Document MMR32xm63QgDMjL8b59vM5kqL

American Journal of Industrial Medicine 21:681-687 (1992) Environmental Household Exposures to Asbestos and Occurrence of Pleural Mesothelioma Daniela Dodoli, md, Maurizio Del Nevo, md, Carla Fiumalbi, md, Tonina Enza laia, md, Alfonso Cristaudo, md, Pietro Comba, dsc, Cecilia Viti, ms, and Giuseppe Battista, md We reviewed the certificates of 39,650 deaths which occurred in the period 1975-1988 in Leghorn and of 45,900 in La Spezia (Italy) in the period 1958-1988 In total 262 cases have been recorded as pleural mesothelioma. The main occupational exposures occurred in the shipbuilding industry. Regarding non-occupational exposures to asbestos. 13 cases of mesothelioma were found in women who had washed the work clothes of their relatives at home: we also found other domestic uses of asbestos which were rarely or never discussed previously in the literature: six cases might be explained by the installation of fireproof or nonconductive materials in the domestic environment. These exposures probably are more frequent than realized until now. 1992 Wilcy-Liss, Inc. Key words: asbestos household exposures, pleural mesothelioma in women, non-occupational as bestos exposures, death certificate study X INTRODUCTION Numerous investigations, particularly case reports and case series, have studied the occurrence of mesothelioma as a consequence of non-occupational asbestos ex posure. An exhaustive review has recently been presented by Gardner and Saracci [1989]. A number of reports have addressed the health effects of asbestos exposure for those who live around asbestos mines and factories [Arul and Holt, 1977; Green berg and Lloyd Davies, 1974; Lieben and Pistawka, 1967; Newhouse and Thompson, 1965; Wagner et al., I960]. Several reports look at domestic exposure due to asbestos carried into the house by the work clothes of subjects exposed in the workplace. Concentration of fibers in these situations may have been higher than that occurring for residential exposures [Nicholson et al., 1980], Newhouse and Thompson [1965] found 9 patients who had a relative working Unit of Occupational Medicine, Faculty of Medicine, University of Pisa, Pisa, Italy (D.D., M.D.N., C.F., T.E.I., A.C., G.B.). ' Istituto Superiore di Sanila, Rome, Italy (P.C.). Department of Earth Sciences, University of Siena, Siena, Italy (C.V.). Address reprint requests to Professor Giuseppe Battista, Cattedra di Mcdicina Preventiva dei Lavoratori, Universita degli Studi di Siena, Via dei Tuft n. 1, 5100 Siena, Italy. Accepted for publication October 8, 1991. 1992 Wiley-Liss, Inc. 682 Dodoli et al. with asbestos, versus I control. Three cases of mesothelioma who had a relative employed in the asbestos industry were described by Lieben and Pistawka [1967]. Four cases of pleural mesothelioma were detected by Anderson et al. [1976] among the relatives of workers active in a plant where amosite products were man ufactured; one of the cases was the daughter of a worker who also died of mesothe lioma. Two cases of mesothelioma in the same family, described by Li et al. [1987], involved the wife and the daughter of an insulator who was affected by asbestosis and died of lung cancer. Vianna and Polan [1978] examined occupational and environmental exposure to asbestos of female cases of mesothelioma deceased in New York State (excluding New York City) between 1967 and 1977, and a matched sample of controls. A significantly higher number of cases than controls had husbands and/or fathers active in asbestos related occupations, mainly insulation (relative risk: 10, 95% confidence interval; 1.42-37.40). The role of household exposure to asbestos in the development of mesothelioma in young adults has been recently reassessed by Kane et al. [1990], who suggested that mesothelioma in the first four decades of life might be more common than ordinarily believed. According to the authors, a detailed occupational and non-occupational interview may detect unsuspected modes of exposure. As far as Italy is concerned, a survey on