Document r4rO8mvp3YzeQOLDKkw6Ek2r

TUK OCCURRENCE OF ASlWCFTOa'.S AVONG INSOLATION WORKERS IN TV, K CM TF.O aiATES 1. J. SeiiVoff, J. Churg, E. C. !i*T.-.ond PLAINTIFF'S EXHIBIT \ frr^ Ar.r.-I* of The S"ew Vc:< Afnie.r,)' el fcfer.cee Vo I u." e i.:. Article I, F-C^ 31, 1*65 ul. u ASARCO ELP 0002898 J THE OCCURRENCE Or ASBESTOSIS AMONG INSULATION WORKERS IN THE UNITED STATES* I. J. Sc-likotf, J. Chars. . C. Hammond Section ox Eiti-trc-xt.-.t r.'.ci H> cThe Mc-uu. S'lr-ci norpilfl!, NV.-f Fi-re, S.Y. In for:r. a t i oit c u r re nt!y available cc accruing asbislosts has been derived largely from studies of employees cf asbestos textile factories and should properly be referred to such individuals. It is inadequate to speak now of "asbestos workers." With the growth of asbestos utilisation, including rapid multiplication of the number and variety of its applications, it would per haps be inoie accurate to categcuiae workmen exposed to asbestos as "as bestos textile workers," "asbestos insulation workers," "asbestos miners/' "asbestos mill workers," "asbestos-cement workers," etc. The different oc cupations vary widely in important respects; in intimacy, intensity and duration of exposure, in variety and grade of asbestos used, in working conditions,- in concomitant exposure to other dusts or inhalants. The i.-.np-ortance of this distinction and the parallel obligation to evaluate and study the experience of f.sbestos exposure in other trades, is emphasised by the fact that asbestos textile workers are new a minority of those ex posed during the industrial use of asbestos. There were go-id reasons for the early emphasis oc asbestos t-.xtile workers. The first cases of asbestesis were in textile workers.'-3 Following the republicstion of Cooke's case in 1327/ with its rapid confirmation by the report of another case by Seiler,5 the Factory Department in Great Britain hod to decide whether these were exceptional occurrences or repre sented a significant health risk in industry. Accordingly, an investigation into the problem was undertaken during 3S2S and lP29.cThs scope of the study had to be restricted. The textile industry was se-rcted for study since cr.Iy here was there pure or almost pure asbestos exposure. Since it was urgent to investigate the effect of this dust, limiting the investigation to this branch of the industry avoided the possible complications which might be introduced by the presence of other potentially fibrccenic dusts. Moreover, in other asbestos trades, there were varying portions of asbestos in the dust to which workers were exj-osed, which would have aodtd an other complicating factor. It was accepted that there were considerable numbers of workers exposed to mixed dusts whose risk would not i e ci-curaented by study of the asbestos textile industry. Subsequent surveys, similarly designed to study the risk of industrial asbestos exposure, were also largely confined to asbestos textile works'-" * Till; r Yc-rk. dy was uupp-.rt. -J by tl.c Health Ib.-s'-arcr, Council of the City of Hew 139 I ASARCO ELP 0002899 1 iO A nr: r;ls New York Academy of Sciences although si.fTJr <:\s-. rib<-c experience.- in a<he-P..- milK'5-'" asbe.-t'.---ccrnenl works." c*r fn r< p.-.during a xariety -if asbestos pri-ducts.'- Such studies had the ad-. .-.nti-gr of having available for investigation su'hcienUy huge numbers of i::di-. idc.-ds to allow for statistical evaluation of the ob servations marie. Then.- nu the adried advantage that in many of the fac tories there a err a considerable number of individuals with extended periods of exposure, allowing for analysis of the effect of prolonged exposure. An important area of industrial asbestos exposure has been asbestos insulation work. The first asbestos factory uprnrd in Great Britain in 1S71** with the expansion of the asbestos textile industry beginning 10 years later'consequent upon the availability of high grade spinning asbestos from Canada.'1 Yet asbestos was used for heat insulation in lSGSAAsbestos cement was introduced as a boiler covering about 1S70 and other asbestos insulation products were introduced in the r.cxt three decades. Commercial production of asbestos insulation materials was recorded at least in 1374.'" -Just as in Great Britain, early studies concerning asbestosis in the United States did not mention asbestos insulation workers. Neither PancoastTM nor Hoffman-' characterized the asbestos trade in which the work men referred to by them v.ere engaged. The first official claim for c-on-.per..-at ion associated with asbestos in the U. S. was in 1927 and. again, the nature of the work was not stated." ."Umar."' in 1931 mentioned a case of asbestosis in an insulation worker. Other cases wi-re subsequently reported,11'5" and in the annual report of the Chief Inspector of Factories for the year 1SSC,55 "lagging." or insula tion work, was recognized as hazardous. Similarly, Hervieux in France riiew attention in 1062 to the dangers of such end product use as insulation work.TM The only large scale survey of asbestos insulation workers was undertaken in the U. S. by Fleischer tl at. in 1945. They found only thiee cases of asbestosis and concluded that "?sbe.