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FILE NAME Brakes BRK DATE 2007 Oct 27 DOC BRK175 DOCUMENT DESCRIPTION Journal Article - Mesothelioma in Vehicle Mechanics- Is the Risk Different for Australians Occupational Medicine Advance Access published October 27 2007 Occupational Medicine 10.1093 kqm114 Mesothelioma in vehicle mechanics is the risk different for Australians Michael A. Kelsh Valerie A. CravenMary Jane Teta4 Fionna S. Mowat,,and Michael Goodman Background The question of whether vehicle mechanics have an increased risk of mesothelioma has important public health implications Calculations of relative risk using case reports from the Australian Mesothelioma Registry AMR indicate increased risks however this contrasts with the results of 19 epidemiologic studies that have found no association Aim To evaluate potential explanations for the discrepancy of findings from epidemiologic studies and AMR reports Methods We evaluated three hypotheses as possible explanations for the inconsistency between the AMRbased calculations and the findings from published epidemiologic studies ( differences in exposure characteristics of Australian vehicle mechanics versus vehicle mechanics in North America and Europe ii limitations of the AMR data and iii errors in the risk calculations based on AMR data We reviewed available exposure information specific to Australian vehicle mechanics and AMR data obtained from the Australian National Occupational Health and Safety Commission for this evaluation Results We did not identify differences in workplace exposures processes or fibre type among Australian vehicle mechanics compared to vehicle mechanics in other countries Our analysis of primary AMR data identified several errors in exposure classification and in the assumptions used to calculate relative risk Conclusions Discrepancies between epidemiologic studies and AMR calculations cannot be explained by differences in exposure These discrepancies are most likely attributable to inadequate occupational information and classification in the AMR from 1986 forward and to erroneous assumptions used to derive relative risk estimates for mesothelioma among Australian vehicle mechanics Key words Asbestos brakes epidemiology mesothelioma registry motor mechanics motor vehicle mechanics Introduction The question of whether vehicle mechanics have an increased risk of developing mesothelioma from their exposure to asbestos during brake work has been addressed in numerous epidemiologic studies in North America and Europe 1-19 Table ) and summarized in two meta- Exponent Inc. 149 Commonwealth Drive Menlo Park CA 94025 USA 2Department of Epidemiology School of Public Health University of California Los Angeles Box 951772 650 Charles E. Young Drive Los Angeles CA 90095 USA ExponentInc. 500 12th Street Suite 220 Oakland CA 94607 USA Exponent Inc. 420 Lexington Avenue Suite 1740 New York NY 10170 USA Department of Epidemiology Rollins School of Public Health Emory University 1518 Clifton Road NE Room 430 Atlanta GA 30322 USA Correspondence to Michael A. Kelsh Exponent 149 Commonwealth Drive Menlo Park CA 94025 USA Tel +1 650 688 1764 mail mkelsh@exponent.com analyses 20,21 and a qualitative review 22 The stud- ies found no evidence of an association between work as an auto mechanic or brake work and mesothelioma This finding has been disputed however with authors citing case reports of mesothelioma among auto mechanics and limitations in the epidemiologic studies 23,24 The epidemiologic findings are in disagreement with calculations using the Australian Mesothelioma Registry AMR In a document prepared for the World Trade Organization WTO one panellist estimated that vehicle mechanics have a fold increased incidence of meso- thelioma based on data from the AMR 25 AMR data were also used in similar calculations that suggested increased risk 26,27 We explored three possible explanations for this apparent discrepancy i exposure differences between North American and European versus Australian vehicle mechanics ii limitations of the AMR data and iii errors in the risk calculations using the AMR data 'The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine All rights reserved For Permissions please email journals.permissions@oxfordjournals.org Page Table 1. Summary of findings and key characteristics of epidemiologic studies of mesothelioma among vehicle mechanics 2 First Publication Study Exposure Exposed or Exposed Total Total of Relative author year type category observed controls or cases controls risk cases expected estimate