Implementation of the health surveillance program for workers exposed to asbestos in the state of São Paulo: a report of experience

Abstract

Introduction  Asbestos is a serious threat to global public health. In the State of São Paulo, Law No. 12,684/2007 established banning on the use of asbestos in production processes.

Objective  To describe the experience of surveillance for workers exposed to asbestos by the DVST/CEREST Division of the State of São Paulo from 2008 to 2020, and to present the advances and challenges of interventions related to the asbestos ban.

Methods  Documentary research related to occupational health surveillance activities, in addition to institutional documents, systematized database reports, and activity records.

Results  By 2018, there were no longer any companies using asbestos in their production processes in the state of São Paulo; commercial establishments dealing with construction materials, cargo transport, and public administration renovations were inspected throughout the state. In the same year, active searches for exposed workers began, aiming for comprehensive care.

Conclusion  The Visat Amianto Program created a positive agenda focused on protecting workers’ health and defending life. It effectively contributed to the creation of technical references and the early identification of damage to workers and the environment. However, the challenges remain considerable.

Keywords
Asbestos; Worker Health Surveillance; Occupational Health; Environmental Health; Occupational Diseases

Resumo

Introdução  O amianto é uma séria ameaça à saúde pública. No estado de São Paulo, uma lei promulgada em 2007 estabeleceu a proibição do uso do amianto nos processos de produção.

Objetivo  Descrever a experiência de vigilância e atenção à saúde do trabalhador exposto ao amianto articulada pela Divisão de Vigilância em Saúde do Trabalhador/Centro Estadual de Referência em Saúde do Trabalhador de São Paulo, no período de 2008 a 2020.

Métodos  Pesquisa documental realizada com documentos científicos e institucionais, relatórios de bancos de dados sistematizados e registro de atividades.

Resultados  As ações realizadas resultaram na estruturação do Programa de Vigilância à Saúde do Trabalhador Exposto ao Amianto (PVISAT Amianto), e incluíram inspeção sanitária em saúde do trabalhador, vigilância dos trabalhadores expostos ao amianto, organização da atenção à saúde dos trabalhadores expostos, disseminação e popularização do conhecimento e do aprendizado. Houve articulação entre diversas instituições. Em 2018, foi iniciada a busca ativa dos trabalhadores expostos.

Conclusão  O Programa de Vigilância à Saúde do Trabalhador Exposto ao Amianto criou agenda positiva de proteção da saúde dos trabalhadores e defesa da vida. Atuou na criação de referências técnicas e na identificação precoce de danos aos trabalhadores e ao ambiente.

Palavras-chave
Amianto; Vigilância em Saúde do Trabalhador; Saúde do Trabalhador; Saúde e Ambiente; Doenças Profissionais

Introduction

Asbestos is a fiber considered carcinogenic by the International Agency for Research on Cancer (IARC)¹at all stages of its production, transformation, and use, representing a serious threat to global public health²,³. Its harmful effects are not restricted to the countries where it is still exploited³, but extend to those who consume products containing its fibers⁴. Exposure to asbestos is directly associated with a series of fatal, progressive, and irreversible respiratory diseases⁵. Moreover, the long latency period, which can exceed 30 years, makes it difficult to establish the relationship between the disease and work, especially when the workers are no longer with the companies².

Asbestos is a silicate magnesium mineral⁴,⁶that is used in around three thousand products and is widely used in the construction, textile, and automotive industries, especially in the production of fiber cement artifacts such as water tanks and roof tiles, as well as in friction materials, sealing products, cardboard, cellulose, and textiles⁷.

Brazil was one of the largest producers and exporters of chrysotile asbestos, with production reaching around 200,000 tons per year at the beginning of the 21st century⁷, with the fiber cement sector being the main domestic consumer of this material⁸. In the state of São Paulo, the municipality of Itapira has an anthophyllite asbestos mine, which operated from 1956 to 1996. In addition, the state was home to an industrial park with approximately 200 companies in the fiber cement, automotive and textile sectors, among others⁷.