-tcs pipe coverir.,, cf naval vessels is a relatively safe operation."5" Unfortunately, 95 per cc-r.t of these examined by them had worked for less than 10 years at the trade-and. as we shall see. evaluation of the risk of insulation workers limited to study of men with relatively short durations of exposure may be misleading. Axtfsfos /nst'iofion ir. thr United Stale.-; Asbestos. ns a mixture of fiber and sodium silicate, was first u.-ed ns an ir.-alatii-n material in 1566 ar.d as asbestos ceir.rnt about 1370. Magnesia v. i:h a-bestes as a hinder vn follc.-v.c-i and air-cell covering, made with corrugated asbestos paper, was introduced in li'9S." These materials are still in ;..-e. with others. The f.i-'t union of insulation workers in the United Slates was formed ii: New York City in i Sr I under a charter issued by the Knight.- of Labor \ ASARCO ELP 0002900 S'Jinun rl nl.: Asli-ilosis Among Insulation Workers Ml -iccessor of the American Fed-.-raticn of Labor), as "The Sal.-.-ntntk-r <*c:;iti<jn of Koii-rr and Pipe- Filters.In 1510, the present union of ulalic-n w-.rkc-rs in this country was chartered by the A. F. i>f L., :;s the astic-no! Association of lieat nr-ri Frost Insulators and Asbestos Work- , with the amalgamation of the Salamanders' Association of NV.v York I other locals through the country.*1 The members of this .on are insulation \ur5-.ers. primarily employed in. the building trades ~r.s construction insulatic-n -.cork hut also employed as insulation workers .-hipyarcs and powerhouse construction and repair. Much of their work `n the open air but i! sometimes is, as aboard ship, in rather tight quar ts with poor ventilation. The men generally work at all parts of the =dc; few are specialists at one part of it or limit themselves to one -terial. Conditions of work vary from job' to job and from company to .np-any. Among the 1,117 men we have examined (see below). fer ,i,i nine per cent of those with 20 years of work experience or more had rked for c-ne employer primarily -- even after four years of work c-x- ric-rice less than half had remained with their original employer. Review ` work practices with insulation workers from various parts of the United .`-as and with knowledgeable officials of the union and insulation em- s indicates that techniques, materials and practices are rather the ..ie through the country. Similarly, data published concerning the work -dices in oilier countries"' suggest that asbestos exposure in insulation rk is approximately the same the world over. Che asbestos exposure to which insulation workers are subject is limited I intermittent. Some of the materials used contain r.o asbestos. Sever,ty- i years ago, the magnesia pipe coverings had shredded rope as a binder, fh no asbestos. Later, much work was undertaken with hair-felt, wool- cc-rk, rock-v.-c-cl. In the past three decades, fibrous glass products have :r.e into increasing use and these have been supplemented recently with -med and expanded plastics for certain applications. Of the r.sbc-stos- r,Paining products which are widely used by these men, magnesia bb-ck vulation was and remains perhaps the most important. This usually con- ins approximately 15 per cent asbestos. While asbestos cement has a .rying asbestos content depending upon its manufacture, it also generally s 15-20 per cent or less o: asbestos. -Asbestos pap-er products such as .--cell have a higher asbestos content but are used in much smaller .entities. V-'e have studied the insulation materials with which these men worked the past, in several ways. First, review of old trade and technical pa fa ctions from the early part of the century to about ISSO15 indicates that .e major asbestos-containing materials have remained about the .same, penally t:.^<-lar as the amount and nature of the :.s:.---stos content, is oun- rr.ed. As t-xp-.-c'.td from knowledge of sources of U. S. imports of r.s- ASARCO ELP 0002901 Antals Xew York Academy of Sciences (.-to.-. I'hry-o'i!v a-bi--tio was largely used.*'' This has been confirmed :ttudi.-< nf megne-iai block obtained during repair work. In later spe* mens > ob:;;lr..-d, crnciduiiti; has also been found. Moreover, materials us fur insulation. w hile containing the same amounts of asbestos as abc*v began in Ito hate significant amounts of smosUs in addition to chrysi tile. lii-f.-mse f the lighter weight uf the material.-" Marr'J has recent: brought shipyard insulation experience up to date. Comparing it with th <.liorv,t*ions uf Fleischer and colleagues,5'* and concludes that ".. . insult lion :n.v.-riai- and work methods have remained essentially the same' Miiri* i:i;5. Mi-a.- .n men: of dust exposures of insulation workers have been but in* fieijiieotly rej-.rfed and have been hampered by the varied nature of the v..*rk. As in other asbestos work, peak counts are met which are exces sively high but g*-r.*-rul!y counts for asbestos fibers have been within the fiw mpi-cf. M.P.r. of the A.C.G.I.HA*'" Such counts as have beer, available, made during work engaged in by the men studied by us, have shown a range similar to that of published counts."4 Prrsent [nvextigation We undertook to study the question whether asbestos e'xposure during in~ulutinn work in the U. S. was associated with the hazard of ajbestosis and its complications. Our investigations have been concerned with the 1-V22 nvTr.bvrs of the insulation workers union in the Xew York (Local 12) Xi-w Jersey ' Local 32 > metropolitan area. The Xew York Local of the I'nion is a direct lineal descendant of the Salamanders' Association, and is the oldest Union of insulation workers in the U. S. The 1522 men studied by it.