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Maanedsskrift for a/men praksis 2014; 92:1030-1038.
Asbestos is still a health problem
Ro/f Petersen, M.D., Ph.D*
Sigurd Mikkelsen M.D., Dr.MedSc** *Department oJ occupational Medicine, Slagelse Hospital, Denmark **Department of Occupational and Environmental Medicine, Bispebjerg Hospital, Denmark
This year it asbestosis,
is 50 years since lung cancer
a
scientific
consensus
was
achieved
that
asbestos
can
cause
international
and conference in
mesothelioma. New York.
It
happened
at
a
big
and
later
very
famous
Yet two decades went by before Denmark a ban against th
effective
prevention
was
adopted
in
the
western
world.
In
e use of asbestos was first introduced in 1986. But globally about 150
wmoilrlkioenrspdeioepelevedrayilyyecaornfrtionmueatsobebsetoexsp-roeslaetdedtodaissebaessetso.s in their work. Approximately 107,000
In Denmark, about 250 work with asbestos. D
people
each
year
get
lung
cancer
or
mesothelioma
as
a
result
of
previous
number
of
those
who
eaths die in
from asbestos-related accidents in the w
diseases
are
4-5
times
higher
than
the
asbestos
in
1986,
asbestos
continues
to
be
ork place, and despite the the working environment fa
ban
on
the
use
of
highest number of deaths in Denmark.
ctor that causes the
The incidence of asbestos-related turns. Asbestos is remove
cancer
is
expected
to
rise
until
around
2025
before
the
curve
significant
quantities
in
d or encapsulated, but exposure buildings, ships, trains etc.
may
still
occur.
Asbestos
still
exists
in
The history of asbestos, Economic interests hav
both
internationally
and
in
Denmark,
is
a
working
environment
scandal.
e over-ruled the prevention of serious and fatal diseases. It is an
eimnvpiorortnamntelnetssmounsot fbheisptuobrlyictlhyaatvtahielabreles,eatrracnhsapnadreanstsaensdsminednet poef nridskesntin the working
applies to the decisions of the authorities.
of industry. The same
What is asbestos?
Asbestos asbestos,
is a generic small, long
term
for
a
variety
of
fibrous
minerals
found
in
rocks.
In
the
mining
and
use
of
and
deposited
in
the
and thin asbestos fibers lungs. The fibers are fib
are
dispersed
in
the
air,
from
where
they
are
inhaled
thinner
the
fibers
are.
Alveolar
rogenic and carcinogenic macrophages are damaged by atte
-
the
more,
the
longer
and
sreulbesaesqeureenatcftiibveroosxisygaennd rcaadniccaelrs(1a)nd(sevearFioigu.s1c).ytokines that cause inmflpatms mtoaptihoangoacnydtipzeostshieblmy and
1
The main asbestos related asbestos can also ca
diseases
are
lung
asbestosis,
lung
cancer
and
mesothelioma
but
use laryngeal cancer, exudative pleuritis'and pleural plaques
WHO estimates that approximately and that about 107,0
150
million
people
are
daily
exposed
to
asbestos
in
their
work,
00 workers die each year from asbestos-related diseases (2).
Asbestos production world countries. T
and
consumption
is
still
increasing
in
Russia,
China,
Brazil
and
other
third
increase
in
the
his means years ahead.
that
the
incidence
of
asbestos-related
diseases
will
continue
to
Asbestos is now world. Asbestos
banned is
in
55
countries
and
therefore
allowed
in
the
other
135
countries
in
the
asbestos
should
used especially in many stop, and many occup
developing
countries.
WHO
recommends
that
all
use
of
Ramazzini,
the
International
Joint
ational medicine societies, Policy Committee of Soc
including
the
Collegium
Federation
of
Public
Health
Associations,
are
advocating
ieties of Epidemiology for a worldwide ban.
and
the
World
Lobbyists from the asbestos developing countrie
industry
are
trying
to
avoid
a
ban.
