Epidemiology of Mesothelioma & Asbestos Diseases,

DOSH, Malaysia July 2, 2010 Epidemiology of Mesothelioma & Asbestos Diseases, A Global Perspective Ken Takahashi Professor of Environmental Epidemiology Acting Director of WHO-CC for Occup Health University of Occup & Environ Health, Japan

Core Points 1. Basic Facts 2. The Japanese Experience 3. Context of Global Health 4. Implications for Malaysia

Basic Facts

Malaysia Cumulative use of raw asbestos = 821,672 metric tonnes 94,540 (-1970; #30) + 727,132 (1971-2008; #36) [USGS] Ranks # 27 among all countries in total asbestos use No report of mesothelioma deaths to WHO

Asbestos, definition asbestos means the fibrous form of mineral silicates belonging to rock-forming minerals of the serpentine group, i.e. chrysotile (white asbestos), and of the amphibole group, i.e. actinolite, amosite (brown asbestos, cummingtonite-grunerite), anthophyllite, crocidolite (blue asbestos), tremolite, or any mixture containing one or more of these (ILO C.162) chrysotile >95%; amosite 2-3%; crocidolite 1%

Asbestos chrysotile 0.02-0.03 (200-300 nm) vs. human hair 100

Commercial Values > Wide Applications Thermal insulation values (wide temperature ranges) Acoustical insulation qualities Resistance to corrosive chemicals Electrical insulation values (satisfactory) Wear/friction resistance Binding/adhesive qualities Workability Abundance and low cost Construction material (>70%) Roofing Siding Flooring Asbestos Cement Pipes Friction material Vibration joint cloth (ductwork) Mechanical gasketing Brake shoes/clutch lining Duct insulation, adhesive and sealant materials Tank insulation Fire hoses Heat resistant gloves Electrical wire cover Etc.

Asbestos Diseases/ ADs asbestos fibers 1. Lung Cancer 3. Asbestosis 4. Pleural Thickening 2. Mesothelioma (M) Pleural M Peritoneal M

ARDs: Exposure Level & Latency Time Exposure Level asbestosis lung cancer plaque calcification mesothelioma Latency Time (adapted from Bohlig 1975)

The Japanese Experience

Non-Accidental Occupational Diseases Recognized by WACIL

Kubota Shock of 2005 Japanese Asbestos Scandal 2005.6.29 Mainichi Newspaper

Chronology of related laws and reguls ISHL=Industrial Safety & Health Law; its enforcement order (EO); its ordinance Ordinance*=on Prevention of Hazards Due to Specified Chemical Substances 1971 (S46) 1975 (S50) 1995 (H07) Ordinance* enforced: regulated as Group 2 Substance (prevention of leakage; appointment of Operations Chief; implementation of Work Environment Measurement) Ordinance* amended: asbestos spraying is prohibited; implementation of Specific Medical Examination for asbestos-handling workers (on placement and every 6 mo.) EO (ISHL) amended: prohibition of crocidolite and amosite Ordinance amended: PPE mandated for designated jobs; reinforcement of regulatory procedures for removal of sprayed asbestos 1996 (H08) 2004 (H16) 2005 (H17) Health Administration Diary distributed and Medical Examination provided to retired workers who handled asbestos under a particular condition EO(ISHL) amended: chrysotile prohibited in principle (construction material, abrasive material, etc.) Ordinance on Prevention of Asbestos Hazards separated from Ordinance*

Total Ban of Asbestos Effective Sep.1 2006 Prohibition of manufacture, import, sales, provision, use for products containing 0.1%+ weight of asbestos

5 Top Occup Ca. in Japan Cumulative Number, 1987-2006 Cumulative Number of Compensated Cases 1 Mesothelioma & Lung Cancer (Asbestos) 3,362 2 Urinary Tract Cancer (Benzidine, - naphtylamine) 3 Lung and Upper Resp Tract Ca. 4 (Chromium) Skin Cancer (Soot, Mineral Oil, Tar, Coal tar, Pitches, Asphalt, Parafyn) 608 194 145 5 Lung or Skin Cancer (Arsenic) 77 Lung Cancer (Coke Oven Emissions) 76

