Findings from Situational Analyses of Asbestos-Related Diseases in the World

ANZSOM2011 Wellington, NZ Findings from Situational Analyses of Asbestos-Related Diseases in the World University of Occupational & Environmental Health, Japan Acting Director of the WHOCC for Occupational Health Professor of Environmental Epidemiology Ken Takahashi

Current knowledge, on global scale WHO: >107,000 people die annually from asbestos-related lung cancer, mesothelioma and asbestosis resulting from occupational exposure [WHO Factsheet N343, July 2010] Driscoll: reported 43,000 mesothelioma deaths per year (2005); endorsed by WHO Estimated proportion of exposed workers, levels of exposure and absolute risk measures J Peto: landmark studies on mesothelioma epidemic (1995, 1999) triggered similar evaluation to form a genre

What we want to add Information Gaps across countries Global Situation, in depth Anticipate Future

Period Mortality Rate (PMR) of Pleural Mesothelioma, 1996-2005 (deaths/million/yr) 5DNK 12.9 1UK 31.1 2NLD 30.0 JPN 4.8 pmr (deaths/million/yr) 30 20-30 10 20 5 10 1 5 0 1 3AUS 25.5 4NZL 20.5 Nishikawa, Takahashi et al. Environ Health Perspect, 2008

Correlation at National Levels MORtality (2000-04) rates regressed on ASBestos (1960-69) use rates, weighted by POPulation All meso, male Pleural meso, male Peritoneal meso, male Asbestosis, male All mesothelioma, male: log 10 (MOR)=0.382 ASB-0.135 All mesothelioma, female: log 10 (MOR)=0.208 ASB-0.326 Lin RT, Takahashi K, et al. Lancet 2007; 369: 844-9 5

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

From Relationship to Estimation Hidden Burden of Mesothelioma Data Blanks Countries report mesothelioma for variable years Cumulative Assess relation between asbestos use and reported mesothelioma Extrapolate Many developing countries do not report mesothelioma

Countries Grouped by Data Availability 1) WHO Mortality Database 2) USGS Database Mesothelioma 1) + - Asbestos 2) + - 56 33 11 * 100 83% world s population * Mostly territories with small populations

Stats for 2 Groups of 89 countries Data Availability Asbestos & Mesothelioma (N=56 countries) Asbestos only (N=33 countries) Asbestos use (tons) 1920-1970 51,200,000 14,200,000 1971-2007 52,800,000 71,300,000 Mesothelioma deaths (cases) WHO 91,265 0 Other sources* 868 0 Total 92,133 0 *Articles in English identified by Pubmed

15-year cumulative mortality of mesothelioma, cases (1994-2008) Adjusted R 2 = 0.83, p<0.0001 N=56 N=33 Cumulative asbestos use, metric ton (1920-1970) Park E-K, Takahashi K, et al. Environ Health Perspect, 2011)

Predicted 15-yr Cumulative N of Missed Mesothelioma Cases Cumulative Asbestos Use from 1920-1970 (ton) Predicted 15-yr Cumulative N of Mesothelioma from 1994-2008 (95% CI) Russia 8,443,923 21,308 (15,026 to 30,218) Kazakh 2,301,286 6,500 (5,006 to 8,440) China 1,767,086 5,107 (3,976 to 6,558) India 688,015 2,158 (1,700 to 2,739) Thailand 152,378 545 (400 to 741)

Findings on Global Mesothelioma Worldwide, 1 case is unreported for 4 to 5 reported cases (38,900 unreported vs. 174,300 reported) Total burden is 213,200 (1994-2008; 15 yr) or 14,200 annual cases under 5% growth Park EK, Takahashi K, et al. Environ Health Perspect, 2011

Concerns are Greater for Asia!

Kubota Shock of 2005 Japan Asbestos Panic 1 Asbestos-related Diseases Kubota Company Discloses 51 People Dead in 10 years 2 5 Residents Develop Mesothelioma Kubota to Compensate 2 Already Dead 2005.6.29 Mainichi Newspaper

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

Predicted Future Deaths, Male Pl. Mesothelioma (Japan) Murayama T, Takahashi K et al. Am J Ind Med, 2006

Effect on Residents Dose-response relation between SMRs of mesothelioma and asbestos concentarations Distribution of asbestos concentrations with places of residence for 96 mesothelioma victims. :plant Kurumatani & Kumagai. Am J Respir Crit Care Med (2008) 178: 624 629.

The National Story on Asbestos Déjà vu??

