Document yrVozZ98moXdQa5ERjrMQ5Gd

FILE NAME: Asbestos Cement Pipe and Sheet (ACPS) DATE: : DOC#: ACPS0 KhMENT DESCRIPTION::Z - Cement, Asbestos, and CementAsbestos Pneumoconioses \l:j~ ,.,.J Cement, Asbestos, and Cement-Asbestos Pneumoconioses A Comparative Clinical-Roentgenographic Study Giovanni Scansetti, MD; Giancarlo C. Coscia, MD; Walter Pisani, MD; Giovanni F. Rubino, ~ID The Incidence and characteristics of cement-asbestos pneumoconiosis were compared with those of asbestosis and cement pneumoconiosis in three homogeneous samples of cases. The clinical, functional, and radiological features of cement-asbestos pneumoconiosis are similar to those of classical asbestosis, but the observed changes are less common and occur after a longer exposure. / About two thirds of all the asbes. .ti. to::; produced in the world is con- sumed by the cement-asbestos (CA) industries.'" Mvdium- and short-fiherf'd serpentine (chrysotilc) is the most widely used Yariety, wlwreas long--lihcred amphibolc (crocidolite) is u:'ed le,;s often. Schction of substance depends on whether it is desired to endPw the finished product with gri.'ater flexibility or, in the tase of crol'idolite, strength and resistance to al'ids. The asbestos is mixed in a proportion of 15';'r to 20',7 with artificial Portland n'ment that eonsists of calcium silkak, tricalcium aluminak, and tricalcium ferrite. Portland cement also contains from Vi, to 5% of frel' silica (SiOJ ant! smalkr amounts of otlwr i-ulnnitkd for pulilil'ativn Aui;: \l, 1\17-1; ll<' C\.'Ph'd ~t\pt :!I. Frum tlu In,titute nf (kn1pati11nal ~k,hdnc of th, l"ni1l'rs1t1 or Turin. Ital\'. ltlprinl n:qu1:ts to th..- l11;-.t1luto di ~ttditina ,ld La,..r,,, l'rn,,rs1l:\ ,II Torino, ~!l, \'ia Zurt'lti, hlt:;1; Turin, Italy (llr ~,ans.tt1). compounds, mainly CaO, as well as aluminium, iron, and magnesium oxides. Exposed workers may develop a combined pneumoconiosis in whieh fibrosis caused by the asbestos, mostly in the middle and lower zones of the lungs, is associated with rounded lesions and hilar adenopathy attributable to the silica:' The pathologic changes are therefore produced by the partly unaltered asbestos fibers in the mixture, and partly by the cement that has been shown experimentally to have a sclerotic effect on the peritoneum in the rat when its content of free silica approximates 5%." Nordmann and Sonnenberg' have suggested that the enlargement of the hilar lymph nodes may be due to the lime. The incidence of this pneumoconiosis, usually diagnosed as asbestosis, was found to be 5% in exposed workers in CA industries near Naplcs1 and 12%' or 12.91:ci in CA factories near Casale.'' DeRosa et al' in\'estigated the distribution of the workers with asbestosis in the Yarious workshops. Tlwy found that 501' of those employed in preliminary processing of the fibers and 15%, to 18% of those emplopd in dry manipulation of the finishld product Wl're afkcted. Rubino and Scansetti found that the incidence of asbestosis among exposed worker:; in CA industril'S was 01w half of that foun1l among- exp,isld workers in brake and fridion mal1ri:il anti one third thilt of worlwr:s in aslil'stos tlxlill' fact11rics. The incidl.'lh'C of aslHstosis is \'l'l) hig-h in India'" (~r; of l'Xpostd subjects) and in Eg-ypt, 11 where ~1', of th(' workers l'Xposed to CA for more than 20 yiars Wl'l'C found to