5 Top Occup Ca. in Japan Recent Trends, 2000-2006 Recent Trends of Compensated Cases (annual 1 Mesothelioma & Lung number) Cancer (Asbestos) 1000+ 2 Urinary Tract Cancer (Benzidine, - naphtylamine) 3 Lung and Upper Resp Tract Ca. 4 (Chromium) Skin Cancer (Soot, Mineral Oil, Tar, Coal tar, Pitches, Asphalt, Parafyn) 5 to 10 3 to 5 0 to 1 5 Lung or Skin Cancer (Arsenic) 0 Lung Cancer (Coke Oven Emissions) 3 to 12 Lung cancer among pneumoconiotics 30 (2000-01) to 100+ (2002-07)

Unique Spread of Asbestos Exposure Direct Occupational Exposure: Workers, including self-employed Indirect Occupational Exposure: Workers, including self-employed Domestic Exposure: Families/Relatives of exposed workers Neighborhood Exposure: Residents lived near asbestos plant, mine, etc: residential exposure Environmental Exposure: the Public, from building, car, etc. Exposure which origin cannot be traced

Estimated future deaths from male pleural mesothelioma in Japan Murayama T, Takahashi K et al. Am J Ind Med, 2006

Context of Global Health

International Trends Declaration on Elimination of ARD (WHO, 2006) 108,000 annual deaths from ARDs (125 M exposed) International tools by ILO ILO C. 162 (1986) Resolution concerning asbestos of 2006 Rotterdam Convention All asbestos (excepting chrysotile) included in PIC List Inclusion of chrysotile advanced by RC

Ecological Relationship MORtality (2000-04) regressed on ASBestos (1960-69), weighted by POPulation All meso, male Pleural meso, male All mesothelioma, male: Log10 (MOR)=0.382 ASB-0.135 Peritoneal meso, male Asbestosis, male All mesothelioma, female: Log10 (MOR)=0.208 ASB-0.326 Lin RT, Takahashi K, et al. Lancet 2007; 369: 844-9 23

In numbers Historical consumption explains 74% of variation for mesothelioma and 79% of asbestosis (both p<.0001) Increment of 1 kg per capita corresponds to 2.4-fold increase in mesothelioma, 2.7-fold in asbestosis

Pleural Mesothelioma, males Period Mortality Rate (1996-2005) : pmr (deaths/million/yr) DNK 12.9 UK 31.1 NLD 30.0 JPN 4.8 pmr (deaths/million/yr) 30 20-30 10 20 5 10 1 5 0 1 AUS 25.5 NZL 20.5

Pleural Mesothelioma, males Annual Percent Change (1996-2005): APC (%/year) ISL -1.4 NOR -2.7 FIN -0.3 AUT -5.9 FRA -1.0 HUN 11.0 DEU 3.3 HRV 11.0 JPN 3.9 BRA 9.0 APC (%/yr) 5 over 1 to 5 0 to 1-1 to 0-5 to -1-5 less AUS 4.6 ARG 8.9 Nishikawa, Takahashi et al. Environ Health Perspect, 2008

Change in Use vs. Change in during 1950-1990 Mortality during 2000-2005 Adjusted R 2 0.5 0.4 0.3 0.2 0.1 0 [Linear Regression Analyses x 21 combinations] 0.415 (p<0.0001) 0.466 (p<0.0001) 0.366 (p<0.0001) -0.1 1950-1960- 1970-1975- 1980-1985- Environ Health Perspect, 2008

Motion Chart by Google http://envepi.med.uoehu.ac.jp/motionchart.html

Asbestos use vs. economic development in WORLD 10 Environmental Kuznets Curve 1 0.1 GDP per capita --x-- High Income --x-- Middle Income --x-- Low Income --x-- Others 0.05 0 5,000 10,000 15,000 20,000 25,000 30,000 GDP per capita (1990 GK dollars) Le GV, Takahashi K et al. Environ Health Perspect, 2010

Asian concern for the present and future Data scanty Only 4 Asian countries reported 17.8% of all mesotheliomas in WHO-DB (1994-2004) True? Short lag-time? Inadequate surveillance systems? Poor political commitment 2 Asian countries ratified ILO C.162 among 32 6 Asian countries banned asbestos among 44 Asian takeover of global asbestos share From 19% (840/3,500) in 1985 to 47% (950/2,040) in 2000 Takahashi K. Occup Med (Oxford) 2008.