*, include ail members of these Locals from 1942 to 1962. On December .11, 1912. there were 032 members and 830 men subsequently joined be tween 1912 and Dev.-mbor 31. 1902. This includes every man who was a member uf either of the.-e locals at any time in this period, whether or not In* reniaiiii-.l in the trr.de as an insulation worker. It is believed that the i*x;uTirn,*e of these men fairly represents a cross section of the experience of insulation workers during the history of this trade in the U. S. Records of the union indicate that these locals had 335 members in 1914 sr.d that 1738 member.- wer admitted tn these locals from 1915 to 1953. In the United Slates a- a wh*>ie. the Insulation Workers Union in 1914 had 14S7 members and 29.338 *.vr-re admitted from 1915 to 1963. The adequacy of our sample vast be gavg-tl by reference to these figures (see TABLE 1). However, our data d*--> r...( include infm motion concerning nonunion in-ulattoti ttorkr".. niart.ten.mio insulation workers, insulation work as part of oth-r trade- undertaken by insulation workers in ether unions. The .number of u:-:i :::\o|\,d it: insulation work in these areas is not known to ns. Solikoff 11 ill-: Asbfstcsis Amunj; Insulation Workers 143 Tai:u: 1 Srunv or Asi.esths Ismtathw Woekeks is the C.vtn;o States: AMtQl'ACV OF SaMI'LE Totat U. S. Membership, IAHFIAW, 1363 . . . 14,603 Tout NY-NJ .Membership, IAKF'AW, 1963 . . . 1,258 Examined NY-NJ Membership, L4HFIAW, 1363___ 1,117 Following insulation workers not studied: 1. JCcnunion insulation workers. 2. Some maintenance insulation workers. 3. `Sprayc-d insulation* workers. 4. Insulation work as part oi other trades. 5. Insulation workers in other unions. From January 1, 1943 to December 31, I9G2, 264 men died. At the start of this study on January I, 1063. 125S men were alive. V.'e attempted to locate and examine every man alive on that cate, whatever his employ ment status. For this purpose, invitation for examination was voluntary. The cooperation of the union and its membership was freely given. Union .cords were made available and were very valuable. The union is a stable one. Its members are well-paid, skilled craftsmen, with little turnover among these workmen. Accurate, detailed employment records, collected weekly, are maintained by the union and from these records it was possible. to obtain the entire work history of each man. This data was used to sup plement the work histories obtained from the men during Iheir examina tions (see below), and was utilized to provide employment data sufficient to establish onset of employment and duration of work experience for these men not examined. From the health and welfare records, information was available concerning every death among the members of these locals during the period covered by our study and, utilizing these records, death certifi cates were obtained, facilitating the location of hospital records, autopsy protocols, histological material, etc. Of the 125S men alive at the start of this study, 1025 were active work ing members of the union, 63 were retired (principally because of age), 34 were not working because of illness and 75 had withdrawn from the union and were no longer engaged as insulation workers, but were other wise employed (table 2). One thousand one hundred and seventeen of the 125S living members tS9.9 per cent) presented themselves for examination. This included SJS4 of the lubo of the worxmg members, 50 of the 63 retired members, 23 of ASARCO ELP 0002903 in Annr.ls New York Ac.'tfU-my of Sciences T-.cu: i A.-s:r_-Tts \V*:nKr:.s I's'ms Si'itw.t liinr.-jtifti Years from onset Deceased Retired III Withdrawn Working rr.e.T.b^rs 50* 40-49 30-39 20-29 10-19 0-9 25 22 8 79 35 17 107 6 5 39 0 2 9 02 5 00 25-s 63 34 1 10 22 7 24 11 75 5 43 155 75 355 393 loss 1,522 members January 1, 1943-December 31, 1952 Total alive 36 105 218 ci 411 404 1253 the .71 who were ill and 55 of the 75 members who had withdrawn from insulation work (TABLE 3i. TaP.LE 4 contains an analysis of the 125S men nt-cnrding t lapsed lime from onset of (heir employment. It,will be seen I hat the very large majority of men in each lapsed time category was examined. This inclusiveness of the survey was very gratifying for two rr,-i.iii. First, it will be seen from an analysis of table 2 that a high proP'Tli-.n af the cider members, with long work experience and with icr.rer prri'.ds of lapsed time fn-rrt onset of employment are included among the "retired." "ill." or "withdrawn" classifications. To have omitted these men would have led to inaccurate, selected data. It would certainly have made T tr-LE 3 AsUKsTus Whkkeus Cmiin N.Y.-N'.J. HMO-lfSi Status January 1, IS63 (1,522 members) 1. Deceased 264 2. Alive....................................................... 1,258 Status No. Examined' Retired D1 Withdrawn Working . 53 24 5 1,035 1.25S 50 28 55 9S4 1,117 652 Mi-mlvrs Dec. 21. 1942 R'n ts-. ; status of ii.er. examined during f-rvey 1353-1564. %' Examined 79.3 52.4 75.* 90.6 SS.9 .r in.- -i> jaea ASARCO ELP 0002904. Selikvfi <: /.: Asbeslcxsis Ainoiig Insulation Workers 7a<le 4 Examination <ir ArcxsTos Js&'latios V'<`>rnvss 1-15 Onset of exposure Prior to examination (y.