Accepted Manuscript

An asbestos contaminated town in the vicinity of an asbestos-cement facility: The

case study of Sibaté, Colombia

Juan Pablo Ramos-Bonilla, María Fernanda Cely-García, Margarita Giraldo, Pietro

Comba, Benedetto Terracini, Roberto Pasetto, Daniela Marsili, Valeria Ascoli,
Benjamin Lysaniuk, María Camila Rodríguez, Agata Mazzeo, Rocio del Pilar López
Panqueva, Margarita Baldión, Diana Cañón, Luis Gerardo García-Herreros, Bibiana
Pinzón, Luis Jorge Hernández, Yordi Alejandro Silva
PII: S0013-9351(19)30247-6
DOI: https://doi.org/10.1016/j.envres.2019.04.031
Reference: YENRS 8464

To appear in: Environmental Research

Received Date: 30 January 2019

Revised Date: 26 April 2019
Accepted Date: 27 April 2019

Please cite this article as: Ramos-Bonilla, J.P., Cely-García, Marí.Fernanda., Giraldo, M., Comba, P.,
Terracini, B., Pasetto, R., Marsili, D., Ascoli, V., Lysaniuk, B., Rodríguez, Marí.Camila., Mazzeo, A.,
Panqueva, Rocio.del.Pilar.Ló., Baldión, M., Cañón, D., García-Herreros, L.G., Pinzón, B., Hernández,
L.J., Silva, Y.A., An asbestos contaminated town in the vicinity of an asbestos-cement facility:
The case study of Sibaté, Colombia, Environmental Research (2019), doi: https://doi.org/10.1016/
j.envres.2019.04.031.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

Authorship

Dr. Juan Pablo Ramos-Bonilla, Dr. María Fernanda Cely García, Dr. Pietro Comba, Dr.
Benedetto Terracini, MSc. Roberto Pasetto, MSc. Daniela Marsili, MSc. Margarita Giraldo, and
Dr. Benjamin Lysaniuk contributed in the design of the study, in the acquisition and analysis
of the data, and in the interpretation of the results.
Dr. Juan Pablo Ramos-Bonilla lead the project and wrote the manuscript.

PT
MSc. María Camila Rodríguez, and MSc. Yordi Alejandro Silva contributed in the acquisition
and analysis of the data, and in the interpretation of the results.
Dr. Valeria Ascoli, Dr. Agata Mazzeo, Dr. Rocio del Pilar Lopez Panqueva, Dr. Margarita
Baldión, Dr. Diana Cañón, Dr. Luis Gerardo García-Herreros, Dr. Bibiana Pinzón, Dr. Luis Jorge

RI
Hernández contributed in the analysis of the data and in the interpretation of the results.
All authors read and approved the manuscript.

U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

An asbestos contaminated town in the vicinity of an asbestos-cement facility: the

case study of Sibaté, Colombia

Juan Pablo Ramos-Bonilla1*, María Fernanda Cely-García1, Margarita Giraldo1, Pietro Comba2,11,
Benedetto Terracini3, Roberto Pasetto2,11, Daniela Marsili2,11, Valeria Ascoli4, Benjamin Lysaniuk5,
María Camila Rodríguez1, Agata Mazzeo6, Rocio del Pilar López Panqueva7, Margarita Baldión7,
Diana Cañón7, Luis Gerardo García-Herreros8, Bibiana Pinzón9, Luis Jorge Hernández10, Yordi

PT
Alejandro Silva1.

1 – Department of Civil and Environmental Engineering, School of Engineering, Universidad de los

Andes, Bogotá, Colombia

RI
2 - Environment and Primary Prevention, Istituto Superiore di Sanità, Rome, Italy
3 - Professor of Biostatistics, University of Turin (Now Retired), Turin, Italy
4 – Department of Radiology, Oncology and Anatomy Pathology, “Sapienza” University of Rome,

SC
Rome, Italy
5 – IRD, UMR Prodig, Paris, France
6 - Department of History and Cultures, University of Bologna, Bologna, Italy
7 – Department of Pathology and Laboratories, Fundación Santa Fe de Bogotá, Associate Clinical

U
Professor, School of Medicine, Universidad de los Andes, Bogotá, Colombia
8 – Thoracic Surgery Section, Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá,
AN
Colombia
9 – Diagnostic Imaging Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia
10 - School of Medicine, Universidad de los Andes, Bogotá, Colombia
11 - WHO Collaborating Centre for Environmental Health in Contaminated Sites, Istituto Superiore
M

di Sanità, Rome, Italy

* Corresponding author. Phone: 57 316 840 4250 Fax: 57 1 332 4313, email:
D

jramos@uniandes.edu.co, Address: Cra. 1 Este #19A-40 ML 328 Bogotá, Colombia

TE
C EP
AC

1 Abbreviations

1ACM: Asbestos containing Material; AIHA: American Industrial Hygiene Association; ARD:
Asbestos Related Diseases; ASTM: American Society for Testing and Materials; DANE:
Departamento Administrativo Nacional de Estadística; DEM: Digital Elevation Model; EPA:
Environmental Protection Agency; ICD: International Classification of Diseases; IARC:
International Agency for Research on Cancer; MPM: Malignant Pleural Mesothelioma; PLM:
Polarized Light Microscopy; ReNaM: Italian National Register of Malignant Mesothelioma;
SISPRO: Sistema Integral de Información de la Protección Social; USGS: United States
Geological Survey; WHO: World Health Organization

1
 ACCEPTED MANUSCRIPT

Abstract

Introduction: The asbestos industry began operations in Colombia in 1942, with an asbestos-
cement facility located in the municipality of Sibaté. In recent years residents from Sibaté have been
complaining about what they consider is an unusually large number of people diagnosed with
asbestos-related diseases in the town. A study to analyze the situation of Sibaté started in 2015, to

PT
verify if the number of asbestos related diseases being diagnosed were higher than expected, and to
identify potential asbestos exposure sources in the town.
Methods: A health and socioeconomic survey was implemented door-to-door to identify potential
asbestos-related diseases. Several self-reported mesothelioma cases were identified, and for

RI
confirmation purposes, copies of the medical record with the histopathology report were obtained.
A panel of six physicians analyzed the medical records. Information of validated cases was used to
estimate the male and female age-adjusted incidence rate for Sibaté. Based on reports of the

SC
existence of potential asbestos-contaminated landfills, topographic maps, a digital elevation model,
and current satellite images were crossed using a geographic information system to identify
potential landfilled areas, and soils samples were collected in some of these areas.
Results: A total of 355 surveys were completed, and 29 self-reported mesothelioma cases were

U
identified. Twenty-five of these cases have been persons who had lived at some moment of their
lives in Sibaté. It was possible to obtain copies of the medical diagnosis for 17 cases. Of these, the
AN
panel of physicians classified 15 cases as certain pleural mesothelioma, one as probable, and one as
not mesothelioma. Based on this information, the estimated age-adjusted incidence rate of
mesothelioma in Sibaté was 2.6 x 105 persons-year for males and 2.1 x 105 persons-year for females.
These rates are high in comparison to those reported in other cities, regions, and countries of the
M

world. Using geographic information systems, landfilled zones in the urban area of Sibaté were
identified, on top of which a school and different sports facilities were built. The analysis of four soil
samples collected in landfilled zones, confirmed the existence of an underground layer of friable
D

and non-friable asbestos.

Conclusion: The collected evidence suggests the presence of a malignant pleural mesothelioma
cluster in Sibaté.
TE

Key Words: Asbestos; Malignant Pleural Mesothelioma; Asbestos Cement Facility; Environmental
EP

Exposure; Soil Contamination; Sibaté; Colombia; Mesothelioma Cluster

C
AC

2
 ACCEPTED MANUSCRIPT

Funding sources

This study has been funded with internal funds of Universidad de Los Andes.

Ethics

PT
Universidad de Los Andes Ethics Committee approved the survey, the participatory workshop, and
the collection, storing, and analysis of clinical information and materials of the people diagnosed
with asbestos related diseases that participated in this study.

