The global burden of asbestos-related disease - occupational exposures

The global burden of asbestos-related disease - occupational exposures Tim Driscoll School of Public Health University of Sydney

Outline Background to GBD Overview of methods relevant to asbestos Overview of GBD 2013 results relevant to asbestos Consideration of some of the important issues Consideration of uses and implications of the results NB: GBD 2013 results presented are DRAFT results

A little GBD history 3

GLOBAL, COMPARABLE, EVIDENCE-BASED information on injuries and diseases and associated risk factors A response to the need for comprehensive, consistent and comparable information on diseases and injuries at global, regional and national levels (WHO) Diseases and injuries, and the risk factors that cause them

GBD 1990 5

GBD 1990 Commissioned in 1991 by World Bank Run by Chris Murray and Alan Lopez Focussed on 1990 Released in 1996 Involved collaborators from many countries Primarily looked at outcomes (overall burden) - 107 diseases and injuries and ten risk factors

The Comparative Risk Assessment project

The Comparative Risk Assessment project Ran from 2000 to 2004 Looked at burden in 2000 Focussed on risk factors Involved working groups for specific areas Occupational risk factors working group led by Marilyn Fingerhut

The new GBD initiative 9

The new GBD initiative Run by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington Funded by Bill and Melinda Gates Foundation Expert groups provide advice to central team but final decisions made centrally Originally GBD 2005, became GBD 2010 and now GBD 2013 Regular updates planned Each update incorporates new information and methods

GBD 2013 21 regions

Occupational risk factors 12

Occupational risk factors that were included Carcinogens Airborne exposures Ergonomic risk factors for low back pain (combined exposure) Noise Occupational injury risk factors (Pneumoconiotic dusts)

Occupational risk factors that were included Carcinogens Airborne exposures Ergonomic risk factors for low back pain (combined exposure) Noise Occupational injury risk factors (Pneumoconiotic dusts)

Carcinogens Only IARC Group 1 carcinogens Only outcomes with sufficient epidemiological evidence (as per IARC) 14 carcinogens Seven cancer types 18 carcinogen cancer pairs - Four involve asbestos ICOH 2015 Seoul Burden from occupational risk factors

Asbestos-related cancers included in GBD 2013 Laryngeal cancer Lung cancer Mesothelioma Ovarian cancer ICOH 2015 Seoul Burden from occupational risk factors

Results 17

Global deaths from occupational risk factors - 2013 350,000 300,000 250,000 Deaths 200,000 150,000 100,000 50,000 0 18

Global deaths from occupational risk factors - 2013 350,000 300,000 250,000 Deaths 200,000 150,000 100,000 50,000 0 19

Global deaths from occupational asbestos exposure - 2013 215,000 - cancer: 194,000 - asbestosis 21,000 87% male 10% of all lung cancer deaths 64% of all occupational cancer deaths

Age - deaths 90,000 Asbestos-related cancer deaths 80,000 70,000 60,000 Deaths 50,000 40,000 30,000 20,000 10,000 0 15-24 25-34 35-44 45-54 55-64 65-74 75+ Age 21

Age deaths per capita 450 Asbestos-related cancer deaths (per million) 400 350 300 Deaths per million 250 200 150 100 50 0 15-24 25-34 35-44 45-54 55-64 65-74 75+ Age 22

Type of cancer Asbestos-related cancer deaths Mesothelioma Ovarian cancer Cancer type Lung cancer Larynx cancer 0 50,000 100,000 150,000 200,000 Deaths 23

Type of disease Asbestos-related deaths Mesothelioma Ovarian cancer Disease type Lung cancer Larynx cancer Asbestosis 0 50,000 100,000 150,000 200,000 Deaths 24

Cancer type ALL exposures - type of cancer Leukemia Mesothelioma Kidney cancer Ovarian cancer Nasopharynx cancer Lung cancer Larynx cancer 0 50,000 100,000 150,000 200,000 250,000 300,000 Deaths 25

Cancer type ALL exposures - type of cancer Leukemia Mesothelioma Kidney cancer Ovarian cancer Nasopharynx cancer Lung cancer Larynx cancer 0 50,000 100,000 150,000 200,000 250,000 300,000 Deaths 26

Cancer type ALL exposures Type of cancer excluding lung cancer Leukemia Mesothelioma Kidney cancer Ovarian cancer Nasopharynx cancer Larynx cancer 0 5,000 10,000 15,000 20,000 25,000 30,000 Deaths 27

