Document 6RQB5GaLvMpYJNeoo8rraoM1

FILE NAME: Neighborhood Exposures (NE) DATE: 1970 DOC#: NE024 DOCUMENT DESCRIPTION: Medical Journal Article - Epidemiology of Malignant Mesothelioma in Hamburg ENVIRONMENTAL. HISKAIUU .'5, 3 6 5 -3 7 2 (1 9 7 0 ) E p id e m io lo g y of M a lign a n t M esotheliom a in Ham burg A Prelim inary Report H. Bohuc,1 A. F. Dabbert,2 P. 1)ai.ouent,` E. IIain,1 and I. lira/.' R eceived June 27, li)6`9 Oiu` hundred and nineteen cases of inesothelioina of the pleura were studied. A striking concentration was found about a large asbestos processing factory. In 55 cases, occupational exposure could be ascertained by retrospective study of ease histories. In 21 eases, anamnestic data could no longer be obtained. Tile desirability and diiliculty, ol undertaking prospective investigations is reviewed. Diffuse malignant mesothelioma is considered to be a rare tumor. Yet, as early as 1943 Clat/el reported such tumors were three to four times as frequent m some German and Danish seaside towns as in equally large communities in t>'" Interior of the country. The first mesothelioma in an asbestos worker suffering from asbestosis was described in Germany by Weiss in 1953; a case of asbestosis associated with malignant mesothelioma of the peritoneum was reported by Leicher in 1954. In 1955, Jacob and Bohlig reviewed the problem of malignant tumors in asbestosis natients, and noted a disproportionately high incidence of the malignant meso thelioma in literature surveys. Koenig (1999) reported an increased frequency of mesothelioma among asbestosis patients examined at autopsy in Hamburg. besides mesotheliomas noted as a result ol occupational exposure in asbestos textile and friction material or brake lining plants (Entieknap and Smither, 1901; llueper, 1965; Jacob and Anspach, 1965; Knox, Doll, and Hill, 1965; Sewhouse and Thompson, 1965; Bohlig, 1967; Demy and Adler. 1967; Avril and Clumpeix. 1969; Yigliani, 1969) an increasing frequency has been noted since I960 due to exposure in asbestos mining (Wagner, Sleggs, and Man-hand, i9601. in the insulation industry (Selikoff, Churg, and Hammond, 1965; Selikoff, Hammond, and Churg. 1969), and in the* construction industry (Enterline, 1965; l.icbcn and Pistawka. 1967; Selikoff and Hammond, 1969), where workers have v handle asbestos-containing insulation and building materials. 1mconnection with these studies a particularly dangerous exposure was noted n the shipbuilding industry (Owen, 1964; Elmes, McCatighey, and Wade, ]9(i5: Stoesscl. 196S: Ashcrolt and lleppleston, 1969; Stumphius, 1969), where ,hipbuilding workers have* to apply or dismantle insulation materials, often under very unfavorable conditions. 'Municipal Hospital, 5S.S I.iibilonscliekl, (ermaiiy, Department of Internal Diseases, General Hospital, Ilaniburg-Bergedorf, Wideilt Dr. Selnvarting. : 1Department of Chest Diseases, General Hospital, Hamburg-llarburg. Tuberculosis Dispensary I lamburg-Bergedorf. ` Stoessel. li. G,, Millieh,.shaven, personal communication. 365 1971 b> A. ad<'inii* l 'ri'ss, hu*. Med. Snper- 366 BOIILIG KT AL. Epidemiological investigations have moreover shown mesotheliomas not clue to occupational exposure but to possible contamination with asbestos in a family setting or in the neighborhood of asbestos factories (Anspach. Roitzsch, and Clausnit/.er. 1963, Selikolf, Bader, Bader, C'lmrg, and llammond. 1967); the latter allow or allowed uncontrolled asbestos emissions to enter the atmosphere (Wagner at al., I960; Elmos at al., 1965; Newhouse and 'lliompson. 1965: Gilson, 1966, Sclikoll and llammond, 1969). As the city-state Hamburg in the German Federal Republic has been carrying on extensive asbestos and shipbuilding activity since the beginning of this cen tury, it seemed useful to investigate the epidemiology of mesothelioma in 1lamburg. Hamburg has 1,860,000 inhabitants. The sites of the four largest asbestos factories are shown in Fig. 1. The shipyards arc located primarily along the banks of the River Elbe islands. Working conditions of these factories were uncontrolled until the middle of the thirties; after this the plants undertook dust suppression but without con trolling the exhausted air. Only after World War 11 did the asbestos factories, for economic reasons, begin to control the exhausted air and to filter out the asbestos dust, in order to conserve it for reuse. This fact is important in view of the long lapsed period--several decades--between exposure and disease in mesothelioma (Selikolf at al.. 1967). No dust control measure's have so far been adopted in the shipbuilding industry. MATERIALS AND METHODS In some of the Hamburg hospitals and in a tuberculosis clinic, more than 250 diffuse malignant mesotheliomas were ob,creed from 1958 to 1968. This number is conservative, since, owing to shortage of personnel. It .. s not pos sible to investigate all ambulatory and inpatient medical institutions Among these cases, Dalquen. Dabbert. and Hin/ (1969) have, to the present, reviewed residence and occupational histories, as well as the histological diag nosis in 119 The cases originated from tin following medical institutions. 