco smoking, unhealthy diet, physical inactivity, overweight, and excessive alcohol use, are amongst the major causes of cancer deaths. The aims of this study was to estimate the number of deaths attributable to lifestyle factors for italy and for italian regions in 2013 and to describe its variation in relation to the regional prevalence of risk factors exposure. For Italy and for each italian region, deaths attributable to lifestyle factors were estimated using the methodology of the Global Burden of disease (GBd) study. italian mortality data of 2013 and risks attributable to these lifestyle factors for each cancer site for italy from the GBd study were used. Prevalence of exposure to lifestyles in Italy and in each Italian Region was collected for the period 2008-2013. In 2013, at least 66,605 cancer deaths in italy were attributable to lifestyle factors, accounting for 37.9% of all cancer deaths: 34.1% of cancer deaths in men and 9.0% in women were attributable to smoking; in men and women, respectively, 3.3% and 2.8% were attributable to excessive alcohol consumption; 5.3 % and 6.7% to overweight; 10.1% and 7.1% to dietary risk factors; 1.9% and 4.2% to physical inactivity. A moderate variability of percentage of deaths attributable to modifi able lifestyle factors by region was also detected due to different prevalence values of exposure to lifestyles occurred in last decades. At least 45,000 cancer deaths in men and 21,000 in women occurred in 2013 were attributable to modifi able risk factors, whose prevalence varied by region and which could be averted through the implementation of primary prevention interventions."

Objective Asbestos is a known human carcinogen, with evidence for malignant mesothelioma (MM), cancers of lung, ovary, larynx and possibly other organs. MM rates are predicted to increase with a power of time since first exposure (TSFE), but the possible long-term attenuation of the trend is debated. The asbestos ban enforced in Italy in 1992 gives an opportunity to measure long-term cancer risk in formerly exposed workers. Methods Pool of 43 previously studied Italian asbestos cohorts (asbestos cement, rolling stock, shipbuilding), with mortality follow-up updated to 2010. SMRs were computed for the 1970–2010 period, for the major causes, with consideration of duration and TSFE, using reference rates by age, sex, region and calendar period. Results The study included 51 801 subjects (5741 women): 55.9% alive, 42.6% died (cause known for 95%) and 1.5% lost to follow-up. Mortality was significantly increased for all deaths (SMR: men: 1.05, 95% CI 1.03 to 1.06; women: 1.17, 95% CI to 1.12 to 1.22), all malignancies combined (SMR: men: 1.17, 95% CI to 1.14 to 1.20; women: 1.33, 95% CI 1.24 to 1.43), pleural and peritoneal malignancies (SMR: men: 13.28 and 4.77, 95% CI 12.24 to 14.37 and 4.00 to 5.64; women: 28.44 and 6.75, 95% CI 23.83 to 33.69 and 4.70 to 9.39), lung (SMR: men: 1.26, 95% CI 1.21 to 1.31; women: 1.43, 95% CI 1.13 to 1.78) and ovarian cancer (SMR=1.38, 95% CI 1.00 to 1.87) and asbestosis (SMR: men: 300.7, 95% CI 270.7 to 333.2; women: 389.6, 95% CI 290.1 to 512.3). Pleural cancer rate increased during the first 40 years of TSFE and reached a plateau after. Discussion The study confirmed the increased risk for cancer of the lung, ovary, pleura and peritoneum but not of the larynx and the digestive tract. Pleural cancer mortality reached a plateau at long TSFE, coherently with recent reports.

Objective Asbestos causes mesothelioma (MM) and cancer of lung, ovary, larynx and possibly other organs. Risk reduction after cessation of exposure and at long latency is debated. For MM, the predicted increase of rates with time since first exposure (TSFE) might be attenuated by fibre clearance. The ban of asbestos use in Italy gives an opportunity to measure long term risk in formerly exposed workers. Methods In a pool of 43 Italian asbestos cohorts (asbestos-cement, rolling stock, shipbuilding and other industries), standardised mortality ratios (SMRs) were computed for the major causes, with consideration of time factors (period, duration, latency). The functional relation between pleural cancer mortality rates and TSFE was evaluated using Poisson regression, including a term for fibre clearance. Results The study includes 54,409 subjects (6,054 women): 55.3% alive, 43.0% died (cause known for 94%; 789 pleural cancers), and 1.7% lost to follow-up. Mortality was increased for all causes (SMR = 1.06; p Discussion Our results provide information on the risk after asbestos exposure, even for rarer diseases. Increased risk for ovarian cancer is confirmed. Results agree with the hypothesis that pleural cancer risk, rather than increasing indefinitely, reaches a plateau at long latency, coherently with asbestos clearance from the lungs. As a consequence, early exposures to asbestos cannot be considered to be the exclusive determinant of the long term development of pleural cancer, with implications also for the risk related to non occupational exposure and for asbestos removal.

Introduction Due to the strong causal association with asbestos fibres, the distribution of incident malignant mesothelioma (MM) cases over time and space likely reflect different kinds of asbestos exposures occurring in the past, as previously demonstrated in several studies. Starting from the data of a disease-specific national registry, namely the Italian mesothelioma registry (ReNaM), a geographic cluster analysis was integrated with information about exposure, either occupational or non occupational, in order to trace patterns of asbestos exposure in Italy. Methods A total of 15,322 incident cases of all-site MM, recorded by ReNaM in the period 1993 to 2008 were analysed, corresponding to 11,852 occupational, residential and familial histories reconstructed by interview. Observed cases were mapped based on the municipality of residence at diagnosis and age-specific rates of the area where municipality was located was used to calculate expected cases. A Bayesian hierarchical model was applied to identify municipality clusters and each cluster was characterised by type and source of asbestos exposure of cases. Results Thirty-two clusters of MM were mapped. Asbestos manufacturing industries and shipbuilding and repair facilities were the more common sources of asbestos exposure, but other activity sectors, such as non-asbestos textile, metal engineering and construction had a relevant contribution in some clusters. Environmental asbestos exposure was detected more frequently in clusters with an asbestos cement industry or a natural source of asbestos-like fibres. Differences by gender among clusters were attributable to environmental fraction but also to high female employment in selected activity sectors, such as textile industry. Discussion This study while indirectly confirming the role of specific natural or industrial sources of asbestos exposure for mesothelioma risk, highlights the great public health implications of spatial tracing of asbestos exposure for risk prevention, health surveillance and welfare policies.