hv affected, liut low in West Germany where 2a of ,t,500 (approximately 0.5''i) exposed workers were found to bt' affl'l'lld and wen awarded compensation for aslil',;losis from l!l:>.'I to 1%7. Bohli~ also found that the incidPnec of a,;!wstosis was 11 tinh's low1.'l' in tlw CA inrln,;try than m other industries in which aslw,;tos is w,ed. METHOD The purpos,,; of thi,; in\'estig-at1nn w,n (l) to ascertain the indihnn' of{':\ p:;,.i- moronim,is that, as inclieat,_,1 aho\ <', ,-,,ni- to ditf,r wid,I:, in tlilf,r1.nt countnl',, t'>'l'l' rially Whl'll n;mpand to that of d.1,-.,1, .d ashesto~is and(~) to dl't11\l tlw clini,:d f,atun'~ of this pn,ummnnio,-is th:1t i, a:tnhutahk to the n1mhinerl, althnugh d.tf,r, 11'., ai:tinn of t110 du,ts--1,nwnt-a l''",-d,1, cause of ,ilic,1~is. aml-a,h,stos- th::t 1s present un,l,r tlw form of ;i,;h,,to; ;1! .. r,. throughout the ,ntin ma1H1f:1dur11:1,; pr,,- \'l':SS and in th, tini,hl'd prn,111.-t. Thr,1 ,;:t!nplt group,. , "h n11J11ha.1:,: 100 $llhj1l'ls. lll'rc ,,amin,,i. Th, t:r,t. d,nominatl'tl the ,<m,nt "r l 1,;r""l' ., ., - ll'l'tt'll frnn: ~1 "tri~ uf ::;,: \\11!~.,r ... 1'\ JH1s,d to ti., ,lu,t form,-,! 111 'i'Lt:T', ,'.,'. marl for 11,,t11r:t! c,ni.-nt, r 1n ti., .. ,..- c.f:lclttrl' of 1L1tur.d 11r :1.n:l111.d ,, 11, r.:"' The see,l!ld, ,kn,,11:a1:,1<d th" ,.: ., : .. lw~tos or l'.\ g-r,iup. \\ ., ....... '.1, tt .: f~,,:, " ~t'rit'~ of tit~ \\t)r}... ... r~ ,!lli' ,~t1i ;': 1 \ : 1 torit'~. Tht\ th.rd. dtn, 1:~1:r.,~ 1 \! tl , ., or :\ t!T1'lii' \\ ,l"'- "tl, \ ~,,! fr :, .l .. , ~ ,1 .. ;{11 wurht'r:-. ,1:qil11.\1,! ii: .l .. l 1 --'1 . ~. \' f,Lltori, >. :-;1arti1:~~ i"r..:n th,:....... ,. ii,,! , rorn:,pt1n,ling ... 11l1J1, ~ tn , .ll 't ,.: ' 272 Arch Environ He:ilth!Vol 30. June 1975 Gro111l CA C A Table 1.-Physical Findings Cluhbing Sh11ht Severe ~----- Cyanosis Slil1ht Severe Bronchial Ralcs 3 0 12 0 11 f 0 1 0 4 8 2 1r; 3 4 Crcpitant Bas;il Rales 8 7 13 Pleural Friction Ruh 3 0 5 Group CA C A Table 2.-Electrocardiographic Signs of Right Cardiac Impairment "Pulmonary" P wave . Delayed Rinht lntraventricular Conduction Focal Bundle Complete Bundle Branch Block Branch Block 1 2 2 4 1 1 3 2 2 Table 3.-Respiratory Function Tests Group CA C A vc 100 (Mean) theorVC 69.80 75.95 66.53 FEV10 100 (Mean) theor FEV 69 97 72.93 66.53 FEV1 0 - - 100 (Mean) vc 69.49 65.19 69.88 VC and FEV1 care expressed in percent of the standard value established by the European steel and coal community. other series was selected by computerization so as to obtain groups of three ra~es of equivalent( 5 years) age and duration of exposure. A total of 33 subjects in th, strits t-xposcd to cement dust were discanlld. no corre~ponding subject having bt,n foun1l in Ont' or both of the two other group~. thus lc:n-ing 100 series of three su hj,,:ts eaeh. The mean ag-, of the three samples rang-ed from :, 1..-, to ;if,_:, yl'ars and the nwan duration of exposure from 18.5 to 21 year:;, Group CA (' :\ ).lean Age, yr 5-t.5 55.5 55.5 .Mean Exposure, yr 19.9 21.0 18.5 The thrl'c g-roup:< were compared taking into at'rnunt the incirlenrc of rnrious physi- ,al (cluhhing, l'yanosis, bronehial and .:r,pitant rail'>', p1,ural friction rub), ell'cln>t'anli\ll!;raphic (l'vidence of cardiac imp.1irnwnt on tlll' rig-ht su,h a;; pulmonary P wan an,! ,hlaytd intran'ntrkular conduction on th<' ril-!ht). and rolntgl'nographic 111~, ",\l<nd,d" lnll'rnational Labor 01'ti,, Ill.Ill l'la,,ification) lindings, and tht 1n,.1n , .tlt1t, nh"n ,d in pul111011ar.1 fune- t,..n l,,h I, ital , .1padty I\'(' I and for.