RI
U SC
AN
M
D
TE
C EP
AC

3
 ACCEPTED MANUSCRIPT

Introduction

Asbestos are mineral fibers classified into two major groups: Serpentines (i.e., Chrysotile), and
Amphiboles (i.e., amosite, crocidolite, tremolite, actonolite, antophilite) [1, 2]. Asbestos causes more
than half of the occupational cancer deaths worldwide [2, 3]. The International Agency for Research
on Cancer (IARC) has classified all forms of asbestos as human carcinogens [4]. Asbestos causes

PT
mesothelioma, and cancer of the lungs, larynx, and ovaries [4]. Asbestos also causes non-neoplastic
diseases such as asbestosis [4].

In spite of its adverse health effects, asbestos has been totally or partially banned in only 66 nations

RI
worldwide, most of them high-income countries [5]. Thus, most of the current consumption and
production of asbestos is concentrated in low- and middle-income countries [2]. In 2016 global
asbestos consumption was estimated at 1.4 million tons per year [6].

SC
Our research group, using the database of international trade and commerce Legiscomex, has
estimated that the amount of asbestos used in Colombia between 2009 and 2016 ranged from
11.907 to 24.822 tons per year (i.e., the Government does not have official records of asbestos

U
consumption). Currently, asbestos use in Colombia is concentrated in the construction and
automotive sectors, and there is still a chrysotile asbestos mine in operation located in
AN
Campamento (Antioquia). Although the asbestos industry has been present in Colombia for more
than seven decades, little is known regarding the magnitude of the problem and risks resulting
from asbestos use. Only five peer-reviewed studies have been published in the international
literature analyzing the risk experienced by auto-mechanics that manipulate asbestos containing
M

friction products [7-11]. One additional peer-reviewed study estimated occupational cancers
associated with asbestos exposure in Argentina, Brazil, Colombia, and Mexico [12]. To the best of
our knowledge, the current study is the first to evaluate environmental exposure risks, and not only
D

occupational, resulting from asbestos use in Colombia.

The asbestos industry began operations in Colombia in 1942, with an asbestos-cement plant
TE

located in the municipality of Sibaté, five kilometers north from the town’s center, and twenty five
kilometers south-west from Bogotá, Colombia´s capital [13]. In 2017 the population of Sibaté was
39.817 inhabitants (i.e., 19.817 females and 20.000 males) [14]. Originally, Sibaté was part of a
larger municipality called Soacha, and in 1967 the municipality of Sibaté was created, next to El
EP

Muña reservoir [15]. The plant began operations manufacturing asbestos-cement corrugated sheets
[13]. Because of the high demand, two additional asbestos-cement facilities were created in Cali
(Valle del Cauca) and Barranquilla (Atlántico) in 1944 [13]. Data from Legiscomex shows that
C

between 2009 and 2016, the Sibaté asbestos-cement facility imported more than 22.000 tons of
asbestos and exported less than 300 tons, suggesting that most of the asbestos containing materials
AC

(ACM) produced by the facility are for local consumption. The largest asbestos importation
occurred in 2012, with 5.955 tons, which coincides with the year that the local asbestos mine was
closed. The Sibaté asbestos-cement facility has employed and still employs large numbers of people
from Sibaté and has had a close interaction with the town. In recent years, residents of Sibaté have
been denouncing in the media that an unusually large number of people from the town are being
diagnosed with mesothelioma, lung cancer, and other asbestos-related diseases. Furthermore, there
are also reports from members of the Sibaté community indicating that, a few decades ago, it was
common to dispose ACM in public areas of Sibaté, and these materials were used to build landfills.
Currently on top of areas identified as potential landfilled zones there are residential, commercial,
and recreational facilities. Both the disposal of ACM in open areas and the landfilled zones are
perceived by members of the community as a major asbestos exposure source.

4
 ACCEPTED MANUSCRIPT

Outbreaks of mesothelioma in the general population as a consequence of environmental

contamination from industrial uses of asbestos have been reported in other parts of the world [16,
17]. Some outbreaks have reached dramatic dimensions (i.e., hundreds of victims over decades),
such as Casale Monferrato (Italy), that resulted from the operation of an asbestos-cement plant [18,
19], and Wittenoom (Western Australia) because of an asbestos crocidolite mine [20-22].
Additional cases of mesothelioma in communities living in the vicinity of asbestos cement plants

PT
that used both amphiboles and chrysotile have also been documented in Bari (Italy) [23],
Amagasaki (Japan) [24, 25], and Aulnay-sous-Bois (France) [26].

Since 2015, an interdisciplinary research group has been analyzing the situation in Sibaté, trying to

RI
unravel the potential health and environmental problems that are present in the town. The aim of
this study is to investigate the potential existence of a mesothelioma cluster in Sibaté. To
accomplish this, at this stage the study has been focused on two aspects of the problem: 1- An initial

SC
assessment and validation of asbestos related diseases (ARD) diagnosed in the population,
specifically mesothelioma, and 2 – Understanding potential asbestos exposure sources, focusing on
the history and characteristics of several landfills reported by community, that were built with ACM
in different areas of Sibaté.

Methods
U
AN
To collect information from the population and to explore the characteristics and dimension of the
situation in Sibaté, a survey was constructed and validated using a focus group. The survey was
designed to gather both health and socioeconomic information at the household level, including the
M

identification of ARD cases diagnosed. The questionnaire had mixed format questions, with both
closed- and open-ended questions, and was administered face-to-face. The survey was carried out
mainly in four neighborhoods of the municipality, door-to-door, between June 2015 and June 2016.
D

Fifteen interns trained by members of the research team conducted the interviews. An adult
resident of each dwelling answered the survey on behalf of all the residents of the house. When a
person diagnosed with an asbestos related disease was identified, only the diagnosed person, a first
TE

degree relative or the spouse could answer the survey. The neighborhoods where the surveys were
conducted were selected based on the presence of potential landfilled areas. The four
neighborhoods cover 77% of what has been identified as potential landfilled zones within the
urban area of Sibaté, and represent 37% of the total urban area of Sibaté (i.e., excluding the Pablo
EP

Neruda neighborhood which is not part of the main urban area of the municipality).

The survey was designed to collect information regarding ARD patients, and for most of these
C

patients the respondents were close relatives (i.e., parents, siblings, partner, son/daughter).
Sections of the survey were also designed for non-diseased respondents. The survey had 8 main
AC

sections including: 1) identification and general characteristics of the respondent and/or the
patient (if not the same), 2) general knowledge of the respondent or the patient (if not the same)
about asbestos, 3) Occupational history of the patient, 4) Family and household information of the
patient, 5) Potential activities conducted by the patient that may increase his/her risk of exposure,
6) Familiar history of the respondent and/or the patient (if not the same) that could help identify
additional cases, 7) health and medical information of the patient, 8) cigarette consumption of the
patient.

Because of the size of the study and the specificity of the etiological role of asbestos in causing
mesothelioma (i.e., asbestos is the only well-known risk factor for the disease [27]), the initial focus
of the study has been on this disease.

5
 ACCEPTED MANUSCRIPT

Since cases of ARD identified in the survey are self-reported, validation strategies were
implemented, collecting copies of the medical record including the histopathology of each case. The
medical records collected were reviewed (i.e., blinded) by four pathologists (i.e., three Colombian,
and one Italian), a Colombian radiologist, and a Colombian thoracic surgeon. Reliability of
diagnoses was assessed following the Italian Mesothelioma Registry (i.e., ReNaM) standardized
criteria. Each case was classified in one of the following categories: certain, probable, possible, to be

PT
defined, or not mesothelioma [28]. Physicians based their classification on their area of expertise.
The classification of physicians was then compared, and in case there were differences, the final
classification of each case was reached by consensus. The definition for each category of
mesothelioma classification in ReNaM can be found in Supplementary Material A.

RI
The survey, and the collection, analysis and storing of clinical information and materials were
approved by the Universidad de Los Andes Ethics Committee. All participants of the study signed an

SC
informed consent also approved by the Universidad de Los Andes Ethics Committee.

