title: Epidemiological patterns of asbestos exposure and spatial clusters of incident cases of malignant mesothelioma from the Italian national registry.
abstract: BACKGROUND
  Previous ecological spatial studies of malignant mesothelioma cases, mostly based on mortality data, lack reliable data on individual exposure to asbestos, thus failing to assess the contribution of different occupational and environmental sources in the determination of risk excess in specific areas. This study aims to identify territorial clusters of malignant mesothelioma through a Bayesian spatial analysis and to characterize them by the integrated use of asbestos exposure information retrieved from the Italian national mesothelioma registry (ReNaM).
  
  
  METHODS
  In the period 1993 to 2008, 15,322 incident cases of all-site malignant mesothelioma were recorded and 11,852 occupational, residential and familial histories were obtained by individual interviews. Observed cases were assigned to the municipality of residence at the time of diagnosis and compared to those expected based on the age-specific rates of the respective geographical area. A spatial cluster analysis was performed for each area applying a Bayesian hierarchical model. Information about modalities and economic sectors of asbestos exposure was analyzed for each cluster.
  
  
  RESULTS
  Thirty-two clusters of malignant mesothelioma were identified and characterized using the exposure data. Asbestos cement manufacturing industries and shipbuilding and repair facilities represented the main sources of asbestos exposure, but a major contribution to asbestos exposure was also provided by sectors with no direct use of asbestos, such as non-asbestos textile industries, metal engineering and construction. A high proportion of cases with environmental exposure was found in clusters where asbestos cement plants were located or a natural source of asbestos (or asbestos-like) fibers was identifiable. Differences in type and sources of exposure can also explain the varying percentage of cases occurring in women among clusters.
  