Exposure to asbestos occurs at various stages of the production chain, from extraction to the final disposal of waste²,⁹. Asbestos fibers, with a diameter of up to 3 μm and a length greater than 5 μm, are classified as respirable, which allows them to reach the deepest parts of the respiratory system, depositing in the alveoli, alveolar ducts and respiratory bronchioles, as illustrated in Figure 1⁶,¹⁰. Due to their microscopic size, these fibers can remain in the air for long periods, expanding the potentially exposed population, which includes workers, residents near factories, and workers’ families, due to contact with contaminated objects and clothing³,⁷,⁹.

Figure 1
Fiber pathway through the respiratory system, adapted from Gualtieri¹⁰

The relationship between exposure to asbestos and asbestos-related diseases is well documented scientifically. In Brazil, the pioneering studies by Costa¹¹, Freitas¹², and Mendes¹³ showed the impact of asbestos on the morbidity and mortality of the population. The inhalation of fibers is responsible for the onset of disabling and fatal diseases, such as neoplasms of the stomach, colon, rectum, larynx, bronchi, and lungs, mesothelioma, ovarian and other non-traumatic mitral valve disorders, as well as non-malignant diseases such as asbestosis, pleural effusion, and pleural plaques¹⁴. These health problems are progressive, irreversible, and difficult to treat, which makes it urgent to implement public policies to mitigate these risks.

Technical documents¹,⁷, research, and international literature¹⁰,¹⁵have investigated the potential health effects of exposures, which occur from conception to maturity at the age of 18. These studies warn of a possible increased risk of cancer in other parts of the body among workers who have been exposed to asbestos. The impacts on public health and the environment justify national and international bans on its use⁸.

In this context, the implementation of intersectorally articulated public policies, with the active participation of society, becomes essential to tackle this serious problem. Thus, in the state of São Paulo, the Health Surveillance Center of the State Health Department, through the Occupational Health Surveillance Division/ Workers’ Health Reference Centers (DVST/State CEREST), structured the Health Surveillance Program for Workers Exposed to Asbestos (PVISAT Asbestos), with strategic intervention actions in work environments and processes, surveillance of health problems and organization of care in the Health Care Network of the Brazilian Unified Health System (SUS), especially regarding diagnosis and establishing the relationship with work¹⁶-¹⁸.

The aim of this report is to describe the experience of surveillance and health care for workers exposed to asbestos articulated by the São Paulo State DVST/CEREST between 2008 and 2020. The aim is to present the progress and challenges of the interventions based on the experiences of the authors, taking as a basis the National Occupational Health Policy (PNSTT) and the São Paulo legislation on the banning of asbestos. It is hoped that sharing experiences will strengthen integrated actions and bring progress in tackling this serious public health problem.

Methods

This report of experience type is based on the authors’ experience of organizing and developing the actions of PVISAT Asbestos, a programmatic activity developed by the State DVST/CEREST, prioritized in the State Health Plans since 2008¹⁸-²⁰ and based on the context of the publication of the São Paulo law banning asbestos in 2007²¹.

The documental research included scientific and institutional sources. The scientific sources consisted of articles, conference proceedings, and texts resulting from seminars. Institutional sources include documents such as health plans, inspection reports, minutes of planning meetings with municipalities and institutional partners, publications on the official website of the Health Surveillance Center, as well as laws, decrees, ordinances, manuals, leaflets, and other publicity publications.

The selection of documents was based on the criteria of relevance and representativeness within the context of the program and the surveillance actions carried out, prioritizing those that reported actions directly related to the health of workers exposed to asbestos and their legal implications. The data extracted from these documents was systematized and organized into categories according to the main axes of the program: 1. Sanitary inspection in workers’ health; 2. Surveillance of workers exposed to asbestos; 3. Organization of health care for workers exposed to asbestos; and 4. Dissemination and popularization of knowledge and learning.

The narrative begins in 2008, from the activities that followed the publication of State Law No. 12.684/2007²¹, which established the cessation of exposure to asbestos from the prohibition of its use in production and consumption processes, until the publication of SS Resolution No. 70/2020²², which standardized the procedures for the organization of surveillance and health care for workers exposed to asbestos.

Historical background to PVISAT Asbestos

To provide a chronological overview of the process, a timeline was drawn up of the specific national and state legislation on asbestos, which underpinned health surveillance and care actions until the publication of the state ban law (Figure 2). A table was also drawn up showing the most important worker health surveillance actions related to exposure to asbestos carried out in the state from the 1980s until the program was formally created in 2008 (Table 1).

