Asian-Pacific Newsletter 2/2014, Asbestos-related diseases

Asian-Pacific Newsletter O N O C C U PAT I O N A L H E A LT H A N D S A F E T Y Volume 21, number 2, November 2014

Asbestosrelated diseases

Asian-Pacific Newsletter on Occupational Health and Safety Volume 21, number 2, November 2014 Asbestos-related diseases Published by Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki, Finland Editor-in-Chief Suvi Lehtinen Editor Inkeri Haataja Linguistic Editing Alice Lehtinen Layout Kirjapaino Uusimaa, Studio Printing SLY-Lehtipainot Oy /Kirjapaino Uusimaa The Editorial Board is listed (as of 1 September 2014) on the back page.

This publication enjoys copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts of the articles may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Finnish Institute of Occupational Health, International Affairs, Topeliuksenkatu 41 a A, FI-00250 Helsinki, Finland.

Contents 23 Editorial Sang Gil Lee, Republic of Korea 24 The ticking time-bomb of asbestos consumption in the Asian region Matthew Soeberg, Nico van Zandwijk, Australia 28 Mesothelioma in Australia – monitoring disease incidence and past asbestos exposure with the Australian Mesothelioma Registry Fleur E. Champion de Crespigny, Ewan MacFarlane, Paula Laws, Malcolm R. Sim, Australia 32 ICOH Statement: Global Asbestos Ban and the Elimination of Asbestos-Related Diseases (October 2013) 34 Outline for the Development of National Programmes for Elimination of Asbestos-Related Diseases 35 Eliminating asbestos hazards – Meeting report Suvi Lehtinen, Finland 36 The Helsinki Declaration on Management and Elimination of Asbestos-Related Diseases 39 Asian Asbestos Initiative Toolkit for the Elimination of Asbestos-Related Diseases

The electronic version of the Asian-Pacific Newsletter on Occupational Health and Safety on the Internet can be accessed at the following address: http://www.ttl.fi/Asian-PacificNewsletter The issue 3/2014 of the Asian-Pacific Newsletter deals with occupational health services and primary health care.

Photographs on the cover page: Ken Takahashi, UOEH, Japan Korea Apparel Testing & Research Institute

Printed publication: ISSN 1237-0843 On-line publication: ISSN 1458-5944 © Finnish Institute of Occupational Health, 2014

The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office, the World Health Organization or the Finnish Institute of Occupational Health of the opinions expressed in them.

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sbestos is a well-known occupational and environmentally hazardous substance. Humans have been using asbestos for a long time. Diseases associated with asbestos have also been reported since its use began, but especially so since asbestos began to be used in large quantities for industrial purposes. Most asbestos exposure comes from the use of asbestos for economic purposes. Environmental exposure is closely related to the commercial use of asbestos.

Asbestos is a carcinogen. According to studies, types of cancer related to asbestos continue to increase. As our knowledge increases, so does the number of diseases related to asbestos. The relationship between asbestos and lung cancer, malignant mesothelioma, laryngeal cancer, and ovarian cancer has already been proven. Further research on stomach cancer and colorectal cancer is needed. Asbestos can also cause asbestosis, ventilator impairment, obstruction and chronic airway diseases. These diseases are closely related to patients’ quality of life and mortality.

Because asbestos is a well-known hazardous substance and so many studies have been carried out, some people think studies on asbestos exposure or the prevention of exposure are tedious and derivative. But, at this moment many people are suffering from asbestos-related diseases and the number of patients is increasing globally. Thus we should not underestimate the importance of asbestos exposure prevention.

Asbestos exposure has caused global health problems. At first, the asbestos industry was mainly centered in Europe and North America. These industries moved to Asia, i.e. Japan, South Korea, Indonesia etc., and now, through unawareness or ignorance in the pursuit of economic benefit, the number of victims of asbestos-related disease are increasing in Asia. For example, asbestos textile machines operating in North America were moved to Japan, then the Republic of Korea. These machines now operate in Indonesia. If we do not intervene, they will be moved to another country and take new victims.

Because the disease does not occur immediately after exposure, people still use asbestos. But the cost of using asbestos is a long-standing, fatal curse. The safe use of asbestos is impossible.

Through new effective diagnostic technology, we are able to reduce the number of deaths and patients who suffer from severe disease caused by asbestos exposure. But we cannot rescue everybody. In addition, even though those exposed to asbestos may not yet have a disease, they have to live in fear and anxiety about becoming ill their whole lives.

For these reasons, the use of asbestos must be strictly regulated globally. We must know that the benefit of using asbestos now will have high costs through illness and death in the future. We also know that the best way to reduce the risk is to eliminate the risk factors. We already know how to save lives.

It is now time to do the right thing. It is an ethical obligation.

Sang Gil Lee, MD/ Senior Researcher Occupational Health Research Team Center for Occupational Health Research Occupational Safety and Health Research Institute, KOSHA Republic of Korea Email twincokes@gmail.com

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Occupational health and safety practices for handling roof sheets containing asbestos in Thai Nguyen province, Vietnam.

Photo courtesy of Pham Vinh Thuan at Union Aid Abroad, APHEDA, Vietnam office.

Matthew Soeberg, Nico van Zandwijk, Australia

The ticking time-bomb of asbestos consumption in the Asian region Global consumption volumes of asbestos – the most significant occupational carcinogen – peaked in the 1980s.

However, the devastating burden of asbestos-related diseases, and the far-reaching social and financial impacts have only recently become visible. This is one of the consequences of the long latency period between first asbestos exposure and disease: the morbid effects of asbestos use remain hidden for several decades. The most striking aspect of the change over time in global asbestos consumption patterns is the change in the geographical regions in which asbestos is being used. Approximately two million metric tons of asbestos continue to be consumed globally each year. The Asian region has become by far the largest consumer, and this high consumption can be best described as a ticking time-bomb with a long fuse (1). We are all aware that asbestos-related diseases are largely preventable. Thus implementing a universal ban on asbestos and organizing comprehensive occupational health and safety programmes in Asia are top priorities.

Changing patterns of global asbestos consumption Asbestos is the name given to a group of naturally occurring fibrous minerals. The two main groups of these minerals are: serpentine, including chrysotile (white asbestos); and amphiboles, including crocidolite (blue asbestos), and amosite (brown asbestos). The physical properties of asbestos, including its strength, poor heat conduction, and chemical resistance, have led to its widespread use in a 24

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multitude of products (2) including asbestos-containing sheets, pipes and fittings, as well as asbestos-containing friction materials such as brake pads and linings.

Time-series data on asbestos consumption volumes available from the US Geological Survey (USGS) allow us to assess how asbestos consumption has changed over time and by region. The analyses of the USGS data performed at the Asbestos Diseases Research Institute confirm that global asbestos consumption peaked in the 1980s (4.7 million metric tons were consumed in 1980) and declined over the next two decades (Figure 1). Since the early 2000s, approximately two million (metric) tons of asbestos have been consumed each year. The survey data also reveal that a substantial shift has occurred in asbestos consumption levels by geographical region. In 1990, the Asian region contributed to 25% of the global asbestos consumption. By 2010, this figure had risen to 66%, i.e. two-thirds of the global asbestos consumption in 2010 took place in Asia (Figure 2). These figures were calculated using consistent grouping of countries in each geographical region at each time point.

It is important to note that these geographical data do not provide us with insight into the asbestos consumption per capita. Take Australia as an example: despite comprising a small proportion of total global asbestos consumption volumes at each point in time, Australia had one of the highest per-capita asbestos consumption levels up to the early 1980s (see the article by Champion de Cres-

pigny and colleagues in this newsletter edition for their discussion on the Australian malignant mesothelioma epidemic). Per-capita asbestos consumption calculations provide important information about the association between asbestos consumption volumes and the level of asbestos-related disease, and are discussed later in this article.