hyaline pleural plaques occurrence, examining 343 necropsies performed on females in the years 1979-1984, was con ducted in Monfalcone (northeastern Italy). The prevalence of pleural plaques was 21.6%. In most cases, domestic exposure to asbestos was detected, mostly linked to contaminated work clothes of relatives active in a shipyard. Two of these women were affected by pleural mesothelioma [Bianchi et al., 1987]. The present paper describes a cluster of cases of pleural mesothelioma attrib utable to non-occupational exposure to asbestos in the towns of La Spezia and Leghorn. These towns, located on the western coast of Italy, have been selected because their mortality rates from pleural neoplasms are among the highest in Italy. In 1980-1983 the province of La Spezia had a mortality rate of 7.13 X 10-5 in males and 1.59 x 10-5 in females; Leghorn, in the same years, had rates of 4.92 x 10-5 and 1.96 X 10~s, respectively [Bruno et al., 1988]. Both towns are important centers of the shipbuilding industry. In contrast, rates for the whole of Italy are l .35 x 10"5 in males and 0.75 x 10"5 in females. MATERIALS AND METHODS This work is concerned with non-occupational exposures to asbestos among 16 cases of mesothelioma that occurred in the towns of Leghorn (1975-1988) and La Spezia (1958-1988). In all, the causes of death were examined for 39,650 subjects deceased in Leghorn and 45,650 in La Spezia. There were 88 deaths (60 men, 28 women) in Leghorn and 174 (146 men, 28 women) in La Spezia recorded as pleural mesothelioma in the quoted periods, for a total of 262 cases (206 men, 56 women). It was not possible to collect any informa tion on 60 subjects (43 males, 17 females) that we considered "lost cases" (Table I). We took under consideration the diagnosis of death of the mortality registries of general population. Household Exposures and Mesothelioma 683 TABLE L Asbestos Exposure of Subjects Deceased from Pleural Mesothelioma in Leghorn (1975-1988) and La Spezia (1958-1988) Exposure Men Women Total Sure, occupational Probable, occupational (Indirect), non-occupational Non-del"inite 114 3 117 24 2 26 3 13 ( + 3)" 19 22 18 40 Total interviews "Lost cases" 163 39 202 43 17 60 Total cases recorded on mortality registries 206 56 262 ""Domestic asbestos exposure, very probably, but not sure. It was possible, through direct or telephone interviews with close relatives of the deceased, to obtain information on 202 persons (77% of total cases): 163 men (79%) and 39 women (70%). Among 202 cases on whom we collected satisfactory information, we can classify 143 subjects (138 males and 5 females) as occupationally exposed ("surely" or "probably" exposed). The exposures of cases were classified by three hygienists with intimate knowledge of the industrial processes of the area. People "surely" exposed were mainly shipyard and insulating workers. For 16 cases, as mentioned, we found non-occupational exposures, usually domestic, to asbestos ("indirect" exposure); for 40 subjects we have not been able to assess any definite exposure to asbestos. For these female cases (in brackets in Table I) we considered domestic exposure to asbestos very probable, but not sure. Table I briefly summarizes there findings; the most frequent occupational ex posures occurred in shipyard industry. The non-occupational exposures in our review are noteworthy because they have not been reported previously and awareness of new sources can contribute to prevention. Because of the long latency, we were not able to achieve technically reliable information about the insulating materials installed in the houses of the subjects deceased of mesothelioma. Nevertheless, we analyzed 5 panels and a cord still used as fireproofing in houses in Leghorn and La Spezia. We collected these specimens in the dwellings of low social class individuals and submitted them to inspection of a geologist and to scanning electron microscopy. RESULTS In Table II, the cases of mesothelioma with non-occupational exposure to asbestos are described (13 women and 3 