Figure 2
Timeline of national and state legislation, specific to asbestos, which underpinned VISAT actions

Table 1
Workers’ health surveillance actions related to exposure to asbestos, state of São Paulo, 1980-2006

Period	Actions taken
1980s	Surveillance carried out by the team from the North Zone Workers’ Health Program (PST-Zn), in conjunction with the State Health Surveillance26; a company that manufactures gaskets, yarns, and fabrics.
	Projects developed by the Workers’ Health Reference Centers in the municipality of São Paulo, as part of the Brazil-Italy Technical Cooperation Project27: manufacture of talc contaminated with asbestos, manufacture of gaskets, hydraulic cardboard, taparil.
1990s	Surveillance in a hospital to assess exposure to asbestos during procedures to remove the coating from water pipes28.
2000s	Inter-institutional actions, coordinated at the Health Surveillance Center between 2001 and 2006 in companies that use asbestos, based on Federal Law No. 9.055/95, on controlled use29: manufacture of friction materials and fiber cement.

In 2007, State Law No. 12.684/2007 had its constitutionality challenged in the Supreme Court (Supremo Tribunal Federal – STF), which suspended it for a year. On June 4, 2008, the injunction was revoked and the legal validity of the law maintained, ratifying the ban on the use of any product containing asbestos in the state⁷,²¹.

With the revocation of the injunction, the Legal Consultancy of the State Department of Health issued an opinion on the application of the law, reinforcing the ban on the use of asbestos in the production, sale of products containing it, and installation of building materials containing asbestos, as well as demanding health protection for workers involved in the demolition, removal, and final disposal of these materials.

The STF case dragged on until 2017, with requests for review, suspensions, resumption of the trial, and a public hearing with experts from various sectors. Furthermore, other lawsuits from states such as Rio Grande do Sul, Pernambuco, and the municipality of São Paulo were added. On November 29, 2017, ten years after the publication of the São Paulo law, the STF finally ruled that the laws were constitutional⁸,³⁰. Quoting an excerpt from Justice Celso de Mello’s vote on the São Paulo law: “What is really at stake in this case is, in the final analysis, the lives of workers and the indispensable defense of their inalienable right to health protection. Rights that cannot be disregarded or disregarded by the state”³¹.

Therefore, the state law, declared constitutional and aligned with the principle of health protection, has moved towards completely banning the substance from Brazilian daily life, as 70 other countries have done¹⁷.

And it is in this context that PVISAT Asbestos is organized and has its actions defined and developed throughout the state, as will be reported below.

Results

The initial aim of structuring PVISAT Asbestos was to develop worker health surveillance actions, including interventions in work environments and processes and surveillance of health problems resulting from exposure to asbestos. However, over time, the program began to adopt a broader approach, establishing strategic guidelines to ensure comprehensive health care for workers exposed to asbestos. This included actions at various points in the SUS health care network, aimed at preventing and diagnosing ARDs (asbestos-related diseases). The continuous dissemination of information about asbestos and its health effects was also a fundamental part of the actions carried out throughout the stages of the program¹⁵,¹⁷,¹⁸,³².

In 2008, in the context of the construction of the State Health Plan (São Paulo) for the four-year period 2008-2011¹⁹, the State Workers’ Health Surveillance Programs were structured, including PVISAT Asbestos, as a priority for action by the Health Surveillance Department (VISA)¹⁸,²⁰. The prioritization of the program led to the inclusion of issues related to workers’ health on the health agendas of all the state’s municipalities.

The State DVST/CEREST coordinated the implementation of PVISAT Asbestos, with decentralization to the 36 state VISA groups and subgroups, 645 municipal VISA, and 41 CEREST. The intersectoral coordination involved various players at different stages, such as the São Paulo Regional Labor Superintendence, the 15th Region Labor Prosecutor’s Office (MPT), Fundacentro (SP), the Brazilian Association of People Exposed to Asbestos (ABREA), the Heart Institute of the University of São Paulo Medical School’s Hospital das Clínicas (InCor), and the State University of Campinas (UNICAMP)³³.