J^/rvholm 1988 Hansen 1989 Cohort Cohort Car mechanics Auto mechanics OCUPATINL cases and 95 CI 122 21 905 workers followed 19 years for incidence and 13 years for mortality NA 122 21 800 workers followed 10 years NA Gustavsson 1990 McDonald 1980 Teta 1983 Spirtas 1985 Cohort Bus garage workers 122 control Garage li control Automobile repair and 1 related service control Brake lining installation or A 695 workers followed 35 years for mortality and 27 years for incidence 12 156 156 5 147 464 N 259 259 NA MEDICN 0.910.35-2.34 0.65 0.80-5.53 1.0 0.6-1.6 repair Woitowitz 1994 control Motor vehicle mechanics 16 28 324 497 0.87b 0.43-1.70 Teschke 1997 control Vehicle mechanics 6 20 Agudo 2000 control Mechanics motor vehicles 3 14 Hansen 2003 control Repair of motor vehicles 10 12.5 51 154 54 162 N A 0.8 0.2-2.3 0.62b 0.11-2.36 0.8 0.4-1.5 and motorcycles Hessel 2004 control Brake lining installation or 12 28 repair Welch 2005 control Tire or brake repair 8 6 Rolland 2006 control Skilled auto mechanic NA NA 147 358 24 24 375 714 1.04 0.46 2.22 1.50 0.36-6.45 1.15 0.53-2.47 maintenance or repair Peterson 1980 PMR Mechanics and repairmen 0" 0 0 automobile n = 1833 Olsen 1987 PIR deaths Repair of motor vehicles 0 N 2 0 and motorcycles total number of deaths NA Coggon 1995 PMR Motor mechanics 12" 26 n = 15 435 total deaths Milham 2001 PMR Automobile mechanics 7 9 and repair workers 2 NA 2 0.46 0.24-0.80 0.75 0.30-1.55 n = 10 473 total deaths NIOSH 2002 PMR Automobile mechanics 15a 19 n = 66 787 total deaths McElvenny 2005 PMR Motor mechanics total 60 80b Appendix number of deaths NA 2 NA 0.81 0.45-1.34 0.48 0.37-0.62 CI = confidence interval NIOSH National Institute of Occupational Safety and Health PIR = proportionate incidence ratio PMR = proportionate mortality ratio NA = not applicable and A = not available Results presented for pleural cancer bValues have been calculated using Epilnfo v3.2 http://www.cdc.gov/EPIINFO/epiinfo.htm http://www.cdc.gov/EPIINFO/epiinfo.htm Total number of deaths all causes among vehicle mechanics M. A. KELSH ETAL MESOTHELIOMA IN AUSTRALIAN VEHICLE MECHANICS Page 3 of 9 Methods To evaluate potential exposure differences we considered three questions regarding exposure characteristics of Australian versus North European vehicle mechanics ) Are exposure levels to airborne asbestos fibres higher in Australia ii Are there differences in the brakehandling procedures and iii Do the asbestos fibre types used in brake linings differ Published studies and unpublished reports were the source of information used to address these three exposure questions 28-42 To better understand the types of data included in the AMR we reviewed the literature describing AMR data collection procedures and evaluated identified information from the AMR pertaining to individuals reportedly engaged in brake manufacturing and repair The AMR began as the Australian Mesothelioma Surveillance Program or the Program in 1980 43 For each case a full occupational and environmental history was obtained by direct interview 43 Starting in 1986 the Program was replaced by a Register which involved less systematic data collection resulting in less rigorous occupational and environmental data Since 1986 40 of the exposure information is collected via a short questionnaire with the remaining collected by other programs 44 Beginning in 1996 the National Occupational Health and Safety Commission NOHSC of Australia reports of AMR data listed a category called circumstances of ex- posure that included brake repaired The final NOHSC publication to provide information on this category included 78 total mesothelioma cases with occupational and occupational brake work 59 cases of exclusive exposure to brakes and 19 cases with other asbestos exposures for the period 1986-2001 44 From NOHSC we obtained identified copy forms and electronic data pertaining to these 78 cases Because the electronic database contained substantially less information we relied on the copy forms for our analysis Through detailed record review we identified which of the 78 cases from the AMR would be classified as motor mechanics according to the rules of the Australian Census Classifying AMR data proved difficult given the paucity of information and NOHSC has now abandoned the use of the circumstances of exposure categories in its reports and uses only industry and occupational history information Results A comparison of asbestos exposure levels in Australia USA and Europe is presented in Table 2. Exposure surveys among Australian vehicle mechanics report generally low 