4 000 000 3 000 000 2 000 000

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Asbestos as a carcinogenic agent Scientific evidence on the carcinogenic effects of asbestos has been accumulating over the last forty years and new data have recently become available. The most recent review was published by the International Agency for Research on Cancer (IARC) in 2012 (3). IARC has used a standardized approach to evaluating the strength of the evidence for carcinogenicity, which is now being applied to a wide range of different agents. IARC assigns one of five possible classifications to a potential carcinogenic agent, with Group 1 representing the agents with sufficient (abundant) evidence for human carcinogenicity.

After re-evaluating the evidence obtained in human populations and in experimental animals, IARC determined that asbestos is definitely carcinogenic to humans (one of the one hundred and fourteen human carcinogenic agents included in the Group 1 category). IARC confirms that there is well-established epidemiological research showing that asbestos exposure causes malignant mesothelioma, and cancer of the lung, larynx and ovary. There is more limited evidence for the association of asbestos exposure and other cancer sites. In making their determination, IARC has stated that the carcinogenic risks of asbestos apply to all forms of asbestos (including chrysotile).

The asbestos industry and their proponents continue to attempt to promote the so-called safe use of chrysotile asbestos. These assertions lack any scientific basis and in this context it is worthwhile mentioning that the very high incidences of lung cancer in Eastern Europe and the Russian republics are closely associated with the unrestricted use of chrysotile and smoking. However, the asbestos industry tries to obscure the devastating human health impacts of asbestos exposure. Combined evidence clearly indicates

5 000 000

Calendar year Africa

Asia

Central and North America

Europe

Oceania

South America

Unknown

Figure 1. Global asbestos consumption (metric tons), 1920–2010, by geographical region and calendar year (first year of each decade)

Asbestos consumption in the Asian region as a proportion of total global consumption 100% 80% 60% 40% 20% 0%

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Calendar year Figure 2. Global asbestos consumption (metric tons), 1920–2010, by geographical region and calendar year (first year of each decade)

that there are no levels at which exposure to any form of asbestos is considered safe, and increased cancer risks have been observed in populations with a low level of asbestos exposure (4–9). All these recent reports confirm again that asbestos exposure (primarily chrysotile), leads to increased risks of malignant mesothelioma and lung cancer. These studies from a variety of countries include data from the Asian region.

Asbestos-related diseases and the latency period An international expert framework aiming to establish uniform diagnoses of asbestos-related diseases and their causal relationship with asbestos exposure has presented the Helsinki Criteria (10). The Criteria, first published in 1997, represent the consensus views of a range of international experts in the field of asbestos-related lung and pleural disease. The Criteria describe various aspects of asbestosis,

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Managing roof sheeting containing asbestos in Thai Nguyen province, Vietnam.

Photo courtesy of Pham Vinh Thuan at Union Aid Abroad, APHEDA, Vietnam office.

pleural disorders, malignant mesothelioma, and lung cancer. Focusing on malignant mesothelioma, the consensus report states that the great majority of mesotheliomas is due to asbestos exposure and that mesothelioma can occur in cases with relatively low asbestos exposure. The Criteria also state that a minimum of ten years from the first exposure is required to attribute the mesothelioma to asbestos exposure. However, in most cases, the latency period is much longer; in the range of 30–50 years.

It is an appropriate time to consider the Helsinki Criteria, as the consensus statement has recently been updated and published by Wolff et al., 2014 (11). A number of areas of the Helsinki Criteria were updated: CT (computed tomography) screening for asbestosrelated lung cancer, follow-up of asbestos-exposed workers and the diagnosis of non-malignant asbestos diseases, new asbestos-related disease entities, and pathology and biomarkers. Each of these issues is succinctly addressed in the article by Wolff et al. However, most of the original criteria published in 1997 have remained unchanged. The Helsinki Criteria, alongside the carcinogen reviews performed by the International Agency for Research on Cancer and the rapidly accumulating body of evidence on asbestos-related disease, represent an important international reference point for asbestos-related disease.

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Global burden of asbestos-related disease Understanding the global burden of asbestos-related disease is an important yet challenging task – both for countries in which asbestos use has been banned as well as countries and regions in which such bans are yet to be implemented. This is because asbestos exposure occurs not only when handling raw asbestos products or asbestos-containing materials in occupational settings, but also through exposure in non-occupational settings due to in situ asbestos located in buildings and other structures in the physical environment.

There is clear evidence of an increase over time in the number of people who have died due to occupational exposure to asbestos. A study published by Lim et al. (2012) on the global burden of disease attributable to a range of different risk factors included analyses of the number of deaths due to occupational exposure to asbestos in 1990 and 2010 (12). These analyses show that there was a 46% increase in the number of deaths due to occupational asbestos exposure between 1990 and 2010. The investigators estimated that 23 057 people died from occupational asbestos exposure in 1990, and that this rose to 33 610 in 2010, with men making up approximately 75% of all estimated deaths.

These data likely reflect deaths in countries and regions in which occupational asbestos exposure occurred in previous

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decades and in which asbestos bans are now likely to be in place. The global burden of deaths from occupational asbestos exposure in countries in which asbestos is still in use will not be felt for decades to come as the latency periods have not yet expired.

There is also international evidence for clear and plausible associations between deaths from asbestos-related disease and previous asbestos consumption, such that an increase of asbestos consumption is correlated with an increase in asbestosrelated disease mortality rates. These data are presented in an ecological study investigating the association between levels of per-capita asbestos consumption and deaths from asbestos-related disease published by Lin et al. (2007) (13). In this study, the investigators calculated age-adjusted mortality rates for malignant mesothelioma and asbestosis and per-capita asbestos consumption for 33 countries.

The results of this study show that historical asbestos consumption was a significant predictor of malignant mesothelioma deaths among both sexes and of asbestosis deaths among males. The study findings add important scientific weight to the calls for a complete international ban of asbestos use. Further analyses published by Nishikawa et al. (2008) assess changes over time in country-specific mortality rates from pleural mesothelioma according to when asbestos bans were introduced (14).

This study showed that the change in asbestos use during 1970–1985 was a significant predictor of changes over time in pleural mesothelioma mortality.

The global burden of asbestos-related disease can also be measured using incidence and mortality data. The International Agency for Research on Cancer and the World Health Organization publish calendar period-specific, populationbased data on the global incidence and mortality of malignant mesothelioma.

These global data are recognized as being high-quality, as stringent data quality control and analysis procedures are applied centrally, and enable international comparisons. However, it is important to note that the incidence and mortality data from low- and middle-income countries are often incomplete due to limited resources for collecting vital statistics and health information. These global in-

cidence and mortality data frequently also fail to contain (individual and/or population) asbestos exposure data. The IARC incidence and mortality data sets are publicly available at http://www-dep.iarc.fr/.

Summary: Taking action against the ticking time bomb of asbestos in the Asian region In countries in which asbestos consumption levels peaked in the 1970s and 1980s, the full devastating effects of asbestos exposure are only now beginning to be fully understood. The enormous impacts on human health have major financial consequences in the form of health care costs (15), compensation costs for those who were exposed occupationally, careful removal of asbestos from the (built) environment and remediation of asbestos factories and mines. The substantial decrease of asbestos consumption in largely high-income countries during the 1980s has coincided with a dramatic increase in asbestos consumption in low- and middle-income countries, particularly in the Asian region. Ongoing, and increasing as-

bestos consumption in the Asian region is a ticking time-bomb with a fuse of 20–50 years or more depending on the removal of asbestos from workplaces and the environment.