-s.) 5C+ 42-49 40- zi 25-29 20-24 25-23 20-24 15-19 10-14 S-9 0-4 No. 26 41 es 92 125 18 65 125 225 1S4 220 1,253 Exammed- 23 29 54 33 111 16 61 174 (91.63,) 205 154 192 (87.6?,) i,in Analysis by group, according to octet of -crk exyrsure. difficult the establishment of the effect of a long !ap#--d period from onset ' exposure or the effect of a loot; duration of exposure. Second, in addition to data concerning onset of employment, information was obtained detailing the actual number of years worked during the period from onset of employment. While in many cases the two periods more or less coincided, in some cases the number of years worked w-?.s significantly less than the elapsed time from onset of exposure. The com parison of such data is of interest when attempting to separate the effect of actual work exposure from the effect of mere passage of time from the initial exposure with inhalation and retention of asbestos fibers. Examination of each man included a detailed occupational history. Data were recorded concerning onset of employment, interruptions for whatever cause, number of employers, use of protective respirators, materials han dled and employment in particularly suspect areas of insulation work such as shipyard work and powerhouse construction work. Health experience was noted, including previous illnesses ai d hospitalizations, as were cur rent symptoms such as dyspnea, cough, sputum, hemoptysis, gastrointes tinal complaints. Smoking habits were recorded in detail including ace at onset, numl-c-r of cigarc-ttcs smo) ed, and pipe and cigar smoking, if the individual wr.s no longer working, the reason for this was ascertained. Physical examination was particularly directed to the chest, but included examination of (he skin, nose and throat, finger clubbing and cyanosis. Chest expansion was measured, hemoglobin ana urine were routinely c-x- J ASARCO ELP 0002905 1 If*. Annals Xew- York Academy of Sciences Vital capacity w;:.> measured in all cases and in many, additional niea:.rv:.-.onts such a-' M.K.r.R. TVC and MBC were also made. In many sputum was examined fur asbestos bodies and in almost l.alf. blood w;i> drawn fur special serological studies. In selected cases, extended pul monary function investigations were undertaken, including arterial gas 'todies. lent; compliance. pulmonary airway resistance, measurement of ventilatory parameters and diffusion studies. X-ray studies were ; erknps the most important part of the examination. ` In each case, a stand..: d posteroanterior film was taken but, in addition, another posteroanterior film utilizing a slightly more penetrating kilovoltage tcrhiihp.ie was also exposed. Our experience indicates that this maneu ver is valuable in X-ray examinations in this disease. The standard tech nique is required since over-penetration may well result in the loss of fine reticular fibrosis and. indeed, in individuals with relatively brief work histories, it is sometimes advantageous to take a third posteroanterior film with a slightly under-penetrating technique if such minimal fibrosis is- suspected. However, in the men with longer work experience, increased penetration may be required. First, these mc-n do a good deal of manual labor and are often heavily muscled. Second, pleural fibresis is common" and parenchymal fibres;? usually coexists, both decreasing radioper.etrahility. Third, such increased penetration is often required to demonstrate calcification, especially when it coexists with extensive pleural thickening or is located in such areas as the posterior diaphragmatic sulcus, behind the heart, in the meiiiastir.nl pleura, etc. Oblique films in hoth anterior oblique positions were also routinely taken in each case. While this has obvious applicability in a disease with such lower lobe preponderance as asbestosis, we have found it particularly val uable in the demonstration of pleural calcification. Results Among the asbestos insulation workers examined fcy us, evidence of pulmonary asbestosis was present in almost half the men examined. In this evaluation, radiological change has been used as the sole criteria (7A3LE a;. We understand, of course, that evaluation of the presence and extent of a.-hostosis limited only to X-ray findings tends to result in underestima tion -f the incidence of asbestosis. but few instances of disabling disease will l-o so overlooked. Analysis of our data indicates that radiologically evi dent pulmonary asbe.-ie-is varied directly with the duration of exposure. Insulation workers with, relatively short periods of exposure have a signifi'-anlly lower incidence of pulmonary asbestosis and this, when present, wa- gcm-rallv of minima! extent. (If ttlG men whose v.xp-.-uie had begun less than ten years before exami nation. miK t((> or in. l per ivi.i .-honed nnv radiological abnormality. In ASARCO ELP 0002906 Sclfkou ft al.: Asbeslosis A:non<j Insulation Workers Taele 5 X-ray Changes in Astcstos Insulation Workers 147 Onset of exposure (yrs.) No. % Kormal 40+ 30-39 20-29 10-19 C-9 ** 121 194 77 379 346 1,117 5.8 12.9 27.2 53.9 89.6 51.5 % Abnormal 94.2 87.1 72.8 44.1 10.4 43.5 Asbes tesis (grade) `1 2 3 35 51 33 102 49 18 35 17 4 158 9 0 36 0 0 366 126 50 each of these cases, the reticular infiltration was rninii.ial in extent and i_* cone was there evidence of pleural calcification. In only four was pleural fibrosis seen. Of 379 men whose exposure had begun from 10 to 19 years before examination, more than half still had normal X-rays. Some abnor mality v as seen on X-ray in 167 of these cases but in only nine was the asbeslosis greater than minimal. In So of these men thc-re was some pleural fibrosis and in five, evidence of calcifies lion.