Potential asbestos exposure type for each case was also determined following the criteria of ReNaM
[28], using the information available in the surveys regarding occupational history of the

U
respondent, if the respondent lived with someone that worked with asbestos, and activities
performed by the respondent that may increase his/her risk of asbestos exposure. ReNaM
AN
classification includes 10 exposure categories: certain professional exposure (code 1), probable
professional exposure (code 2), possible professional exposure (code 3), household exposure (code
4), environmental exposure (code 5), non-professional exposure (code 6), unlikely exposure (code
7), unknown exposure (code 8), undergoing exposure definition (code 9), and unclassified exposure
M

(code 10). Three members of the research team classified the exposure of each case blinded.
Exposure classification was compared between members, and in case of differences, a final
classification was reached by consensus. The 10 exposure categories of ReNaM can also be found in
D

Supplementary Material A.

Potential asbestos exposure of non-diseased respondents of the survey was also assessed. This
TE

analysis was also based on ReNaM criteria, focusing on what are considered three major asbestos
exposure sources: 1 – Environmental asbestos exposure because of access to the ACM disposed in
different areas of the municipality and the construction of the landfills with the disposed material,
which it is estimated occurred between 1975 and 1990, 2 – Professional asbestos exposure (i.e.,
EP

certain, probable, and possible) of those who worked at the asbestos cement facility, and 3 –
Household exposure of those who lived with someone that worked at the asbestos cement facility.
Exposure was only determined for non-diseased respondents (i.e., excluding those diagnosed or
C

that self-reported having mesothelioma, lung cancer, larynx cancer, ovarian cancer, and asbestosis).
People that were born or move to Sibaté after 1990 were not included in the analysis, if they had no
AC

other relevant potential exposure.

Potential asbestos exposure sources in the town were also assessed. Based on information provided
by the town residents, one potential exposure source identified consisted of landfills that
potentially contain ACM, located in the current urban area of Sibaté. Topographic maps from 1950
and 1978 (i.e., obtained from Instituto Geográfico Agustín Codazzi), a digital elevation model (DEM)
(Shuttle Radar Topography Mission-SRTM, 1 Arc-Second, USGS), and current satellite images, were
crossed using a geographic information system (GIS) (ARGIS 10.4.1. ESRI), which allowed the
identification of 10 sites where drastic changes in land use occurred or where depressed areas
existed and could have been filled. In potential landfilled areas, exploratory soil sampling
campaigns were conducted, and samples of both soils and materials were collected in four sites

6
 ACCEPTED MANUSCRIPT

following ASTM D7521-16 method [29] and EPA soil screening guidance [30]. Samples were
analyzed by polarized light microscopy (PLM) following EPA Method 600/M4-82-020 and 600/R-
93-116. Samples were analyzed by an US accredited AIHA laboratory (i.e., Forensic Analytical
Laboratories, Hayward, CA, USA). Samples were collected using wet methods to minimize potential
asbestos fibers volatilization, and proper personal and respiratory protection equipment was used
by all personnel involved in soil sample collection.

PT
To complement the information resulting from the GIS analysis and the soil sampling campaigns, a
participatory workshop was conducted with residents from Sibaté to better understand the history
and characteristics of the landfills. The participatory workshop was conducted on April 28th, 2018,
adapting participatory methodologies [31, 32]. During the workshop the main topics discussed

RI
were the location of the landfills, history and important dates related to the construction of the
landfills, the characteristics of the materials used in the landfills, and how the landfills were built.
Each topic was discussed in smaller groups, and all the participants had the opportunity to

SC
contribute in all the topics. Individual maps of Sibaté were distributed to each participant to
facilitate the process, and focal groups were also organized. At the end, a plenary discussion was
conducted to reach consensus. The activities associated with the workshop were approved by the
Ethics Committee of Universidad de Los Andes.

U
To estimate the magnitude of mesothelioma incidence in Sibaté, an initial attempt was conducted
AN
using the Colombian National SISPRO database (i.e., Sistema Integral de Información de la
Protección Social) [33]. SISPRO is managed by the Ministry of Health and Social Protection. This
database includes information of mesothelioma cases diagnosed between 2009 and 2017 at the
municipality level, and uses the 10th version of the International Classification of Diseases (ICD) of
M

the World Health Organization (WHO) [33]. For the dates in which the search was conducted,
SISPRO database did not identify any new mesothelioma case for Sibaté during the period 2009 –
2017. However, our research group had collected clinical information of 17 persons that had lived
D

during some period of their lives in Sibaté and were diagnosed with Malignant Pleural
Mesothelioma (MPM), 13 of them diagnosed over the last 10 years (2007-2017). Thus, the SISPRO
database resulted as a not valid source to identify mesothelioma cases. Detail information regarding
TE

how the search in SISPRO was conducted is included in Supplementary Material B.

As an alternative way to assess the magnitude of mesothelioma incidence in Sibaté, age-adjusted

MPM incidence rates were recomputed using data of cases identified in the survey and validated by
EP

the panel of physicians using ReNaM [28]. For this, cases identified and validated by our research
group that were diagnosed in the last 10 years were considered (i.e., 2007-2017), and only cases
that were diagnosed while living in Sibaté were included in this estimate. In this time-window, the
C

first case identified is from 2008. The reason to focus the estimation of the age-standardized
incidence ratio on cases diagnosed over the last 10 years was to reduce the possibility of recall bias
AC

(i.e., the first step in the process of case identification were personal interviews), and that the time-
window considered has a temporal correspondence with the database for morbidity and mortality
for Colombia (SISPRO). To estimate the persons-years at risk, the size of the population of Sibaté for
each year and by gender was obtained from the National Department of Statistics (DANE, for its
Spanish acronym), which uses as baseline the information of the 2005 census, the most recent data
available [14]. The age-standardized MPM incidence rate for Sibaté was estimated using as
reference the world standard population. The age-standardized MPM incidence rate for Sibaté was
compared with mesothelioma figures available in the report Cancer Incidence in Five Continents,
volume X [34], which also uses as reference the world standard population. Such figures were also
compared with the ones observed in Casale Monferrato (Italy) and attributed to environmental

7
 ACCEPTED MANUSCRIPT

exposures in the first period of epidemiological surveillance, which used the 1981 Italian
population for standardization purposes [35].

During the study, meetings were held with the Mayor´s office of Sibaté, obtaining the authorization
for the collection of soil samples in public areas and keeping the municipality informed about the
findings of the soil sampling campaigns.

PT
Results

Results of the health component of the study

RI
The survey was conducted applying 355 questionnaires at the household level. The overall
response rate for the four neighborhoods located on potential landfilled areas was 23% (number of
surveys completed in these four neighborhoods = 270; number of residential dwellings = 1164),

SC
with the lowest response rate in the San Martín neighborhood (15%), followed by El Carmen (18%),
San Rafael (23%), and El Progreso (39%). Based on the information collected, a number of self-
reported ARD cases were identified:

U
o 29 mesothelioma cases. Of these, four never lived in Sibaté, although two worked in
the asbestos-cement plant, one lived with a former worker of the asbestos cement-
AN
plant, and the last one lived in the neighboring municipality of Soacha, which is
located in the area of influence of the asbestos-cement plant. These four cases were
excluded from further analysis, resulting in a total of 25 mesothelioma self-reported
cases.
M

o 26 lung cancer cases.

o 1 larynx cancer case.
o 3 ovarian cancer cases.
D

o 7 asbestosis cases.

As it was explained before, in this initial effort to understand the asbestos problem in Sibaté, the
TE

focus of the study was on mesothelioma. Copy of the medical record including the histopathology
report could be obtained for 17 of the 25 self-reported potential mesothelioma cases diagnosed in
persons who had lived at some moment of their lives in Sibaté. Medical records were obtained
either directly from the case or from relatives of the case, or from the hospital where the case was
EP

diagnosed or treated. From these 17 cases, four survey questionnaires were answered by the case,
and relatives of the case answered the other 13. To verify the diagnosis of the 17 cases, the panel of
six physicians conducted a blind review. Once the physicians finished their evaluation, an initial
C

meeting was held among the five physicians that are located in Colombia. The classification made
by the pathologists was used as the prevailing classification criteria, over the radiological and
AC

clinical classification. Because of differences in the information available for each case, when
comparing the assessment of the 5 Colombian physicians, in only eight of the 17 cases there was
coincidence in the classification (i.e., all eight were classified as Certain MPM). By consensus, the
group of five Colombian physicians classified 15 of the 17 self-reported mesothelioma cases as
certain MPM, one case as to be defined, and one case as probable. Subsequently, this classification
was compared with the blinded classification of the Italian pathologist, and there was a complete
coincidence in the classification of the 15 certain MPM cases and in the classification of the
probable case. A slight discrepancy was found in the other case, which was classified as “to be
defined” by the Colombian panel and was classified as “to be defined” or “not mesothelioma” by the
Italian pathologist. By consensus this case was classified as “not mesothelioma”.