men), by year of death and by occupa tion. The average age of death was 63 years (range 60-65) for men and 76 (range 66-87) for women. Among the thirteen women, ten (Cases 1-10) lived with workers who were exposed to asbestos for occupational reasons: 8 of them were the wives and one was 684 Dodoli et al. TABLE II. Cases of Mesothelioma With Non-Occupational Exposure to Asbestos (Leghorn, 1975-1988; La Spezia, 1958-1988) No. Year of death City" Sex Age Occupation 1 1967 SP F 73 Housewife 'y 1979 LI F 70 Housewife 3 1980 LI F 73 Housew'ife 4 1981 SP F 87 Housewife 5 1982 LI F 75 Housewife 6 1985 LI F 74 Housewife 7 1985 LI F 66 Housewife 8 1987 LI F 79 Housewife 9 1988 LI F 82 Housewife 10 1988 SP F 74 Housewife 11 1980 SP F 83 Housewife 12 1984 SP F 74 Housewife 13 1988 SP F 79 Housewife 14 1967 SP M 60 Musician, wine dealer1' 15 1970 SP M 64 Ovster cultivator 16 1988 SP M 65 Shipyard employeeb "SP = La Spezia. Li = Leghorn. ''Both lion-occupational and occupational exposure (see text). the sister of shipyard workers; another was the wife of an oil refinery worker.1 By interviewing relatives, it was learned that the ten women used to wash the work clothes of their relatives at home. Two of these cases also used asbestos boards for ironing clothes. In the kitchen of the Case 11, the exposed insulation of hot water pipes was asbestos. The last two women (Cases 12 and 13) were exposed to asbestos panels that had been installed behind radiators to limit heat dispersion. In a similar manner, the three men (Cases 14-16) lived in houses where as bestos panels were employed to limit heat dispersion. However, two of these males also experienced occupational exposures; one (Case 14) prepared filters to improve the quality of the wine he sold2 and another (Case 16) worked as warehousemen at the military shipyard in La Spezia. It is remarkable that the occupational exposures of these two cases occurred so near the date of death (six and two years before, respec tively) that a causal relation to occupational asbestos exposure cannot be estimated as sufficient. It seems likely that there is sufficient latency with regard to the nonoccupational exposure to permit a causal relation. All of the interviewees recalled the duration of domestic exposures to be a long, not well-specified, period ("the whole life," "many years," etc.). Table III sum marizes the quoted form of non-occupational exposures to asbestos. In addition to the case-series described, there are also three female cases (not 'The mail who worked in the oil refinery was exposed to asbestos fibers while repairing insulated pipes and boilers there. 2Filters were made and periodically replaced by inserting asbestos pbwder in a suitable net, placed along the wine passing. Household Exposures and Mesothelioma TABLE III. Non-Occupational Exposure to Asbestos of 16 Subjects Deceased From Pleural Mesothelioma in Leghorn (1975-1988) and La Spezia (1958-1988) Work clothes wash Domestic use of fireproof panels Domestic insulation for hot water pipes Men 0 3" 0 Women 10 2 1 "Both non-occupational and occupational exposure (see text). 685 reported in the tables) for whom exposure to asbestos has to be considered very probable, but not sure. One of the women could have inhaled asbestos fibers that were brought into the domestic environment by her son, who was an employee in a firm that sold nonconductive material used as substitute for asbestos (i.e., ceramic fibers). As a conse quence, this man worked daily in environments where asbestos was present and where he went to propose the alternative products. We have no confidence about the exposure of this case to asbestos and/or to ceramic fibers, but it is clear that the son also kept some samples of ceramic material in his house. Two other women had been married to men occupationally exposed to asbestos (a ship engineer and a locomotive engineer in the port), but their interviewed relatives did not remember if the deceased women had washed their husbands' work clothes at home. No other supplementary information about