PVISAT Asbestos was implemented with preventive guidelines and strategies, focusing on the care of exposed workers and the dissemination of guidelines to both the general population and workers. The CERESTs were strategic in promoting the actions throughout the state, fulfilling their role of technical support, permanent education, cooperation in assistance projects, promotion, and Workers’ Health Surveillance in their areas of coverage.

The results obtained will be presented in the following categories: Sanitary inspection in workers’ health; Surveillance of workers exposed to asbestos; Organization of health care for workers exposed to asbestos; Dissemination and popularization of knowledge and learning.

Sanitary inspection in workers’ health

The health inspection of workers’ health, an exclusive action of the public authorities, was carried out with the aim of intervening at various stages, from production to the use of asbestos.

Intervention in asbestos cement production

In 2008, when the state law came into force, most of the companies had already stopped producing asbestos. At the time, 19 establishments were registered with the Ministry of Labor and Employment as asbestos users. The registrations were canceled by the agency, except for those that were removing asbestos systems.

These companies were inspected by an inter-institutional team made up of technicians from the municipal and state (Regional and Central) VISAs and the Regional Superintendence of Labor and Employment (SRTE). The inspections sought to identify the procedures adopted by the companies to replace asbestos production lines, dispose of the waste generated, and monitor workers’ health. The companies that still used asbestos were fined and banned by the municipal VISAs and the SRTE, accompanied by the MPT.

Despite being banned, two companies obtained an injunction from the Regional Labor Court to continue using asbestos in their production process. Production was only halted in 2015, when these companies signed a Conduct Adjustment Agreement with the MPT, pledging to ban asbestos from their operations by January 1, 2017, including stocks of roof tiles, water tanks, and the like produced using the substance³⁴.

In 2018, there were no more companies using asbestos in their production processes in the state of São Paulo.

Action in the building materials trade

Although a large part of the industries had already stopped using asbestos, the production of the two companies with injunctions and companies from other states was still sold in 2009 in the São Paulo trade. For this reason, it was necessary to organize actions aimed at curbing the sale of products containing asbestos.

To have an impact, the surveillance of commercial establishments required the implementation of collective actions, which were carried out simultaneously throughout the state. The intervention in hardware stores was aimed at verifying the sale of products containing asbestos and the presence of these materials in stocks. In addition to health inspections, activities were carried out to communicate the risks of asbestos to society.

To support the teams in carrying out their actions, as the coordinating body, the State DVST/CEREST drew up specific regulations containing guidelines for health inspections in the trade, published in CVS-DVST Statement No. 16, of May 20, 2016¹⁸,³⁵, which also included references for the transportation of asbestos in natura and finished products containing asbestos on São Paulo roads.

CVS-DVST Statement No. 16/2016¹⁸,³⁵ describes the sequence of operations that make up the inspection action, namely:

1. Identification and recognition of products containing asbestos in the establishment, based on labeling, according to the standard established in Annex 12 of NR No. 1521. Products containing asbestos must be labeled and accompanied by instructions for use, with information on health risks, related diseases, and protection and control measures. In other words, they must have the lower-case letter “a” printed on them, as well as the characters “Warning: contains asbestos”, “Breathing asbestos dust is harmful to health”, and “Avoid risk: follow the instructions for use”.

2. Drawing up a notice of infraction, upon finding such products, “for exhibiting for sale, keeping in stock, or maintaining a display of any product containing asbestos in its composition, contrary to State Laws No. 10.083/1998, (Sanitary Code)²⁵and No. 12.684/2007²¹(banning the asbestos)”;

3. Drawing up the penalty notice and the interdiction notice in the same act, specifying the nature, quantity, and quality of the interdicted products;

4. Assigning responsibility to the owner or their legal representative for the banned materials, which cannot be sold or removed without the authorization of the health authority.

5. The banned products may be returned to the manufacturer or rendered unusable: a.The products must be returned to the manufacturer upon request and upon presentation of documentation to municipal VISA - a return invoice or collection document issued by the manufacturer. b.Disposal must be carried out in accordance with CONAMA Resolution No. 348/2004³⁶. Waste containing asbestos must be disposed of in an industrial landfill for hazardous waste.

6. Owners must notify the municipal authority, upon presentation of the Certificate for the Movement of Waste of Environmental Interest (CADRI).