8
 ACCEPTED MANUSCRIPT

Further analysis of MPM cases was focused on cases diagnosed over the last 10 years (i.e., 2007-
2017, with the first case diagnosed in 2008), which excluded four of the 17 cases. Two of the
excluded cases were Certain MPM cases, one diagnosed at age 45 in 2002 (i.e., male with household
and environmental exposure. This case was the brother of patient 6 – Table 1), and the other
diagnosed at age 53 in 2006 (i.e., male with possible professional and household exposure. This
case was the uncle of patient 1 – Table 1). It also excluded a Probable MPM case diagnosed at age 34
in 1997 (i.e., Female with household exposure), and a case classified as Not Mesothelioma (i.e.,

PT
originally diagnosed in 2002, female with environmental exposure). Table 1 shows the information
of the 13 Certain MPM diagnosed between 2008 and 2017. For these 13 cases, three of the survey
questionnaires were directly answered by the case, and relatives of the case answered the
remaining 10.

RI
Table 1 – Malignant Pleural Mesothelioma cases diagnosed in Sibaté between 2008 and 2017
Born

SC
Age at the # Years lived in
ReNaM Year of Exposure Classification in
Patient time of Gender Sibaté (Range of
Classification Diagnosis1 based on ReNaM Sibaté
diagnosis years)
(Y/N)

1 Certain 2008 44 Male Household exposure N 418 (1969-2010)

U
2 Certain 2009 454 Female Non-professional exposure Y 46 (1964-2010)
AN
3 Certain 2010 42 Male Household exposure Y 48 (1968-2011)
Certain professional
42 Certain 2012 54 Male Y 56 (1957-2013)
exposure
Household and Non-
53 Certain 2012 41 Male Y 43 (1971-2014)
M

professional exposures
Household and
6 Certain 2013 52 Male Y5 7 (1961-1968)
Environmental exposures
7 Certain 2013 44 Male Environmental exposure Y 469 (1969-2015)
D

Household and Non-

83 Certain 2014 47 Male Y 48 (1967-2015)
professional exposures
TE

9 Certain 2014 38 Female Environmental exposure N6 17 (1975-1992)

Household and Non-
103 Certain 2016 58 Female N 5610 (1961-2017)
professional exposures
11 Certain 2016 48 Male Environmental exposure Y 32 (1968-2000)
EP

12 Certain 2016 52 Male Unclassified exposure ---7 ---

132 Certain 2016 51 Female Household exposure Y 54 (1964-2018)
1. The histopathology report includes the date of the report and the date when biopsy was received. If the date of the report was
not legible, the date when biopsy was received was used.
C

2. Patients 4 and 13 are siblings.

3. Patients 5, 8, and 10 are siblings.
AC

4. Discrepancy between ages reported in the pathology and in the clinical record. Based on the year of diagnosis and the date of
birth, the estimated age of diagnosis is 45 yo.
5. Based on the information collected in the survey of this case, the patient lived in Sibaté from birth to age 7 yo.
6. This patient was born in Bogotá, Colombia, but arrived in Sibaté 3 days after birth.
7. Relatives of this case voluntarily stopped participating in the project, and the information available for the case was not
sufficient to establish these dates.
8. This case was born in Bogotá, Colombia in 1964 and based on the information gathered with the survey he moved to Sibaté in
1969. It was not possible to contact relatives to determine where this case lived from 1964 to 1969.
9. Based on the clinical history, this case was born in 1969 in Sibaté. However, the survey reports that he lived in Sibaté
beginning in 1974. It was not possible to contact the relatives to confirm where the case lived from 1969 to 1974.
10. This patient was born in Bogotá and moved to Sibaté at age 4 yo.

Within the 13 certain MPM diagnosed between 2008 and 2017, one was diagnosed in her 30s,
seven were diagnosed in their 40s, and five were diagnosed in their 50s. Nine cases were men

9
 ACCEPTED MANUSCRIPT

(69%), and four were women (31%). Potential asbestos exposure sources were identified for all
MPM cases, as summarized in Table 1. Among these, the only case that had occupational exposure
(i.e., certain professional exposure) was diagnosed at age 54.

Table 2 presents a comparative analysis of age-standardized MPM incidence ratio calculated for
Sibaté (2008-2017) using 9 of the 13 cases presented in Table 1. These 9 cases selected were living
in Sibaté at the time of diagnosis. The 4 cases excluded from the age-standardized estimate were

PT
living elsewhere, and were patient 6 (male), 9 (female), 11(male), and 12 (male). The age-
standardized MPM incidence rate for Sibaté was 2.6 x 105 persons-year for males and 2.1 x 105
persons-year for females. These rates were compared with the age-standardized (world) incidence
rate for mesothelioma (C45) reported by IARC (i.e., most areas reporting data for 2003-2007)

RI
(Table 2) [34]. Table 2 also includes for comparison purposes information for Casale-Monferrato in
Italy (1980-1989), which uses the 1981 Italian population for standardization purposes [35].

SC
Excluding self-reported asbestos related diseased cases from the 355 filled surveys, there were a
total of 276 non-diseased respondents of the survey. Based on the information obtained from the
surveys (i.e., without additional validation), 148 non-diseased respondents (54%) lived in Sibaté
between 1975 and 1990, the period when it is estimated the ACM were disposed in the urban area

U
of Sibaté and the landfills were built with the disposed material (i.e., potential environmental
exposure). Moreover, 13 non-diseased respondents (5%) worked in the asbestos cement facility
AN
(i.e., potential occupational exposure), and 18 non-diseased respondents (7%) lived with a worker
of the asbestos-cement facility (i.e., potential household exposure). Eighty-nine non-diseased
respondents did not live in Sibaté between 1975 and 1990 nor worked or lived with someone from
the asbestos cement facility. For 8 respondents it was not possible to classify the exposure.
M

Potential sources of asbestos exposure: Landfilled areas

Sibaté residents have reported that during the mid-1970s and -1980s residues containing asbestos
D

were disposed in different areas of Sibaté. To study this, depressed zones in the current urban area
of Sibaté were identified by DEM and were labeled in the framework of the current study as possible
TE

landfilled areas that could contain asbestos. The comparison of a 1978 georeferenced topographic
map of Sibaté with current satellite images allowed for the identification of areas within the possible
landfilled zone that were labeled as probable landfilled areas. The probable landfilled areas include
sport facilities that replaced the water reservoir within the possible landfilled areas. Thus, there is
EP

less uncertainty associated with probable landfilled areas compared to possible landfilled areas
(Supplementary Material C shows an example of this land use change analysis). This analysis is
based on the assumption that in depressed zones landfills may have been constructed, which has
not been completely confirmed. Furthermore, the boundaries of both possible and probable
C

landfilled zones have unavoidable errors associated with the precision of topographic maps and the
DEM. Based on this analysis, it was identified that landfilled zones included two soccer fields (i.e.,
AC

one with an athletic track), a school, a bullfight arena, and several residential areas. The urban area
of Sibaté has an extension of 158 Ha (i.e., excluding the Pablo Neruda neighborhood located outside
the urban area – see Figure 1). The analysis conducted suggests that probable landfilled areas have
an estimated extension of 2.8 Ha (1.8% of the urban area), and possible landfilled areas have an
estimated extension of 23 Ha (14.6% of the urban area).

A soil sampling campaign was originally planned in 10 sites of Sibaté (i.e., the four black dots and
six stars in Figure 1). On September 14, 2017, the soil sampling campaign was conducted collecting
four samples at sites marked as black dots in Figure 1 (i.e., P1- Stadium, P2-School, P3-Inside soccer
field with athletic rack, P4-Outside soccer field with athletic rack). In three of the four sites where

10
 ACCEPTED MANUSCRIPT

soil samples were collected, a layer of friable asbestos was found, with chrysotile asbestos content
ranging from 5 to 10 %, and one sample also had 2% crocidolite asbestos. Soil samples and non-
friable ACM were also collected. Table 3 summarizes the results of asbestos content for all the
samples collected.