asbestos fibers inhalation was available. Table IV summarizes the results of the mineralogic examination of 5 fireproof panels and a cord still used in houses in the area of Leghorn and La Spezia. Crocidolite was found in none of the examined specimens; we stress, however, that these results can be referred only in hypothetic terms to the aetiology of the cases of mesothelioma above reported. DISCUSSION Our findings are consistent with previous reports in the literature [Gardner et al., 1989] and have also been described earlier by some of us [Neri et al., 1989]. However, the present series deals with more numerous findings. Our study is based on death certificates, which have the advantage of systematic coverage of the population, even if it is well known that pleural mesothelioma is underreported as a cause of death [Delendi et al., 1991], It is well known that the diagnosis of mesothelioma requires pathologic evi dence, and death certificates are affected by a margin of error [Nelson and Farebrother, 1987]. Pleural mesothelioma, nevertheless, is included among the sentinel health events described by Rutstein et al. [1983], and an example of surveillance of me sothelioma by use of death certificates is provided by Schwartz [1986]. Previous studies by us show that only about 70% of patients affected by pleural mesothelioma are correctly registered as malignant neoplasms of pleura at death [Bruno et al., 1990]. A general discussion of the issue can be found in the paper by Dubrow et al. [1987], For the cases we report, a diagnostic bias for compensation payment matters 686 Dodoli et al. TABLE IV. Mineralogic Examination of Fireproof Materials Still Used in the Area of Leghorn and La Spezia Macroscopic features SEM* investigation fiber types SEM investigation fiber average sizes Non-fibrous particles A: Flexible, 4 mm thick panel. Slightly breakable: friability and maximum fiber dispersion mostly along rims and angles. B: Poorly flexible, 2 mm thick panel. Poorly breakable; friability and maximum fiber dispersion mostly along rims and angles. C: Flexible, 6 mm thick panel. Highly breakable; spread friability and maximum fiber dispersion along rims, angles, and flaking planes. D; Stiff, 1 cm thick panel. Slightly breakable; friability and maximum fiber dispersion mostly along rims and angles. E: Poorly flexible, 2 mm thick panel. Poorly breakable; friability and maximum fiber dispersion mostly along rims and angles. F; Totally moldable, 1 mm thick cloth (cord). Poorly breakable; very low friability and fiber dispersion. Chrysotile Chrysotile Glass fibers. chrysotile Chrysotile Chrysotile Chrysotile Length = up to 1 mm, diameter = 1-5 p Length = up to 1.5 mm, diameter 1-5 p Length = up to 1 mm, diameter = 5-15 p Chrysotile3 Chrysotile3 Quartz, barite, chrysotile3 Length = up to 1.5 mm, diameter 1-10 p Length = up to l mm, diameter = 1-10 p Length = up to 1.5 mm, diameter = 1-5 p Chrysotile3 Chrysotile3 Chrysotile3 *SEM = scanning electron microscopy. aNon-fibrous phase. cannot be suspected. Furthermore, items about exposure were collected without in forming the interviewed persons about the aims of the study and information can therefore be deemed fairly reliable. Briefly, in thirty-nine women with a pleural mesothelioma diagnosis on their death certificate and for whom it has been possible to collect medical records and interview information, thirteen were definitely exposed to asbestos in the domestic environment; three more cases were probably exposed and 5 were exposed at work. In addition, the number of "lost cases" plus the cases without definite exposure could obscure some additional cases with non-occupational exposure. It is very dif ficult, in fact, through the interviews of the decedents' relatives to identify domestic or "free-time" activities that occasion the inhalation of asbestos fibers. Domestic washing of work clothes seems especially to constitute an important non-occupational exposure. According to Huncharek et al. [1989], the total amount of inhaled fibers in this operation may be