Cancer type ALL exposures Type of cancer excluding lung cancer Leukemia Mesothelioma Kidney cancer Ovarian cancer Nasopharynx cancer Larynx cancer 0 5,000 10,000 15,000 20,000 25,000 30,000 Deaths 28

Carcinogen ALL exposures Lung cancer carcinogen type Silica PAH Nickel SHS Diesel Chromium Cadmium Beryllium Arsenic Asbestos 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000 Deaths 29

Carcinogen ALL exposures Lung cancer carcinogen type Silica PAH Nickel SHS Diesel Chromium Cadmium Beryllium Arsenic Asbestos 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000 Deaths 30

The legacy of asbestos use 31

Region ALL exposures Region deaths per capita World Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia 0 50 100 150 200 250 300 Deaths per million 32

Region ALL exposures Region deaths per capita World Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia 0 50 100 150 200 250 300 Deaths per million 33

Asbestos-related cancers deaths per capita Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0 20 40 60 80 100 120 140 160 180 Deaths per million 34

Asbestos-related cancers deaths per capita Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0 20 40 60 80 100 120 140 160 180 Deaths per million 35

Asbestos-related cancers deaths per capita Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0 20 40 60 80 100 120 140 160 180 Deaths per million 36

Occupational cancer deaths % asbestos-related 37

Occupational cancer deaths % asbestos-related Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Per cent 38

Occupational cancer deaths % asbestos-related Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Per cent 39

Occupational cancer deaths % asbestos-related Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Per cent 40

What can the data be used for?

What can the data be used for? Guide sensible decisions on prevention and control Highlight and learn from disparities Raise awareness 42

Asbestos-related cancers deaths per capita Western Sub-Saharan Africa Southern Sub-Saharan Africa Eastern Sub-Saharan Africa Central Sub-Saharan Africa South Asia North Africa and Middle East Tropical Latin America Central Latin America Andean Latin America Caribbean High-income North America Southern Latin America Western Europe Australasia High-income Asia Pacific Eastern Europe Central Europe Central Asia Oceania Southeast Asia East Asia Global 0 20 40 60 80 100 120 140 160 180 Deaths per million 43

Some things to think about

Methodology and assumptions Burden estimates need information on Exposure Proportion of population exposed Risk measure Background exposure Population measures of the disease or injury of interest Considerable assumptions or methodological decisions often needed for all of these

Methodological issues Lack of relevant exposure data Matching the risk information to the exposure level Latency Persistent risk after exposure ceases Reduction of risk after exposure ceases How much evidence is required? 46

More issues

More issues Populations not included: - Informal workforce - Child workers Represents the effect of past exposures

Relevance of burden estimates - issues

Relevance of burden estimates - issues Interventions now may take many years to have an effect need to convey this effectively to the decision makers. For asbestos-related disease, current burden measures can t be used as a sensitive monitor of recent interventions. Different groups produce different estimates due to different assumptions this makes it difficult for external users of the information. 50

Does the uncertainty matter? 51

Does the uncertainty matter? It doesn t matter what the exact number of deaths is. The key aspects to consider are: Are the results in appropriate relative order? Is the problem big enough to do something about? If so, what should be done? What are the priorities? What is the best evidence available for deciding this?

Occupational risk factors - collaborators 53

Occupational risk factors - collaborators EWG CORE MEMBERS Tim Driscoll Lesley Rushton Sally Hutchings Kyle Steenland Kurt Straif GBD CORE TEAM MEMBERS Greg Freedman Astha KC Mehrdad Fourzanfar Theo Vos Steve Lim Majid Ezzati OTHER CONTRIBUTING MEMBERS Carissa Bonner Claire Bryan-Hancock James Harrison Anthony Hogan Ryan Hoy Gemma Jacklyn Kevin McGeechan Jess Orchard Erin Passmore Neil Pearce Warwick Williams Qialing Zhang 54

Conclusions 55

Conclusions The Global Burden of Disease study is explicitly evidenced-based. It provides evidence on burden, and the risk factors that produce that burden. Occupational exposure to asbestos is estimated to cause about 215,000 deaths per year. This is probably an underestimate. The findings for Developed countries provide key lessons for Developing countries.

Conclusions Methodological challenges remain. The information from the GBD study should be used to guide policy and resource allocation, and to raise awareness through education. Most importantly, the information should lead to ACTION to eliminate exposure to asbestos as much as possible!

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