0.1 cc airborne asbestos concentrations In the USA and Europe personal sample concentrations ranged from 0.002 to 2.33 cc for passenger cars and light trucks and from 0.003 to 7.09 cc for heavy trucks and buses For passenger vehicles and light truck repair h timeweighted average TWA concentrations ranged from 0.002 to 0.68 cc mean 0.04 cc For heavy trucks and buses the mean reported h TWA was 0.2 cc range 0.002-1.75 cc Exposure levels have decreased over time in both Australia and the USA 29,3236,39,41 Thus available data show no discernable differences in Australian workplace asbestos concentrations peak or TWA asbestos exposures compared to North America and Europe However these data are limited by lack of exposure information for earlier time periods which makes them somewhat less relevant due to the long latency of mesothelioma On the other hand studies designed to simulate historical mechanic exposures did not find asbestos concentrations above the current US Occupational Safety and Health Administration permissible exposure limit of 0.1 cc 42 Brake repair cleaning practices used in Australian garages included use of aerosol brake cleaners for dust control and degreasing squirt bottles for washing brake parts spraying compressed air to dry brake assemblies and removing dust using a scalpel and then dry wiping 29 In the USA cleaning methods included the above methods plus wet and dry brushing and various vacuum enclosures Surveys of both Australian and American garages provide no evidence that grinding sanding or drilling which could result in additional expo- sures were more common in Australia than in the USA These activities were rarely undertaken after the late 1970s in either country 29,39,41 In Australia as in North America and Europe raw chrysotile asbestos was used in the manufacture of brake disc pads brake linings and brake blocks 29 Armstrong et al 45 stated that crocidolite was used in brakes in Western Australia however there are no published data that confirm this statement Given that amosite crocidolite and other amphibole asbestos varieties were not considered suitable for brake products 39 and that chrysotile asbestos is much softer than the amphiboles much easier to process more abundant and has good heat resistance it is unlikely that crocidolite was used in brakes In our evaluation of the original AMR data we identified 48 of the original 78 cases that could be considered possible motor mechanics after inclusion of all potentially related occupational categories such as apprentice mechanic motor mechanic of farm machinery diesel motor mechanics and motor mechanics working in the armed forces Figure ) The thirty remaining cases were ) individuals who were not professional vehicle mechanics ii worked near mechanics but did not personally conduct the work iii worked in brake manufacturing or iv women whose husbands were Table 2. Summary of exposure surveys of asbestos levels among motor vehicle shops Author Population Work activity Sample duration Number of samples Results Page 4 Comments of Australia Francis 30 VOHSC 31 VOHSC 31 NICNAS 29 Measurements by factory inspectorate in New South Wales Australia Survey conducted by Victoria Department of Labour of Australian automotive firms Same as above Ten surveys in Western Australian brake shops 1979-1989 Blowing out brake drums finishing riveting Large specialist automotive brake and clutch firms NA NA Smaller NA NA independent firms Brake maintenance P one sample 6 one sample 175 18m5in two grinding brake samples 3 h discs and linings remainder duration NS NICNAS 29 Same as above Brake maintenance A two samples 9 including radius 10 min remainder grinding duration NS < ml 2-4 ml 0.1 ml Presented at Second OCUPATINL Australian Pneumoconiosis Conference Occasional excursions up to 1.0 ml MEDICN 0.2-0.3 ml TWA 0.1 ml All but one /0.m1 l by MFM single sample collected in 1983 = 0.7 ml Report noted majority of fibres 0.1 limited information so unsure of peak versus TWA exposures h duration Two of nine exceeded detection limit Same as above did not include results DIV ========= 0.01-0.5 ml from brake bond ing Belt grinding 1979 0.4 ml 10 min Task NS 1982 10 ml duration NS NICNAS 29 NICNAS 29 Same as above Aftermarket survey of five automotive service garages in 1996 four automobile one bus Brake maintenance Drum and disc brake changing Type and duration NS P A 1-2 MFM analysis Yeung et al 28 Four Australian garages three for passenger cars and light vehicles one for truck brakes Servicing brakes P 77 12m5in 5 0.2-1.3 ml 5 P 31 A collected from 