-,d ,,11r.d11r~ ,11l11nw I Ft:V , I 1,pr,cs<d in I'< runt ut tit, ,t:111>::ll"II 1:1lt1t~ <'~lahlish,d !.~ 11, l-'11r111,,:111 tn,d and :-.ltI 111tu1t111111t~. I 1"\ \I' r ti .... RESULTS Clubbing of the fingers and cyanosis (Table 1) were more common in the A group (10% and 19% of the cases, respectively) than in the C group. Cyanosis was present in 12% of eases and clubbing only in 3% in the CA group. Crepitant basal ralcs, a charaetcrislie symptom in asbestosis, were also more common in the A group (13% of the cases) but were found as often in the CA group (8% of the cases) as in the C group (7% of the cases). Symptoms of bronchitis were espceially common in the CA group (11% of the cases) and were found less often in the two other groups (4% of the cases in both). Pleural friction rub \\'as found only in the A and CA groups (5':~ and 3''o of the cases, re- spcctiYcly). Electrocardiographic signs of car- diac ;mpairment on the right were Ull('0mmon. Their inl'idenee did not dill'l'r signilil'antly in the thn'l' g-roups (Tahll' ~). Right \'l'ntrirnlar hypl'rtrophy or strain was ne\'t't' ohSl'l'\'l'll. Tht' re:-mlts of pulmonary fun rt ion st 11di1s are shown in Tahlt :I. Thl typ, and Sl'\"<'l"ily of tlw ohs,nl'd changes ,!iff<>rcd in the thrtc groups. Mild, prl'llorninantly ohstru<'tive impairment of pulmonary funetion wm1 fou11d in I ht C g'1'011p and morl' S<'\'l'rl' impairnunl, of a pndominanlly n- strirlive type, in the A group, in which the Ft:V, .,l\'C ratio was low but still within the normal range. Thl' pattern in the CA group wac; similar to that ohservrd in the A group. hut the dPgnt of impairnwnt was lt>ss Sl'vere and of a less clearly n.stridivti type. The roentgcnographic findings (1968 ILO classification) arc shown in Table 4 in which only the type of the shadows, but not their extension and profusion, is considered. Tahle 4 shows the number of positive cases. As customary in this type of analysis, cases showing only minimal (Oil) profusion of the shadows arc omitted. Figure 1 groups the cases of rounded shadows, irregular shadows, and those in which rounded and irregular shadows were present together. Irregular shadows were found in three quarters of the cases in the A group and in two thirds of those in the CA group. The incidence of type s was about the s,um in thl' tw1J groups. Irregular shadows. mostly (~8 out of 33 cases) type s. were prl',;tnt in one third of the C group. Rounded shadows were \'irt ually lll'\"l'r found except in subjects exposed to :;iliea, even if exposure was not Sl'l't'rt. They were found in 10% of the CA group and in lS'I, of the C group. None of the subjects in the A group had rounded shadows alone. Three had rounded shadows assol'iatl'<l with irregular shadows (thl' g-roup with mixed shadows also ineludl's ra:ws classified as grade 0/l of profusion). Types u and r were not found in any of the three groups. The profusion and l'xtension of tht obsern:-d roentg-enographir ,;hadows are shown in Tables 5 and ri. For pnctical reasons, the linding,; an grouped togl'l her as follo11s: pr"lllsion-low (0/1, l/0, l/1), nwdium (1. :.!, 211, 2n) and high (othir "la"s1sl: ,.,_ tension-small (two lung- ZO!ll'S), llll' dium (four lung zotws), and ~:nal (morl' than four lum~ ;...11,,I. In llH cas, ,11 irr, '.1il:r1 .!u,I\\ ,. 