Table 2. Age-standardized Malignant Pleural Mesothelioma incidence rates for Sibaté per
100.000 per-year compared to other cities, regions, and countries of the World

PT
Males Females
World Region City/Country
Standardized rates Standardized rates
cases cases
per 100.000 per year per 100.000 per year

RI
Sibaté1 8 2.6 5 2.1
Bucaramanga2 4 0.2 2 0.1

SC
Colombia -
Cali2 17 0.4 8 0.2
South America
Manizales2 0 - 0 -
Pasto2 2 0.2 0 -

U
Argentina (4 cities) 2 1 - 27 0.6 - 0.9 0-19 - - 0.5
South America Brazil (6 cities) 2 1 - 39 0.0 – 0.2 0 - 22 - - 0.2
AN
Ecuador (2 cities) 2 1-9 0.1 – 0.3 4 0.1 – 0.3
Canada (Country) 2 1860 1.4 388 0.3
North America
Canada (Quebec) 2 589 1.9 152 0.4
M

Denmark (Country) 2 416 1.8 82 0.3

France (11 Districts) 2 14 – 130 0.6 – 2.5 3 – 38 0.1 – 0.5
D

Italy (33 cities/regions) 2 5 - 249 0.5 – 5.6 1 - 64 0.1 – 1.3

Casale Monferrato case study 3 20 8.2 3 16 5.1 3
TE

Europe The Netherlands (Country) 2 2003 3 307 0.4

Russian Federation – St Petersburg 2 66 0.4 88 0.3
Spain (13 Regions/Cities) 2 3 – 121 0.2 – 1.2 0 – 44 - - 0.6
EP

Ukraine (Country) 2 790 0.5 671 0.3

UK, England (Country) 2 8224 3.6 1677 0.6
Oceania Australia – Western Australia 2 350 4.5 71 0.9
C

China (7 cities – 7 counties/regions) 2 0 – 95 - - 0.5 0 – 74 - - 0.6

AC

Asia India (12 cities) 2 0 – 15 - - 0.1 0–8 - - 0.1

Japan (7 prefectures and 1 city) 2 18 - 415 0.3 – 1.4 7 – 129 0.1 – 0.3
1. Cases identified directly by research team. Study period 2009-2017. Rates were standardized for age with the 2005 Colombian population
census in the age range 0+, broken down in quinquennial age groups.
2. Taken from Cancer Incidence in Five Continents Volume X, IARC Scientific Publication No. 164. Important notes in the report for the following
cities/regions included in the table: Tierra del Fuego (Argentina), Sao Paulo (Brazil), Quebec (Canada), all 11 regions in France, The
Netherlands, Granada (Spain), Cixian County (China), Nangang District, Harbin City (China), Shanghai City (China), Wuhan City (China),
Yangcheng County (China) Yanting County (China), Zhongshan City (China), all 12 cities in India, Osaka Prefecture (Japan).
3. Study period 1980-89. Rates were standardized for age with the 1981 Italian population in the age range 0+, broken down in quinquennial
age groups [35].

11
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
C EP
AC

Figure 1. On the left a map of Sibaté urban area shows the location of probable and possible landfills and the sites where soil samples were
collected (P1-P4). The satellite image in the center is from Sibate urban area (2016). The satellite image on the right (2016) shows the
relative location of Sibaté urban area, the Muña Reservoir, the asbestos cement facility, the neighborhood Pablo Neruda, and a partial view of
Soacha, another municipality close to the asbestos cement facility.

12
 ACCEPTED MANUSCRIPT

Table 3 – Results of the soil sampling campaign in Sibaté

Sample depth Asbestos Asbestos
Zone Sampling site Sample description
(cm) type found content (%)
Non friable construction
17 cm ND ND
material1
Sample of friable
10 cm Chrysotile 10%

PT
P1 - Outside construction material2
Stadium
Stadium Sample of friable material2 110 cm Chrysotile 5%
Sample of sandy gravel3 23 cm ND ND

RI
Sample of sandy gravel3 105 cm ND ND
Sample of friable material2,
4
35 cm Chry / Cro 10% / 2%

SC
P2 - Public
Public School Sample of silt3 71 cm ND ND
school
Sample of sandy gravel3 18 cm ND ND
Sample of friable material2 63 cm Chrysotile 5%

U
Sample of friable material2 67 cm Chrysotile 5%
P3 - Inside Sample of friable material2 80 cm Chrysotile 10%
AN
soccer field
Sample of friable Chrysotile 10%
with athletic 80 cm
material/soil5 Chrysotile 2%
track
Sample of friable material2 98 cm Chrysotile 5%
M

Soccer field
Sample of soil6 44 cm Chrysotile 2%
with athletic
track Non friable construction
77 cm Chry / Cro 2% / 2%
material7,8
D

P4 - Outside Non friable construction

soccer field 85 cm Chry / Cro 2% / 2%
material7,8
TE

with athletic
track Sample of sandy gravel3 45 cm ND ND
Sample of sandy ND ND
105 cm
gravel/friable material9 Chry / Cro 10% / 2%
EP

ND: Non Detected, Chry: Chrysotile, Cro: Crocidolite

1. Reported by the laboratory that analyzed the samples (i.e., Forensic Analytical Laboratories, Hayward, CA, USA) as “Grey Non-Fibrous
Material”.
2. Reported by the laboratory that analyzed the samples (i.e., Forensic Analytical Laboratories, Hayward, CA, USA) as "Grey Semi-Fibrous
Material".
C

3. Reported by the laboratory that analyzed the samples (i.e., Forensic Analytical Laboratories, Hayward, CA, USA) as "Brown Soil".
4. Total asbestos content of the sample is reported as "12 %", by the laboratory that analyzed the samples (i.e., Forensic Analytical
Laboratories, Hayward, CA, USA).
AC

5. Sample had 2 layers, one reported as "Brown/White Soil" with 2 % of chrysotile content (i.e., 50 % of the sample), and other reported
as "Grey Semi-Fibrous Material" with 10 % of chrysotile content (i.e., 50 % of the sample). Total asbestos content of the sample is
reported as "6 %".
6. Reported by the laboratory that analyzed the samples (i.e., Forensic Analytical Laboratories, Hayward, CA, USA) as "Brown / White
Soil".
7. Reported by the laboratory that analyzed the samples (i.e., Forensic Analytical Laboratories, Hayward, CA, USA) as "Grey Cementitious
Material".
8. Total asbestos content of the sample is reported as "4 %", by the laboratory that analyzed the samples (i.e., Forensic Analytical
Laboratories, Hayward, CA, USA).
9. Sample had 2 layers, one reported as "Brown Soil" without asbestos (i.e., 95 % of the sample), and other reported as "Grey Semi-
Fibrous Material" with 10 % of chrysotile content and 2 % of crocidolite content (i.e., 5 % of the sample). Total asbestos content of the
sample is reported as "Trace".

13
 ACCEPTED MANUSCRIPT

Since the friable layer that contained asbestos was an unexpected finding, soil sampling was
stopped to analyze the new situation and re-design the sampling campaign. Thus, the soil sampling
campaign was not conducted in the six sites marked as black stars in Figure 1. Currently, other
options to identify both landfilled zones and the presence of the underground layer of friable
asbestos are being considered, including diachronic analysis of available geographic information
and non-invasive methods of soil exploration.

PT
The participatory workshop was conducted on April 28, 2018 with 11 residents from Sibaté who
have knowledge regarding the history of the landfills (i.e., residents who lived close to the areas
where the ACM was disposed, were in contact with the ACM dumped, and/or knew about the
construction of the landfills). The group included 4 former workers of the asbestos-cement plant.