10 workers 0.05 ml P 0.03 ml A ND DLV = 0.05 ml Same as above samples collected 1981 Stated that service stations rarely undertook cutting grinding or sanding activities 0.01 asbestos equivalents by TEM Samples collected in 1995 Table 2. Continued Author Population Work activity Sample duration Number of samples Results Comments Europe Hickish and Knight 32 Car and truck exposures Servicing brakes in England P 2 ^ 45 min collected > h R^delspergeret al 37 Service stations for cars Servicing brakes trucks and buses in PA3 Plato et al 40 Germany Repair shops in Sweden Vehicle repair work P 6m0in 6 TWA 0.68 cc car Evaluated use of TWA 1.75 cc truck compressed air samples collected during 11 brake jobs 31 samples car 36 Mean 0.04 0.1c2 c M. samples truck and bus car mean 0.05 0.39 cc truck and bus KELSH 103 mechanics TWA 0.02-0.20 cc Exposure data collected KELSH from 1976 to 1988 USA Johnson et al 33 Roberts 34 NIOSH survey of seven Servicing brakes garages NIOSH study of one Servicing brakes garage P A 5.7 h TWA 0.5 3.m0in for peak P 4.3 h TWA 1 min for peak 94 TWA 6 peak 1 TWA 1 peak Roberts 35 NIOSH study of one garage Servicing brakes P 6.2 h TWA 1-3 min for peak 2 TWA 2 peak Roberts and Zumwalde NIOSH survey of six 36 Moore 38 garages 31 US garages Servicing brakes Servicing brakes Sheehy et al 39 NIOSH study of engineering control technologies in Servicing brakes P A 2.3-6.2 h TWA 0.33-21 min for peak P 10 6m0in mean 29 min P A 120 min garages Paustenbach et al 41 Review of US European Brake repair activities P and Australian exposure data Blake et al 42 Exposure simulation of | Four brake drum brake repair replacement P A 262 39m5in 13 TWA 23 peak 35 83P 200 A TWA 0.01 0.2c0 c Evaluated various ETAL - 0.45-14.54 cc peak cleaning techniques TWA 0.04 cc evaluation of one 0.33 cc peak garage included in MESOTHLIA TWA 0.006-0.04 cc 0.25-0.37 cc peak TWA 0.01 0.2c8 c Johnson et al Evaluated cleaning with compressed air and solvent Evaluated various 0.00-15.0 cc peak cleaning techniques IN 0.01-0.15 cc Evaluated various cleaning techniques AUSTRLIN 0.003 0.01c6c Evaluated various cleaning techniques TWA 0.002 0.6c8c VEHICL car TWA 0.002 1.75 cc truck 0.0042-0.0937 cc P Evaluated filing sanding 0.0010-0.0031 cc A and arc grinding MECHANIS A area static sample DLV detection limit value cc fibres per cubic cenumetre ml fibres per millilitre MFM standard membrane filter method light microscopy min minute NICNAS National Industrial Chemicals Notification and Assessment Scheme NIOSH National Institute for Occupational Safety and Health NA not applicable or not available ND not detected NS not stated P personal sample TEM transmission electron microscopy and VOHSC Victoria Occupational Health and Safety Commission Page 5 of Page 6 of 9 OCCUPATIONAL MEDICINE Total cases in category brake linings - repaired 78 | not Definitely mechanics 30 Possible motor me= chanics Unclear if motor mechanics = 10 Insufficient info | Definite motor mechanics 38 I Other asbestos exposures possible 20 i No other asbestos exposures mentioned 18 | One Job recorded = Two jobs recorded n | Three or more jobs recorded 3 Figure 1. Analysis of AMR data mechanics Figure 1 None of these cases would be classified as a motor mechanic using Census coding procedures Thirty cases of the possible 48 possible mechanics were identified as definite motor mechanics of whom 18 had no other recorded asbestos exposure However 15 of those 18 individuals had only one or two jobs recorded raising concerns about the completeness of their occupational histories Twenty of the 38 cases had other occupational asbestos exposures determined by matching their occupational histories against a previously published list of asbestos jobs 5 Calculations that used the AMR data to estimate the relative risk of mesothelioma for Australian vehicle me- chanics have been presented in various reports and letters 25 2I7n a WTO report regarding human health risks associated with chrysotile asbestos one of the panellists stated that the AMR data included 58 mesothelioma cases among brake mechanics with no other exposure to asbestos This number combined with an estimated 200 000 current and former vehicle mechanics in Australia to calculate disease rates would result in a dis- ease rate that is fold higher than background meso- thelioma rates assumed to be one to two cases per million year 25 This background rate however is likely too low for Australia given the potential environmental crocidolite exposure in certain regions of the country 46,47 Based on our review of AMR records not 18 