*-' On the other hand, among the 392 men with more than 20 years elapsed from onset of exposure, the very large majority had X-ray evidence of pul monary nsbostosis. Among the 77 whose exposure began from 20 to 29 years prior to examination, 56 showed abnormal films. Among 194 whose examination took place from 30 to 39 years following onset of exposure, almost 9 of 10 showed abnormal films while, of those with more than 40 years from onset of exposure only one in 20 showed no abnormality. More over, the astestesis in these cases tended to be considerably more extensiveand severe and pleural calcification and fibrosis were commonly seen." Pulmonary asbestosis has been called a mor.csympfomatic disease, with dyspnea the essential complaint.^Analysis of our data concerning this symptom among the men studied by us indicates that it was uncommonly seen in those men with less than 20 years from onset of exposure but was an important symptom after that. Thus, of 725 men with less than 20 years from onset of exposure, only one had significant dyspnea although 32 others complained of minimal dyspnea on exertion (Tahle 6). On the other hand, of the 392 men with more than 20 years from onset of ex posure, 134 had dyspnea of some degree. 61 of them with disability of greater or lesser extent. There was incomplete correlation between the roentgen!-graphic findings (considered as parenchyma! fibrosis i and dyspnea on exertion. Two cases were seen with no roentgenographic evidence of parenchymal fibrosis but ASARCO ELP 0002907 l`.S Annals New York Academy of Sciences TaULE s Il\#l'NKA AMONG ASKEsTOS Insulation Woekcks Onset of exposure (yrs.) No. % Normal 40+ 30-39 20-29 10-19 0-9 121 194 77 379 346 1,117 52.1 70.6 76.6 92.6 S3.6 % Dyspnea 47.9 29.4 23.4 7.4 1.4 Dyspnea (de gree) l2 3 26 n 35 14 12 3 27 L 50 105 35 16 8 3 0 0 27 with complaints of significant dyspnea, but discrepancy of this extent was rare (ta3LE7>. On the other hand, of 99 cases with more than 20 years from onset of exposure, and with evidence of moderate or extensive parenchymal fi brosis. moderate or severe dyspnea was present.in little more'than one of four. Thus, significant disability may be present with relatively little to be seen on X-ray and, conversely. X-ray changes may be extensive with little functional difficulty. Similar incomplete correlation has been recorded be tween the results of pulmonary function studies and roentgenographic appearances.*1 We have been able to obtain lung tissue for examination from 45 asbestos ' insulation workers, primarily from the 307 rnen who died from 1942 to ' 1964. although in a few cases operative specimens were available. In r.o Parle 7 Correlation or Dyspnea and Roentcenolocic Evidence or Pulmonary Fibrosis among 092 .Asbestos Insulation Workers with at Least 20 Years tp.om Onset o'* Exposure Grade of parenchymal fibrosis 0 1 2 3 No. 53 240 77 22 292 Years Crora onset of e.vpc-3sir e Per cent Grade 2-3 dyspnea *5 11% 21% 27% 33+ Grads of dys pr.ea 0 l 2-3 IS 0 75 20 27 8 45 121 33 1 27 16 6 50 20-34 Grade of dyspnea 0 1 2-3 31 s 36 28 14 8 33 l 4 4 1 134 n* 10 \ ASARCO ELP 0002908 Selikoff ct at.: Asbcstosis Among Insulation Workers 149 case did we fail to find typical pulmonary asbestcsis. wjth fibrosis and asbestos bodies present. However, our material is inadequate to evaluate early changes since in only one case was there a history of less than 15 years from onset of exposure. In 15 cases, the pulmonary fibrosis was Grade I, in 16, Grade II and in 1-1, Grade III. We have the impression that the asbcstosis suffered by these asbestos insulation .workers is less severe than that occurring in workers exposed in factories. We have had the op portunity of examining lung tissue from 11 men working in a -factory making asbestos insulation material (one of the brands actually utilized by the members of the Asbestos Workers Unioni. Although (he data are limited and conclusions perhaps unwarranted, analysis of the findings sug gests that the pulmonary fibrosis among these men was significantly greater Table 8 Pulmonary Fibrosis on Histological Examination Fibrosis (grade) Ko. 0 1 2. 3 1. Asbestos insulation building trades -ac-rkers a. Less IS years from onset...................... i 0 100 b. Over 15 years from onset-.................... 44 0 14 16 14 45 0 15 16 14 2. Asbestos insulation factory workers a. L-ess 13 years from c-r.set....................... S 0 . 0 2 3 b. Over 15 years from onset................ 60 02 4 11 0 047 than among the Building Trades Union Insulation Workers. Table S sum marizes these pathological studies. Mortality experience in this group of men will be separately reported.31 It may be remarked here, however, that the incidence of lung cancer and mesothelioma of the pleura and peritoneum was found to be considerably beyond that expected.