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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 47:458-462 (2005) Brief Report Mesothelioma in Household Members of Asbestos-Exposed Workers: 32 United States Cases Since 1990 Albert Miller, md* Background Mesothelioma is significant as an indicator of asbestos exposure, as a continuing major cause ofdeath in those exposed, and as a riskfollowing lesser exposures. One such exposure is living in the household of an asbestos worker, and coming into contact with fibers brought home on his/her body, clothing, etc. Methods Law firms throughout the US known for their pursuit of asbestos claims were polled for mesothelioma claims brought on behalf of family members of identifiable asbestos-exposed workers. Cases with any occupational, environmental, or otherpossible exposure were not included. Results This study reports 32 household-exposure mesothelioma cases, diagnosed since 1990. Relationships were wife (15), daughter (11), son (3), sister-in law (1), niece (1), and boarder (1). Occupations of the workers included shipyard (13), insulator (7), and other (12). Ofthe 27pleural cases, 13 were epithelial, 5fibrous, 3 biphasic, and 6 not specified; ofthe 5peritoneal cases, 4 were epithelial and 1fibrous. Latency was greater than 40 years in 27 cases; 6 cases were 40-49 years ofage and 17 were 60 or older. Conclusions Recordsfrom lawfirms were a useful source ofinformation. Mesothelioma resulting from household exposure is a continuing problem. It is more likely to present in the elderly, after latencies of >40 years. Am. J. Ind. Med. 47:458-462, 2005. 2005 Wiley-Liss, Inc. KEY WORDS: mesothelioma; household exposure; family members; asbestosexposed workers INTRODUCTION The risk of mesothelioma in the United States from inhalation of asbestos fibers remains high even as new use of asbestos has largely ceased. This is attributable to the long NewYork Medical College,Valhalla, NewYork and Saint Vincent Catholic Medical Center of NewYork-Brooklyn-Queens Division, New York 'Correspondence to: Albert Miller, Research Professor, Center for the Biology of Natural Systems, Queens College of the City University of New York, 163-03 Horace Harding Ex pressway, Rushing, NY 11365. E-mail: almiller@svcmcny.org Accepted 1 March 2005 D0110.1002/ajim.20167. Published online in Wiley InterScience (www.interscience.wiley.com) latency for this disease, the wide presence of asbestos in place in buildings and equipment, and the potential for this malignancy to be induced by relatively low levels of exposure. One such exposure, recognized since 1965 [Newhouse and Thompson, 1965] is asbestos brought home to family members on the hair, clothing and personal effects of asbestos workers. Review of the literature on this exposure is difficult. Many of the descriptions are of single or of a few cases; a report of the same four cases appeared in the literature a second time [Joubert et al., 1991] 24 years after the first [Anderson et al., 1976]. Family exposures are com bined with building exposures (asbestos present in offices or schools) or environmental exposures as "non-occupational" exposures [Konetzke et al., 1990; Iscovich et al., 1999; 2005 Wiley-Liss, Inc. Magnani et al., 2000]. Many cases described as family * nosis, and exposure are provided in Table I. Patients are members had their own, sometimes less recognized expo- ordered by date of onset of symptoms (or of diagnosis if the sures [Risberg et al., 1980; Lynch et al., 1985; Hammar et al., onset of symptoms is unclear). 1989; Dawson et al., 1992; Bianchi et al., 1993; Ascoli et al.. Age at first exposure was < 10 years in 13, 10-19 years 1998; Hiyama et al., 1998]. The concern of other reports of in 5,20-29 years in 9,30-39 years in 2, and unavailable in 3. family cases was with a possible genetic cause, looking at Mean latency was 49.0 10.7 year. Latency was skewed mesothelioma in occupationally exposed blood relatives towards greater length consistent with the requirement that [Risberg et al., 1980; Martensson et al., 1984; Krousel et al., the disease be manifest no earlier than 1990; 20-29 years in 1986] who may have lived in the same household [Hammar 2,30-39 years in 2,40-49 years in 12, >50 years in 15, and etal., 1989]. unavailable in 1. Latency for offspring was slightly longer This report of 32 cases of mesothelioma since 1990, than for wives, 52.9 versus 45.4 years, a difference which attributable only to asbestos brought home by another approached significance (0.07). Mean age at presentation resident of the household, demonstrates the continuing was 62.3 11.7 year; 17 cases were age 60 or greater, nature