7. The costs of moving the banned material to its final destination are the responsibility of the owner or representative of the establishment.

From 2012 to 2019, annual, coordinated, and simultaneous actions were carried out, organized regionally by the 28 regional VISA, with the active participation of municipal VISA and CEREST. Between 2012 and 2016, 6,767 establishments were inspected in 496 municipalities, which corresponds to 77% of São Paulo’s cities. Around 160,000 products were banned and, as part of the administrative procedure, the seized materials were returned to their manufacturers.

In 2019, the final year of collective actions, 1,712 inspection procedures were carried out in 375 (58%) of the state’s municipalities. In 2020, the COVID-19 pandemic interrupted planning for the implementation of the actions that year.

The municipalities played a crucial role, acting in accordance with their duties to promote and protect the health of the population in their territory. Health inspections, together with educational activities with the population, resulted in the withdrawal of materials containing asbestos from the building materials trade in the state of São Paulo.

Transportation of asbestos-containing cargo

As well as production and sale, the transportation of asbestos and natural and artificial fibers is considered a high-risk activity. Article 10 of Federal Law 9^.055/1995²⁴ defines the transportation of asbestos as a high-risk activity and establishes the procedures to be adopted in the event of accidents, such as isolating the area and measures to ensure that the material is repackaged in accordance with safety standards, under the responsibility of the transport company. Furthermore, Resolution 420/2004 of the National Land Transport Agency³⁷ also classified asbestos in the category of dangerous products.

Of the 19 asbestos-using companies inspected, mentioned in the sub-item “Intervention in the production of asbestos cement”, two were transport companies that carried out storage, transport, distribution, and containerization of cargo, destined for shipment directly to ships at the Brazilian Marine Terminal of Santos. These companies participated in the process of receiving and forwarding cargo for export, especially to Asian countries. In total, 1,600 tons of asbestos in natura, from the chrysotile asbestos mine located in the municipality of Minaçu, in Goiás, were interdicted due to the receipt, packaging in containers and transportation to the Marine Terminal. It is important to note that, in both companies, storage conditions were precarious, carried out in the open air, and torn packaging was found.

Although the state law does not prohibit the transportation of asbestos and VISA is not responsible for acting directly in the transportation of dangerous products, the action carried out focused on the storage of the product in São Paulo territory, aggravated by the precarious storage conditions, in which the release of fibers into the environment was observed.

In CVS-DVST Statement No. 16/2016³⁵, already mentioned in the sub-item “Action in the building materials trade”, the conduct of the health authorities was specified for action on this issue, with the aim of preventing the stock and sale of the product in the state, as well as checking the conditions of storage and packaging of the cargo in the trucks, in order to observe whether there is a release of asbestos fibers and exposure of workers.

Construction and renovation in public administration

Under Law No. 12.684/2007²¹, direct and indirect administration bodies in the state of São Paulo, as well as private facilities for public use, were banned from acquiring, using, and installing asbestos-containing materials in their buildings and premises.

As part of the PVISAT Asbestos actions, the government agencies responsible for construction were instructed not to use asbestos-containing products in constructions, extensions, or renovations, including in temporary facilities (construction sites), including requiring that bidding notices and contracts for public works include the obligation to comply with Law No. 12.684/2007²¹, applying to direct administration units, municipalities, foundations, public companies, and state-controlled entities.

Surveillance of workers exposed to asbestos

In 2018, after ten years since the start of PVISAT Asbestos, having carried out inspections in industries and annual actions in the building material trade, the program began to focus on drawing up guidelines for the surveillance and health care of those exposed to and those affected by asbestos-related diseases (ARDs).

These guidelines were standardized and published in SS Resolution 70/2020²², which established individual and collective actions aimed at the health care of the population exposed to asbestos. The Resolution was built collectively, under the coordination of State DVST/CEREST and with the participation of CEREST Piracicaba and Rio Claro, MPT, UNICAMP, FUNDACENTRO, INCOR, and ABREA. Aimed at professionals in the health care network of the SUS and private services, including the SESMT, the standard aims to direct care, diagnosis, and surveillance of exposure and ARDs.