  
  CONCLUSIONS
  Our study demonstrates shared exposure patterns in territorial clusters of malignant mesothelioma due to single or multiple industrial sources, with major implications for public health policies, health surveillance, compensation procedures and site remediation programs.
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. m.corfiati@inail.it.
authors.forename: Marisa
authors.initials: M
authors.lastname: Corfiati
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. a.scarselli@inail.it.
authors.forename: Alberto
authors.initials: A
authors.lastname: Scarselli
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. a.binazzi@inail.it.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Binazzi
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. d.dimarzio@inail.it.
authors.forename: Davide
authors.initials: D
authors.lastname: Di Marzio
authors.affiliation: Regional Operating Center of Valle d'Aosta (COR Valle d'Aosta), Valle d'Aosta Health Local Unit, Aosta, Italy. mverardo@ausl.vda.it.
authors.forename: Marina
authors.initials: M
authors.lastname: Verardo
authors.affiliation: COR Piedmont, Unit of Cancer Prevention, University of Turin and CPO-Piemonte, Torino, Italy. dario.mirabelli@cpo.it.
authors.forename: Dario
authors.initials: D
authors.lastname: Mirabelli
authors.affiliation: COR Liguria, Epidemiology and Prevention Department, National Cancer Research Institute (IST), Genova, Italy. valerio.gennaro@istge.it.
authors.forename: Valerio
authors.initials: V
authors.lastname: Gennaro
authors.affiliation: COR Lombardy, Department of Preventive Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Milano, Italy. carolina.mensi@unimi.it.
authors.forename: Carolina
authors.initials: C
authors.lastname: Mensi
authors.affiliation: COR Province of Trento, Provincial Unit of Health, Hygiene and Occupational Medicine, Trento, Italy. gert.schallenberg@apss.tn.it.
authors.forename: Gert
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authors.lastname: Schallemberg
authors.affiliation: COR Veneto, Occupational Health Unit, Department of Prevention, Padua, Italy. enzo.merler@sanita.padova.it.
authors.forename: Enzo
authors.initials: E
authors.lastname: Merler
authors.affiliation: COR Friuli-Venezia Giulia, University of Trieste -Trieste General Hospitals, Clinical Unit of Occupational Medicine, Trieste, Italy. negro@units.it.
authors.forename: Corrado
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authors.lastname: Negro
authors.affiliation: COR Emilia-Romagna, Health Local Unit, Public Health Department, Reggio Emilia, Italy. romanellia@ausl.re.it.
authors.forename: Antonio
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authors.lastname: Romanelli
authors.affiliation: COR Tuscany, Cancer Prevention and Research Institute, Unit of Environmental and Occupational Epidemiology, Firenze, Italy. e.chellini@ispo.toscana.it.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Chellini
authors.affiliation: COR Tuscany, Cancer Prevention and Research Institute, Unit of Environmental and Occupational Epidemiology, Firenze, Italy. s.silvestri@ispo.toscana.it.
authors.forename: Stefano
authors.initials: S
authors.lastname: Silvestri
authors.affiliation: COR Marche, Environmental and Health Sciences Department, University of Camerino, Hygienistic, Camerino, Italy. mario.cocchioni@unicam.it.
authors.forename: Mario
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authors.lastname: Cocchioni
authors.affiliation: COR Marche, Environmental and Health Sciences Department, University of Camerino, Hygienistic, Camerino, Italy. cristiana.pascucci@unicam.it.
authors.forename: Cristiana
authors.initials: C
authors.lastname: Pascucci
authors.affiliation: COR Umbria, University of Perugia, Department of Hygiene and public health, Perugia, Italy. fabs@unipg.it.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Stracci
authors.affiliation: COR Lazio, Department of Experimental Medicine, University La Sapienza, Roma, Italy. e.romeo@deplazio.it.
authors.forename: Elisa
authors.initials: E
authors.lastname: Romeo
authors.affiliation: COR Abruzzo, Health Local Unit, Occupational Medicine Unit, Pescara, Italy. medlav.tocco@virgilio.it.
authors.forename: Luana
authors.initials: L
authors.lastname: Trafficante
authors.affiliation: COR Campania, Department of Experimental Medicine, Second University of Naples, Napoli, Italy. italof.angelillo@unina2.it.
authors.forename: Italo
authors.initials: I
authors.lastname: Angelillo
authors.affiliation: COR Campania, Department of Experimental Medicine, Second University of Naples, Napoli, Italy. simonamenegozzo@alice.it.
authors.forename: Simona
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authors.lastname: Menegozzo
authors.affiliation: COR Puglia, Department of Internal Medicine and Public Medicine, University of Bari, Section of Occupational Medicine "B. Ramazzini", Bari, Italy. m.musti@medlav.uniba.it.
authors.forename: Marina
authors.initials: M
authors.lastname: Musti
authors.affiliation: COR Puglia, Department of Internal Medicine and Public Medicine, University of Bari, Section of Occupational Medicine "B. Ramazzini", Bari, Italy. d.cavone@medlav.uniba.it.
authors.forename: Domenica
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authors.lastname: Cavone
authors.affiliation: COR Basilicata, Epidemiologic Regional Center, Potenza, Italy. gabriella.cauzillo@regione.basilicata.it.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Cauzillo
authors.affiliation: COR Calabria, Public Health Unit, Crotone, Italy. federicotallarigo@libero.it.
authors.forename: Federico
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authors.lastname: Tallarigo
authors.affiliation: COR Sicily, "Civile - M.P. Arezzo" Hospital, Ragusa Cancer Register Unit, Ragusa, Italy. rtumino@tin.it.
authors.forename: Rosario
authors.initials: R
authors.lastname: Tumino
authors.affiliation: COR Sardegna, Regional Epidemiological Center, Cagliari, Italy. massimelis@gmail.com.
authors.forename: Massimo
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authors.lastname: Melis
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. s.iavicoli@inail.it.
authors.forename: Sergio
authors.initials: S
authors.lastname: Iavicoli
authors.affiliation: Epidemiology Unit, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Rome, Italy. a.marinaccio@inail.it.
authors.forename: Alessandro
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authors.lastname: Marinaccio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001194:Asbestos / Q000009:adverse effects*; D001499:Bayes Theorem; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D004781:Environmental Exposure / Q000009:adverse effects*; D005260:Female; D005843:Geography; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007558:Italy / Q000453:epidemiology; D008175:Lung Neoplasms / Q000453:epidemiology* / Q000209:etiology*; D008297:Male; D008654:Mesothelioma / Q000453:epidemiology* / Q000209:etiology*; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D012042:Registries; D062206:Spatial Analysis; D055815:Young Adult
chemical_list: D001194:Asbestos