In
particular
they
are
active
in
the
s. Independent researchers, doctors and public health experts have recently
warned against these lobby activities (3).
The history of asbestos
From about the beginning fibrosis of the lung
of
the
1900s,
there
has
been
suspicion
that
asbestos
dust
can
cause
During
World
War
tissue (lung asbestosisL 2 it was suspected
and
this
was
generally
recognized
from
the
1930s.
in
population
studies
from
mid
1950s
that asbestos can cause (4). In 1960, studie
lung
cancer,
and
this
was
confirmed
mesothelioma
among
those
exposed
to
asbestos
(5).
s also But even
showed an increased if the results w
incidence
of
scientific d
journals,
and
doctors
and
other
experts
warned
against
the
harmful
ere published in effects, the warnin
id
not
reach
the
public
and
were
concealed
from
the
workers
so
as
not
to
create
gs "unnecessary"
unrest and to avoid adverse economic effects on the asbestos industry.
This held
policy of silence the first Intern
ceased
only
gradually
after
1964,
when
the
New
York
Academy
of
Sciences
breakthrough
for
ational Congress on the broad recognition that
biological
effects
of
asbestos
(6).
This
congress
was
the
and fatal lung disease.
working with asbestos involved a high risk of disabling
Nevertheless, mainly due to
the the
road
to
effective
prevention
was
long
and
is
still
very
deficient
worldwide.
This
is
fact that the asbestos industry in the UK, USA and Canada from the early 1960s
awsebnetstmosa.sTsihveelcyaimntpoaaigcnawmapsaiignnsptiorebdlobcykthpreecvaemntpivaeigmn easures, which would result in less use of
on
smoking.
The
methods
were
disinformation
and
of the lobbying.
tobacco industry The industry cre
to
avoid
restrictions
controlled
"independent"
research
institutes
which
were
intended
to
create
ated, funded and continuously and
2
systematically damage from
doubt
regarding
the
results
of
independent
scientific
studies
th
exposure
to
asbestos.
The
asbestos
industry
employed
highly
at showed estimated m
health
e
tphreofeevsisdoerns,cereosef aasrcbheesrtsosanhdazdaordctaonrs who used their authority to reassure the public, cast ddoicuabl t on
reduce the use of asbestos.
d influence the authorities not to impose measures that could
A particularly glaring associated with
example
is
the
activities
that
were
carried
out
by
"The
C
the
world's
McGill University largest asbestos exp
in
Canada,
supported
by
the
Canadian
hrysotile Institute" government. Canada
adverse
effects
on
other
types
orter of white asbestos of asbestos (cro
(chrysotile).
The
strategy
was
to
was blame the
it
was
possible
to
work
safely
with
white
cidolite and asbestos ("safe
amosite)
than
white
asbestos
and
claim
was closed McGill
in
2012.
There
has
subsequently
been
use' of chrysotile hearings on the role
asbestos").
The
Institute
University. There research. These accu
have
also
been
raised
accusations.of
and responsibilities scientific fraud with th
of
sations
have
not
been
met
by
the
presentation
of
original
data
e Institute's (8). After the
lcolobsbuyriengotfothoeppinossteitubtaenhoingha-srabneksitnogs,mfoermebxearms of the Institute have been employed by industry
has
unfortunately
succeeded
in
preventing
or
ple, recently in delaying actio
Pakistan.
(3)
The
asbestos
Industry
Worldwide a decrease
consumption
rose
sharply
until
1980,
after
n against the use which it gradually d
of
asbestos.
in
consumption
in
the
western
world,
while
consumption,
ecreased particularly in
mainly Asia
due
to
mincerteriacsteodnsdraamyeaatric. ally. Worldwide consumption in recent years has stayed at around 2 m, hilalison
Asbestos history in Denmark In Denmark, the local asbestos story is as dramatic as the international one.
