Asbestos: health effects and risk. Peter Franklin Senior Scientific Officer, EHD Senior Research Fellow, UWA

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1 Asbestos: health effects and risk Peter Franklin Senior Scientific Officer, EHD Senior Research Fellow, UWA

2 What is asbestos Naturally occurring mineral that has crystallised to form long thin fibres and fibre bundles (silicate fibres) Two main types (6 specific materials) Amphibole crocidolite (blue asbestos) amosite (brown) (tremolite, actinolite, anthophylite) Serpentine chrysotile (white) Other winchite, richterite (asbestiform)

3 Asbestos-related Diseases (ARDs) Malignant Mesothelioma Lung cancer Other cancers Larynx, ovarian (IARC Group 1 human carcinogen) Pharynx, stomach, and colorectum (+ve associations) Non-malignant Asbestosis Diffuse pleural thickening Pleural plaques

4 Why does it cause disease? Fibre shape and size Long thin fibres Penetration deep into the lung Smaller fibres can migrate to pleural space Persistence Cant be broken down Properties that make asbestos a great product (tensile strength, chemical, electrical, heat and acid resistant) Poor clearance = high retention in lungs

5 Pathogenesis of disease Not fully known Multiple direct and indirect mechanisms direct interaction with target cells Cell damage, cell death, functional changes Indirect via inflammatory and oxidative stress pathways Scarring, inflammation and oxidative stress leading to; Fibrosis Cancer Genetics Not all exposed people get disease No way to determine those at genetic risk

6 Determinants of toxicity Fibre type Crocidolite > amosite > chrysotile Mesothelioma risk: 500 (croc):100 (amos):1 (chrys)? LC risk: (amphiboles):1 (chrys) (may be equipotent) * ALL fibre types are toxic Size Longer (> 5uM) > shorter (but considerable uncertainty) Longer fibres cleared more slowly Cytotoxicity Surface area * ALL fibres sizes are toxic

7 Development of disease Level of exposure Exposure to fibres over time (cumulative exp) Peak exposures? Dose-response Increase exposure = increase risk Mesothelioma rate (per 100,000 person years) <5 5-9 >=10 Cumulative exposure (f/ml-years)

8 Development of disease Latency years ( latency with exposure) risk with time (up to ~50 years) 400 Mesothelioma rate by time since first exposure Mesothelioma incidence (per 100,000 person-yrs) Time since first exposure (years)

9 Malignant ARD 1. Malignant Mesothelioma (MM) cancer in the membrane (mesothelium) between the chest wall and the lungs (pleura); and between the stomach and intestines (peritoneum). asbestos is the only known cause of MM erionite universally fatal short survival time (diagnosis to death)

10 Malignant ARD 2. Lung cancer Main cause is smoking. Asbestos also an independent cause. The combination of smoking and asbestos exposure increases the risk of lung cancers to a greater extent than either of them alone (>additive but <multiplicative). Asbestosis as a precursor? Fibrosis cancer hypothesis Probably not both related to high exposures, biological process of fibrosis to cancer is hard to establish (mechanistic speculation) Survival depends on stage at diagnosis CXR usually identifies too late (stage 4) LDCT provides for earlier detection

11 Malignant ARD 3. Other cancers Cancer IARC evidence for causation Laryngeal Sufficient Ovarian Sufficient Colo-rectal Limited sufficient Pharyngeal Limited Stomach Limited

12 Non-malignant ARD Asbestosis: progressive disease caused by scarring of the lung leading to diffuse interstitial pulmonary fibrosis. Causes shortness of breath, coughing and lung damage. Although smoking doesn t cause asbestosis it will make the disease worse. Pleural thickening: is a scarring and thickening of the lining of the lung (pleura), which restricts the expansion of the lung and reduces lung function. Also causes symptoms such as chest pain and shortness of breath Pleural plaques: also scarring and thickening of the pleura but only in isolated areas. Plaques are often the earliest sign of exposure to asbestos but are not generally related to symptoms or impaired lung function.

