Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI)

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1 100 C /45J Santé travail Maladies chroniques et traumatismes Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI) Craftsmen and craftswomen from the self-employed workers social insurance fund retired between 2004 and 2008 Janvier 2013 Hélène Goulard 1,2, Julie Homère 1,2, Sabyne Audignon-Durand 2,3, Marcel Goldberg 1, Ellen Imbernon 1,2 et le Régime social des indépendants 1/ Institut de veille sanitaire (InVS), Département santé travail, Équipe associée en santé travail (Essat), Saint-Maurice - France. 2/ Université de Bordeaux, Institut de santé publique, d épidémiologie et de développement (Isped), Centre Inserm U897 Épidémiologie-biostatistique, Équipe associée en santé travail (Essat), Bordeaux - France. 3/ Laboratoire santé travail environnement (LSTE), Institut de santé publique, d épidémiologie et de développement (Isped), Université Victor Segalen, Bordeaux - France. 100 C/40M 70 N Background Asbestos imports peaked in France in the 1970s, when tons were used annually; this mineral was banned completely in Asbestos is the leading cause of occupational cancers (lung cancer and mesothelioma) in France. According to PNSM (national mesothelioma surveillance program) data, the theoretical proportion of cases of pleural cancer and mesothelioma that would be avoided if occupational asbestos exposure did not exist is 83.2% among men and 38.3% among women. The health effects of asbestos on the French population continue to be felt today, and 700 to 850 new cases of mesothelioma are identified each year 1. The department of occupational health (DST) at the French Institute for Public Health Surveillance (InVS) has developed systems of epidemiological surveillance directed specifically toward the occupational risks associated with asbestos in particular populations of workers 2. Special attention must be paid to self-employed workers, in particular, craftspeople who, unlike salaried workers, do not receive any medical follow-up for occupational risks, either while working or after retirement, as defined by article D of the Social Security Code. Nonetheless, as part of its expert assessment of the utility and methods of follow-up of retirees who were occupationally exposed to asbestos, the French Authority for Health (HAS) has recommended that this medical follow-up be extended to all retired workers in France, regardless of their status 3. ESPrI: a two-part program The ESPrI program (Epidemiology and surveillance of independent workers) comprises two components: i) identification of retired self-employed craftsmen and craftswomen who were exposed to asbestos, to offer them post-retirement medical followup, and ii) epidemiologic follow-up of this population. It was created by a joint project between the national self-employed workers social insurance fund (RSI) and InVS, following the recommendations of the Espaces study, published in Programme national de surveillance du mésothéliome : publications/2010/indicateurs_en_sante_travail/index.html post-professionnel_-_recommandations.pdf 4. This document focuses only on the medical follow-up component, which had the following specific health objectives: - to identify retired self-employed craftspeople who had been exposed to asbestos during their working life and inform them of the availability of free medical follow-up and their rights to compensation; - to estimate, from the data thus collected, the lifetime prevalence of occupational asbestos exposure in the French population of retired craftspeople, and to describe it according to gender and industry. Methods and population The ESPrI program began in 2005 in 7 regions: Aquitaine, Limousin, and Poitou-Charentes in southwestern France, and Basse-Normandie, Nord-Pas-de-Calais, Picardie, and Haute- Normandie in the northwest. It relies on the expertise of two occupational health services, one at Pellegrin Hospital in Bordeaux and the other at the Côte de Nacre Hospital in Caen, both referred to hereafter as the expert centers. A group within the DST coordinated the project. The RSI mailed self-administered questionnaires to new retirees annually for five years. This questionnaire asks for the respondents social and demographic characteristics, their occupational history, the frequency of their performance of job tasks involving potential exposure to asbestos, and their perception of their exposure. Based on the responses to this questionnaire, two industrial hygienists, one in each area, assessed each subject s occupational asbestos exposure. Each job was first classified according to exposure in four classes: high, intermediate, low, and unexposed, as recommended by the 1999 consensus conference [1]. Next, each subject was classified according to the level of the job with the highest exposure during his or her career. Those classified as asbestos-exposed in the intermediate or high categories were offered a three-stage baseline medical workup: an initial consultation with the physician of their choice, a chest scan (computed tomography, CT), and then a second consultation. The medical questionnaires completed by the physicians made it possible to calculate lifetime exposure prevalence. Finally, the prevalence of asbestos exposure in the total population of retired self-employed craftspeople was estimated from the data collected in this survey. Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI) Institut de veille sanitaire / p. 1