Interim summary Burden of Disease correlates with national use of asbestos, lagged Developing countries at cross-road to benefit from primary prevention Lag in national phases provides opportunities for technology share and transfer Amenable to primary prevention; concern by international organizations: WHO, ILO, UNEP, UNU Gaining place on Global Health agenda

Implications for Malaysia

Cumulative Asbestos Use vs. Estimated 15-yr Cumulative Incidence of Mesothelioma Based on the strong correlation between the above, Malaysia s missed # of mesothelioma cases can be estimated.

Imported Volume of Raw Asbestos Upper: Total Volume (metric tons) Lower: Per Capita Volume (kilograms) 60 70 75 80 85 90 95 2000 Malaysia 2,868 14,321 19,932 32,242 19,064 22,000 28,200 17,711 per capita 0.4 1.3 1.6 2.3 1.2 1.2 1.4 0.8 Japan 92,403 319,473 255,551 398,877 264,327 292,701 193,800 98,595 per capita 1.0 3.1 2.3 3.4 2.2 2.4 1.5 0.8 Thailand 6,433 21,272 42,521 58,756 71,516 116,652 181,692 120,563 per capita 0.2 0.6 1.0 1.3 1.4 2.1 3.1 2.0

<Male All Mesothelioma>

<Male All Mesothelioma>??? 60 70 75 80 85 90 95 2000 0.4 1.3 1.6 2.3 1.2 1.2 1.4 0.8 Now +10yr +20yr

Underlying Principles of AAI Focus on all Three Levels of Prevention with emphasis on primary prevention Recognize Societal Transitions may take some time with need to recognize unique national situations and variable-term goals Co-ordinate among academia, administration and NGO in close line with International Organizations Give ARDs a higher place on the Global Health Agenda!

Primarily, Who are WE? Academia, Researchers and Practitioners Administration (national and regional) Recognition by International Organizations WHO (HQ & regional) ILO (HQ & regional) UNEP UNU TRADITIONAL NEW Potential to cooperate with NGOs UNIQUE

What are our STRENGTHS? OBJECTIVITY EXPERTISE Quality information ( mandate to produce, compile and disseminate) RECOGNITION Enhance connectivity Power to influence (people and political will) We are the KEY PLAYERS!

Asian Asbestos Initiative (AAI) AAI1 in Kitakyushu 2008/10 AAI2 in BKK, Thailand 2009/12

Conclusion Asbestos has been used ubiquitously in and around Malaysia Recent current burden of ARDs is a consequence of use during 1960-1970 Because Malaysia has peaked asbestos use around 1980, its effect should surface around 2010-20. Joining international effort (incl., adopting ban) is strongly recommended

DOSH, Malaysia July 2, 2010 Epidemiology of Mesothelioma & Asbestos Diseases, A Global Perspective Ken Takahashi Professor of Environmental Epidemiology Acting Director of WHO-CC for Occup Health University of Occup & Environ Health, Japan

References 1. Le GV, Takahashi K* et al. National use of asbestos in relation to economic development. Environ Health Perspect 2010, 118(1):116-9. 2. Takahashi K. Asbestos-related diseases: time for technology sharing (editorial). Occup Med (Oxford) 2008, 58:384-385. 3. Nishikawa K, Takahashi K* et al. Recent mortality from pleural mesothelioma, historical patterns of asbestos use, and adoption of bans: a global assessment. Environ Health Perspect 2008, 116:1675-1680. 4. Lin R-T, Takahashi K* et al. Ecological association between asbestosrelated diseases and historical asbestos consumption: an international analysis. Lancet 2007, 369:844-849. 5. Murayama T, Takahashi K et al. Estimation of future mortality from pleural malignant mesothelioma in Japan based on an age-cohort model. Am J Ind Med 2006, 49(1):1-7. *corresponding author