1spt1ially t) p, t, hi,~h .:, :;r,, , ,o! 1' 11 ,\rch I nv11,>11 Ht,11th1Vol :10 . .lune 19/!i Pneumnco111ose:;/Sca11sl'lt1 et .,t 273 J fusion wtn tnll<'h morP t'ommon in tlw A group. Cas,s 1-lassifkd as types ,.; and t with a hi~h d1g-rPt' of profusion of the shadow:; \V('rt' found in the CA group, although not as often as in the former group. No type t with a high dPgrce of profusion was found in the C group. Rounded shadows in the A and CA groups never showed a high degree of profusion. Two cases of rounded shadows (type q) in the C group showed a high degree of profusion. The incidence of rocntgenographic changes in the pleurae is shown in Fig 2. The conclusron seems warranted that, especially from this standpoint, CA pneumoconiosis is similar to classical asbestosis. Obliteration of the costophrenic angle and thickening of the parietal pleura without calcification were found together in about one quarter of the cases in the CA group and in about one sixth and one quarter, respectinly, of the A and C g-roups. Calcifications of the parietal and diaphragmatic pleura were found in 7"~ of eases in the CA group and in 9~;, of cases in the A group. All these ('hanges were mueh less common in the C group. However, one of the cases in this ~roup had calcifications of the parietal pleura and another calcifications of the diaphragmatic pleura. COMMENT Our findings point to the conclusion that CA pneumoconiosis is similar to classical asbestosis although less adrnnced at an equal duration of exposure. 1. Respiratory or cardiorcspiratory insuffidency was found in a number of cases in the CA group, although less oftpn than in the A group, but not in the C group. 2. The pattern of impairment of nspiratory function was the same (predominantly n,;t ridi\'t') in th<' CA and A groups. l\lodt>rall'ly impairl'd respiratory function (pndominantly obstructhc) was found in the C g-roup. The l'hangt's \\'t..'I'<' mon se\erp in the A group. :t Irregular shadows \\'l'l"l' found in ,\II three g-roup:;, 'l'lwir i11tid,n,,- wa.. :,;imilar in tlw CA an(l A groups (respe1:ti\'l'ly two thirds and thrl'l' quar- D 100 r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Ccmrmt-Asbestos 90 80 ~ Cement 70 ~ Asbestos 60 '# 50 40 30 20 10 Irregular Opacities Rounded Opacities 1fflth Irregular and Rounded Opac1t1es Fig 1.-lncidence of the various types of roentgenographic shadows (1968 "extended" ILO classification), Cases showing only a minimal degree of profusion of thfi shadows (grade 0/ 1) are omitted except in the case of the group with associated irregular and rounded shadows, Table 4.-lncidence of the Various Types of Roenlgenographic Shadows' Irregular Shadows Group CA C A Types 55 28 53 Type t 11 5 22 1968 "extended" ILO classification. Rounded Shadows Type p 6 11 1 Type q 4 7 2 Table 5.-Profusion of the Various Types of Roentgenographic Shadows Irregular Shadows Rounded Shadows Group CA C A Types r---"----, L M H 20 38 6 18 19 4 18 27 1G Type t ,---->------. L MH 4 8 2 14 0 0 9 13 Type p ,----->----,, L MH 4 3 0 10 9 0 0 10 Type q ,---------1---- L M H 5 10 2 3 2 1 1 0 L, low; M, medium; and H, high (1968 "extended" !LO classification). ! Table 6.