of the problem in the United States. It utilizes an All patients lived in the same household as the exposed under appreciated data source, the files of law firms worker(s). In the three cases of dual relationship (daughter throughout the United States which are active in the pursuit and sister, daughter and wife, daughter and wife), the earlier of asbestos-related claims. exposure is counted. Relationships were: wives (15), METHODS daughters (11) (one stepdaughter), sons (3) (one stepson), sister-in-law (1), niece (1), and boarder (1), this last being a woman who lived in a boarding house with several shipyard Law firms throughout the United States known for their workers from age 20 to 28. pursuit of asbestos-disease claims were polled on three Occupations of the worker who lived with the present occasions over 5 years for mesothelioma claims brought on cases were: shipyard (13), insulator (other than shipyard) (7), behalf of family members of identifiable asbestos-exposed railroad (2), manufacture of asbestos materials (2), boiler- workers. Of 25 firms, 15 submitted demographic and maker(2),steelmill(2),refinery(l),pipefitter(l),refractory exposure information, and medical records on such clai- bricklayer (1), and construction (1). mants. Cases with any occupational, environmental (e.g., Histologic classification of the 32 cases is typical of wives living in the same community as their Manville, NJ mesothelioma in general: 27 pleural (13 epithelial, 5 fibrous, asbestos factory worker husbands), building (other than the 3 biphasic, and 6 not specified) and 5 peritoneal (4 epithelial, dwelling shared with the exposed worker), or other possible 1 fibrous). Among the 29 female cases, 24 were pleural and exposure (e.g., smokers of Kent cigarettes, whose filters 5 peritoneal; all 3 male cases were pleural. Diagnosis was contained crocidolite asbestos) were not included. Cases confirmed by immunohistochemical reactions in 29 and was from nine firms met criteria, including onset after 1990. The based on multiple specimens reviewed by pathologists in diagnosis of mesothelioma was based on the pathology different institutions in the remaining three, report, confirmed by immunohistochemical staining in 29, Although information about other asbestos-related autopsy in 2, and surgery in the remaining case. Exposure disease was incomplete, pleural plaques were present in at information from testimony, depositions and employment least 10 household mesothelioma cases, 4 of whom also had records and medical data were reviewed. Latency was asbestosis. estimated from year of first exposure until onset of symptoms (or of diagnosis if the former was not available). Differences DISCUSSION in latency between wives and offspring were assessed by pooled and Saterthwaite r-Tests. Inhalation of asbestos fibers is the predominant cause of In the final analysis, many of the firms had gone out of mesothelioma. The majority of cases result from occupa- existence, split and/or merged. It was not possible to obtain a tional exposures of the patient, not infrequently far removed total member of mesothelioma cases from them, let alone the in time and memory. Mesothelioma resulting from household outcomes. exposure to asbestos brought home on the hair, clothing, and RESULTS effects of workers has been recognized since the report of Newhouse and Thompson [1965] which included seven wives and two sisters of asbestos workers among 83 cases of From the files of nine plaintiff law firms throughout the mesothelioma dating back to 1917. Anderson and coworkers United States, 32 cases of mesothelioma were analyzed who reported four cases of mesothelioma attributable to house- had no occupational, environmental, or other exposure to hold exposure in 1976 and reviewed the literature totaling asbestos than as a household member of a worker with a clear 37 cases [Anderson et al., 1976]. Most reports have been of occupational exposure. Information on demographics, diag- single or a small number of cases [Huncharek, 1986; Maltoni NA NA BM , boilerm aker, DOB, date o l b irth ; Dx, diagnosis; H ist, histologic diagnosis; INS, insulator, MF, m anufacture asbestos product; PE, peritoneal; PF, pipe fitte r, PL, pleural; Refr., refractory; RR, railroad; Sx, sym ptom s; SY, shipyard. CM s E eg eg t 2 CM s ss m c ts tr GO m 35 S2V0NS50NS50Ntt>r.Z^O0^5CcCMo50jSi5f0iNW50^2SS3 CrDr cOo iLnO tno 05 05 D 05 o0)eo0o)oZS.OiNn05r)0teo)0i^5n,0mf)sQsi>on0S)^0ic)n0oo)0,fi)fo0ini)sff^ii0os) CM oC>D (LOO NTf NTT v s v v v ar r; 05 05 CD SOzcM.wcow ^0OlZO)0)01 IfiNCMCMNVlflSrOO^COCM^ 0)0)0)0)0)0)0)^$0)o$en0)0) mmJJ(/)s-v>.s.Lj-m & *5 as 07 aj SI <3 5. 