Recent international agency efforts (16) have highlighted the fact that the elimination of asbestos-related disease is a top priority and can be achieved through a number of practical measures. The devastating effects of future asbestos-related disease in the Asian region can be largely eliminated by planning, collaborating, and implementing evidence-based actions including: • recognizing that the only way to elimi nate asbestos-related disease is to im plement a universal ban on asbestos • providing information, incentives and mechanisms for solutions that replace asbestos with safer substitutes • implementing comprehensive preven tive asbestos-related disease pro grammes in workplaces and other set tings in which asbestos exposure is likely; and • improving the capacity and capability

to effectively diagnose and treat asbes tos-related disease at the local level.

Together, this framework of actions will help stop the asbestos time-bomb ticking in the Asian region.

Dr. Matthew Soeberg 1,2 Professor Nico van Zandwijk 1,2 1 Asbestos Diseases Research Institute, Sydney, Australia 2 The University of Sydney, Sydney, Australia

Corresponding author Dr. Matthew Soeberg Research Fellow Cancer Epidemiology and Services Research Group/Asbestos Diseases Research Institute Level 6 North, The Lifehouse (C39Z) Royal Prince Alfred Hospital, The University of Sydney NSW 2006 Australia Email: matthew.soeberg@sydney.edu.au

References 1. Linton A, Vardy J, Clarke S, van Zandwijk N. The ticking time-bomb of asbestos: its insidious role in the development of malignant mesothelioma. Critical reviews in oncology/hematology 2012;84(2):200–12. Epub 2012/03/31.

2. Dodson R, Hammar S. Asbestos Risk Assessment, Epidemiology, and Health Effects. 2nd. ed. United States of America: CRC Press 2011.

3. International Agency for Research on Cancer. A review of human carcinogens. Part C: Arsenic, metals, fibres, and dusts/ IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Lyon, France. 2012.

4. Kanarek MS. Mesothelioma from chrysotile asbestos: update. Annals of epidemiology 2011;21(9):688–97. Epub 2011/08/09.

5. Lacourt A, Gramond C, Rolland P, Ducamp S, Audignon S, Astoul P, et al. Occupational and non-occupational attributable risk of asbestos exposure for malignant pleural mesothelioma. Thorax 2014;69(6):532–9. Epub 2014/02/11.

6. Lacourt A, Leffondre K, Gramond C, Ducamp S, Rolland P, Gilg Soit Ilg A, et al. Temporal patterns of occupational asbestos exposure and risk of pleural mesothelioma. The European respiratory journal 2012;39(6):1304–12. Epub 2011/11/15.

7. Offermans NS, Vermeulen R, Burdorf A, Goldbohm RA, Kauppinen T, Kromhout H, et al. Occupational asbestos exposure and risk of pleural mesothelioma, lung cancer, and laryngeal cancer in the prospective Netherlands cohort study. Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 2014;56(1):6–19. Epub 2013/12/20.

8. van der Bij S, Koffijberg H, Lenters V, Portengen L, Moons KG, Heederik D, et al. Lung cancer risk at low cumulative asbestos exposure: meta-regression of the exposure-response relationship. Cancer causes & control: CCC 2013;24(1):1–12. Epub 2012/11/29.

9. Wang X, Yano E, Qiu H, Yu I, Courtice MN, Tse LA, et al. A 37-year observation of mortality in Chinese chrysotile asbestos workers. Thorax 2012;67(2):106–10.

Epub 2011/09/23.

10. Asbestos, asbestosis, and cancer: the Helsinki criteria for diagnosis and attribution. Scandinavian Journal of Work, Environment & Health 1997;23(4):311–6. Epub 1997/08/01.

11. Wolff H, Vehmas T, Oksa P, Rantanen J, Vainio H. Asbestos, asbestosis, and cancer, the Helsinki criteria for diagnosis and attribution 2014: recommendations.

Scandinavian Journal of Work, Environment & Health 2014. Epub 2014/10/10.

12. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2224–60. Epub 2012/12/19.

13. Lin RT, Takahashi K, Karjalainen A, Hoshuyama T, Wilson D, Kameda T, et al. Ecological association between asbestos-related diseases and historical asbestos consumption: an international analysis. Lancet 2007;369(9564):844–9. Epub 2007/03/14.

14. Nishikawa K, Takahashi K, Karjalainen A, Wen CP, Furuya S, Hoshuyama T, et al. Recent mortality from pleural mesothelioma, historical patterns of asbestos use, and adoption of bans: a global assessment. Environmental health perspectives 2008;116(12):1675–80. Epub 2008/12/17.

15. Watterson A, Gorman T, Malcolm C, Robinson M, Beck M. The economic costs of health service treatments for asbestos-related mesothelioma deaths. Annals of the New York Academy of Sciences 2006;1076:871–81. Epub 2006/11/23.

16. World Health Organization. Elimination of asbestos-related diseases. Geneva, Switzerland: 2006.

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Fleur E. Champion de Crespigny, Ewan MacFarlane, Paula Laws, Malcolm R. Sim, Australia

Mesothelioma in Australia – monitoring disease incidence and past asbestos exposure with the Australian Mesothelioma Registry Introduction Australia’s long-term production and use of asbestos has resulted in one of the highest rates of mesothelioma per capita in the world [1] and presents ongoing challenges for policy-makers, occupational health and safety and the general health and safety of Australians today. By 1954, Australia was ranked fourth in the Western world in terms of gross consumption of asbestos cement products and was clearly the highest consumer per capita [1]. Most of the asbestos was used in the asbestos cement manufacturing industry and much of the output of this industry remains present in the built environment today – in houses and in sewerage and water piping – representing a continuous potential source of exposure to asbestos for the Australian community in the future.

Photos by Caroline Reid

White asbestos in rock, as mined at Barraba, NSW, Australia 28

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The use of asbestos has been regulated in Australia since the late 1970s, initially by imposing occupational exposure limits for the different types of asbestos [1]. By the mid-1980s most uses of asbestos had been phased out and in 2003 the use (or re-use), importation, transport, sale, storage and manufacturing of all forms of asbestos and asbestos containing products was formally prohibited across Australia. The prohibition banned all new uses of asbestos but did not require removal of asbestos products that were in situ on 31 December 2003.

The long latency between exposure to asbestos and diagnosis of mesothelioma (20 to >40 years) [2, 3] means that Australia may not yet have seen the peak in mesothelioma diagnoses. However, models suggest that the peak is likely to occur between 2014 and 2017 [4]. Data from the Australian Institute of Health and Welfare (AIHW) have shown an apparent potential plateau in the number of new diagnoses between 2007 and 2010 at around 670 cases per year [5]. Recent Australian Mesothelioma Registry (AMR) data for 2011 to 2013 suggest the beginning of a decline in the number of new cases, but because these numbers are likely to be revised upwards due to late registrations with the AMR, it is too early to determine the ongoing trend [6].