2 Excellent participation by retired workers Between 2005 and 2009, craftspeople who retired between 2004 and 2008 were invited to participate. The response rate to the self-administered questionnaire after the reminder was quite good (61%) and highlighted their interest in the program. The response rate varied substantially between regions and was best in the southwest (Figure 1). Women responded at a higher rate than men (64% versus 60%). The respondents mean age was 60 years. Overall, occupational episodes were identified from the occupational histories of the men and women. I Figure 1 I ESPrI questionnaire response rate in France. Retirees Industries and occupations potentially exposed to asbestos More than 80% ( of ) of the men s jobs were considered to entail asbestos exposure. In the construction industry, which accounted for the largest portion of jobs, nearly all jobs were considered exposed (96%). In automobile sales and repair, this percentage reached 75% and in manufacturing 45% (Figure 2). Regardless of the exposure category (low, intermediate, or high), the most frequent socio-occupational categories of men were skilled workers in traditional manufacturing (51%), craftsmen (31%), unskilled workers (9%), and skilled industrial employees (6%). The occupations of painters, construction finishing workers, masons, plasterers, automobile mechanics (maintenance and repair), plumbers, roofers, and heating engineers were those that were exposed most often. Women Career, industry, occupations The 1307 women who reported at least one job had averaged three. The mean duration of work was 39 years and 5 months, including nearly 29 years as a craftswoman (Table I). More than 67% had worked for at least 40 years. Among these women, 29% were craftswomen throughout their lives, most with the same lifelong job. The most frequent jobs were hairdressers, manicurists, and beauticians. The other women (71%) had been employees and tradeswomen. Finally, the sector of community, social and personal services accounted for 61% of all the women s jobs. Industries and occupations potentially exposed to asbestos Men Career, industry, occupations Throughout their careers, these retired craftsmen had had a mean of four jobs (as craftsmen or other) (Table I). More than 85% had worked for 40 years or more. Of the 7715 men who reported at least one job, 15% were craftsmen throughout their lives, and most often had the same job during their careers. The most frequent job was that of mason/plasterer. Most men (85%) had worked as employees and finished their careers as independent craftsmen. Their mean duration of work was 43 years, including 28 years and 4 months as a craftsman. The industries (French nomenclature of activity NAF2000) of construction, manufacturing, and automobile and appliance sales and repair accounted for 76% of all the jobs reported. The 3797 jobs held by women were much less frequently exposed to asbestos than the men s jobs (see Figure 3). Regardless of the exposure category (low, intermediate, or high), the most frequent socio-occupational categories were unskilled workers (13%), skilled workers (11%) and craftswomen (5%). Ignorance of exposure The questionnaire included the following question: "Do you think you have been exposed to asbestos?" Among the retirees classified as exposed, 37% of the men and 60% of the women either thought they had never been exposed or did not answer the question. Of the 3904 men who thought they had been exposed to asbestos during their career, 99% were classified as exposed by the expert. Of the 40 women who thought they had been exposed, the expert classified only 26 (65%) as exposed. p. 2 / Institut de veille sanitaire Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI)

3 Medical workups offered to retirees with at least one exposed job Of the 5993 men and women to whom this assessment was offered, 44% began it, 32% completed it and 30%, that is, 1810 men and women, had a complete medical workup with a chest scan. The diseases detected by the program were most often benign Of the 1798 men who had the complete assessment (CT and clinical examination), more than 16% had thoracic radiologic abnormalities, mainly benign pleural diseases (pleural plaques, diffuse pleural thickening, and asbestosis) and 28 men had lung cancer or mesothelioma. Of the 12 women with complete medical examinations, three had benign diseases and none malignant disease. Currently, no individual medical benefits appear to have been shown from CT screening for chest lesions in people who had been exposed to asbestos. Nonetheless recent data show encouraging results about the benefit of early annual CT screening in smokers. A reduction of 20% was shown in mortality from lung cancer after two years, among those who had a CT scan every year compared with a chest radiograph [2]. Lifetime prevalence of occupational asbestos exposure among retired self-employed craftspeople The lifetime prevalence was estimated from data collected in this program (see sidebar 1): 65% of the men were considered to have been exposed to asbestos at least once during their career (95% CI: 64%-66%). This rate reached 74% among those with at least one job in the construction industry (Table II). It was 57% in automobile sales and repair, 30% in manufacturing, 17% in the transport sector, and 3% in community, social, and personal services. The mean duration of exposure was 26 years and was highest in the construction industry, where the proportion of men exposed for more than 30 years was also highest (48%). The overall prevalence of exposure among women was 2.6% (95% CI: 2%-3%]. Particularly high lifetime prevalence of exposure in the construction industry The estimated prevalence of exposure is high in the construction industry. Because of a slight over-representation of this industry among respondents, the overall prevalence of exposure is probably overestimated. The estimated mean duration of exposure exceeds 10 years overall and 20 years in the sectors of construction and industry. According to the literature, exposure exceeding 20 years engenders high cumulative levels and increases the risk of developing an asbestos-related disease. Retired self-employed craftspeople more exposed than employees The literature contains no data related to the population of craftspeople that allow a strict comparison of the results. Data from the DST sample of job histories of approximately subjects aged years, representative of the French population by sex, age, and region, enabled us to estimate the prevalence of lifetime asbestos exposure with the asbestos job-exposure matrix. It reached 33% among all retirees. In the Espaces study (based on individual expert assessments of exposure and estimates according to a comparable method, 27.7% of employees from another insurance health fund (Régime Général de Sécurité Sociale) who retired from 1994 through 1996 at a mean age of 63 years and 6 months had been exposed to asbestos at least once during their working life. The estimates of prevalence among retired craftspeople are therefore globally twice as high as those of retired employees. This is probably due in part to the fact that the service sector, generally little exposed to asbestos, accounts for a relatively high proportion of employees while the majority of selfemployed craftspeople are manual workers, who are more often exposed. Conclusion The involvement of the RSI played an important role in the success of this program. Established in 2005, ESPrI met its objectives. The first was to enable RSI to identify among their recipients those who had been occupationally exposed to asbestos. The high participation rate of craftspeople in this program following successive recruitment campaigns and its smooth course demonstrated the feasibility of such a system and provided useful information to the expert advisory group appointed by the French Authority for Health (HAS) to develop new recommendations for post-retirement medical follow-up of asbestos exposure (see also Sidebar 2). The program estimated, for the first time, the lifetime prevalence of occupational asbestos exposure in the total population of retired craftspeople and described it according to both industry and duration of exposure. The results show that the proportion of craftspeople occupationally exposed to asbestos is high and differs according to industry; it thus allowed a better characterization of the groups at risk of developing an asbestos-related disease. These results also show that the asbestos exposure of retired craftspeople most often lasted for more than half their career and thus requires Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI) Institut de veille sanitaire / p. 3