-15-55' In addition! the incidence of carcinoma of the stomach arid colon was also found to be elevated. In the roentgenological survey, because of the known increased risk of lung cancer among workmen exposed to asbestos, particular attention was paid to this finding among the men examined. In 10 men, lur.g cancer v.-as found, and in one, pleural mesotr.elicn-.?.. In each, histological verification was obtained. In six cases, thoracoluny was undertaken. Three men are currently alive following apparently successful removal of neoplasms. As J ASARCO ELP 0002909 150 Annals NV.v York Acndemy of Sciences with signif.-int pulmonary nsbestois. positive findings insofar as lung cancer ar.d fleural mesothelioma were concerned occurred among the 302 ir.<-u in the 20 years from firs: exposure group (TABLE 9). The importance of including the men with longer work experience in a survey of workers exposed to asbestos is well-illustrated by these findings. Similarly, the im portance of including all members of an original cohort is also demon strated. Table 9 provides a a analysis of the occurrence of lung cancer according to status of the individuals examined. Of the 1035 working members, 9;4 were examined and among these, seven were found to have lung cancer (0.7 per cent). There were 172 men no longer actively at work, being retired, ill or having withdrawn from the group to work at other trades. One hundred and thirty-three were examined and four were found to have lung cancer (three percent). Table 9 Luxe Cancer Found during Examination of i,n7 Asbestos Insulation Workers Tears from onset ot exposure 30-39 20-29 10-19 0-9 Number examined 121 194 77 379 345 1,117 Working members Number Cancer 45 1 lc-3 3 72 3 352 0 337 0 934 7 Others Number 76 26 S 17 9 133 Cancer 2 2 0 0 0 4* . Includes one instance c: pleural mesothelioma. It will be seen from Tasls 9 that we found no cancer of the lung among ii... _ men examined w'-ose work had begun less than 20 years before the date of examination. We find it difficult to compare the results of this investigation with previously reported surveys of workers exposed to asbestos. In many in stances. the conditions of the studies do not allow for such comparisons. In Merewether's study.'1 363 men were analyzed but only 133 were X-rayed. All were at work, except one. on the day of examination. Oniy 21 or 5.2 per cent had 20 years or more of work experience. The 125 men studied by Lanza' were ''selected at random" and were at work at the time of r-xanunation. Smith'" hn drawn attention to the dangers of drawing cor.vh'.sion- fr-'Hi n:eu a: work, pointing out that examination of "23 Jcachiinstnl fail.ri to reveal any lung cancer, yet 43 of SO pust-morle:ns l ASARCO ELP 0002910 Sc-JikoiT<:lat.: Asbestosis Among Insulation Workers 151 a!non? these men showed this nc-oplaMn. The cases studied by Slone4' were weighted in another direction, since they wete individuals, "applying for compensation." Wegelius" studied J2S cases of 17C ir.r-n at work and de tails of employment are not given in this report. It is likely that the group contained few m~n with prolonged experience since the industry being studied was in existence for "about 20 years." In the study by Horai in Japan," of the 320 men surveyed, only 10 had more than 20 years of work experience. As mentioned, in the study under taken by Fleischer ft cl.,~' ordv 51 of the 1074 men examined had more than -10 years of -Work experience and in this study, too, it was ihe men at work who were examined. Frost" et at. studied 31 of 34 asbestos insulation v.orkers in Copenhagen with more than 20 years of asbestos exposure, but this survey was limited to currently active men who represented -a re'id uni of approximately or.e-third of an original cohort of `Vomit 100." Ever, the study by Doll" is not comparable. The 105 consecutive autopsies reviewed by him were "coroners' necropsies." These are not necessarily consecutive cases since these necropsies are ordered by the coroner when, in his opin ion, there may be a question of asbestosis being a contributory cause of death. There were IS cases of lung cancer found in this croup of men, 15 among 75 ca^es with asbestosis and three among 30 cases without asbes tosis. However, this series excludes those individuals whose death did not, in the opinion of the coroner, include the possibility of asbestosis being a contributory cause. In the second part of this study, Doll traced all men who hoc worked in one particular factory for at least 20 years. Of 113 such men there were 39 deaths, 11 due to lung cancer, all with asbestosis, while O.S was expected. However, these men included only these who had worked in heavily ex-posed areas and may in this regard be considered as a select group. With reference to comparison with findings in other surveys, primarily of asbestos textile workers, it appears evident tliat asbestosis is an im portant risk among insulation workers exposed to asbestos. This is par ticularly true of those men who have at least 20 years from onset of ex posure. This risk induces lung cancer and mesothelioma assoc:ated*v;ith the pulmonary asbestosis. It might be added, parenthetically, that other neoplasms were also found during the survey. Scleral jaundice led to the provisional diagnosis cf abdominal neoplasm in one case, later confirmed at laparcdomy to be a carcinoma of the pancreas. Marked hypochromic anemia in another led to hospitalisation during which an inoperable carci noma of the stomach was found. Other carcinomas present in men appear ing for examination included carcinoma of the tongue, carcinoma of the nasopharynx, carcinoma of the color., and carcinoma of the bladder. Scattc; ri .