Asian Asbestos Initiative (AAI) Asian Forum for the Elimination of ARDs Represented by Academia and Administration at National Levels Share and Transfer of Preventative Technologies at primary, secondary and tertiary level Coordination with WHO, ILO, UNU-IIGH and UNEP-RCS AAI-1 (2008) Kitakyushu; AAI-2 (2009) BKK, Thailand; AAI-3 (2010) Fukuoka

New York Times June 21, 2011 Important Background is the COP-5, Rotterdam Convention Le GV, Takahashi K et al. Respirology 2011

Update of Global Situation 92,253 deaths (C45, ICD-10) identified in WHO Mortality Database,1994-2008 83 countries reported mesothelioma, of which 76 countries (88%) are high and middle income Mean age at death 70.0 yr (SD 11.6 yr) Minimal difference between gender Pleura (70.1 yr) > Peritoneum (66.0 yr) > Pericardium (61.1 yr) Crude mortality rate is 6.2 per million population; age-adjusted mortality rate is 4.9 per million population AAMR is Males (9.0 per Million) >> Females (1.9 per Million) Age-specific mortality rates increased sharply with age to exceed 100 per Million in elderly Vanya D, Takahashi K, et al. Bull World Health Organ, in press

Trends of reported mesothelioma AAMR increasing at +5% during past 15 yr Japan shows statistically significant increase at +3.5% USA shows statistically significant decrease at -0.8% Compound Interest 5% 15 yr >> 2-fold 23 yr >> 3-fold 29 yr >> 4-fold Vanya D, Takahashi K, et al. Bull World Health Organ

World Leaders Mortality rate <crude> <age-adjusted> 6.2/million/yr 4.9 /million/yr Change rate + 5 % Death Number (Reporting Yr) N (%) 1. USA (7) 17,062 18.5 2. UK (9) 13,517 14.6 3. Japan (14) 11,212 12.1 4. Germany (9) 9,569 10.4 5. France (8) 6,608 7.2 Mortality Rate (Reporting Yr) /million/yr 1. UK (9) 17.8 2. Australia (8) 16.5 3. Netherlands (13) 15.7 4. New Zealand (7) 13.0 5. Finland (13) 8.5 21. Japan (14) 3.3

Takahashi K. Occup Med (Oxford), 2008; Le GV, Takahashi K, Respirology, 2011

Burden of ARDs in Asia-Pacific & Globally, Conclusions National, regional and global situations are quantifiable with data from global databases Information gaps still exist for Asian (& PI) developing countries, but can be filled with improved recognition, diagnosis and reporting Anticipated future for Asia-Pacific is grim but obvious interventions can be a game changer

ANZSOM2011 Wellington, NZ Findings from Situational Analyses of Asbestos-Related Diseases in the World University of Occupational & Environmental Health, Japan Acting Director of the WHOCC for Occupational Health Professor of Environmental Epidemiology Ken Takahashi

Dept. Environ Epidemiol, IIES, UOEH (Japan) R-T. Lin K. Nishikawa V. Delgermaa E-K. Park G-V. Le

*corresponding author 1. Vanya D, Takahashi K* et al. Global trends in mortality caused by mesothelioma, 1994-2008. Bull World Health Organ, in press. 2. Le GV, Takahashi K* et al. Asbestos use and asbestos-related diseases in Asia: past, present and future. Respirology 2011, 16:767-75. 3. Park EK, Takahashi K* et al. Global magnitude of reported and unreported mesothelioma. Environ Health Perspect, 2011, 119: 514-8. 4. Takahashi K and Kang S-K. Towards elimination of asbestos-related diseases: a theoretical basis for international cooperation. Safety Health Work 2010, 1:103-6. 5. Le GV, Takahashi K* et al. National use of asbestos in relation to economic development. Environ Health Perspect 2010, 118(1):116-9. 6. Takahashi K. Asbestos-related diseases: time for technology sharing (editorial). Occup Med (London) 2008, 58:384-385. 7. 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. 8. Lin R-T, Takahashi K* et al. Ecological association between asbestos-related diseases and historical asbestos consumption: an international analysis. Lancet 2007, 369:844-849. 9. 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: 1-7. 10. Takahashi K and Karjalainen A. A cross-country comparative overview of the asbestos situation in ten Asian countries. Int J Occup Environ Health 2003, 9(3):244-8.

Homepage http://envepi.med.uoeh-u.ac.jp/acoh/ 21 st ACOH Meeting in September, 2014 20 th 2011 Thailand 19 th 2008 Singapore 18 th 2005 New Zealand 17 th 2002 Taiwan 16 th 1999 Philippines 15 th 1997 Malaysia

The Economic Argument Isn t Asbestos Doing Any Good? Economic argument is incapable of incorporating future disease burden (40 yr!) All ARDs are preventable Safer (and economically viable) substitutes exist AC waterpipes ductile iron, high-density polyethylene, wire-reinforced concrete pipes AC construction material (roofs & walls) replace ASB with polyvinyl alcohol fiber and cellulose fiber

All Reported Mesothelioma, World Average death age 70.0±11.6 yr Male-to-female ratio 3.6 Anatomical Site % Pleura(C45.0) 41% Peritoneum(C45.1) 5% Pericardium(C45.2) 0.3% Others(C45.7) 7% Unspecified(C45.9) 43%

ACOH2011 Bangkok Burden of Asbestos-Related Diseases in Asia and Globally University of Occupational & Environmental Health, Japan Acting Director of the WHOCC for Occupational Health Professor of Environmental Epidemiology Ken Takahashi

Chronology of Laws and Regulations 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) 1996 (H08) 2004 (H16) 2005 (H17) 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 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*

Asbestos Use vs. Economic Development, 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