Among the actions defined are: active search for exposed workers; diagnosis of ARDs and notification in the Notifiable Diseases Information System (SINAN); assistance to workers with ARDs; labor and social security guidance; and issuing of a Work Accident Report (CAT), when necessary.

A flow was created for active search for cases. Initially, the Mortality Information System (SIM) and Hospitalization System (SIH) databases were linked to the nominal list of workers sent by the MPT, with the aim of identifying cases of workers diagnosed with the following diseases: pleural plaques (ICD J92.0); pleural effusion due to asbestos (there is no specific ICD); diffuse pleural thickening (ICD J92.0); asbestosis (ICD J61); malignant mesothelioma of the pleura (MMP) (ICD C45.0 or C45.9), peritoneum (ICD C45.1 or C45.9), retroperitoneum (ICD C45.7 or C45.9), pericardium (ICD C45.2 or C45.9), tunica vaginalis (ICD C45.7 or C45.9), and bronchogenic carcinoma (lung cancer) (ICD C34).

The cases identified by linking the databases are forwarded to CEREST in the area covered by the company to complete the investigation and notify confirmed cases on SINAN.

In SINAN, the records on the Pneumoconiosis Investigation Form (ICD J92.0 and J61) and the Work-Related Cancer Investigation Form (ICD C45.0, C45.9, C45.1, C45.7 and C34) totaled 2,042 cases notified between 2006 and 2024 (July), of which: 1.640 (80.3%) pleural plaques, 210 (10.3%) asbestosis, 66 (3.2%) other pneumoconioses, 36 (1.8%) lung cancer, 30 (1.5%) mesothelioma, and 60 (2.9%) other cancers (esophagus, stomach, base of tongue, floor of mouth, colon, larynx).

With the aim of organizing the surveillance of workers exposed to asbestos, the State DVST/CEREST was part of a national working group that designed the basis for the construction of a tool for the national registration of the population exposed to asbestos. Developed by the Brazilian Association of Toxicological Information and Assistance Centers and Toxicologists (ABRACIT) and the Federal University of Santa Catarina (UFSC), with funds allocated by the MPT, the System for Monitoring Workers and Populations Exposed to Asbestos (Datamianto System)³⁸ was created. It is a platform that functions as an electronic medical record and database of workers and the population exposed to asbestos, in which health surveillance data is recorded, including information on monitoring the health of workers in companies that handle asbestos. The system also has a Business Intelligence (BI) platform that enables epidemiological analysis and the visualization of information in alert panels, which generate reports to support decision-making. Its interoperability with the National SUS Card makes it possible to update the address of those exposed, facilitating the active search process.

The Datamianto system consists of a management tool for planning, executing, monitoring, and evaluating surveillance and assistance actions for the exposed population, through which it was possible to organize the registration of 13,550 workers from 24 companies in the state. Although significant, the data still doesn’t represent the total number of exposed workers, considering that São Paulo’s industrial park once had around 200 companies. However, the system has proved to be fundamental for estimating and monitoring the exposed population, identifying cases of illness, updating notifications on SINAN, and drawing up the epidemiological profile of ARDs.

There are many challenges to identifying workers who have been exposed to asbestos in the state, considering only those involved in industrial activities. Most companies either no longer exist or the mandatory thirty-year period for periodic medical examinations of their workers has expired²³. Also noteworthy is the long latency period for ARD, which makes it difficult for both workers and health services to associate the relationship between the disease and work.

Table 2 shows, by municipality, the number of companies and workers currently exposed to asbestos in the state of São Paulo. The database is currently under construction and is being updated with information from companies, worker health surveillance processes, and ongoing investigations by the MPT, as well as individual data from care provided by reference services in occupational pulmonology, such as FUNDACENTRO, INCOR, and UNICAMP.

Table 2
List of municipalities and number of companies and workers exposed to asbestos registered with Datamianto, state of São Paulo

Municipality	Companies (n)	Workers (n)
Capivari	1	3,042
São Caetano do Sul	1	2,784
Osasco	2	2,782
Leme	3	2,261
Hortolândia	1	1,480
Campinas	3	588
Salto	1	412
São José dos Campos	1	190
São Paulo	3	3
Diadema	1	1
Indaiatuba	1	1
Ipeúna	1	1
Itapira	1	1
Nova Odessa	1	1
Santa Bárbara D`Oeste	1	1
São Bernardo do Campo	1	1
São José do Rio Preto	1	1
Total	24	13,550

Organization of health care for workers exposed to asbestos

Comprehensive health care for workers and the population exposed to asbestos must be developed at all points in the SUS network, from primary care to medium and high complexity services, including CEREST and Health Surveillance. Care should cover actions at an individual and collective level, including guidance and referrals for work and social security.