4 monitoring of their health status. Because of the high proportion exposed to asbestos at least once during their career, the rate of more or less asbestos-induced diseases associated with it may be higher among retired self-employed craftspeople than among other retirees. The ESPrI Program has helped to reduce inequalities by promoting medical follow-up and access to the asbestos compensation fund (FIVA) for this population that does not receive specific monitoring for occupational risks. The results highlight the need to reinforce information provided not only to retired craftspeople but also to general practitioners, who are their principal medical advisors. They must be especially aware of and vigilant about medical follow-up for these asbestos-exposed retirees because these asbestos-induced diseases can occur 30 to 40 years after exposure. Passive epidemiologic monitoring of the cohort At the moment, the second component of this program, the follow-up of the cohort of volunteers, is underway (decision N CCTIRS, decision CNIL N ). The objective is to learn more about the health consequences of asbestos exposure in the population of craftspeople. Initially, passive epidemiologic monitoring will make it possible to describe their deaths according to cause and to compare the health status of the population of asbestos-exposed retired craftspeople to that of the general population. This process involves the collection of diverse data from various health-related administrative data bases: vital status and causes of death from the national individual identification directory (Répertoire National d Identification des Personnes Physiques, RNIPP) and the national cause-of-death database (CépiDc), and healthcare utilization data from the national health insurance fund cross-fund information system (SNIIR-AM) and the French hospital discharge database system (PMSI). Sidebar 1 - Method for estimating the prevalence of lifetime occupational asbestos exposure in the population of retired craftspeople The representativeness of the data was verified by comparing the distribution by industry of the ESPrI program participants and the nationwide population of retired craftspeople, by age and industry. Because the representativeness by age and industry of the women is less clear, prevalence of exposure was estimated only among men. The ESPrI data used with random drawing simulation methods allowed us to estimate the career prevalence of asbestos exposure and its confidence interval by industry in the entire population of retired self-employed craftspeople at their retirement. The probability of exposure associated with each past job was available for each retiree. The principle consisted in simulating the effective exposure of each person, based on these probabilities, to obtain a simulated proportion of retirees exposed during their career, and then to repeat this simulation a substantial number of times to obtain a wide distribution of these proportions. The estimated prevalence corresponds to the mean of this distribution. Sidebar 2 - Recommendations 1 In 2010, the early ESPrI results contributed to the development of new recommendations by the HAS for medical post-retirement follow-up of those occupationally exposed to asbestos. The HAS recommended the continuation of post-retirement follow-up for such workers and specified that this includes all workers (employees, civil servants, the self-employed, craftspeople, farmers, etc.). It also recommended that cohorts of populations such as ESPrI be established for prospective follow-up. The interministerial working group on asbestos and fibers (GTNAF) also recommended that this medical post-retirement follow-up be extended to all the social welfare funds. The French Senate and Parliament did the same in The HAS also recommended reviewing the types of examinations to be performed for this followup. Accordingly, a decree dated December 6, 2011, modified the decree dated February 28, 1995, for the application of article D of the Social Security Code on this subject. The examinations currently covered by the national health insurance fund for post-retirement asbestos follow-up are a medical consultation and a chest CT scan: every 5 years for those who were highly exposed, and every 10 years for those in the intermediate exposure category. 1 amiante_-_suivi_post-professionnel_-_recommandations.pdf Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI) Institut de veille sanitaire / p. 4