1. 53 eases from the General Hospital Hamburg Bergedort. a local hospital in the southeast of the city, where the largest asbestos factors' of the town lies in the immediate vicinity of a residential quarter. 2. 4 cases from the tuberculosis dispensary of the same suburban residential quarter. 3. 44 cases from the General Hospital Hamburg !larhurg. 4. 18 cases from the Wintermoor Hospital, which is the responsibility of the Hamburg health authority. The latter two hospitals are clinical centers when' patients, particularlv those with diseases of the chest, ol the whole Hamburg area are collected and treated. The diagnosis of mesothelioma in these cases was considered established by the following criteria: (a) 44 postmortem examinations; (b) 40 biopsy findings with subsequent follow-up including additional clinical and radiological data and (c) 35 clinical, with clinical data, radiological findings, and the course of MALIGNANT M ESOTHELIOM A IN HAMBURG 367 Fu, 1. CGeographical distrihution of 103 oases of mesothelioma in Hamburg and main asbestos dust sources in the cits the disease evaluated l>y a team of chest physicians, radiologists, and internists. All ot the eases were mesotheliomas of the pleura. Peritoneal tumors have so far not been observed in Hamburg. Since most of the patients had died before the epidemiological investigations were begun, relatives or factory management for whom they had worked had in some cases to be questioned. In all, the occupational history remained un known in 21 cases, the family ease history or domiciliary asbestos exposure remained unknown in 112 eases and the smoking habits in 60 cases. RESULTS Tlie'age and sex distribution are reported in Table 1. The occupational exposures are listed in Table 2, whereby mention must be 368 BOHLIG KT AL. TABLE 1 AoK AM) iS k\ ok 110 I'McritAt, M ksothki.ioma I'atikxts Age : 39 40-4!) r>0 ."!) 00-0!) 70+ Tola! Male i 4 15 37 22 7!) Female 0 4 14 15 7 40 i Total 1 8 2!) 52 29 11!) made; of the fact that explosives were produced in asbestos-insulated rooms and that the material had to be transported wrapped in asbestos cloth. Of the 119 cases mentioned above, only 103 lived within the urban area; every unit in Fig. 1 represents either the dwelling place of the mesothelioma patient at the time In' fell ill or in 1940. Sixteen eases not in Fig. 1 lived in surburban districts, from which commut ing to and from the city is common. The incidence of mesothelioma within the urban districts may be seen in Table 3. It shows a marked increase in frequency in Bergedorf, and less so in the Hamburg-Wilhelmsburg district. The particularly unfavorable conditions in the urban district of Bergedorf have been reported in detail by Dalquen et al. (1969) so that they are merely referred to in the present text. Of the 119 cases of mesothelioma, 13 cases also showed pleural plaques as Asbestos exposure Present. Likely Absent or unlikely Unknown Total TABLE 2 O ccupation and E xposukk Occupation Asbestos workers Mattress needlewomen Insulation workers Shipbuilding workers, etc. fitters, plumbers, etc. Engineers Hoofers Explosive production workers Joiners, carpenters, etc. Stokers, drivers, etc. Painter Construction worker Factory workers White collar workers Housewives, etc. Others No. of eases 12 3 2 17 12 3 1 5 5 2 i ! 11 9 (i 8 Total 17 ,`JS 43 21 119 (I Beni I Tai l i Willi. : All To . A- well ashi Fo have- p le u r No asla s Mi the i. repi a that shi] in s 1 ' histt Sim by Viev. th. wen tioi of i' ttP wo i > It exp. tain (; asla inen fut u MALIGNANT MESOTHELIOMA IN HAMBURG 369 City district TABLE 3 I niimu i \ xts and Incidence ok Mesothelioma No. of cases of mesot holioma Inhabitants" Me:uithelio n a /10,000 Inhabitants Bergedorf 51 Marburg 1) Wilhchnsbnrg ti All other districts it; Total 103 53,155 114,473 til,(US 1 ,(>;'>!), S2.