RI
Some relevant conclusions regarding the history, dates, and characteristics of the landfills
described by residents of Sibaté during the participatory workshop are shown in Figure 2. Among
the information provided during the workshop, it is important to highlight that it is estimated that

SC
for about 10 years, between 1975 and 1985, it was common to have trucks disposing large volumes
of ACM, including asbestos cement products, in the urban area of Sibaté. Residents of Sibaté had
free access to the disposed material. There were cases in which residents used these ACM in the
foundations or to level the floors of their dwellings. It is estimated that in 1985 the construction of

U
landfills in different areas of Sibaté began. Some of these landfills were built to desiccate the heavily
polluted waters of the El Muña that were present in two specific zones of the urban area of Sibaté.
AN
The landfills were finished by 1990. The information provided by members of the Sibaté
community during the participatory workshop coincides in great extent with the results of the GIS
analysis. It is important to clarify that at this stage of the study the history of the landfills is mostly
based on the description made by residents on both the participatory workshop and in the surveys.
M

It is crucial to continue collecting information about the history of the landfills, to confirm the
findings presented in the current study and improve our understanding of the situation.
D

Discussion

The results of this study are concerning. Although in a preliminary stage, the evidence collected so
TE

far strongly suggest that hazardous asbestos exposures may have occurred among residents of
Sibaté, not only at an occupational and household levels (i.e., para-occupational), but also at an
environmental level.
EP

The age-standardized MPM incidence rates estimated for both males and females that were
diagnosed while living in Sibaté appear to be very high when compared to the incidence observed
on average in cancer registries over the world. Results for females in Sibaté are comparable with
C

those reported in Casale-Monferrato (Italy), a city where the existence of a mesothelioma cluster
has been clearly established. Results for males are also very high, comparable to those reported for
AC

England, Casale-Monferrato (Italy), and to Western Australia, where the city of Wittenoom is
located, another place where the existence of a mesothelioma cluster has been proven. While the
identification of cases was initially focused on neighborhoods where landfills were present, the
entire population of Sibaté was used to estimate the age-standardized incidence rate, which could
result in an underestimation of this rate. Although the understanding of the situation of Sibaté is at
its early stages, the age-adjusted incident rates strongly suggest the existence of a MPM cluster in
this municipality.

The group of 13 certain MPM cases shown in Table 1 have some unique and concerning
characteristics: 1 – Pleural mesothelioma is a disease with long latency periods [16]. Recently in
Italy, the median latency period for malignant mesothelioma was estimated in 48 years [36]. The

14
 ACCEPTED MANUSCRIPT

risk seems to flatten at 40 years for pleural mesothelioma but increases for peritoneal
mesothelioma after 50 years [37]. In Sibaté, the group of MPM cases includes 8 that were
diagnosed in persons in their 30s and 40s, which suggest that asbestos exposure may have
occurred during their childhood. 2 - Based on the information collected in the survey, only one of
the 13 certain MPM cases was diagnosed in a person that worked at the local asbestos-cement
facility (i.e., certain professional exposure). All the other cases occurred among relatives of workers
of the asbestos-cement facility (i.e., household exposure), or had no direct contact with the facility

PT
(i.e., environmental exposure).

Several of the MPM cases identified in the current study are relatives. This raises concerns about
the possibility of having the same asbestos exposure source, which requires further analysis to

RI
determine if the source is still active. Furthermore, this finding should be considered in the design
of both risk management and surveillance strategies, paying special attention to relatives of people
diagnosed with asbestos-related diseases.

SC
Based on the analysis of 276 surveys of non-diseased residents of Sibaté, 179 may have experienced
environmental, occupational, and/or household exposure. Considering that only a fraction of the
residents have been interviewed, it is important to take into consideration that because of the

U
potential of past asbestos exposures, residents that are not currently diagnosed with an asbestos
related disease are at risk of developing asbestos related diseases, a risk that can linger for decades
AN
as it has been observed in Casale Monferrato, Italy.

In other communities where pleural mesothelioma is the result of asbestos environmental

exposures, the male:female ratio is 1:1, with a median age at diagnosis of 60 years [38, 39]. Based
M

on the information presented in Table 1, in Sibaté the male:female MPM ratio is 2.25:1, and the
mean age at diagnosis was 47.4 years (range 38-58). Thus, the results of the current study differ
from what has been reported in other studies. Nevertheless, our understanding of the situation in
D

Sibaté is still in its early stages.

Considering the alarming volumes of asbestos that have been used and are still used in Colombia,
TE

stricter protocols are required to both diagnose and report ARD in the country. Similarly to what
has been done in other countries (e.g., Italy), the implementation of a mesothelioma disease
registry is an urgent need. An information and surveillance system of the asbestos industry
requires urgent implementation; in the few exceptions where information exists, data should be
EP

published and made easily available to the public.

It should be acknowledged that despite the recognized difficulties to diagnose MPM worldwide, in
C

this study it was found that from 17 cases that were originally diagnosed as MPM based on what is
reported in the medical record, 15 (88%) were classified by the panel of physicians collaborating
AC

with the current study as Certain MPM according with ReNaM criteria. Although the percentage of
MPM cases correctly diagnosed seems high, it is unfortunate that the SISPRO database did not
correctly register these MPM cases, suggesting that the SISPRO database requires major reviews
and improvement. One important problem with SISPRO is that it relies on the information
introduced by the treating physician, and there is no validation of this information. Thus, errors are
difficult to identify and correct. The inconsistencies in SISPRO can also be explained because its
original aim was to support the billing process of the health system. Therefore, it was not intended
to be used as a database of morbidity and mortality in Colombia. Similarly to what was observed in
Sibaté, the information reported for the other cities from Colombia that were included in Table 2
may have similar uncertainties, although this information comes from a reliable source (i.e., Cancer
Incidence in Five Continents Volume X, IARC Scientific Publication No. 164).

15
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
C EP
AC

Figure 2. History of the Sibaté municipality, the asbestos-cement plant, and the Muña Reservoir. The history and characteristics of the
landfills of Sibaté were determined from information collected in a participatory workshop conducted with residents from Sibaté.

16
 ACCEPTED MANUSCRIPT

During this study, self-reported cases of ARD different from MPM were also identified. Although
this study was focused on MPM, other ARD cases require attention and should be included in future
studies. For some of the other ARD self-reported cases identified in the current study, preliminary
information that could be useful for validation has already been collected.

The GIS analysis combined with the soil survey and the testimony of residents from the town,
including former workers of the asbestos-cement facility, confirm the existence of the landfills

PT
containing ACM and friable asbestos. However, the area, boundaries, and volume of these asbestos-
containing landfills remain unknown. The maps presented in Figure 1 were initially elaborated to
identify potential sites for the collection of soil samples to confirm the existence of ACM on the

RI
landfills. Therefore, the maps in Figure 1 are an initial and preliminary assessment of the location of
landfilled zones, and should not be interpreted as a frontier that establishes the limit between
asbestos free and asbestos contaminated zones. For this reason, additional studies are required to

SC
determine which are the geographical boundaries of both the landfilled zones and the asbestos
contaminated zones. Furthermore, during the participatory workshop, residents from Sibaté
reported that in some cases, people used the asbestos containing residues disposed to finish the
floors of their dwellings and in the foundations of their houses, which means that asbestos

U
contamination could be present throughout the urban area of Sibaté.
AN
It is important to acknowledge that this study is at a preliminary stage and the results have
limitations. First, the number of surveys administered is small, and is likely that the number of MPM
cases reported is underestimating the magnitude of the problem. The GIS analysis is at its early
stages, and the precise location of landfilled zones has not been established. Furthermore, the
M

history of the disposal of ACM in open areas and the construction of the landfills is based on a
limited number of testimonies collected in the surveys and the participatory workshop.

Unfortunately, the situation that we are starting to understand in Sibaté is not uncommon or
D

unexpected [39]. Several studies conducted in different countries have found associations of
environmental exposure to asbestos and the development of mesothelioma in residents of
TE

communities that have lived nearby asbestos-cement facilities [25, 39]. The disposal of friable and
non-friable asbestos in soils, as it was found in Sibaté, has been documented in Casale-Monferrato
(Italy) [18, 40], and in Hof van Twente (The Netherlands) [41]. Cases of mesothelioma at the
population level (i.e., environmental exposure) in areas where an asbestos-cement facility have
EP

been present have been studied in detail in Casale-Monferrato and Bari (Italy) [18, 38, 40], in Hof
van Twente (The Netherlands) [41], and in Aulnay-sous-Bois (France) [26].

