Asbestos Ban in Italy: A Major Milestone, Not the Final Cut
2. Asbestos in Italy and the Steps Leading to the Law Banning Asbestos
3. Implementing Asbestos Policies after the Ban in Italy
- Public policies for asbestos substitutes. During the 1980s, when the knowledge of the health risks caused by asbestos was spreading, some industries researched possible substitute materials to replace asbestos without compromising their technological functionality . Since there was a risk that the new materials would have been mistakenly considered harmless just because they did not contain asbestos and were therefore used without any precaution, guidelines for their safe use were provided . Asbestos substitutes were selected on the basis of the size of the fibres and their possible solubility in the respiratory system. It is well known that asbestos fibres fracture longitudinally, thus producing fibres with an even smaller diameter while keeping the length unaltered. Most of these materials were and are still made of man-made mineral fibres (MMMF) such as glasswool, rockwool, slagwool and ceramic fibres [34,35,36,37,38,39,40,41]. IARC published a monograph that classified MMMFs as possibly carcinogenic to humans, allocating them in group 2B , but in 2002 it only retained ceramic fibres in this class and moved the others into group 3, that is, “not classifiably as to carcinogenicity to human” . The choice of a substitute material among MMMFs could be done taking the following into account: (i) filaments are preferable to wool, where technical requirements allow it, as their geometric diameter prevents them from being breathed in; (ii) glass materials are preferable because they are more soluble in biological liquids, even more so if the material to be used must necessarily be mineral wool. Since the ban, the products that employed the largest quantities of the mineral (asbestos-cement and friction materials) are now manufactured with cellulose mixed up with cement, organic artificial fibres (kevlar) and inorganic (MMMF) mixed up with phenolic resins. From a strictly economical point of view, substitutes are on average more expensive than asbestos. However, it should be said that if the manufacturing of asbestos products had always been performed with dust control systems, its cost would never have been competitive. Asbestos cannot be replaced by just one single material. Every application generally requires a specific material. Most substitutes are not classified as carcinogenetic or queried as carcinogenetic except for ceramic fibres. From a technological point of view, replacement of asbestos with other materials has now been successful in 100% of cases.
- National surveillance system of mesothelioma incidence. After the 1992 asbestos ban in Italy, there was a growing need for epidemiological surveillance of malignant mesothelioma incident cases, consistently with European Directive 83/477/CEE . A permanent surveillance system of mesothelioma incidence was set up in 2002 by the National Register of Malignant Mesotheliomas (Registro Nazionale dei Mesoteliomi, ReNaM in Italian). The aims of ReNaM (set by law) are to identify cases, estimate mesothelioma incidence, assess asbestos exposure, particularly recognize unknown sources of contamination, and finally promote research projects. ReNaM has a regional organization: a Regional Operating Centre (Centri Operativi Regionali—COR, in Italian), which has been gradually established in all 20 Italian Regions. Each COR works by applying the national standardized methods, described in the national Guidelines . By December 2016, ReNaM had gathered 27,035 MM cases, referring to the period of incidence between 1993 and 2015, and the modes of exposure to asbestos were investigated for 21,108 of them (78%). The epidemiological findings are described and discussed in details in ReNaM national reports . The systematic collection of mesothelioma incident cases and of economic activities involved in asbestos exposure made it possible to have reliable information on the time-trend of the occurrence of disease , the territorial clusters of incident cases and their causes , the characteristics and extent, of environmental and familial modes of exposure, estimating the current weight of non-occupational exposure around 10% of cases . Furthermore, the median period of latency and the determinants of survival rates have been estimated and discussed [47,48]. The aforementioned figures are important to correctly interpret the epidemic curve of mesothelioma in Italy, which so far has not yet decreased. The analysis of the occupations reported by the cases and their next of kin’s have contributed to improving compensation procedures . Mesothelioma registration in Italy, besides providing a description of the occurrence of mesothelioma at a national level, has been crucial in interpreting localized clusters of mortality for malignant pleural cancer. This was the case in Biancavilla (Sicily) were mortality figures suggested the occurrence of an excess risk of pleural mesothelioma that was confirmed with respect to diagnostic procedures, risk estimates and causal agent, a previously unknown asbestiform fibre, subsequently named fluoro-edenite and classified by IARC as carcinogenic for humans [50,51,52,53]. The epidemiological systematic surveillance of asbestos-related diseases incidence, thus, is fundamental in preventing asbestos exposure, to support the efficiency of insurance and welfare systems and for producing epidemiological evidences.