13 Asbestos-related disease waves 1 st people working with raw asbestos miners & millers transport Manufacturing of asbestos products 2 nd people working with asbestos products Construction, insulation, automotive 3 rd in-place exposure (involuntary) In buildings (deterioration, weathering) Home renovation Demolition

14 Domestic Exposure - Disease Risks (with a focus on home renovation) Most of the research focuses on the risk of Mesothelioma. Mesothelioma is a specific outcome of asbestos exposure; No causal factor except for exposure to asbestos (and some other mineral fibres), has been established or even convincingly suspected Difficult to determine risk for other asbestos related disease Other causes (eg lung cancer and smoking) Data not collected (eg if no occupational exposure) a GP may not consider pulmonary fibrosis to be asbestos related

15 Western Australian Meso Register Has every case of Meso from 1960 to present Each case reviewed by: pathologist, occupational physician, respiratory physician, epidemiologist, & Mgr of Cancer Reg Determination of main exposure routes: 23 work categories (inc Wittenoom miners) 5 Non-occupational Wittenoom residents Wittenoom visitors Family member of (non-wittenoom) asbestos worker DIY/Home renovator Other Unknown exposure data not available No known exposure no memory of exposure (background rate?)

16 What is DIY exposure? To be classified as DIY exposure means that no other source of exposure could be identified DIY exposure is defined as: participation in home renovations/home maintenance or as a bystander while such activities occurred. Limitations/difficulties Self-reporting Recall bias/unrecalled exposures particularly for one off exposures such the DIY

17 Asbestos fibres during DIY Background (ambient air): f/ml NOHSC workplace standard (8hr): 0.1 f/ml NB: concentrations rapidly return to pre-activity levels after

18 Mesothelioma cases in WA: Number of cases Proportion of all cases Wittenoom workers Other workers Wittenoom residents Other non-occupational DIY No known Unknown Total Still ~ 100 new cases per year

19 Mesothelioma trends: Wittenoom workers %Other workers Wittenoom residents Other nonoccupational DIY No known Unknown

20 Home renovators Men v women Men: 90/1829 = 5% Women: 58/295 = 20% Will numbers keep increasing?

21 Year of exposure Decade Number 1st exposed 1940s s s s s s 1 (1991) Issues More home renovation since the 1980s, BUT greater knowledge (more precautions) since that time?

22 Surveys of homeowners DIY s 2 surveys NSW and WA NSW (Park et al. MJA 2013; 199: ) n = (14.5%) did home renovation that involved being exposed to asbestos (NB: no information on when they did renovations) Only 12% always took precautions (30% never took precautions) WA (unpublished) 300 households advised to have asbestos 14% were going to do home renovation involving handling or removal of asbestos Most of these (73%) advised they would engage a licensed asbestos removalist

23 DIY and Meso International data Case-control study in the UK (2009) Male: 84% occupational, 1.3% domestic, 14% unknown Female: 22% occupational, 16% domestic, 62%? DIY exposure no > risk than background Do Australians do more home renovation?

24 Is DIY a risk? numbers of MM cases from DIY exposures Don t know rates how many home renovators were there? Is the DIY rate > background? Dose relationship difficult to establish for one off exposures Most exposures occurred <1980s when asbestos was still legal No PPE Use of power tools People now more aware But not all take precautions! If done properly risk is extremely low

25 MM Incidence B ground + Wittenoom Average incidence of MM Wittenoom workers rate 30-50y after first exposed 1000 Wittenoom ex-residents rate 30-50y after first exposed Rate/million Unexposed (Peto, 1984) Age group Background rate: 1 2/million/yr Incidence in workers /million/yr, Incidence in residents /million/yr (depending on; time since 1 st exposure, cumulative exposure & length of stay)

26 Incidence of MM 2. DIY Average incidence of MM Wittenoom workers rate 30-50y after first exposed 1000 Wittenoom ex-residents rate 30-50y after first exposed Rate/million 100 Residential exposure 10 1 Unexposed (Peto, 1984) Age group Incidence in DIY 2/mill/yr (<40yrs) 80/mill/yr (>75 yrs); 2 10 risk than background

27 Non-occupational exposure and other ARDs Plaques Can appear with exposure < than required for disease 1 7% in general pop n. Most, but not all, assoc with occ exp non-occ exposures; living with worker, natural deposits Asbestosis rare in non-occupational groups associated with cumulative exposure (magnitude & duration) non-occ exposures; living with worker, natural deposits Lung cancer Difficult

28 Concluding remarks Risk of ARD from non-occupational exposures is very low BUT there is no known safe threshold level of exposure the consequences are very high ARD are debilitating &/or fatal there is no way of determining who will develop an ARD Asbestos needs to be managed with extreme caution

29 Real v perceived risks

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