Mesothelioma diagnoses in Australia have historically been concentrated among those who worked in the mining, manufacturing and installation of asbestos containing products up until the 1980s [1]. However, because of in situ asbestos still found in Australian houses and infrastructure, it is expected that future mesothelioma cases may be increasingly associated with exposures outside the traditional asbestos-related occupations, for example nonoccupational exposures associated with “Do It Yourself ” (DIY) home renovation [7]. These new groups of people diagnosed with mesothelioma are sometimes referred to as the ‘third wave’ and there is concern that exposures from in situ asbestos may keep the incidence of mesothelioma from falling as fast as it might following the phasing out of the use of new asbestos products. However, current evi-

dence on the nature of asbestos exposures that give rise to mesothelioma is limited, making it imperative that assessments of asbestos exposure associated with new cases of mesothelioma are undertaken in the future.

information flow

NSW/VIC/QLD/WA/SA TAS/ACT/NT

Contact Doctor

information flow

Obtain Doctor’s advice to contact mesothelioma patient

Patient consent Obtain patient consent for collection of asbestos exposure information

Asbestos exposure information collection

information flow

information flow

The Australian Mesothelioma Registry Australia first began monitoring mesothelioma in 1980 with the Australian Mesothelioma Surveillance Program, which actively sought voluntary notification of cases from a wide variety of sources and took a full occupational and environmental history from patients or their next of kin [8]. From 1986, the programme morphed into the Australian Mesothelioma Register (the Register), which had a less detailed notification system and a short section seeking occupational/exposure history. By 2004 it had been clear for several years that the number of mesothelioma cases notified to the Register was well below the number of cases diagnosed and notified, as is mandatory, to the state and territory cancer registries. Furthermore, the quality of information collected about the cases’ asbestos exposure was low [9].

For this reason, report publication ceased in 2004 and the Register was suspended in 2007.

The demise of the Register meant the end of any national information on mesothelioma cases’ asbestos exposure. Considerable effort was made by Safe Work Australia and its predecessor, the Australian Safety and Compensation Council to search for and propose viable options for continuing mesothelioma surveillance and collecting asbestos exposure information. In February 2009, Safe Work Australia held a forum including mesothelioma experts as well as representatives from regulators, industry, unions, cancer registries and asbestos disease support groups to discuss the best way to improve the collection of information on asbestos. The forum’s consensus was to use the mandatory notification of mesothelioma to the state and territory cancer registries, and to combine this with a timely follow-up of consenting patients to collect asbestos exposure information. In 2010, Safe Work Australia, in conjunction with a consortium led by the Cancer Institute NSW, established the Australian Meso-

Mesothelioma notifications from states/territories

information flow

Figure 1. AMR data flow

thelioma Registry (AMR), which became operational in 2011.

Aims of the AMR The AMR collects information about all new cases of mesothelioma diagnosed in Australia since 1 July 2010 in order to: • provide a timely and accurate meas ure of the incidence of mesothelioma in Australia and to track changes in the incidence of mesothelioma over time • determine whether changes in medi cal treatment for mesothelioma result in measurable improvements in sur vival after diagnosis • better understand the relationship be tween asbestos exposure and mesothe lioma, including understanding the nature and levels of asbestos exposure associated with mesothelioma • identify changes in work-related asbes tos exposure among mesothelioma cases and asbestos exposure patterns in non-occupational contexts • identify the groups of workers with the highest risk of exposure to asbestos

•

that results in mesothelioma, and provide a resource for policy-makers dealing with the control of asbestos still present in Australia’s built environment and for people undertaking research related to mesothelioma.

How does the AMR work?

Mesothelioma notifications Mesothelioma is a notifiable disease in Australia. This means that it is mandatory to notify state and territory cancer registries of all new cases of mesothelioma upon diagnosis. The AMR has an arrangement with each state and territory cancer registry that mesothelioma notifications are ‘fast tracked’ and are thereby processed and coded as quickly as possible. The state and territory cancer registries submit notifications to the AMR on a regular basis and these notifications contain demographic and diagnosis information and also details about the deaths of mesothelioma sufferers. Patients are also able to self-notify, but these people are not included in the AMR unless a notifi-

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cation from the relevant state or territory cancer registry is also received, confirming the diagnosis of mesothelioma. Figure 1 shows the process of obtaining both mesothelioma notifications and asbestos exposure data by the AMR.

Chrysotile asbestos, photographed using polarized light Asbestos remains in the built environment – asbestos cement sheeting

Asbestos remains in the built environment, including in telecommunication pits

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Asbestos exposure assessment Once a mesothelioma notification has been confirmed, the state and territory cancer registries contact the relevant clinician to determine whether or not the mesothelioma patient meets the eligibility criteria for participation in the asbestos exposure assessment component of the AMR. Apart from the requirement that the diagnosis was made on or after 1 July 2010, the patient must be alive, aware of their diagnosis and well enough to participate in the research. If these criteria are met, the patient is contacted by the cancer registry and asked for their consent to participate in the exposure research. At the same time they are provided with a postal questionnaire that collects information relevant to asbestos exposure, including residential, school and occupational histories and family history of mesothelioma.

Monash University, through the Monash Centre for Occupational and Environmental Health (MonCOEH) has led the design, implementation and analysis of the asbestos exposure component of the AMR. Their approach is unique among mesothelioma registries internationally in that it uses a Job Specific Module (JSM) questionnaire approach with algorithmbased analysis to estimate asbestos exposure in occupational and non-occupational spheres.

MonCOEH uses information from the postal questionnaire to design a tailored telephone interview for each patient using a web application called OccIDEAS (Occupational Integrated Database Exposure Assessment System). OccIDEAS also provides a platform for systematic exposure estimation using algorithms based on published exposure data and expert input [10]. A comprehensive overview of the use of OccIDEAS in the AMR context is provided in MacFarlane et al. 2012 [10].

The telephone interview is then conducted with the patient and their responses to the JSM questions are recorded in OccIDEAS. Exposure assessment algorithms programmed into OccIDEAS es-

timate asbestos exposure for each participant based on his/her JSM responses [10]. Importantly, as part of the telephone interview, all participants, irrespective of job history, also receive a questionnaire module specific to non-occupational asbestos exposure. This non-occupational module includes questions about ‘thirdwave’-type exposures, for example exposures associated with DIY activities.

Challenges for the AMR The main challenge for the AMR is increasing patient participation rates in the asbestos exposure research. Only around 18% of those diagnosed with mesothelioma during 2011–2013 have participated fully (both questionnaire and interview) in the asbestos exposure component. This relatively small proportion may be due to lags between diagnosis of mesothelioma and notification to registries, or delays with, or lack of approval from, the patient’s clinician to contact the patient (up to 4 weeks in most jurisdictions). Given that mean survival after diagnosis is only nine months, a proportion of patients become too unwell to participate by the time they receive the postal questionnaire.

The AMR is working with cancer registries and clinicians to hasten notifications, reduce patient recruitment time lags and raise awareness amongst clinicians about the importance of asbestos exposure research. One of the initiatives employed to improve patient recruitment is the adoption of a passive consent model whereby clinician consent is assumed if the clinician has not responded regarding patient eligibility within 3-4 weeks.

This has resulted in an increased proportion of patients contacted within the states and territories in which the passive consent model operates. However, further improvements are needed for the AMR to fulfil its most unique function – namely documenting the likely asbestos exposure history for a representative proportion of Australians diagnosed with mesothelioma.

Future directions for the AMR A number of mesothelioma registries or surveillance programmes similar to the AMR exist worldwide. For example, the French National Mesothelioma Surveillance Programme was established in 1998

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3. Marinaccio A, Binazzi A, Cauzillo G, Cavone D, De Zotti R, Ferrante P, Gennaro V, Gorini G, Menegozzo M, Mensi C, Merler E, Mirabelli D, Montanaro F, Musti M, Pannelli F, Romanelli A, Scarselli A, Tumino R, and Italian Mesothelioma Register (ReNaM) Working Group. Analysis of latency time and its determinants in asbestos related malignant mesothelioma cases of the Italian register. European Journal of Cancer 2007;43:2722–8.