To subsidize the organization of health care for those exposed to asbestos in the territories, SS Resolution No. 70/2020²² defined that the construction of the line of care for ARD sufferers should involve the identification of the points of the health care network in the municipal, regional, and state territory, their competencies, the logistical system for care, the support system for diagnosis and treatment, and the network management system, including the spaces for agreement. The procedures for diagnosis, the conduct of health services in the face of diagnosis, and the flowchart for the management of cases by Primary Care teams were established in the Resolution.

Moreover, the role of CEREST was highlighted, in conjunction with Primary Care and Health Surveillance, in carrying out activities that include: entering data and maintaining the Datamianto System³⁸; identifying reference services for diagnosis in their territory; training health professionals and providing matrix support to primary, specialized, and medium and high complexity care teams; identifying and monitoring the cases attended; elucidating suspected cases or diagnostic doubts; monitoring care procedures for workers with ARD at other levels of complexity; notifying cases on SINAN and issuing CATs, when necessary.

It is worth noting that the state of São Paulo has reference services and professionals in the diagnosis and treatment of ARDs, such as the outpatient clinic at INCOR/HC/FMUSP³³, UNICAMP, and FUNDACENTRO, which have supported the implementation of the line of care in the structures and routines of the SUS.

Currently, three municipalities - Capivari, Leme, and Salto - have made progress in implementing the line of care, with the construction of strategies for active search for those exposed, procedures for health assessment (diagnosis and treatment), and ongoing monitoring of those exposed and diagnosed cases. In the municipalities of Hortolândia, Campinas, and those in the Greater ABC region (Santo André, São Bernardo do Campo, São Caetano do Sul, Diadema, and Mauá), the first meetings were held to present and start defining the strategies to be developed in each location.

The municipalities drew up their action plans and defined strategies for approaching workers, the flow of appointments and exams, flexible days and times for exams, communication in accessible and objective language, and accompanying workers to appointments at the specialty outpatient clinic. The three municipalities that have started implementing the line of care have so far evaluated 432 workers, which corresponds to 7.6% of the total number of workers at the three companies based in the respective municipalities: 296 in Capivari (9.8% of those registered), 60 in Salto (14.5% of those registered), and 76 in Leme (3.4% of those registered).

Dissemination and popularization of knowledge and learning

To give visibility to the issue and educate the population about the paradigm shift in the use of products containing asbestos, dissemination strategies were adopted based on scientific knowledge, legislation and the implementation of PVISAT Asbestos. The movement to ban asbestos is a form of socio-political resistance in defense of life and environmental sustainability, aimed at eliminating technologies that cause avoidable deaths²⁹,³⁹.

State law established the “Week of Protection Against Asbestos”, which should take place annually during the week of April 28th, with educational activities on the risks of asbestos, forms of prevention, replacement of the material, and its final disposal²¹. At the state level, the target audience for the educational activities are the regional VISA and CEREST teams, and they aim to encourage and subsidize the organization and reproduction of such activities in the territories.

The State Seminars on Asbestos, held in 2012, 2017, and 2018, provided moments for reflection and evaluation of actions. In 2018, the photographic exhibition “Asbestos: from controlled use to a ban” was inaugurated and toured events such as the 2nd International Brazil without Asbestos Seminar and the III Meeting of Families and Victims. The exhibition helped to build a memory of workers’ health surveillance practices and the banning of asbestos in the state.

To publicize the law and the ban on asbestos, educational materials such as leaflets, posters, and banners were produced and distributed to regional offices and municipalities to support educational actions and inspections. Among the regional actions carried out are: blitz, seminars, workshops with primary health care teams, events for construction entrepreneurs, distribution of educational material, leafleting, and publications in local newspapers. In 2019, the last year of collective actions in trade, 233 procedures related to education were carried out and the ban on the sale of asbestos products was communicated.