-, 1,K57,371 o <; 0 1 2 0 27 0 5<) " As of January 1, Ifrti.'i. well; in 5 of the patients the ease history included occupational or urban asbestos exposure (Kiviluoto, 1965). Four mesothelioma patients showed asbestosis of the lungs, three of them having been exposed occupationally, while in the fourth case asbestosis with pleural plaques was revealed only by autopsy. No systematic data are available concerning the presence or absence of asbestos fibers or bodies in the sputum or in lung or tumor tissue. More exact information concerning the latent period, duration of exposure, the duration of the disease, as well as data relating to the individual cases was reported by Dalquen at at. (1969). In this connection, it should bo observed that in the 30 cases of occupational asbestos exposure, the latent period in the shipyard workers was found to be about 10 years longer than that of workers in asbestos factories (40,6:30,8 years). DISCUSSION The authors are fully aware of the fact that the 35 mesotheliomas without histological evidence include an element of uncertainty in our observations. Since this was. however, a clinical and retrospective study it seemed possible-- by applying strict clinical-radiological criteria--to consider the eases from the viewpoint of their over-all value, especially since this would hardly influence the picture as a whole. On the other hand, it was precisely the 35 east's that were not examined histologically that provided important casuistic contribu tions, whereby Dalquen at al. (1969) were able to demonstrate the importance of the danger of dismantling old insulation material, particularly when breaking up ships, as well as the family hazard owing to one or the other family member working in the asbestos industry, and wearing dusty work clothes. it would be useful to prospectively investigate appropriate cohorts of asbestosexposed individuals, in addition to retrospective studies. Such studies face cer tain difficulties, however: (a) The principal emission sources, which might result in neighborhood asbestos contamination, have been subjected to extensive control programs co incident with improved industrial hygiene precautions. This will obviously affect future exposure-disease correlations. (b) The extensive use of asbestos products has resulted in dust sources being k ; '`-M'-S 370 liOIXUG El VI. transferred more and more from well-controlled factories to uncontrolled stor age places, repair workshops, and building sites. Measurement of emissions from these sources is difficult. (c ) Prospective studies in regard to the mesothelioma problems would have to be extended over a period of at least several decades because of the long latent period from the onset of exposure to evidence of these tumors (d) Registration of asbestos workers in Germany is the responsibility of many different insurance bodies and permits at best the followup of patients with compensated asbestosis, or a related cancer. The social insurance companies as well as the authorities in charge of the professional matters have so far shown no interest in the registration of all persons exposed to asbestos oc casionally' or over a short time, as is, for instance, being done in an exemplary manner in England (Ministry of Labour, Great Britain). lienee it was quite Ircyond our means to consider prospective studies, especially since we had to set about doing this work without support from either governmental or industry sources. The alarmingly high incidence rate of mesothelioma in the city district of Bergedorf should be evaluated against the background of the absence of any cases in the city district of Ilarburg although both regional hospitals had been investigated, and there was no element of selectivity in the 119 case's of the present study. A further 150 histologically confirmed mesotheliomas occurring in flu- s..iiu' period are being studied, including history of asbestos exposure. Eor further details regarding the particular situation in Bergedorf Dulquen ft al. ( 1969) should be consulted. It is not possible to furnish data concerning the use of specific kinds of asbestos in the various Hamburg factories because, with economic blockade during World Wars 1 and II. German industry was forced to change its sources of asbestos supplied very often. CONCLUSIONS An unusual frequency of malignant pleural mesothelioma coinciding with the likelihood of occupational, urban, or residential asbestos exposure was observed in Hamburg during 195S-196S. It is suggested that exposure may he so slight as to be inadequate to result in asbestosis. Exposure was probably associated with emission from asbestos-processing industries, which have been brought under control during the last 20 years. Gurrent dust measurements within the environment of tin* plants could be mis leading, and have? not been made. 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