To put it nicely, authorities wa
the
attitude
of
companies,
authorities
and
the
established
oc
s
to
drag
their
feet,
although
it
was
understood
that
working
cupational medicine with asbestos
le
liunnvgaslidoafttihneg awnodrkfeartasladtistheaesDesanaismhoEngtetrhne employees. The lung clinic in Aalborg took x-rays odf tthoe
within a narrow group of doctors at the citlinfaicctaonryd.tBheutLtahbeoruer,sIunlstspewcetorersl.argely kept confidential
uTnhneeycaepspsaarryenutnlyrewsitsihnetdhetowaovrokipdlawchea. t they considered unnecessary anxiety among the workers or
No action was This and dema
really
taken
until
insulation
workers
threatened
to
refuse
to
w
nds
from
the
Transport
and
General
Workers'
Union
in
ork with asbestos. Denmark (the curren
t
wenhsicuhre, dhothwaetvienr,1e9x7e2mapsbteedsttohsewDaasnbisahnnEetedrnfoitr insulation purposes. In 1980 came a partial ba3nF,)
a total ban on the use of asbestos.
factory, in 1986 a ban with exceptions, and in 2004
In Denmark consumption tons of asbestos
peaked
in
the
mid-1970s
with
an
annual
import
to
(see
Fig.
2)
(7).
Subsequently,
imports
decreased
to
an
Denmark of 30,000 insignificant level in
1986,
3
Asbestos-related mesothelioma Approximately 90% of all cases of malignant mesothelioma of the pleura is believed to be caused by asbestos exposure. The number of new cases continues to rise (Fig. 3 and 4). Because of greater exposure to asbestos, men have a much higher incidence of mesothelioma than women and subjects with known asbestos exposure have a higher risk than subjects without exposure. For example, the incidence of mesothelioma in the period 1961-2005 was 22 times higher for plumbers than for farmers.
Other building workers, sailors and mechanics also had a higher risk (Table 1) (12).
Following a change in workers' compensation law in 2007 all cases of mesothelioma recorded in the National Board of Health are passed over to the Industrial Injury Board to be examined for workers' compensation.
In 2011,106 men and 17 women were diagnosed with cancer in the pleura.
Of these cases, 83 (67%) were recognized for compensation as an occupational disease.
A short-term exposure to low concentrations of asbestos fibers in the air is enough to increase the risk of mesothelioma. The latency period is about 30 years or more.
Asbestos-related lung cancer In a reference document on asbestos exposure and lung cancer it was estimated that 4-8% of new lung cancer cases are caused by asbestos exposure (13), ie 100-150 new cases annually.
Each year, about 75 cases of asbestos-related lung cancer are reported to the Industrial Injury Board and just below half of those are recognized to be compensated as an occupational disease.
Unlike mesothelioma, which can occur after even low exposure to asbestos, the exposure to asbestos needed to cause lung cancer is bigger. Dose-response relationship at low exposures is uncertain. Internationally, it is generally accepted that asbestos exposure equivalent to approximately 25 fibers x year per ml doubles the risk of lung cancer (14).
In a study from Sweden a doubling of risk of lung cancer was found in persons exposed to 4 fibers x year per ml (15). The latency is about 10 to 30 years. Asbestos exposure increases the risk of lung cancer equally in smokers and non-smokers. Lung cancer in asbestos-exposed smokers should be recognized in the same way as in non-smokers, i.e. without prejudice for smoking. It is unfortunately not the case today, but will hopefully be changed in connection with a pending lawsuit (16).
The significance of the remaining asbestos The use of asbestos was banned in Denmark in 1986. At the same time the safety rules were
5
reinforced for workers dealing with the remaining asbestos.
The remaining asbestos is found in Eternit (asbestos cement), insulation and brake linings. Whether release of asbestos fibers takes place depends on the condition of the material. Damaged materials will release the most asbestos fibers.