individuals instead of 58 potentially fit the definition of brake mechanics with no other exposures to asbestos Moreover only three of those cases seem to have a detailed occupational history with at least three jobs recorded In addition the size of the population of vehicle mechanics cannot be accurately estimated because it should include all former and current mechanics over the previous 25-40 years The estimate for the population size calculation was based on the assumption that the ratio of current to ever motor mechanics is 2 however in the USA the ratio of current to ever mechanics was MA MA KELSH AL MESOTHELIOMA IN AUSTRALIAN VEHICLE MECHANICS Page 7 of 9 estimated to be 5 48 Without better methods the actual numbers of current and former motor vehicle mechanics remain unknown Using the same AMR data Leigh and Driscoll 26 provide a table of lifetime risk of 0.7 for vehicle mechanics compared to 0.39 for All Australian Men However these risk calculations have the same limitations as the WTO report and in addition they do not take into account competing risks and specific rela- tive risks or disease rates Discussion Our review identified no discernable differences in work- place levels of exposure processes or fibre type among Australian vehicle mechanics compared to vehicle mechanics in other countries Instead our analysis of pri- mary AMR data identified several errors in exposure classification and in the assumptions used to calculate relative risk Another proposed explanation for this discrepancy is that the numerous epidemiologic studies are flawed and mask a true increased risk 23,24 A full review and discussion of each study's methods and quality are beyond the scope of this paper but have been addressed elsewhere 21,22 Nevertheless the consistency of findings across numerous epidemiologic studies conducted by various researchers in different populations using a variety of study designs and data collection procedures argues against the presence of systematic bias in the same direction in all those studies Ongoing disease surveillance based on accurate cancer data as recorded in a registry system such as the AMR can provide important public health information 43 44 However we noted that the use of the AMR data to accurately classify individuals as motor mechanics is problematic This is primarily due to incomplete work histories and frequent job misclassification Overall we observed that the mesothelioma rate calculation and risk estimate in the WTO report ) overestimated the number of mesothelioma cases among motor mechanics without other occupational asbestos exposures ii used an unverifiable estimate for the number of motor mechanics and iii underestimated the background rate for mesothelioma This research is the first study to evaluate exposure classification of vehicle mechanics work in the AMR data however our analysis should not be viewed as an attempt to estimate the actual risks of mesothelioma among vehicle mechanics We did not conduct a formal data collection nor did we have the data to adequately enumerate the population at risk The most reliable method of identifying occupational risk using AMR data would be a formal epidemiologic study involving systematic case ascertainment rigorous work history data collection and careful enumeration of the source population Currently available data on vehicle mechanics from existing epidemiologic studies should be used instead of rough estimates or calculations Key points There is a discrepancy between the reports of in- creased risk of mesothelioma among motor vehicle mechanics in Australia and the null findings from published epidemiologic studies in North America and Europe Unlike North American and European studies the Australian reports are based on informal calculations using the data from the AMR The observed discrepancy cannot be explained by the differences in asbestos exposure among motor mechanics in Australia and in other countries however there seem to be several errors in the AMR data and in the assumptions used to calcu- late relative risk Estimating risks should be done using carefully designed epidemiologic studies and not from calculations based on only data Funding DaimlerChrysler Corporation Ford Motor Company General Motors Corporation Conflicts of interest All authors have provided scientific consulting services to Daimler Chrysler Corporation Ford Motor Company and General Motors Corporation in the areas of exposure assessment and epidemiologic evaluation Some authors have 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