4. Clements M, Berry G, Shi J, Ware S, Yates D, Johnson A. Projected mesothelioma incidence in men in New South Wales. Occupational and Environmental Medicine 2007;64:747–52.

5. SWA. Asbestos-Related Disease Indicators. Canberra: Safe Work Australia, 2014.

6. AMR. 3rd Annual Report: Mesothelioma in Australia 2013. Sydney: Australian Mesothelioma Registry, Cancer Institute NSW, 2014.

7. Olsen N, Franklin PJ, Reid A, de Klerk NH, Threlfall TJ, Shilkin K, Musk B. Increasing incidence of malignant mesothelioma after exposure to asbestos during home maintenance and renovation. Medical Journal of Australia 2011;5:271–4.

8. NOHSC. The Incidence of Mesothelioma in Australia 1994 to 1996: Australian Mesothelioma Register Report, 1999. Canberra: National Occupational Health and Safety Commission, 1999.

9. ASCC. Preparing an Estimate of the National Pattern of Exposure to Asbestos in Cases of Malignant Mesothelioma. Canberra: Australian Safety and Compensation Council, 2008.

10. MacFarlane E, Benke G, Sim MR, Fritschi L. OccIDEAS: An innovative tool to assess past asbestos exposure in the Australian Mesothelioma Registry. Safety and Health at Work 2012;3:71–6.

11. Goldberg M, Imbernon E, Rolland P, Gilg Soit Ilg A, Saves M, de Quillacq A, Frenay C, Chamming’s S, Arveux P, Boutin C, Launoy G, Pairon JC, Astoul P, Galateau-Salle F, Brochard P. The French national mesothelioma surveillance program. Occupational and Environmental Medicine 2006;63:390–5.

12. Marinaccio A, Binazzi A, Di Marzio D, Scarselli A, Verardo M, Mirabelli D, Gennaro V, Mensi C, Riboldi L, Merler E, De Zotti R, Romanelli A, Chellini E, Silvestri S, Pascucci C, Romeo E, Menegozzo S, Musti M, Cavone D, Cauzillo G, Tumino R, Nicita C, Melis M, Lavicoli S, and R.W. Group. Pleural malignant mesothelioma epidemic: incidence, modalities of asbestos exposure and occupations involved from the Italian National Register. International Journal of Cancer 2012; 130: 2146–54.

13. Fazzo L, Minelli G, De Santis M, Bruno C, Zona A, Marinaccio A, Conti S, Pirastu R, Comba P. Mesothelioma mortality surveillance and asbestos exposure tracking in Italy. Annali dell’Istituto Superiore di Sanita 2012;48(3):300–10.

14. McElvenny DM, Darnton AJ, Price MJ, Hodgson JT. Mesothelioma mortality in Great Britain from 1968 to 2001. Occupational Medicine 2005;55:79–87.

15. HSE. Mesothelioma in Great Britain 2013: Mesothelioma Mortality in Great Britain 1968–2011. London: Health and Safety Executive, 2014.

16. Neumann V, Rutten A, Scharmach M, Muller K-M, Fischer M. Factors influencing long-term survival in mesothelioma patients – results of the German mesothelioma register. International Archives of Occupational and Environmental Health 2004;77:191–9.

and includes an assessment of lifetime asbestos exposure by industrial and environmental hygiene experts [11]. Other examples include the Italian National Mesothelioma Register [12, 13], the British Mesothelioma Register [14, 15] and the German Mesothelioma Register [16], all of which approach mesothelioma surveillance in slightly different ways. A challenge for the AMR as it develops is to learn from and work closely with registries such as these and to share information and document worldwide patterns of diseases and asbestos exposure scenarios that result in mesothelioma. This information is potentially a valuable resource, particularly for developing countries, including those in

Asia where asbestos use continues and/or in situ asbestos remains a potential exposure source. Like some of the registries, the AMR also has the potential to evaluate the impact of quality of care and treatments on life expectancy following diagnosis, to develop robust estimates of asbestos exposure risks and possibly other causes of mesothelioma.

Further information on the AMR Reports and data access More information on the AMR, including the latest statistical reports (e.g. AMR 2014) [6] can be found at http://www. mesothelioma-australia.com Data from the AMR are made avail-

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able to researchers upon request, at the discretion of the data custodian and subject to relevant ethics and administrative approval(s). The process for applying for access to data is outlined in the Data Access Policy on the AMR website.

Funding and management arrangements of the AMR The AMR is funded by Safe Work Australia – the national policy agency for work health and safety and workers’ compensation in Australia, and Comcare - the Australian Government work health and safety regulator for federal workplaces.

The AMR is managed by the Cancer Institute NSW in collaboration with the AMR Management Committee. The Committee consists of a range of stakeholders and experts in the field of asbestos and mesothelioma, including representatives from Safe Work Australia, Comcare, Cancer Institute NSW, MonCOEH (Monash University), Asbestos Diseases Research Institute, School of Public Health of the University of Sydney, the University of Western Australia, and state and territory cancer registries.

Fleur E. Champion de Crespigny1, Ewan MacFarlane2, Paula Laws3, Malcolm R. Sim2 1 Safe Work Australia 2 Monash Centre for Occupational and Environmental Health, Monash Univer sity 3 Cancer Institute NSW Dr. Fleur de Crespigny Safe Work Australia Data and Analysis | Director Policy and Services Branch GPO Box 641 Canberra ACT 2601 Location code: C220 NB2 Email: fleur.decrespigny@swa.gov.au

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ICOH Statement: Global Asbestos Ban and the Elimination of AsbestosRelated Diseases (October 2013)

The International Commission on Occupational Health (ICOH) calls for a global ban on the mining, sale and use of all forms of asbestos and for the elimination of asbestosrelated diseases. To accomplish the elimination of asbestosrelated diseases, we urge each and every individual country to implement a total ban on production and use of asbestos. We also urge complementary efforts aimed at primary, secondary and tertiary prevention of asbestos-related diseases through country-specific “National Programmes for Elimination of Asbestos-Related Diseases” in line with ILO and WHO guidelines.

There is sufficient evidence in humans for the carcinogenicity of all forms of asbestos (chrysotile, crocidolite, amosite, tremolite, actinolite and anthophyllite). Malignant asbestos-related diseases include lung cancer, mesothelioma and cancers of the ovary and larynx. (1). Non-malignant asbestos-related diseases include asbestosis and pleural abnormalities such as pleural thickening, pleural calcification and pleural effusion. (2) International consensus has recommended that a total ban on production and use of all forms of asbestos is the best way to eliminate the occurrence of asbestos-related diseases. In 2006 WHO stated that the most efficient way to eliminate asbestos-related diseases is to stop using all types of asbestos. (3) The ILO Resolution on Asbestos, 2006, calls for eliminating the use of asbestos and identify-

• Asian-Pacific Newslett on Occup Health and Safety 2014;21:28–32

ing and properly managing asbestos currently in place as the most effective means to protect workers from asbestos and to prevent future asbestos-related diseases and deaths. (4) By government decision, a number of countries have already adopted a universal ban on all types of asbestos based on recognition of the substantial human and economic burden of diseases caused by asbestos. Some other countries have banned the use of amphibole asbestos, predominantly crocidolite, but have not banned the use of chrysotile. As there is sufficient evidence by the International Agency for Research on Cancer (IARC 2012) of the carcinogenicity in humans for all forms of asbestos, amphibole-only bans are inadequate; asbestos bans need to include chrysotile as well.