The highest incidence is found in buildings, but how big it exactly is, is not known. A total of 73% of the buildings in Denmark were built before 1980 and therefore potentially contain asbestos (17). In these buildings asbestos can be found as insulation around pipes, in floor coverings, in sheets for walls and ceilings, in glues, in paints and as fire insulation in e.g. stairwells. Outside of buildings, asbestos can be found in the roof and facade panels (Eternit) e.g. on farms. It is particularly buildings constructed between 1920 and 1990 which contain asbestos.
Exposure to asbestos fibers can occur during renovation or demolition of buildings containing asbestos materials, if workers are not aware of it or if the rules deliberately are bypassed to save time and money. The Labour Inspection authorities unfortunately have experience of the latter from time to time (18).
What can we learn from the history of asbestos The history of asbestos is the story of how companies, physicians, regulators and politicians let things happen year after year, regardless of scientifically based knowledge about asbestos hazard. Economic interests were given precedence over the workers' health. The human victims have been - and will remain - considerable in number and suffering. Not undeservedly, the asbestos story today, both in Denmark and internationally, is called the largest safety scandal ever.
But we can learn from history. First of all, there should be openness and transparency in all matters relating to the investigation and assessment of risks associated with the working environment. You cannot count on data, if it is the industry itself that is responsible for investigations and risk assessment.
It is therefore important that the public sector ensure a good framework for independent research and risk assessment. To the extent that industry contributes to public research through research funding, from the date of authorization there should be a clear separation between any influence from the grant donor and the grant-recipient conducting the research task and data should then be publicly available. Transparency and the requirement to operate at arm's length is generally a good protection against misuse of power. It is worth remembering this at a time when there is much talk of cooperation between public research institutions and private industry.
Authorities and other decision makers must in the same way secede from corporate interests and implement the measures necessary to prevent workers from becoming ill from their work.
Economic conflicts of interest: none declared.
6
Figure 1. Electron microscope image of macrophage in alveoli trying to phagocyte an asbestos fiber. (Foto: Lennart Nilsson/TI)
7
30 25 20
...1/1
c:: 0
0 15
0
Q....
10
5 0
1043-47 1948-521951-57 1958-62 '1903-67 190R-72 1973-77 1978-62 1983-87 '1988-92 1993-97 19982003
Figure 2. Annual asbestos imports in Denmark 1943-2003 (7).
8
......... Pleura ........ Peritoneum
Pericardium .-+- Total
2
1.8 -
1.6
1.4
1.2
1
O.S
0.6
0.4
0.2
0
f', N
f',
N \'f',TN T l'"'-
N
I
T::-r;;'~Tc;, I
f', N
N
;;vr::l
f', m
~
I.f)
I.f)
\()
\()
r...
f',
(Xl
(Xl
m
mI'"'- 0
0
0
.0..1.. .m..,.. .m..,.. .0..1.. .0..1.. .0..,1.. .0..1.. 0...1..
M
m 00 M
j
j
.m....
.m....
m
0
N
I
'"'I" I
M0 0
N
N
I
~ cm::t
~
01
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01
mIJ)
ImD
~
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00
f', O't
M
tmXl O't
Mm g?, O't m
0 0
(Xl
0 0
..... <"'i ..... ..... <"'i <"'i ..... ..... ..... ..... ..... N N
'"'" Year
Figure 3. Age-adjusted annual incidence of mesothelioma per. 100,000 men in Denmark 19432009 (9). (The figure was previously published in the Danish Medical Journal and placed with the
authors' permission).
9
Incidence per 100,000 person, years 2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
r 0
r-. N
r-. N
r-.
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,....
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,.... r"O':l l
<m:t
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m m
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('f')
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00
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('f')
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00
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00 O'l
00 O'l
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m
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0 Cl
Cl 0
...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... N N
Year
......... Pleura -.6.- Peritoneum
. Pericardium . -<&-- Tota!
