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com
Para-occupational exposures to
asbestos: lessons learned from Casale
Monferrato, Italy
Leslie Thomas Stayner
The paper by Ferrante et al1 presents the
latest findings from a series of studies2–4
revealing the tragic story of the impact of
an Eternit asbestos cement facility on the
health of the workers and the community
in Casale Monferrato, Italy.
This study provides strong evidence of an
association between pleural mesothelioma
and non-occupational exposures to asbes-
tos. An approximately twofold increase in
risk was observed for having lived with a
family member who worked in the Eternit
asbestos cement plant (OR=2.4, 95% CI
1.3 to 4.4), or having been exposed from
domestic or environmental sources
(OR=2.0, 95% CI 1.2 to 3.2).
This is unfortunately not a new story.
In the seminal report by Wagner in 19605
of a series of mesothelioma cases with
exposure to crocidolite asbestos exposure
in South Africa, 18 of the 32 cases were
born in the vicinity of the mines and had
no known occupational exposures. Since
then numerous cases of mesothelioma
have been reported among family member
of asbestos workers,6 7 although only a
few formal epidemiological studies have
been conducted.8–11
What is new is that this study considers
the exposure–response relationship
between pleural mesothelioma and cumu-
lative exposure to asbestos from domestic,
environmental and occupational. Not sur-
prisingly, the study found strong evidence
of an exposure–response relationship
between higher cumulative exposure to
asbestos from all sources and increased
risk of pleural mesothelioma. Of particu-
lar concern is their finding of an approxi-
mately fourfold (OR=4.4, 95% CI 1.7 to
11.3) increased risk of pleural mesotheli-
oma at relatively low levels of asbestos
exposure (0.1 to <1 fibre/mL-years).
A similar increase in risk (OR=3.8, 95%
CI 1.3 to 11.1) was observed when the
analysis was restricted to exposures from
non-occupational sources. To put this in
perspective the upper range of this
Correspondence to Professor Leslie Thomas Stayner,
Division of Epidemiology and Biostatistics, University of
Illinois at Chicago, School of Public Health (M/C 923),
1603 West Taylor Street, Room 978a, Chicago, IL
60612, USA; lstayner@uic.edu
exposure category (1 fibre/mL-years)
would correspond to an average exposure
level of approximately 0.01 fibre/mL for
individuals residing 70 years in the com-
munity. This level of exposure is roughly
two orders of magnitude lower than what
has been reported in the past in other
communities with an asbestos industry.
Historically ambient air concentrations of
asbestos have been reported to be as high
as 1 fibre/mL in the mining areas of Libby,
Montana,12 Wittenoon, Australia13 and
Quebec.14 Fortunately concentrations of
asbestos in ambient air have been reduced
substantially in these communities, but
still the risk from past exposures remain
in these and other communities with
asbestos-related industries.
The results from this study have serious
implications for communities that are cur-
rently using or producing asbestos.
Despite the cessation of use in Europe
and North America worldwide asbestos
consumption remains relatively high at
approximately two million metric tons
per year due to an increase in use in Asia
and other developing nations.15 Some
may argue6 that this is of less concern
because these populations are only
exposed to chrysotile asbestos, which is
associated with a lower risk of mesotheli-
oma than amphiboles.16 However, it is
important to remember that asbestos
exposure is also associated with an
increased risk of lung, laryngeal and
ovarian cancer17 as well as asbestosis.
There is little if any evidence that the risk
for these conditions vary by fibre type.18
Furthermore, it is difficult to predict what
the risk of mesothelioma will be in these
countries given how little we know about
their levels and patterns of exposure. For
example, a relatively large number of
mesotheliomas (n=48) were recently
reported in a community in China that
produces chrysotile asbestos textiles.
Production of these textiles was con-
ducted in household workshops, which
likely resulted in very high domestic expo-
sures to children and family members as
well as the workers.19
Finally, this study provides strong evi-
dence of an association between pleural
mesothelioma and the use of asbestos-
Stayner LT. Occup Environ Med March 2016 Vol 73 No 3
Commentary
cement roofing (OR=2.5, 95% CI 1.4 to
4.5) and pavement with asbestos tailings
(OR=3.6, 95% CI 1.4 to 9.2). These
findings are a reminder that industrial use
and production of asbestos can have an
impact on communities long after the
industries are gone. The cost of cleanup
from these past activities may be exorbi-
tant, such as in Libby, Montana where the
US EPA has spent at least $447 million
since 1999, and the cleanup is expected
to last several more years. The population
of Libby is only 2691 people and the cost
of the cleanup per person is about
$165 000 per person thus far. Countries
currently using or producing asbestos
should take heed to the lessons learned
from Casale Monferrato, Libby and other
communities around the world that are
suffering from their past use and/or pro-
duction of asbestos. Ultimately it is the
communities that most likely will bear
the costs in terms of health and for the
cleanup of their homes and environments.
Competing interests Dr Stayner has in the past
served as an expert witness in litigation cases on
asbestos for the victims of exposure in the United
States. He has never been involved in legal cases or
research pertaining to workers or the community in
Casal Monferrato, and does not have any competing
interests in this case.
Provenance and peer review Commissioned;
internally peer reviewed.
To cite Stayner LT. Occup Environ Med 2016;73:145–
146.
Received 6 October 2015
Accepted 21 October 2015
Published Online First 9 November 2015
▸ http://dx.doi.org/10.1136/oemed-2015-102803
Occup Environ Med 2016;73:145–146.
doi:10.1136/oemed-2015-103233
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 Downloaded from http://oem.bmj.com/ on February 19, 2016 - Published by group.bmj.com

Para-occupational exposures to asbestos:

lessons learned from Casale Monferrato, Italy
Leslie Thomas Stayner

Occup Environ Med 2016 73: 145-146 originally published online

November 9, 2015
doi: 10.1136/oemed-2015-103233

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