-_. c rip. iris have previously been recorded of neoplasms among insulation workers, including both lung cancer"'" and mesothelioma""'5 J ASARCO ELP 0002911 152 Annals Mew York Academy of Sciences of both the pleura and f.eritcr.e-.rr.. A lung cancer has also been reported ir. a workman in a factory making asbestos insulation.'' However, thc.-e reports, while interesting and valuable, could not establish an association between the two conditions. It is possible that additional lung cancers arid rr.eeothelicmis have occurred and may even have been reported but such reports do r.ot state the nature of the asbestos exposure and such instances ntay be included among car.cers ir. "asbestos workers." Our experience that the lapsed period from or.et of exposure is gener ally prolonged before '.he appearance of lung cancers in asbestos insulation workers coincides with the general experience of long "latent periods" in such cases. Indeed, in the infrequent cases in which very short periods have elapsed from onset of exposure, it might well be that the lung cancer found is coincidental. Such long latent periods would correspond to simi larly prolonged periods associated with lung cancer in chromate \vorkers,r-< nickel" cancers, arsenical lung cancers" and the increased incidence of lung cancer among regular cigarette smokers." Ir. Doll's series," a long latent pe.ric-d was noted in all cases. Neoplasms have also been reported among individuals indirectly exposed to asbestos insulation work, as carpenters,'' steam fitters,1, and other building trade workers.'" Summary An investigation involving 1522 asbestos insulation workers in the New York-New Jersey metropolitan area has bean conducted. Among 3i<2 in dividuals examined mere than 20 years from onset of exposure, radiologi cal evidence of asbestesis was found in 339. In half of these, tlie asbestosis was moderate or extensive. In individual.'; with less than 20 years of exposure, radiological evidence of asbestosis was less frequent and when present, much less likely to be extensive. i. .oplastic complirat?-ns of asbestos exposure were studied among 307 consecutive deaths in this group of men. Lung cancer was founu u> be at least seven times as common as expected ar.d cancer of the gastrointes tinal tract three times as common as expected. There wc-re 10 instances of mesothelioma of the pleura or peritoneum. Of the 125S men alive at the start of this survey. 1117 were examined. Eleven cancers of the king or pleura were found during this survey of the living members, .all among the S!l2 men with more than 20 years from or.srt of exposure. No cancers were found in tho-e men, the onset of whose work experience was less than 20 years. We may conclude that uslrstosis and its complications are significant har.ard< among insulation workers in the United States at this time. 3 ASARCO ELP 0002912 Selikolf 11 a:.: Asbv&tcsis Amon l::?ul;U!on Workers 153 A'.kif- f!ill;: iii nils The executive ot,leers of *!>{ International Association of lf<-at and Frost Insulators end Asbestos Workers, Washington. Ll.C.. and the officers and membership of the New Turk and Newark, N.J.. locals of this union gave valuable cooperation in the Investigation. We are indebted to our Adminis{.native Assistant, Janet .Vaffenburgh. for the successful management of the many details neecs-ary to the completion of this study. ' Etfcri arcs 1. MiT.kaY, H. M. 1007. hi Report of the Departmental Committee on Compen sation for Industrial Disease. Minutes of Evidence, Appendices and Index. : c.d. 305, c.d. 3496. Wyman and Sons. London, England. 2. Ayhibaylt, M. 1306. Note sur I'Hygier.e et la Securite dcs ouvriers duns les Filatures et Tissages d'Amiante. Eull. l'lnspect. Trav. : 126. C. CoOKE, W. E. 1324. Fibrcsis of the lungs due to the inhalation o. asbestos dust. Brit. Med. J. 2:147. 4. COOKE, \V. E. 1527. Pulmonary asbrslosis. Brit. Med. J. 2: I024-1025. 5. SE1LF.R, H. E. 152S. A case of pneumoconiosis. Resuit of the inhalation of asbestos dust. Erit. Med. J. 2: 3S2. 6. Mr.nsv.-EriiSR, E. R. A. A C. V. Price. 1930. Report on enacts of asbestos dust on the lungs and dust suppression in the asbestos industry. Fart I. Occur rence of pulmonary h'crvsis and other pulmonary atfc-cticr.s in asbestos workers. Part II. Processes giving rise to dust and methods for its sup pression. H.M.S.O. London, England. 7. WOOD, W. B. & S. R. Gloyns. 1334. Pulmonary asbestosis. A review of one hundred cases. Lancet 2: 13-33 -1335. S. Lanza, A. J., W. J. McConnell <t J. W. F:-:;;.\'EL. 1935. Effects of the in halation of asbestos dust on the lungs of asbestos workers. Pub.- Health Rep. 50:1-12. 9. McPheetsrs, S. B. 1935. A surrey of a group of employees exposed to' asbestos dust. J. Indust. Hvg. IS: 229-239. 10. Dr.EEfSEN, W. C., J. M. Dallavalle, T. I. EuwAcns, J. W. Miller, H. F. Easo.m & M. F. Trice. 2938. A study of asbestosis in the asbestos textile industry. Public Health Bull. No. 241, U.S.G.P.O. Washington, D.C. 11. Ko.-.ai, Z. & M. Ueshima. 1561. Studies on asbestosis. J. Nara Med. Assoc. 