comparable to that inhaled by workers occupationally exposed to asbestos. Although work clothes have been no longer washed at home in Italy for many years, we have observed that a questionable domestic use of asbestos still exists-- Household Exposures and Mesothelioma 687 namely as non-conductive material to limit heat dispersion, often without any regard to friability and fiber dispersion. We found only chrysotile in the specimens exam ined; but, in our opinion, the unnecessary domestic use of all types of asbestos, even that overlooked in the past, should now be banned. Health education is also required. REFERENCES Anderson HA, Lilis R, Daum SM, Fischbein AS, Selikoff IJ (1976)-. Household contact asbestos neo plastic risk. Ann N Y Acad Sci 271:311-323. Anil KJ, Holt PF (1977): Mesothelioma possibly due to environmental exposure to asbestos in childhood. Int Arch Occup Environ Health 40:141-143. Bianchi C, Brollo A, Bittesini L, Ramani L (1987): Hyalin pleural plaques and domestic exposure to asbestos. Med Lav 78:44-49. Bruno C, Comba P, De Santis M, Malchiodi F (1988): "Mortality per tumore maligno della pleura in Italia: 1980-1983." Roma: Istituto Superiore di Sanita--Rapporti Istisan 88/24. Bruno C, Comba P, Maiozzi P, Vetrugno T (1990): Studio della mortality di pazienti di mesotelioma pleurico. Atti 5 Convegno Nazionale sugli Studi di Mortalita, Firenze, Comitato Italiano Studi Mortalita, CSPO Publ, Firenze, 1990. Delendi M, Riboli E, Peruzzo P, Stanta G, Cocchi A, Gardiman D. Sasco AJ, Giarelli L (1991): Comparison of diagnoses of cancers of the respiratory system on death certificates and at autopsy. In Riboli E, Delendi M (eds): "Autopsy in Epidemiology and Medical Research." Lyon: IARC Sci Publ 112, pp 55-62. Dubrow R, Sestito JP, Lalich NR, Burnett CA, Salg JA (1987): Death certificate-based occupational mortality surveillance in the United States. Am J Ind Med 11:329-342. Gardner MJ, Saracci R (1989): Effects on health of non-occupational exposure to airborne mineral fibres. In; Bignon J, Peto J, Saracci R (eds); "Non-Occupational Exposure to Mineral Fibres." Lyon: IARC Sci Publ 90:375-397. Greenberg M, Lloyd Davies TA (1974): Mesothelioma register 1967-68. Br J Ind Med 31:91-104. Huncharek M, Capotorto IV, Muscat Y (1989): Domestic asbestos exposure, lung fibre burden, and pleural mesothelioma in a housewife. Br J Ind Med 46:354-355. Kane MJ, Chahinian AP, Holland JF (1990): Malignant mesothelioma in young adults. Cancer 65: 1449-1455. Lieben J, Pistawka H (1967): Mesothelioma and asbestos exposure. Arch Environ Health 14:559-563. Li FP, Lokich J, Lapey J, Neptune WB, Wilkins EW (1987): Familial mesothelioma after intense asbestos exposure at home. JAMA 240:467. Nelson M, Farebrother M (1987): The effects of inaccuracies in death certification and coding practices in the European Community (ECC) on international cancer mortality statistics. Int J Epidemiol 16:411-414. Neri S, Iaia TE, Battista G, Roselli MG (1989): Eventi sentinella in medicina del lavoro: L'esempio dela USL n. 1 della Regione Toscana. Epidemiol Prev 39:29--34. Newhouse ML, Thompson H (1965): Mesothelioma of pleura and peritoneum following exposure to asbestos in the London area. Br J Ind Med 22:261-269. Nicholson WJ, Rohl AN, Weisman I, Selikoff IJ (1980): Environmental asbestos concentrations in the United States. In Wagner JC (ed): "Biological Effects of Mineral Fibres." Lyon: IARC Sci Publ 30:823-827. Rutstein DD, Mullan RJ, Frazier TD, Halperin WE, Melius JM, Sestito JP (1983): Sentinel health events (occupational): A basis for physician recognition and public health surveillance. Am J Public Health 73:1054-1062. Schwartz E (1986): Use of death certificate for surveillance of work-related illnesses.--New Hampshire. MMWR 35:537-540. Vianna NJ, Polan AK (1978): Non-occupational exposure to asbestos and malignant mesothelioma in females. Lancet I(II): 1061--1063. Wagner JC, Sleggs CA, Marchand P (1960): Diffuse pleural mesothelioma and asbestos exposure in the North Western Cape Province. Br J Ind Med 17:260-271.