Some countries have banned the production and/or use of asbestos-containing

industrial products, but have continued to mine, sell and export asbestos. This is an unacceptable policy and should be reconsidered by those countries. In order to be effective, a total ban on production, use and export of all forms of asbestos should be achieved in every country.

Even after a total ban on production and use of asbestos is achieved, occupational exposure to asbestos will persist due to the continued presence of asbestos from prior use in building materials and durable machinery/equipment. Workers who carry out maintenance, demolition and removal of asbestos-containing materials will thus continue to be at risk. Therefore a set of protective measures must be implemented to optimize effective prevention. The adoption of a total ban on all use of asbestos and products, equipment and materials containing asbestos implies a need to follow up the implementation of the ban with supplementary regulations and national programmes for ensuring the elimination of all use of asbestos and the required protection from exposure to asbestos. This includes, as appropriate, the review of legislation and regulatory systems regarding trade and the protection of consumers and the external environment.

Primary prevention involves ensuring control of exposures to airborne asbestos fibres, monitoring concentrations according to established standards and reporting exposure levels to appropriate authorities.

There is no exposure level below which asbestos-related disease risk can be totally eliminated. A global ban represents the best form of primary prevention. Additionally, for those countries that have already adopted a ban on the production and use of asbestos, environmental decontamination required for buildings, industrial facilities and infrastructures can represent a further form of primary prevention with beneficial impacts both on the people working in contaminated sites and on the general population. To minimize asbestos exposure, reference exposure limits (i.e., occupational exposure limits) should adhere to international standards. Complying with these limits will reduce, but not totally eliminate, the risk of asbestos-related diseases. Exposed workers should be informed about their working conditions and associated hazards, and provided with appropriate res-

pirators. While respirators should not be relied upon as the sole means of routinely limiting exposure to asbestos fibres, workers provided with them should be trained for their proper use, and encouraged to wear them when warranted. Adequate fitting, changing of filters, sanitary storage and maintenance of respirators are also required for optimal protection. Licensing or authorization procedures need to be considered to ensure safe handling, repair, maintenance and demolishing operations. Ambient air levels at the boundary of demolition sites adjacent to residential areas should be strictly monitored and kept below exposure limits. Proper and safe handling of asbestos-contaminated waste is essential. Finally, in view of the synergistic effect of smoking and asbestos exposure on lung cancer risk, access to smoking cessation programmes is essential for all workers currently and previously exposed to asbestos.

Secondary prevention includes medical monitoring of exposed workers, early diagnosis and individual case management to prevent disease progression. Secondary prevention is not effective for mesothelioma and is not yet proven to be effective for lung cancer among asbestos exposed individuals, but individuals identified with early asbestosis can be transferred away or protected from further exposure with the intent of slowing progression of their disease. Malignant and non-malignant asbestos-related diseases can be diagnosed according to established guidelines. (2, 5) Tertiary prevention includes medical intervention and public health services to limit disease-related disability and help workers affected by asbestos-related diseases to cope with chronic effects of their disease. Appropriate medical care and rehabilitation for the diseases and their potential complications, including immunization against pulmonary infections, should be provided. After disability and impairment evaluation, just compensation and disability benefits should also be provided, as warranted.

Individuals with asbestos-related diseases should be reported to authorities and public health registries. Public health surveillance of asbestos-related diseases, in particular malignant mesothelioma, asbestosis and pleural abnormalities, can

help track progress towards eliminating asbestos-related diseases and may identify where further primary prevention efforts are needed. Public health surveillance of reported exposure levels can also be used to target enhanced primary prevention.

Achieving a worldwide ban on the mining, sale and use of all forms of asbestos and the elimination of asbestosrelated diseases will require that physicians and occupational health personnel responsibly and persistently express their concerns, raise awareness and take necessary action regarding the need to prevent asbestos-related diseases. Recognizing the urgent need for coordinated actions, ICOH will continue to foster global and national collaboration in this endeavour, promoting the engagement of ICOH members in training occupational medicine and health professionals in competencies needed to support comprehensive national efforts to eliminate asbestos-related diseases. http://www.icohweb.org/site_new/multimedia/news/pdf/2013_ICOH%20Statement%20on%20global%20asbestos%20 ban.pdf

References l. IARC, WHO. Asbestos (Chrysotile, Amosite, Crocidolite, Tremolite, Actinolite and Anthophyllite). IARC Monographs, Volume 100C, 2012. http://monographs.iarc.fr/ENG/Monographs/vol100C/mono100C-11.pdf 2. American Thoracic Society. Diagnosis and initial management of nonmalignant diseases related to asbestos. Am J Respir Crit Care Med 2004; 170: 691–715. http://ajrccm.atsjournals.org/content/170/6/691.full.pdf+html 3. World Health Organization. Elimination of asbestos-related diseases. WHO/SDE/ OEH/06.03. September 2006. http://www.who.int/occupational_health/ publications/asbestosrelateddiseases.pdf 4. International Labour Organization.

Resolution concerning asbestos, 2006. http://www.ilo.org/safework/info/standards-and-instruments/WCMS_108556/ lang--en/index.htm 5. Asbestos, asbestosis, and cancer: the Helsinki criteria for diagnosis and attribution [consensus report]. Scand J Work Environ Health 1997; 23: 311–316. http://www.sjweh.fi/show_abstract. php?abstract_id=226

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Outline for the Development of National Programmes for Elimination of Asbestos-Related Diseases The ILO/WHO document entitled Outline for the Development of National Programmes for Elimination of Asbestos-Related Diseases is intented to facilitate countries, particularly those that still use chrysotile asbestos, in establishing their national programmes for elimination of asbestosrelated diseases. Part of the document is published on this page. The whole text is available on the website of ILO and WHO. In order to eliminate asbestos-related diseases, countries need political, operational and information tools as described below.

The National Programme for the Elimination of Asbestos-Related Diseases (NPEAD) is a consensus policy document that outlines the magnitude of the problem and the strategies for elimination of asbestos-related diseases. It also defines long-term objectives and targets, as well as the institutional framework for action and the directions for awareness raising and capacity building. The NPEAD defines the elimination of asbestos-related diseases as a priority in protection of workers’ health, public health and the environment. Therefore, it should be based on a formal governmental decision. Ideally, such a decision should be made by the government cabinet, as it involves different ministries.

The governmental decision about establishing a NPEAD should spell out the political commitment towards elimination of asbestos-related diseases, should define the main elements of NPEAD, such as strategic objectives and targets, mechanism for development, implementation and evaluation, leadership, role of different ministries and periodic reporting on the progress made.

The outline for a NPEAD, containing suggestions for the key areas to be addressed under each section, is described below.

The National Asbestos Profile is an instrument for information. It defines the baseline situation with regard to consumption of the various types of asbestos, populations at risk from current and past expo34

sures (taking into consideration the fact that some uses may have already been restricted or banned and some not), asbestos-related diseases etc.. It is updated periodically and serves as an instrument to measure the progress made towards the objectives and targets set by the NPEAD. The National Asbestos Workplan is an operational tool to put in place measures to achieve the objectives and targets of the NPEAD. As such, it is developed, implemented and evaluated on a step by step basis, taking into consideration progress made in dealing with the various forms of asbestos, available resources, and specific conditions. The Workplan should be feasible and adapted to the national situation, it should include time-sensitive objectives and necessary mechanisms for accountability, monitoring and evaluation. This document should also incorporate provisions for committed national support and sufficient resources for planned activities to be carried out, ensure sustained action, and assign responsibilities. The Workplan needs to be updated periodically to reflect progress in achieving objectives and targets set up by NPEAD and changes in use regulations.