12 (6): 11CS-J163. 12. Weoeuys, C. 1547. Changes in the lungs in 126 cases of asbestosis observed in Finland. Acta Radiolog. 2S: 139-152. 13. Smith, K. \V. 1955. Pulmorary disability in asbestos workers. AMA Arch. Tr.dust. ifealth. 12:1 PS-203. " 14. Clessns, J. 1930. Recherches sur 1'asbestose pulmonaire en Eelcicue. Arch. Re'g. Med. Sc<. S: 557-065. 15. Fylton, W. B., A. Dooley, J. L. Matthews & R. L. Hoytz. 1S35. Asl-cstcsis Par. III. 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Number 221. (Industrial Accidents and Hygiene Series. No. 17) : 40S. Washington, D.C. 22. Lanza, A. J. 1<C5. Asber-.i.-sis. J. A. M. A. 106: S6S-3C9. 23. Ei.lmAN, P. 1634. preumt-conias's: Part III. Pulmonary asbestosis. Brit. J. Radio'.. 7 (N.S. t: 251 -203. 24. IL.ktz. C. W. H. F.KiN" ein. 1539. Asbestos* bei ir.solieren. ArztI. Wochen- . schr. 14: 361-263. 23. Frost, J., J. Cross P. L. MpLLLF.. 1030. .Asbestosis with pleural csiciflca- tior. among insulation workers. Danish Med. Bull. 3: 202-204. 26. Pendergrass, E. i'j-f.S. Silicosis and a few of the other pneumoconioses: ob servations or. certain ?-specls of the prob'em with emphasis on the rote of the radiologist. Caldwell Lecture, 1957. Am, J. Roentgen. SO: 1-41. 27. Annul P.it-oXT. Chief Inspector cf Factories fop. ti:e vcaf. if56. Ctr.nd. 329. Chap. 13. : 141-143. H. M. S. 0. London, England. 23. Hermevx, J. 1362. Certains aspects de i'asbestose. Cah. Med. Interpcof. 2: 41-42. 29. Fleischer, IV. E., F. J. Viles, R. L. Cade & P. Drinker. 1945. A health surrey of pipe-covering operations in constructing naval vessels. J, Ir.-dust. Hyg. ;s: 3-16. ' 30. The Askestcs Worker. 1949. Washington, D. C. 13(8). 31. The Asbestos Worker. IMS. Washington, D. C. 13(3). 32. Unclassified Collection on Asbestos. New York Public Library. New York, N. Y. 33. Mars, W. T. 1964. Asbestos exposure during naval vessel overhaul. Am. Indust. Hyg- Assoc. J. 25: 254-263. 34. SCK ALL, I.. 1964. Occupational Health Program, N. J. State Department of l-lssith. Personal communication. 25. SsL'.EOfF, I. J. 1355. The occurrence of pleural calcification among asbestos insulation workers. This Ar.nal. 36. EaDS.p., M. E,, R. A. oaOER, I. J. Seukoff. 1561. Pulmonary function in asbestosis of the lung. An alveolar-capillary block syndrome. Am. J. Med. 30: 235-242. 37. Hammond, E. C.. I. J. SELtKOrr & J. CiU'SC. 1S63, Neoplasia among insula tion workers in the United Stales with special reference to intraabdominal neoplasia. This Annal. 35. Selikoff, I. J., J. CliVRG E. C. Hammond. 1954. Asbestos exposure and neoplasia. J. A. M. A. IBS: 22-26. 39 Sslixoff, I. .1., J. Chi'RC E. C. Hammond. 1963. Relation between asbestos exposure arid .t.isolhelioma. New Eng. A Med. 272: 365-565. 40. Smith, W. E. 19-73. An evaluation of claims for occupational tactors in cancer of the :ur.ps. Acta Union Intern. Contr. Cane. 9: 50-5S. 41. Stone, M. J. 1940. Clinical studies in asbestosis. Am. Rev. Tubc-rc. 4i: 12-21. 42. DOLL, R. 1555. Mortality from lung cancer in asbestos workers.'Brit. J. Indust. Med. 12: SI-S6.' 43. Holles. H. B. A. A.vcnS5T. 1942. Bronchogenic carcinoma in association with pulmonary asbestosis. Am. J. Path. IS: 123-131. 44. Stoll, R., R. Bass A. A. Anc.f.ist. 1951. Asbestosis associated with . bronchogenic carcinoma. Arch. lot. Mod. SS: S31-S24. 45 Cui.ni'VA. J. r ., H. 7F.-U.fK K. P. Km'TSON. 1562. .Ashe-slcsis and carcinoma of the lung. Cancer 15:71 SI -1167. ASARCO ELP 0002914. I < < t nt.: As!.,w:1i.<js Amc*n*r Ir.;ii!ati<-r. Workers' 355 ir,. Waanec. J. C.. C. A. & I', ''..ciiano. SOOli. i.-t.-fuse pleura! m.eso- thtiior.r. ar.d asbestos, om ssur* ir. *.i.c- North Western Cart Province. hrit. .;. i.Ti..n. i2; 2f.'i-27i. iT. Si-L-ws. C. V. p. M Mtri; ;Nn f; J. C. Wacnek. 1061. Pi-ura: tr.esut . mas ;r. Fc.uth A frit a. S. Afr. Med.35:2S-34. 4S. \VA. rieorr.hrets bet lt:r.;r`'Vu:shes;ce, it. r<co rt-iipnolncisch fcs'chcrt. Mediz. (Strort) 3: l'2-94. <9. Case Records of the Mns.-achussels General Kos;>itai. 1963. Case 62. New Sr.tr. J. Me-;. 2S9: 747-754. 30. EtsENS7Aii7. H. K. jy62. Pleural asbes'.csis. Am. Tract. 13: -'.TC-.'jTS. 51. F?.n:: M. /i H. i-s J tern. 11`01. M <.-'. h.ciioma perltor.cd u> nsbeslcsis putit'r.Rti.T.. .laarb. Kr.r.ht rond. K ar.Vc-il-vstr. Ncrierl. 11: 9'J - 1(1G. 52. f\K. K. 1900. Asbestos:.* and ab.Ptr.ir.a' neoplasms. Lancet 2: 1211-121G. 53. Crr.sroN, E. J. R. 394S. Sf-jsm.vjs cell carcinoma occurring: in asbesiosis ot' t'-e lur.tr. Brit. J. C:.ruxr 24n-253. 54. i'reif.. E. l!'3.r. Lunger.:un-mmi a!s BcrufsI-ranJcuny in Cbrcvr.-itbclreiben. L'cutseh. Med. Wochcnsci.r. 61 : 1597-1202. 55. MohcaX. J. E. 195S. .Smite observations on the incidence of respiratory career in i.-cl-tel workers. indust. Med. 15: 224. 53. Ec-csox, A- O. 5c A. M. i r.~. M-dicir-tl arser.ic poi-oi.in;: and lut.crca: cir. Brit. Med. J. 2: 2<C-'no. 57. Davies. D. F. 5c H. SttiPMAN. 5901. The incidence ar.d tpidemiolotry of hror.chocer.it cancer. Troc. Fourth Nat. Career Conf. : 291-226. Unpin- coit. Philadelphia, Pa. . Br.".?u>\v, L., I.. IfOAGLlN, G. RASMCPir.x 4' If. K. Arr.AMS. 1554. Occupa tion and ciforc-t'.e smoking as factors in iur.y cancer. Am. J. Public HetAth 44: S71-1S3. 59. Thomson-, J. G. 1902. Mesothelioma of the pleura or peritoneum and limited basal a-bistosts. S. Afr. Med. J. 36 : 735-760. J ASARCO ELP 0002915