As public health researchers we are concerned by the possibility that the Colombian society
C

stigmatizes the Sibaté community as being “at risk”: this would result in re-victimizing a group of
people already facing a major public health problem. The situation they are unfairly facing could
AC

happen to any community living nearby an asbestos cement facility. This situation could have been
of lesser magnitude if Colombia had banned asbestos when other countries began this process
more than 30 years ago. We emphasize once again that the best way to prevent asbestos exposure
and ARD is to stop the use of this material. Although an asbestos ban in Colombia will not solve the
adverse health and environmental impacts derived from the legacy of asbestos use, it would halt
the use of asbestos and the introduction of new ACM, a preventive measure urgently needed and
recommended.

As authors, we wish that the publication of these initial results will promote further discussion and
will contribute to strengthen a national and transnational collaboration among professionals with

17
 ACCEPTED MANUSCRIPT

distinct expertise, and will favor the engagement of local communities and health professionals to
elaborate a better understanding of the Sibaté problem [42]. Sibaté is not the only municipality of
Colombia with presence of asbestos-cement facilities or mines. Thus, we express our concerns
about the possibility that similar situations could be present in Barranquilla (Atlántico), Cali (Valle
del Cauca), Manizales (Caldas), Campamento (Antioquia), and Bogotá (DC). In all these cities and
towns, the asbestos-cement facilities, asbestos friction products facilities, or asbestos mines are still
operating.

PT
The current study was carried out because the residents of Sibaté expressed their concerns in the
media about the health situation they were experiencing. As public health researchers we paid
attention to these concerns and began to collect evidence to determine if these concerns were

RI
supported by science. With the evidence collected so far, we believe that these concerns are valid.

There are several areas that require more detailed analysis. We are currently working in all of

SC
them:

1. Continue the identification, collection, and validation of MPM cases and other ARD. We are
in the process of obtaining the core biopsy paraffins or the slides of all MPM cases as yet

U
identified. The group of pathologists collaborating with the study will re-analyze these
samples.
AN
2. We plan to conduct additional studies trying to reduce our level of uncertainty regarding
the boundaries of the probable and possible landfilled zones. If this is accomplished, this
information could be useful for risk management purposes.
3. We are conducting air-sampling campaigns at the surface level of the landfills, to determine
M

if there is a risk of asbestos exposure when activities are performed in these areas (i.e.,
applying activity based sampling – ABS, proposed by EPA [43, 44]).
D

In closing, we strongly recommend that the Governments at the national, regional, and local levels
place the necessary resources to help the Sibaté community in dealing with what seems to be a
public health problem of great dimensions. There have been success stories at the international
TE

level in asbestos contaminated cities, Casale-Monferrato (Italy) being one example, and these
experiences could be used to identify the appropriate strategies to address a problem we are
beginning to understand in Sibaté.
EP

Conflict of Interest

Juan Pablo Ramos-Bonilla, María Fernanda Cely-García, Margarita Giraldo, Roberto Pasetto, Daniela
C

Marsili, Valeria Ascoli, Benjamin Lysaniuk, María Camila Rodríguez, Agata Mazzeo, Rocio del Pilar
López Panqueva, Margarita Baldión, Diana Cañón, Luis Gerardo García-Herreros, Bibiana Pinzón,
AC

Luis Jorge Hernández, and Yordi Alejandro Silva have no financial conflict of interest to declare.
Benedetto Terracini and Pietro Comba served as expert witness in asbestos-related trials. Juan
Pablo Ramos-Bonilla provided expert opinion in the Colombian Senate in the discussions of a Law
banning asbestos in the country.

Acknowledgments

We want to begin thanking the victims and their families for their valuable contributions to this
study. Without the information you generously shared with us, this study would not have been
possible.
This study has been funded with internal funds of Universidad de Los Andes.

18
 ACCEPTED MANUSCRIPT

We want to thank the Mayor’s office and the Secretary of Health of Sibaté for providing access to
areas where soil samples were collected.
We want to thank Sergio Alberto Amorocho Barrera for his help with the graphical design of Figure
2.
Finally, we want to thank the group of students of Universidad de los Andes who contributed in the
design and validation of the survey, the collection of the medical diagnosis of the cases, and in
administering some of the surveys used in this study: Lorena Melo, Natalia Gómez, Andrea Marú,

PT
David Ospina, Giovanni Castellanos, Juliana Pineda, Carlos Andrés Girón, Oscar Galindo, Ana María
Barbosa Gómez, Juan Sebastian Barragán Jerónimo, Mariana Cuartas, María Margarita González
Guerrero, Joseph Esteban Herrera Ruiz, Carolina López Gómez, Laura Rubio Velandia, Geraldine
Suárez Rodríguez, Catalina Valencia Benítez, Fabio Andrés Vanegas, Lina Marcela Valencia Becerra,

RI
Juliana Diazgranados Vives, Laura Camila Bernal González, Camilo Andrés Cáceres Tocora, Miguel
Alfonso Feijoo García, Oscar Alejandro Guzmán Grimaldo, Juan Camilo León Avendaño, Tania
Daniela Martínez Roa, Chrystian Enrique Rincón Buitrago, Angie Daniela Ruiz Morales, Claraestela

SC
Torres Rivero, María Camila Guerrero, Vanessa Mesa, María Paula Rincón, Daniel Gómez, Alexandra
García Vega, Nicolás Navarro Acuña.

Authorship

U
Dr. Juan Pablo Ramos-Bonilla, Dr. María Fernanda Cely García, Dr. Pietro Comba, Dr. Benedetto
AN
Terracini, MSc. Roberto Pasetto, MSc. Daniela Marsili, MSc. Margarita Giraldo, and Dr. Benjamin
Lysaniuk contributed in the design of the study, in the acquisition and analysis of the data, and in
the interpretation of the results.
Dr. Juan Pablo Ramos-Bonilla lead the project and wrote the manuscript.
M

MSc. María Camila Rodríguez, and MSc. Yordi Alejandro Silva contributed in the acquisition and
analysis of the data, and in the interpretation of the results.
Dr. Valeria Ascoli, Dr. Agata Mazzeo, Dr. Rocio del Pilar Lopez Panqueva, Dr. Margarita Baldión, Dr.
D

Diana Cañón, Dr. Luis Gerardo García-Herreros, Dr. Bibiana Pinzón, Dr. Luis Jorge Hernández
contributed in the analysis of the data and in the interpretation of the results.
All authors read and approved the manuscript.
TE

References
EP

1. Collegium_Ramazzini, Asbestos is still with us: Repeat Call for a Universal Ban. 2010.
2. L., S., L.S. Welch, and R. Lemen, The worldwide pandemic of asbestos-related diseases.
Annu Rev Public Health, 2013. 34: p. 205-16.
3. Lene Snabe Nielsen, et al., Occupational Asbestos Exposure and Lung Cancer - A
C

Systematic Review of the Literature. Archives of Environmental & Occupational

Health, 2014. 69(4): p. 191-206.
AC

4. IARC. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Asbestos

(chrysotile, amosite, crocidolite, tremolite, actinolite, and anthophyllite). Volume 100C.
2012 October, 2015].
5. IBAS. Current asbestos ban and restrictions. 2017 June, 2018]; Available from:
http://ibasecretariat.org/alpha_ban_list.php.
6. USGS. Mineral commodity summary. 2018 August, 2018]; Available from:
https://minerals.usgs.gov/minerals/pubs/commodity/asbestos/mcs-2018-
asbes.pdf

19
 ACCEPTED MANUSCRIPT

7. Salazar, N., et al., Asbestos Exposure among Transmission Mechanics in Automotive

Repair Shops. Annals of Occupational Hygiene, 2014.
doi:10.1093/annhyg/meu093.
8. Cely-García, M.F., et al., Estimation of personal exposure to asbestos of brake repair
workers. Journal of Exposure Science and Environmental Epidemiology, 2016.
9. Cely-García, M.F., et al., Factors associated with non-compliance of asbestos
occupational standards in brake repair workers. Annals of Occupational Hygiene,

PT
2016. doi:10.1093/annhyg/mew028. [Epub ahead of print].
10. Cely-Garcia, M.F., et al., Personal exposure to asbestos and respiratory health of heavy
vehicle brake mechanics. J Expos Sci Environ Epidemiol, 2014.

