Epidemiology, exposure patterns and survival of malignant mesothelioma in Apulia, Italy (1993–2025): a population-based retrospective registry study

Objectives To characterise the epidemiology, asbestos-exposure patterns, spatial distribution and survival of malignant mesothelioma in Apulia, Italy. Design Population-based retrospective registry study. Setting Apulian Regional Mesothelioma Registry, a regional operating centre of the Italian National Mesothelioma Registry. Participants All 2281 malignant mesothelioma cases recorded between 1993 and 2025. Interventions None. Primary and secondary outcomes Primary outcomes were case distribution, population-adjusted incidence, asbestos-exposure category and overall survival. Secondary outcomes included temporal trends, municipal patterns, proximity of environmentally exposed cases to the former Fibronit plant in Bari and factors independently associated with mortality. Results Overall, 1689 cases (74.0%) occurred in men; mean age at diagnosis was 67.8 years and 2018 cases (88.5%) were pleural. Occupational exposure accounted for 49.8% of cases, environmental exposure for 8.9% and familial exposure for 2.4%. Taranto had the highest municipal annual incidence (7.43 per 100 000), followed by Bari (4.59). Among 112 environmentally exposed Bari cases with reconstructed residential distance, 89.3% lived within 1 km of the former Fibronit plant. Kaplan-Meier median survival was 1.0-year and 5-year survival was 10.1%. Survival improved across diagnostic periods (p Conclusions Mesothelioma in Apulia reflects persistent occupational and environmental consequences of historical asbestos use. Geographical hotspots and poor survival support continued registry surveillance, remediation of contaminated sites and targeted health monitoring of formerly exposed workers and communities.