-Extension of the Various Types of Roentgenographic Shadows I Irregular Shadows Rounded Shadows l Group ----------------------------- l CA C - - - - - - - - - - 1 A Types s , - - - - , ' - - - - - - . , M G 23 32 9 16 22 3 24 21 16 Type t --s-"--M----G-- :! !) 3 4 0 8 13 Type p s, - - - - , ' - - - - . M G 33 I 3 14 2 0 0 Type q s, . - - - ' - - - - - - , M G ~ 0 4 1 0 2 0 S, small; M, medium: and G. great (19G8 "extended" ILO class1f1cation). tcrs of the cases) hut mul'h lower in tlw C ~r,1up (onL' third of tlw l'!l!\L',;)_ Quantitali\'c dilfor,nt'l'S \\'t'l'l' ohSl'rw1! hl'tween the A anti CA groups. Tlw most ad\'ancrd pil'luns anti t Ji,, hiJ.!hPst dt'l!l'l'l'S of profusion \\'t'l'<' found in tlw A gTollp a~ romp.ir,-,1 with the CA group. Ad\a11t',,'d ro,11t- 274 Arch Environ Health/Vol 30, June 1975 Pneumocon1oses1 Scansett1 et :ti 30 25 20 ..~ 15 10 5 D Cement-Asbestos ~Cement ~ Asbestos suC'h. It occurs aftn a long'l'r exposure, hut is rommon and has a similar morpholog-ieal and fun<'tional pi<'tun. This was also sug-g-f'sled hy Calamari ct al; who also carried out tlwir investig-ations in the Casale area. Tlw finding-s of Vig-liani,' indicating that the CA industry is responsible for th" majority of eases of ashestosis dial.!'nosed in Italy during- the rc11nt pa~t . ean he l'Xplaincd by the fact that in our country the CA industry also includes large factories /employing more than 1,000 to 2,000 workers), : fact that docs not apply to other aslwstos industries (mining, textik, brake and frietion material). 0 Pleural Thickening Costophrenic Angle Other Sites Pleural Calc1f1cat1on Walls Diaphragm References Fig 2.-lncidence of roentgenographically demonstrable pleural changes. I. Lindell K: What are the main uses of a,- bestos~ transcript of the 2 Antigua Conferenc, gcnographic features were very uncommon in the C group, in which high recently proposed classification of CA pneumoconiosis as asbestosis, as- on the Biological Elfeel,; of Asbestos, Qud,ec A,. bestos .Mining Association, Jan 5. 1967. 2. Speil S, Leineweber JP: Ash,s/o.s .l!i1u n,l,, degrees of profusion were never observed. 4. Imolvement of the pleurae was besto-silicosis, or even simple silicosis'" 11 (definable as such from the clinical-roentgenographic findings): in Modern Tfl'hrwlugy Johns-~lamille Res(arc-h and Engineering Center, 196K. r/ 3. Nordmann M, Sonnenberg H: Ashestz,: / mentstaub lunge. Arrh Gewerb,.pntho/ 18 2u:i- found both in the CA group and in the A group. These were the only when the functional pattern observed in patients with predominantly or ex- 219, 1960. 4. Klosterkotter W: Zur Stauhgefahrdung hd der Herstellung und Verarbeitung nm A,h,,t-. / g-roups in which cases with pleural r frirtion r:1b were found. Obliteration of the costophrenic angle without cal- l cifieation was more common in the clusively rounded or irregular shadows was examined separately it was found that subjects with irregular shadows showed mainly a reduction Zement-~laterial Arbcitsmrd 1:ll!l. 196:!. V 5. Bohlig 1-1: Gesundheitsgtfahrdunc: durd, Ashestztment Z,11tra/lJ/ Arhe1ts11111/ :w ::!01-21 !, 1970. 