The implementation of a NPEAD requires an intersectoral mechanism such as a steering committee or a task force. This mechanism should have a clearly defined mandate, responsibilities and accountability to manage the development, implementation and evaluation of NPEAD. It should include representatives of the responsible governmental agencies, such as ministries

• Asian-Pacific Newslett on Occup Health and Safety 2014;21:34

of labour, health, environment, industry, construction, trade, finance and others. It may also include academic experts, representatives of civil society, national insurance and compensation boards and other stakeholders. Depending on the national institutional framework, ministry of health, or other ministries may provide political leadership to the work of the intersectoral mechanism on elimination of asbestos-related diseases.

All these elements require prior consultation between governmental agencies concerned, industry, trade unions and other interested parties on the feasibility of objectives and targets, prevention strategies and responsibilities with a due consideration of local conditions and national situation. Countries may need to organize different forms of consultations in order to build a consensus for the establishment of the NPEAD, such as national workshops, information campaigns, and formal interagency consultations. In such consultations, priority should be given to protection of health and primary prevention of asbestosrelated hazards over economic considerations. However, a consensus can only be reached when protection of health is backed up with political, legal, economic and social arguments. http://www.who.int/occupational_health/ publications/asbestosdoc/en http://www.ilo.org/safework/areasofwork/occupational-health/WCMS_108554/lang--en/ index.htm

Suvi Lehtinen, Finland

Eliminating asbestos hazards – Meeting report A total of 140 experts from 24 countries from Australia, Asia, Europe and North America gathered in Espoo, Finland in February 2014, to update the most recent research information concerning the adverse health effects of exposure to asbestos. The Conference was organized in collaboration between the Finnish Institute of Occupational Health, FIOH, and the International Commission on Occupational Health, ICOH. In addition to the scientific conference on Monitoring and Surveillance of Asbestos-Related Diseases (ARD), the Helsinki Criteria, a consensus report first published in 1997, were also updated on the basis of 1.5 years of work by four Expert Groups.

Asbestos-related diseases continue to be a topical problem, despite the use of asbestos being banned in 55 industrialized countries. As much as 2 million tons of asbestos are still produced in the world, and about 125 million workers are exposed to it. The use of asbestos is being transferred to developing countries who lack the capacities to control and manage its hazards.

Due to wide-scale use of asbestos in the last century, hundreds of thousands of workers in industrialized countries have contracted asbestos-related diseases. The ARDs often have a fatal course. According to WHO, 107 000 people die annually from ARDs, cancers or pulmonary fibrosis. In addition to the major health burden, if all the long-term health and social costs are taken into account, the significant financial impact of asbestos is clearly negative, for companies and national economies alike.

The participants of the International Conference on Monitoring and Surveillance of Asbestos-Related Diseases approved a Declaration, which you can find also on the website of the Finnish Institute of Occupational Health: www.ttl.fi/ helsinkiasbestos2014.

Photos by Suvi Lehtinen

The Expert Meeting organized in 1997 produced The Consensus Report: Asbestos, Asbestosis, and Cancer: Helsinki Criteria for Diagnosis and Attribution. It was published in Scand J Work Environ Health 1997;23(4):311–6 (http://www. sjweh.fi/show_abstract.php?abstract_

id=226). The publication containing the background papers, published by FIOH, is available as a printed publication from FIOH. The results of the most recent research, as discussed by the four Expert Groups in 2013–2014, and commented on by the Conference participants, will

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following adress: www.ttl.fi/hcuasbestos. ”Asbestos-related deaths are preventable: by banning the use of asbestos, as WHO recommends,” says Professor Ken Takahashi from the University of Occupational and Environmental Health, Japan. ”It is painful to see how developing countries are making the same mistakes that we have made in the past. It is partly a question of ignorance; and partly the case that developing countries have not experienced the hazards of asbestos, because of the latency time of 20–50 years between exposure and illness”, he says.

be integrated into the Helsinki 1997 Criteria. The updated Asbestos, Asbestosis, and Cancer: Helsinki Criteria for Diagnosis and Attribution 2014 is available at the

Suvi Lehtinen Chief of International Affairs Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki, Finland Email: suvi.lehtinen@ttl.fi

This leaflet (16 pages) is available free of charge from FIOH. Please contact Ms. Salmensaari, email: mirkka.salmensaari@ttl.fi

The Helsinki Declaration on Management and Elimination of Asbestos-Related Diseases Adopted by the International Conference on Monitoring and Surveillance of Asbestos-Related Diseases, 10–13 February 2014, Espoo, Finland

Declaration We, the participants of the International Conference on Monitoring and Surveillance of Asbestos-Related Diseases (ARDs), declare: 1. The Consensus Report: Asbestos, Asbestosis, and Cancer:

Helsinki Criteria for Diagnosis and Attribution 2014, updated

by an International Expert Group in a two-year preparation

process, and a final meeting in Espoo, Finland, on 10–13 Feb ruary 2014, summarizes the up-to-date information on the

methods for management and elimination of ARDs. The Re port is recommended for use in the programmes and prac tices for detection, diagnosis and attribution of ARDs. 36

• Asian-Pacific Newslett on Occup Health and Safety 2014;21:35–36

Primary prevention 2. Primary prevention is the only effective way to eliminate

ARDs. We confirm our support for the global ban of asbes tos mining, processing, manufacturing, inclusion in any ma terials or products, use and trade, as well as the circulation

of all kinds of existing asbestos. We call for joint international

actions for the implementation of the global ban. Informa tion on the availability and feasibility of safe substitute mate rials for asbestos should be made accessible for all in need.

3. We call for policies, regulations and practices for the preven tion of risks and for effective protection of workers in removal

4.

and waste handling of asbestos from existing structures (construction and industrial) and community infrastructures. Preparedness should also be ensured for the protection of workers, populations and communities against occupational and environmental exposures to asbestos in major hazard events, such as industrial, environmental and natural disasters.

Training on prevention, recognition and diagnosis of ARDs should be provided for all involved experts in health services and occupational safety and health. The competent authori- ties, employers and workers, as well as building owners and the public at large should be adequately informed and trained on asbestos hazards, of the risks of ARDs and their preven- tion and elimination.

Regulation 5. Monitoring of potential asbestos exposures should be organ ized for identification of workers exposed to asbestos in cur rent or previous occupations. Competent authorities should

ensure the systematic registration of asbestos-exposed work ers, their occupations, sectors of employment and exposure

histories. Appropriate regulations and good practices for reg istration of personal data and record keeping should be fol lowed.

6. In many countries health surveillance of asbestos-exposed

workers is stipulated by law. In view of the lengthy latency

periods of ARDs (some even beyond 50 years), health moni toring should continue after exposure has ceased, and among

workers who may have changed jobs or retired. Exposed work ers need to be fully informed of the nature, purpose and re sults of the monitoring. It must not result in any cost or loss

of earnings for the workers. Records of the health monitor ing data should be organized according to regulations and

guidelines for good data protection practice, and kept for ap propriate lengths of time.

Health surveillance and diagnosis 7. For medical, legal, and social reasons ARDs should be diag nosed at the earliest possible stage of disease development.

This is important for the appropriate use of available preven tive and therapeutic opportunities, such as immunization

against influenza and pneumococcus infections, and for min imizing the adverse health effects of asbestos, as well as for

compensation of disease and disability. Ongoing advances in

biomedical research and technology provide good opportu nities for more sensitive and reliable methods for early dis ease detection and management.