RI
11. Cely-García, M.F., et al., Personal Exposures to Asbestos Fibers During Brake
Maintenance of Passenger Vehicles. Annals of Occupational Hygiene, 2012. 56(9): p.
985-999.

SC
12. Pasetto, R., et al., Occupational burden of asbestos-related cancer in Argentina, Brazil,
Colombia and Mexico. Ann Glob Health, 2014. 80(4): p. 263-8.
13. Eternit. Historia. 2019 January, 2019]; Available from:
https://www.eternit.com.co/web/eternit/historia.

U
14. DANE. Departamento Administrativo Nacional de Estadísticas. 2019 January, 2019];
AN
Available from: www.dane.gov.co.
15. Alcaldía Municipal de Sibaté. 2017. Sibaté: Pasado, Presente y Futuro. 2017 July 6,
2018]; Available from: http://sibate-
cundinamarca.gov.co/MiMunicipio/Paginas/Pasado-Presente-y-Futuro.aspx.
M

16. Fazzo, L., et al., Epidemiology surveillance of mesothelioma mortality in Italy. Cancer
Epidemiology, 2018. 55: p. 184-191.
17. Marsh, G., et al., Non-occupational exposure to asbestos and risk of pleural
D

mesothelioma: review and meta-analysis. Occupational and Environmental Medicine,

2017. 74(11): p. 938-846.
TE

18. Magnani, C., et al., Increased risk of malignant mesothelioma of the pleura after
residential or domestic exposure to asbestos: A case-control study in Casale
Monferrato, Italy. Environmental Health Perspectives, 2001. 109(9): p. 915-919.
19. Ferrante, D., et al., Pleural mesothelioma and occupational and non-occupational
EP

asbestos exposure: a case-control study with quantitative risk assessment. Occup

Environ Med, 2016. 73(3): p. 147-53.
20. Hansen, J., et al., Malignant mesothelioma after environmental exposure to blue
C

asbestos. Int J Cancer, 1993. 54(4): p. 578-81.

21. Hansen, J., et al., Environmental exposure to crocidolite and mesothelioma: exposure-
AC

response relationship. American Journal of Respiratory and Critical Care Medicine,

1998. 157(1): p. 69-75.
22. Reid, A., et al., Cancer incidence among women and girls environmentally and
occupationally exposed to blue asbestos at Wittenoom, Western Australia. Int J Cancer,
2008. 122(10): p. 2337-44.
23. Musti, M., et al., The relationship between malignant mesothelioma and an asbestos
cement plant environmental risk: a spatial case-control study in the city of Bari (Itali).
Int Arch Occup Environ Health., 2009. 82: p. 489-497.

20
 ACCEPTED MANUSCRIPT

24. Kumagai, S. and N. Kurumatani, Asbestos fiber concentration in the area surrounding
a former asbestos cement plant and excess mesothelioma deaths in residents. Am J Ind
Med., 2009. 52(10): p. 790-8.
25. Kurumatani, N. and S. Kumagai, Mapping the risk of mesothelioma due to
neighborhood asbestos exposure. American Journal of Respiratory and Critical Care
Medicine, 2008. 178: p. 624-629.
26. Institut de Veille Sanitaire. 2007. Etude de santé publique autour d'une ancienne usine

PT
de broyage d'amiante, le Comptoir des minéraux et matières premières à Aulnay-sous-
Bois (Seine-Saint-Denis). December 2007]; Available from:
http://invs.santepubliquefrance.fr//display/?doc=publications/2007/amiante_auln

RI
ay/index.html.
27. ACCP, American College of Chest Physicians. Pulmonary Medicine Board Review: 26th
Edition. 2012.

SC
28. ISPESL. Guideliness for the Identification and Definition of Malignant Mesothelioma
cases and the Transmission to ISPESL by Regional Operating Centres, Mesothelioma
National Register (Article 36, D.Lgs.n°277/91 – Dpcm 308/02). 2002 Lastly accessed,
December 2018]; Available from:

U
https://www.inail.it/cs/internet/docs/renam_guidelines.pdf?section=attivita.
AN
29. ASTM., ATSM D7521-16 Standard Test Method for Determination of Asbestos in Soil.
2016.
30. EPA. Soil Screening Guidance: User’s guide. Second Edition. . 1996 September 2017];
Available from: https://rais.ornl.gov/documents/SSG_nonrad_user.pdf
M

31. Rubio Torgler, H., A. Ulloa Cubillos, and C. Campos Rozo, Manejo de fauna de caza,
una construcción a partir de lo local. Métodos y herramientas. 2000, Bogotá,
Colombia: Orewa, Fundación Natura, Ministerio del Medio Ambiente (UAESPNN),
D

Organización de Estados Iberoamericanos-OEI, Instituto Colombiano de

Antropología e Historia (ICANH), Fondo Mundial para la Naturaleza, Programa
TE

Colombia (WWF)
32. Candelo, C., G.A. Ortíz, and B. Unger, Hacer talleres. Una guía práctica para
capacitadores. 2003, Cali, Colombia: WWF Colombia.
33. Minsalud. SISPRO Sistema Integral de Información de la Protección Social. 2015
EP

October, 2017]; Available from: http://www.sispro.gov.co/.

34. IARC, Cancer Incidence in Five Continents, in IARC Scientific Publications No. 164, D.
Forman, et al., Editors. 2014: Lyon, France.
C

35. Magnani, C., et al., Pleural malignant mesothelioma and non-occupational exposure to
asbestos in Casale Monferrato, Italy. Occup Environ Med, 1995. 52(6): p. 362-367.
AC

36. Binazzi, A., et al., ReNaM Working Group, The Fifth report: results, interpretation,
comments, 5th ReNaM Report [in Italian]. 2015: p. 21-27.
37. Ferrante, D., et al., Italian pool of asbestos workers cohorts: mortality trends of
asbestos-related neoplasms after long time since first exposure. Occup Environ Med,
2016. 74(12): p. 887-898.
38. Vimercati, L., et al., Environmental asbestos exposure and mesothelioma cases in Bari,
Apulia region, southern Italy: a national interest site for land reclamation.
Environmental Science and Pollution Research International, 2018. 25(16): p.
15692-15701.

21
 ACCEPTED MANUSCRIPT

39. Liu, B., et al., Epidemiology of Environmental Exposure and Malignant Mesothelioma J.
Thorac Oncol, 2017. 12(7): p. 1031-1045.
40. U.O.A., Prevenzione e Sicurezza negli Ambienti di Lavoro - S.Pre.S.A.L., Regione
Piemonte, A.S.L. 21 - Casale Monferrato, Procedura sperimentale per interventi di
bonifica da amianto friabile in aree non confinate (Autorizzata da Conferenza dei
Servizi indetta dal Ministero dell´Ambiente in merito all sito di bonifica di interesse
nazionale di Casale Monferrato in data 08/01/2003). 2003.

PT
41. Driece, H., et al., Assessment of cancer risk due to environmental exposure to asbestos.
J Expos Sci Environ Epidemiol, 2010. 20(5): p. 478-85.
42. Marsili, D., et al., Communication and health education in communities experiencing

RI
asbestos risk and health impacts in Italy. Ann Ist Super Sanita, 2019. 55(1):70-79.
43. EPA. Standard Operating Procedures for Activity Based Air Sampling for Asbestos (SOP
2084). 2007; 1-27]. Available from:

SC
https://semspub.epa.gov/work/HQ/174392.pdf.
44. EPA. Framework for investigating asbestos-contaminated superfund sites. Asbestos
Committe of the Technical Review Workgroup of the Office of Solid Waste and
Emergency Response. 2008 September 2017]; Available from:

U
https://www.epa.gov/superfund/asbestos-superfund-sites
AN
M
D
TE
C EP
AC

22
 ACCEPTED MANUSCRIPT

Highlights

• High rates of malignant pleural mesothelioma (MPM) cases were identified in

Sibaté.
• Many of the MPM cases were diagnosed at unusually young ages.
• An asbestos-cement facility has been in operation in Sibaté for more than 70
years.

PT
• An underground layer of friable asbestos was discovered in Sibaté.
• The evidence suggests the existence of a MPM cluster in Sibaté.

RI
U SC
AN
M
D
TE
C EP
AC