- Health surveillance for asbestos ex-exposed subjects and asbestos exposed workers. After the national ban, health surveillance of workers still exposed to asbestos, i.e., those engaged in the maintenance, removal and disposal of asbestos containing materials, continued to be the employer’s responsibility and liability [31,54,55]. As regulated by Decree n. 257/2006  and fine-tuned by art. 259 under the Decree n. 81/2008  and subsequent updates, the asbestos exposed workers currently undergo a medical examination by an occupational health physician at least every three years. The examination includes lung function tests and, whenever required according to updated scientific knowledge, radiological or other diagnostic tests . Exposure registries are also filled in at company/plant levels and transmitted to both the National Health System inspection authorities and, for epidemiologic purposes, to the Italian workers’ compensation authority (INAIL). The need to monitor the health status of workers after the cessation of asbestos exposure has been also considered in the Italian legislation since a medical examination at the end of the working life has been mandatory since the mid-1990s. In the course of the examination, the company doctor must inform workers about long-term possible adverse effects. Regional Governments are responsible for health facilities and different procedures were adopted by the various Italian regional administrations . A great number of experiences of health care programs targeted to formerly exposed workers were conducted at regional or local levels, mainly involving the Prevention, Health and Safety at Work Services of the Local Health Units of the National Health System [57,58]. A joint WHO and Italian National Institute of Health research project “Cohort Studies in Areas of High Environmental Risk in Sicily” investigated, inter alia, former workers of an asbestos-cement plant located in San Filippo del Mela, near Messina (Sicily), in the Milazzo–Valle del Mela area. One of the project’s goals was to study the feasibility of a medical surveillance programme of former asbestos workers [59,60]. To standardize procedures and offer the same the health services and benefits to ex-exposed workers and patients, CCM (Center for Diseases Prevention and Control—National Ministry of Health), INAIL (National workers compensation authority) and the Conference of Regions and Autonomous Provinces drafted a National Protocol for health surveillance of asbestos ex-exposed workers . The main features of this Protocol can be summarized as follows. It should be based on scientific evidence, and its contents should comply with declared aims. Criteria for inclusion, diseases to be identified, medical facilities involved, procedures for communication, and the role of general practitioners (GPs) should be clearly stated. Workers and employees involved should have the appropriate skills. Pneumologists, radiologists, pathologists, surgeons, cancer specialists (oncologists) and technical staff are essential. Liaison with specialized centers for the treatment of neoplasms, and in particular mesothelioma, will be very important. The minimum level of the health surveillance programme can be summed up as follows: (a) medical examination; (b) lung function tests (LFT such as flow/volume curve, Dl, co); (c) chest X-rays, CXR, performed and interpreted in accordance with ILO indications ; (d) smoking cessation; (e) planned procedures for handling cases requiring further diagnosis; (f) pneumococcal disease and influenza vaccinations . Points (a), (b) and (c) should be repeated at five-yearly intervals. Workers who test negative for asbestos-related diseases and whose first exposure to asbestos is remote should not have to undergo further check-ups, but subjects should be informed that if specific symptoms occur they should consult their GPs who will, if necessary, refer them back to the programme. Subjects who test negative and whose first exposure was less remote should repeat the check-ups five years after joining the programme. Workers who test positive for asbestosis should be vaccinated yearly against influenza and pneumococcal disease, and be given five-yearly check-ups in accordance with the programme . Medical examinations, LFT and CXR should in any case be suspended when reaching a predefined age. For further investigation (i.e., pulmonary nodules) properly equipped facilities should carry out further tests until a clear diagnosis is reached and treatment decided. Where the diagnosis and treatment of pleural mesothelioma are concerned, appropriate liaison will have to be arranged with facilities and personnel having the necessary experience in this field . Smokers should be encouraged to give up smoking. All the instruments used must be consistent to requirements that, in the case of lung function tests (LFT) and chest X-ray (CXR) for occupational lung diseases, already exist [62,65,66,67,68,69].
- Fostering epidemiological research on asbestos. Even if the law of asbestos ban did not specifically address the notion of fostering scientific research on asbestos, it indirectly favored the development of research that was supported by the National Research Council, the Ministry of Health and other authorities. The law established the National Conference of environmental and health safety of industrial technological processes, materials and products, was aimed at a wide range of participants, namely, experts, trade unions, companies, environmentalist and consumer associations, universities and research institutes. The First National Conference on asbestos was held in Rome in 1999, and provided the setting for presenting and discussing research findings, including epidemiological studies that threw light on previously insufficiently investigated items. The implementation of epidemiological surveillance of mortality for malignant pleural neoplasm in all 8000 Italian municipalities brought to light a number of high-risk areas such as the town of Broni in Lombardy where there was a large asbestos-cement plant  and the town of Biancavilla in Sicily that had a naturally occurring fluoro-edenite fibres in soil and building materials used in the local construction industry [71,72]. Both areas were subsequently included among National Priority Contaminated Sites.