6. Einbrodt HJ, lkntschel D: T1r,,i,erim1:1- CA group than in the A group, whereas pleural cakifications were of the VC, total lung capacity, and pulmonary diffusing capacity for car- tclle Untersuehungen mit Arbe1t,plat1., .u1h,-n iz aus einem HuttenzPmt1ntwerk. Ar,h Gt u't'tlnpu- thol 354-366. I%ti. more common in the A group, although the difference between the bon monoxide, single breath and those with rounded shadows showed 7. DeRosa R, F.listo V, Lordi B: Sulla morl-:lit:\ deg-Ii op,,rai di ur,o ,tahilimcnto pcr J., lavorazione di manufatt1 di c<n1tntr>-amianto. two groups was not very great. an increase of the res'idual v~lume Folia Med 47:-16:l--lSl, 1%-1 Thcsr findings indicate a similarity hctw,en CA and A pneumoconiosis, whereas the FEV," did not differ sig- nificantly between the two groups.'''' 8. Calamari F, Brusasca F, Priidone L. ct :,I / Aspctti rad1ologil'i e patog-tnttil'i dt'll'aslw,t,hl. Inei,ltnza in l'rmi,wi.1 di -\k,sandria /;11 /\. \ alt hough certain minor diffcrenel'S ean also he distinguished. Symptoms of hronehitis were more severe in the The rl'sults of functional tests in our patients gave similar results. Our results point to the conclusion that ('/'..t !S.:l~)\)..11:1, 1%S 9. Rubino t;F, Scansl'lli G Stu,h ,p1tlt-m:,>- Jogici sull'asbestosi nl'll'in,lustr1.1 manufattll / ricra. 1\!t d Lau G:t2S:!-2~)S, 1tll:!. CA group than in the A or C groups. / A "synl'rgistie" action of the t\\'o the incidence of CA pneumoconiosis is high in the circumstance of a long du- 10. Banerji DP: :\sblsto,1s in an ashesto-c,- mcnt factorv. lnrli,n, J J,d .\[,,/ l l'l:,7-11;1;, l!,:~. 1J. El Sc;,cfy AZ: Radio!o,;i, lin,lin;.:s in .1 n dusts or. perhaps, the microrlimatie ration of exposure (average 20 years mcnt-asbestos pipe fact,,ry. .T fo,)i!ll'I .lfrrl ..t.-s,,.. enYironmental conditions may be in\'olwd lwrc. in our series). This suggests that the figures reported by other investiga- 52.83G-8-1-I, 1969. 12. Solle E: Bcobachtung-,'n zur :\,h,,tns, i:1 dt'r Ashest-wm,nt lndu,lrll'. l, 11/,.11/1,/ .tr- v Rounlkd shadows unassociated with irrtgular shadows were- not found in the A group, but ,,err found tors arl' too low. However, Bohligstressed the great mobility of workers in this type of industry in West b,ilsm,d 20.211-2JS, 19~u. l:!. Enttrlinc I', \\';,ill II: A,1.,.,tosh Ill ,l'" lK1:--to~ 1.1.nwnt \\orh.Pr-.:. Prelimit1.1n rtpor1 \;1\ :!:X. l~t'.HI lllfort thl lnll'tn:iti,nal t'11nll'rt'Th'l' 1111 in tht> CA g-roup and, l'spel'ially, in the C group. The ineicilnec of rounded Germany. This docs not apply to the Casale ana in whieh our in\'estiga- Hiolog-1l'al 1-:tfti:t:-i of .h.ht,to-.., L:i t 11l. \ kt11!1,r 1!7~. 1-1. \\\ill II, \\'a!'.r:tn,1ack (', l(.,"1t,r C, t't ,ti shado,,s associated with irregular tions were carried ont. as pro\'ed by Raliiog-r.q1hi.: and ph~-.:11 1;0L!II..' li.ttt1'n1-.. an11 1n).'.: , shadows in the CA group was about half of that found in thl' C group hut the high llll'an duration of exposure in OU r l'aSl'S. worklrs t'ng-a~td in ma1rnf.1durt ol a,hl :-tti..., \ \ / tnlnt prtldu1.t..;.. ,J (J, { u, '.',1' 1.) ~h-~.-iJ, l~t7,i 1:,. \'1g-lia111 EC ,\..,ht'-t,,... '''f""'''rt .tnd 11 -.. ..,._ wa~ \'<'ry low (:l'r of tlw casts) in tlw A ~~rn11p. Thl.~t lindings bring to mind till' From nlmost every standpoint CA pllt'lllllOL'oniosis is similar to elassic-al asbestosis and ean be diagtH>sl'd as suh:-. 111 ltah, Lll ~h..1 , it \ h:.J:)-..:i--,i..' , 11111;;11111,,..,,.,! 11 .. ,,,.:.,, ,,,_,;:/ I , , , 1 1 .. , .: 1 /1rtll1'1 .foh111.n1 ).,,,,: !'n,' 1 \ 11, i',,,\'. 11,1, ulll\'l'~lt)' i'll'!--S, }!170, J1p l-"1Ll...._,; Arch [nviron lkalth. Vol 30, ,June 1!l75