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L CL 0ivZ 0^iZ>jssUJiZ 9lfliii-JiQij-v-^UsZ<J5ili.5iiil.<sZ n n n~* --I --I n LLl^JrH Q_ ""0-0- 0-0- CO 05 N M^ 05 05 05 <z.coMy)rjcc\soj>ni22i;ccI2^oroo:>SD?!?icnJsjo;i5on0o55,5:e,'9s"0-%5r,ir^_^0t5oc0--5;cr0on5j o~0--^5^r)E^l 9; 02 o^coos^mj-nS^ioMcoNj;woNioCcMo 05 05 05 05 05 05 05 05 05 05 05 s orB w r05 i I 05 C/5 S> 5 S o lip 8 J0--5 S05 SV S05j s*^* Q &!5 Co 5 co J: Ji .S `X S55HP! |S5 OQ in to r*> 00 05 o 460 Mesothelioma in Household Members 461 et al., 1995; Schneider et al., 1996]. Two series report more than eight cases. Leigh et al. [2002] list 4,838 cases from the Australian Mesothelioma Register 1986-2000 of whom 42 "lived with/washed clothes [of an] asbestos/products worker" and 29 "lived in [an] asbestos [containing] dwell ing;" no information on gender, age, relationship, etc. is provided. Roggli et al. [1997] reported that 33 of 59 female mesothelioma cases with an available exposure history were family contact only. Calendar years of exposure, onset of symptoms, or diagnosis were not provided, so that the number of cases since 1990 cannot be determined. These 59 cases were among 770 reviewed by the senior author, an expert pathologist to whom histologic materials are sent for review by other pathologists and by attorneys. The present series is similar to that of Roggli et al. in that both comprise cases from throughout the United States, many or all of which came to legal attention. The 33 household exposure cases in the Roggli series were similar to the present series in the distribution of peritoneal versus pleural cases (4 vs. 29), age, frequency of pleural plaques, (9), distribution of family relationships (22 wives, 6 daughters, 2 mothers, and 6 mul tiple), and occupation of household contact (10 insulators, 6 shipyard workers, 4 pipe fitters/steam fitters, 2 oil refinery, 7 miscellaneous, and 7 not available. (Family relationships and occupations of these household contacts total 36 since 3 cases had their own occupational exposures). The identification of household exposure as the mechanism for family mesothelioma has been complicated by reporting family cases with their own occupational [Bianchi et al., 1993; Hiyama et al., 1998] or other nonoccupational exposures such as neighborhood proximity to an industrial source, asbestos present in buildings of employment, or asbestos in cigarette filters. Family cases resulting from household exposure have been confounded with possible genetic predisposition to mesothelioma report ed in consanguineous family members who have been occupationally exposed [Risberg et al., 1980.; Martensson et al., 1984; Lynch et al., 1985; Krousel et al., 1986; Hammar et al., 1989]. Similar to wives, daughters, and boarders, household pets are at risk from asbestos brought home by exposed workers. An asbestos related occupation of a household member was associated with mesothelioma in dogs diag nosed with mesothelioma at the Veterinary Hospital of the University of Pennsylvania [Glickman et al., 1983]. Wives predominated in the present and in Roggli's series. Anderson reported a far higher frequency of benign radiographic abnormalities in wives (48%) compared with daughters (21%), despite similar durations of exposure [Anderson et al., 1979]. This is consistent with a greater burden of asbestos in wives. Household exposure has been suggested as the source for mesothelioma presenting at an earlier age. This was identified in 5 of 10 cases of mesothelioma presenting in patients <40 years of age at one medical center [Kane et al., 1990], None of our patients presented <40 years of age; only 6 cases presented in the age decade 40-49 (4 offspring, 2 wives). That more than half the cases were 60 years of age or greater demonstrates that household exposure should not be ruled out when mesothelioma is detected in an older patient. Although household exposure is generally thought to be low level, and is often classified with other low level exposures (building, neighborhood), fiber content of lung tissue from such exposure was found to be similar to that of shipyard and most asbestos-exposed trades other than insulators, and far greater than that of building occupants [Roggli and Longo, 1991]. In contrast to men, in whom 90% of mesotheliomas are attributable to asbestos and 90% are pleural [Spirtas et al., 1986], only 20% of mesotheliomas in women are said to be attributable to asbestos and two-thirds are pleural [Spirtas etal., 1994], The higher proportion (83%) of pleural to peritoneal mesotheliomas in the present series tends to confirm asbestos as the source. 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