- Asbestos removal and waste disposal. The 1992 ban has provided for the adoption of technical regulations to deal with both the general aspects of reclamation and particular aspects for which the reclamation works needed specific technical conditions . Over the past 25 years, major reclamation projects have involved thousands of railway carriages, many military ships, chemical plants, and power plants. Many asbestos cement production sites have been converted to produce non-asbestos-containing fibrous cement and have also been reclaimed . Today, the largest number of reclamations concerns the removal of industrial and civilian coverings made with asbestos cement and a much smaller amount for friable thermal insulations.
- Updating the asbestos removal workers protection legislation. Italian legislation on dust protection in workplaces dates back to 1956 and was in force for asbestos until 1991 . The law did not set limit values but simply stated that workers should be completely protected from dust exposure. The asbestos-related diseases that occur today are mainly the consequence of exposures that took place 30/50 years ago and therefore during the years in which the aforementioned law was in force. Clearly, the law was not properly applied. The final version of the legislation that protects the asbestos cleaners during work was introduced and enacted some 10 years ago . A respiratory limit value, based on air quality standards for Western Europe published by the WHO in Copenhagen in 2000, has been introduced . Hygienic accidents that may occur during work overcoming the respiratory limit value (0.01 ff/cc) must be recorded in a special register to be kept for at least 40 years.
- International cooperation in global public health perspective. Italian scientific cooperation on asbestos has collaborated with countries still using asbestos to promote the prevention of asbestos-related diseases, sharing the vision of health equity in a global public health perspective [101,102]. This is consistent with the goal of contrasting health inequities causing the highest burden of preventable, unnecessary and unjust diseases affecting asbestos exposed communities in the countries currently using asbestos with respect to those countries that already banned asbestos and experienced prevention measures. On the basis of its standing experience within the context of a public health approach, Italy contributes by supporting national efforts of those countries for moving toward prevention and asbestos ban .
4. Key Factors for Asbestos Policy in Public Health Perspective
5. Lesson Learned
- Engaging local and central authorities avoiding delays between local and national decision-makers and fragmentation of regulations. Banning the use of asbestos in a given country is necessarily a policy decision based on the awareness that the contribution of asbestos to economic development is fallacious, in as much as the economic costs of health care and environmental clean-up are not externalized, and that the distributive aspects of costs and benefits are duly considered. Furthermore, overwhelming scientific evidence clearly documents the dimensions of the health impact of asbestos including the future burden of disease associated with the long latency times of asbestos-related disease. Once such a decision is taken, consistency among the action of central and peripheral environmental health authorities has to be insured.
- Training professionals and administrators. Engaging affected communities. The pursuit of this aim requires a major health literacy campaign in order to develop a common language based on sharing accredited scientific evidence and evaluations. The process also requires training professionals, local authorities, and informing affected communities and the media.
- Creation and implementation of national health and epidemiological systems of asbestos disease. It is of primary importance to set up and implement a health information system concerning the occurrence of asbestos-related disease, including time and space coordinates and variation, as well as correlation with exposures circumstances. Concurrently, capacity building for asbestos fibre sampling and analysis must be performed. International scientific cooperation may ensure major support.
- Policies for managing asbestos contaminated sites. Given the widespread use of asbestos, the high costs of environmental clean-up (including appropriate procedures for waste management) and the unavoidable budgetary constraints, procedures for priority setting have to be put in place, considering the estimated number of preventable cases (taking into account the size and age structure of the exposed population, together with the current exposure levels), the feasibility aspects including the costs, and the equity implications of the decision-making process. The latter implies assigning priority to the worst-off settings, thus concentrating the efforts on marginalized and peripheral communities where environmental risks and unfavourable socioeconomic conditions may concurrently be operating.
- Promoting further research on asbestos exposures and related health impacts where needed. Finally, where needed, ad hoc research on previously unknown or underestimated exposure circumstances should be developed, in order to ensure a clear representation of the problem and to contribute to the advancement of knowledge that could be helpful even in different settings.
Conflicts of Interest
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Marsili, D.; Angelini, A.; Bruno, C.; Corfiati, M.; Marinaccio, A.; Silvestri, S.; Zona, A.; Comba, P. Asbestos Ban in Italy: A Major Milestone, Not the Final Cut. Int. J. Environ. Res. Public Health 2017, 14, 1379. https://doi.org/10.3390/ijerph14111379
Marsili D, Angelini A, Bruno C, Corfiati M, Marinaccio A, Silvestri S, Zona A, Comba P. Asbestos Ban in Italy: A Major Milestone, Not the Final Cut. International Journal of Environmental Research and Public Health. 2017; 14(11):1379. https://doi.org/10.3390/ijerph14111379Chicago/Turabian Style
Marsili, Daniela, Alessia Angelini, Caterina Bruno, Marisa Corfiati, Alessandro Marinaccio, Stefano Silvestri, Amerigo Zona, and Pietro Comba. 2017. "Asbestos Ban in Italy: A Major Milestone, Not the Final Cut" International Journal of Environmental Research and Public Health 14, no. 11: 1379. https://doi.org/10.3390/ijerph14111379