Figure 4. Age-adjusted annual incidence of mesothelioma per. 100,000 women in Denmark 19432009 (9). (The figure was previously published in the Danish Medical Journal and placed with the authors' permission).
10
Figure 5. Number of mesothelioma cases among men in Denmark and standardized incidence ratio
(SIR) for the period 1961-2005 in selected trades with a statistically significant SIR (12).
Trade (isco 1958) Technical skills Teachers Farmers Sailers Welders Mechanics Plummers Electricians Wood workers Machine operators
Obs
SIR
136
1.53
14
0.36
32
0.18
26
2.53
101
3.53
187
2.46
27
3.92
31
1.69
109
2.13
34
1.78
11
Figure 6. There are still many thousands of square meters of asbestos cement sheets on roofs in Denmark as a potential source of exposure to asbestos fibers (Private photo Jonathan Aavang Petersen)
Literature: 1. IARC Monograph 100C. http://monographsiarc.fr/ENG/Monogr-aphs/ vol1 00C/mon01 OOC.pdf p. 219-309. 2. WHO. http://www.who.intlmediacentre/ factsheets/fs343/enl 3. Statement in response to asbestos industry efforts to prevent a ban on asbestos in Pakistan: Chrysotile asbestos use is not safe and must be banned. Arch Environ Occup Health 2013; 68: 243-9. 4. Doll R. Mortality from lung cancer in asbestos workers 1955. Br J Ind Med 1955;12:81-6) 5. Wagner JC, SIeggs CA, Marchand P.Diffuse pleural mesotelioma and asbestos exposure in North Western Cape Province. Br J Ind Med 1960; 17: 260-271 6. Selikoff IJ, Churg J. Biological effects of asbestos. Annals of the New York Academy of Science, 1965;132:1-766. 7. Brauer C, Baandrup U, Jacobsen Pet al. Screening for asbestbetingede sygdomme? Ugeskr Lreger 2009; 171: 433-36.
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8. Ruff K. Asbestos: a continuing failure of ethics by McGiII University. Int J Occup Environ Health 2014;20:1-
3 9. Skammeritz E, Omland 0, Hansen J, Johansen JP. Regional differences in incidence of malignant
mesothelioma in Denmark. Dan Med J 2013;60:1-5 10. BOlow Hans. Under anklage - En beretning om asbesten og dens ofre .. Kf2lbenhavn: Tiderne Sklfter, 1989. 11. Jacobsen Kurt. Asbest - magisk mineral og drceberstf2lv. Kf2lbenhavn: Informations Forlag, 2012. 12. Pukkala E, Martinsen JI, Lynge E et al. Occupation and cancer - follow-up of 15 million people in five Nordic countries. Acta Oncologica 2009;48:646-790. 13. Sherson D et al. Occupational asbestos exposure and lung cancer. Odense: Odense UniverSity Hospital, 2013. http:// www.ask.dkHmedia/ASKlpdf/Rapporter/ Udredningsrapport%20asbestos%20 lung%20cancer%202013pdf.ashx 14. Tossavainen A. Asbestos, asbestosis, and cancer: the Helsinki criteria for diagnosis and attribution. Scand J Work Environ Health 1997;23:311-316 15. Gustavsson P, Nyberg F, Pershagen G et al. Low-Dose Exposure to Asbestos and Lung Cancer: DoseResponse Relations and Interaction with Smoking in a Population-based Case-Referent Study in Stockholm, Sweden. Am J Epidemiol2002; 155: 1016-22. 16. Frost P, Petersen R, Thomsen JF, Mikkelsen S. Problematisk afgf2lrelse I Ankestyrelsen i sag om erstatning til asbestudsatte rygere med lungekrceft. Ugeskr Lceger 2014;176:1070-71. 17. Rasmussen TV. Asbest i Bygninger.Aalborg: Statens Byggeforskningsinstitut, Aalborg Universitet, 2010. 18. Mortensen H. Tilsynschef, Danish Labour Inspection (personal information).
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