5 I Figure 2 I Asbestos exposure according to most frequent industries jobs self-employed craftsmen retired between 2004 and 2008 I Figure 3 I Asbestos exposure according to most frequent industries jobs self-employed craftswomen retired between 2004 and 2008 I Table 1 I Characteristics of the career of retired self-employed craftspeople - N=9022 Men N=7715 Women N=1307 Number of job reported Mean (standard deviation) 4.0 (2.4) 2.9 (1.9) Number of years of work years as craftspeople % of subjects craftspeople throughout their live 15% 29% I Table 2 I Estimate of the prevalence and mean duration of occupational exposure of men exposed to asbestos according to industrie (French nomenclature of activity - Naf 2000) Construction (F) Automobile sales and repair (G) Manufacturing (D) Transportation (I) Community, social, and personal services (O) % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI Prevalence (%) ,9 Mean (years) p. 56 / Institut de veille sanitaire Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI)

6 References [1] Conférence de consensus : élaboration d une stratégie de surveillance médicale clinique des personnes exposées à l amiante : 15 janvier Paris - La Villette. Énergies santé, (2): p [2] Aberle DR, et al., Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med, (5): p Teams and Partners: Institut de veille sanitaire Département santé travail : S. Ducamp, M. Goldberg, H. Goulard, J. Homère, E. Imbernon, D. Lauzeille, JL. Marchand, P. Rolland, D. Touzon CHU Bordeaux : S. Audignon, J. Barbary, P. Brochard CHU Caen : B. Clin-Godard, L. Lécrivain, M. Letourneux, JP. Voivenel RSI national : C. Blum-Boisgard, A. Chompret, S. Deschaume, B. Heuls-Bernin, C. Lescure, A. Paumier, A. Perrin, M. Risse, L. Yami RSI Aquitaine : V. Duprat, V. Farines, M. Kieffer, B. Lescarret, W. Roy, E. Saubusse, MN. Vibet RSI Limousin : M. Chassain, P. Flahou, S. Cosse, F. Sardin RSI Poitou-Charentes : K. Baloge, J. Cottin, C. Fleury, C. Germon, B. Martin-Silva, P. Rumeau, D. Simon RSI Basse-Normandie : R. Bazille, F. Dupont, JP. Lechartier, M. Monel, T. Preaux, P. Wissocq, I. Zen RSI Haute-Normandie : L. Druaux, M. Leroy RSI Nord-Pas-de-Calais : J. Deligne, C. Hantson RSI Picardie : J. Caron, JP. Orain, E. Therry RSI Midi-Pyrénées : F. Suarez, M. Tanguy Centre de recherche et de développement en informatique médicale (Credim) Bordeaux : D. Belougne, N. Belougne, B. Boulant, N. Boulant, L. Houinou, F. Pereira, P. Terrasson, G. Palmer Scientific collaboration: Équipe Risques post-professionnels - Cohortes (RPP-C), Unité 1018 Inserm-CnamTS : S. Bonnaud, M. Carton, D. Luce, M. Nachtigal Équipe Coset, Institut de veille sanitaire : L. Bénézet, J. Chatelot, B. Geoffroy-Perez Équipe SPP-Amiante : J. Baron, P. Brochard, JC. Pairon, C. Paris Département produits d informations, Institut national de recherche et sécurité (INRS) This program was funded by RSI as part of a contract with the InVS. To learn more: Goulard H, Homère J. Programme de surveillance post-professionnelle des artisans ayant été exposés à l amiante : artisans retraités entre 2004 et 2008 du Régime social des indépendants. Saint-Maurice: Institut de veille sanitaire; p. Disponible à partir de l URL : Key words: post-retired medical surveillance, cohort, epidemiological surveillance, occupational risks, asbestos, craftspeople, france Citation suggérée : Goulard H, Homère J, Audignon-Durand S, Goldberg M, Imbernon E, et les collaborateurs du Régime social des indépendants. Post-retirement medical surveillance of retired self-employed craftspeople exposed to asbestos (ESPrI). Craftsmen and craftswomen from the self-employed workers social insurance fund retired between 2004 and Saint-Maurice: Institut de veille sanitaire; p. Disponible à partir de l URL : Institut de veille sanitaire, 12 rue du Val d Osne Saint-Maurice Cedex France Tel.: 33 (0) Fax: 33 (0) ISSN : ISBN-NET: Réalisation : Service communication - InVS Dépôt légal : janvier 2013

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