Figure 3 illustrates some of the activities carried out in the state, publicizing health inspections and educational actions in different electronic media.

Figure 3
Examples of PVISAT Asbestos actions publicized in different electronic media

Figure 3, image 1^c highlights news about the actions promoted by VISA Presidente Prudente on “D-Day” to combat asbestos, when around 100 inspections were carried out in commercial establishments in 2017. Figure 3, images 2^d and 3^e, highlight the work of CEREST in Jundiaí, which inspected 254 establishments, identifying three selling products containing asbestos in 2018, and the holding of the Asbestos Exposure and Commercialization Awareness Week, from April 8 to 12, 2019. Finally, Figure 3, image 4^f, shows an intervention in the streets of Marília, with a banner reading “The use of asbestos is prohibited in the state of São Paulo. State Law No. 12.684/2007. Asbestos Kills”.

Final remarks

The legislation banning the use of asbestos in the state of São Paulo spurred the development of the PVISAT Asbestos Program, creating a positive agenda aimed at protecting workers’ health and defending life.

The Program has achieved its objectives related to health inspections in the industry and trade of products containing asbestos, contributing to the elimination of the use of this mineral and interrupting the cycle of production and consumption in the state of São Paulo. The success of the intervention was based on coordination between the various institutions, both within and outside the SUS. Integrated work ensured greater uniformity in actions, strengthening inspections in the face of legal measures adopted by companies, such as writs of mandamus, injunctions and other appeals sought by companies.

PVISAT Asbestos collaborated effectively in the construction of technical and legal instruments to strengthen comprehensive health care for this population. Technical guidelines¹⁹ were drawn up for the surveillance and health care of workers exposed to asbestos, as well as a Datamianto system³⁸, aimed at recording and monitoring the exposed population.

It should be noted, however, that the surveillance of exposed workers and comprehensive care for these individuals face major challenges related to the implementation of a line of care for early, preventive, and timely actions. In addition to the long latency period for these diseases being a challenge for the organization of the health care system, the lack of investigation into occupational history obstructs anticipatory health measures and social and welfare rights for workers and their families.

Environmental liabilities and asbestos-containing products represent current threats, not least because of climate change and disasters that produce major changes in potential health risks.

On the national stage, the fight for a ban has not yet been concluded. The chrysotile asbestos mine, located in the municipality of Minaçu/Goiás, continues to produce and sell asbestos in natura, generating impacts in the state of São Paulo as well. This production, which is mostly destined for the international market, travels along São Paulo’s roads to be exported via the Brazilian Marine Terminal of Santos. As long as there is extraction activity at the mine, asbestos will circulate in the country.

This report has presented a series of concrete actions implemented by the PVISAT Asbestos Program to improve the quality of the working and living environment, guaranteeing adequate conditions for health, safety, and public well-being. However, it is important to note that the challenges are still significant.

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• Data availability:
  The entire data set supporting the results of this study has been published in the article itself.
• Presentation at a scientific event:
  The authors declare that the study was not presented at a scientific event.
• c
  https://g1.globo.com/sp/presidente-prudente-regiao/noticia/vigilancia-sanitaria-fiscaliza-lojas-de-materiais-de-construcao-para-combater-o-comercio-de-amianto.ghtml
• d
  https://jundiai.sp.gov.br/noticias/2018/04/25/cerest-fiscaliza-mais-de-200-empresas-para-combater-o-amianto/
• e
  https://jundiai.sp.gov.br/noticias/2019/04/05/cerest-realiza-semana-de-conscientizacao-sobre-os-riscos-do-amianto/
• f
  https://g1.globo.com/sp/bauru-marilia/especial-publicitario/prefeitura-de-marilia/noticias-de-marilia/noticia/marilia-faz-campanha-contra-amianto-e-flagra-venda-do-produto-ilegal.ghtml

• Funding:
  The authors declare that the study was not subsidized.

Edited by

• Editor-in-Chief:
  Leila Posenato Garcia

Data availability

The entire data set supporting the results of this study has been published in the article itself.

Publication Dates

• Publication in this collection
  13 Oct 2025
• Date of issue
  2025

History

• Received
  20 Dec 2024
• Reviewed
  23 May 2025
• Accepted
  28 May 2025