8. New scientific evidence provides support for the health ben efits of screening people with a high risk of smoking-related

lung cancer. Such screening programmes are also recom mended for workers with a history of asbestos exposure who

are at high risk of lung cancer. Screening should be carried

out in organized screening programmes with ongoing qual ity control, allowing assessment of lung cancer mortality.

Registration 9. Systematic collection of data on ARDs is important for well informed occupational and environmental health policies,

prevention and treatment practices, and for compensation

for ARDs. Diagnosed ARDs should be notified and registered

according to national law and practice, based on international

guidance (ILO Code of Practice, ICD10 and 11).

Research and collaboration 10. Further research is still needed on distribution and levels of

asbestos exposures, epidemiological research on occurrence

of asbestos-related cancers, further developments of methods

for early diagnosis, and economic appraisal of asbestos-relat ed diseases. International collaboration in research for follow up, screening of asbestos-related diseases, and prevention and

management of the global asbestos epidemic is recommended.

In order to prevent the epidemic of asbestos-related diseases from being repeated among workers and communities in the developing world, ceasing the use of new asbestos is essential. We commit ourselves and invite all scientific and professional communities in occupational health and safety, environmental and public health, intergovernmental and nongovernmental organizations to join forces, for extension and implementation of the global ban of asbestos in all countries and protection of workers being currently exposed, as guided by the World Health Organization (WHO), International Labour Office (ILO) and the International Commission on Occupational Health (ICOH).

Harri Vainio Chair of the Organizing Committee International Conference on Monitoring and Surveillance of Asbestos-Related Diseases

Kazutaka Kogi President International Commission on Occupational Health

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The Helsinki Declaration on Management and Elimination of Asbestos-Related Diseases Background Over two million tonnes of asbestos are still produced, marketed, exported and used annually in some parts of the world, mainly in construction materials, asbestos cement, insulation and fire protection. The production and use of asbestos has moved steadily from industrialized countries to the developing world and to countries in rapid industrialization. A total of 125 million workers are estimated to be exposed to asbestos in the world.

There is convincing evidence that asbestos in all its forms, even at low doses, is a proven human carcinogen. It is associated with an increased risk of cancers of lung, larynx, ovary and mesothelioma (cancer of the pleura) among exposed workers. Other adverse health effects, pulmonary fibrosis (asbestosis), pleural changes (thickening), and related respiratory dysfunction are also caused by asbestos exposure. In a high proportion of cases, the diagnosis of asbestos-related diseases (ARDs) takes place at an advanced stage of the disease, with limited possibilities for effective cure. New diagnostic and therapeutic methods are continually being developed, thus permitting better and earlier diagnosis.

Due to wide-scale use of asbestos in the last century, hundreds of thousands of workers in industrialized countries have contracted ARDs. ARDs often have a fatal course. According to WHO, 107 000 people die annually from ARDs, cancers or pulmonary fibrosis. In addition to the major health burden, if all the longterm health and social costs are taken into account, the signifi-

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• Asian-Pacific Newslett on Occup Health and Safety 2014;21:36–38

cant financial impact of asbestos is found to be clearly negative, for companies and national economies alike.

Fifty-five countries have banned the use of new asbestos and undertaken regulatory and practical measures for the protection of workers and implementation of the ban. Notwithstanding, the adverse health effects from exposures in the past will be seen for many decades to come. The management and disposal of asbestos waste from existing buildings, community infrastructures and industrial facilities still constitute a risk and stringent legislation must be provided for workers’ protection.

Countries which have not yet undertaken to ban the use of new asbestos nor instituted other necessary measures for prevention will face the burden of ARDs for even longer periods.

Thus, the global epidemic of ARDs is expected to continue well into the second half of the 21st century. Successful asbestos risk management and elimination of ARDs requires implementation of the global ban of the use of new asbestos and effective preventive and protective policies and practices for the management of risks from existing asbestos. http://www.icohweb.org/site_new/ico_news_detail.asp?id=83

Asian Asbestos Initiative Asia has recently become the world’s center of asbestos consumption. Many Asian countries, particularly those in the midst of rapid industrialization, are increasingly

using asbestos at substantial levels. Somehow the burden of asbestos-related diseases has not become apparent in many of these countries, mainly because the latency time has not been reached yet and also because the recognition of these diseases is poor. However, the experiences of industrialized countries that have extensively used asbestos in the past show that an epidemic of asbestos-related diseases is predictable in the region.

The Asian Initiative for the Elimination of ARDs (i.e. the Asian Asbestos Initiative or AAI) aims to develop an academic platform on which researchers and administrators from different countries can share relevant core technologies. The ultimate goal of this project is consistent with the efforts of the WHO and the International Labour Organization, to eliminate

ARDs. Proponents agree that the most effective means to prevent ARDs is to discontinue the use of asbestos; however, they acknowledge that the process will require a gradual transition involving progressive steps.

The AAI considers the traditional public health approach as the central pillar on which to develop intervention strategies as this model addresses all three levels of prevention. Thus, clinical technologies (i.e. including the diagnosis and treatment of ARDs) are as important as technologies at the primary level of prevention (i.e. reducing or eliminating exposure). These efforts will focus on Asian countries, while attempting to formulate a regional model from which other parts of the world may benefit. The time is ripe for technology sharing. http://envepi.med.uoeh-u.ac.jp/aai/ aboutaai.html

Toolkit for the Elimination of AsbestosRelated Diseases We are pleased to hereby deliver the “Toolkit for the Elimination of AsbestosRelated Diseases”. This toolkit has been developed to serve as a concise and easy-to-use reference source of knowledge, technologies and information that merit attention for the purpose of eliminating asbestos-related diseases (ARDs). As such, the traditional public health approach, i.e., to address the three levels of prevention, was considered to be the basic means to tackle ARDs. Today it is a sad reality that many countries, especially those which are rapidly developing, continue to use asbestos at alarming levels. The developing countries in Asia are at the forefront of this trait, so we intended the administrators, practitioners and researchers therein to be the primary beneficiaries. But our hope is that any party with concern on ARDs can have something to benefit from this toolkit. Whoever the party, a core principle to bear in mind, while referencing this toolkit, is that the most effective means to prevent ARDs is to stop using asbestos.

On behalf of all Contributors and the Secretariat, Ken Takahashi, MD, PhD, MPH Professor and Chair of Environmental Epidemiology, IIES Director of the International Center University of Occupational and Environmental Health, Japan

The Toolkit can be accessed at the following address: http://envepi.med.uoeh-u.ac.jp/toolkit/index.html Asian-Pacific Newslett on Occup Health and Safety 2014;21:39 •

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Editorial Board

as of 1 September 2014

Chimi Dorji Licencing/Monitoring Industries Division Ministry of Trade and Industry Thimphu BHUTAN N.B.P. Balalla Head Occupational Health Division Block 2 G5-03 Jalan Ong Sum Ping Bandar Seri Begawan BA 1311 BSB BRUNEI DARUSSALAM Yang Nailian National ILO/CIS Centre for China China Academy of Safety Sciences and Technology 17 Huixin Xijie Chaoyang District Beijing 100029 PEOPLE’S REPUBLIC OF CHINA Ho Ho-leung Deputy Chief Occupational Safety Officer Development Unit Occupational Safety and Health Branch Labour Department 14/F, Harbour Building 38 Pier Road, Centrum Hong Kong, CHINA

K. Chandramouli Joint Secretary Ministry of Labour Room No. 115 Shram Shakti Bhawan Rafi Marg New Delhi-110001 INDIA Lee Hock Siang Director OSH Specialist Department Occupational Safety and Health Division #04-02, Ministry of Manpower Services Centre 1500 Bendemeer Road Singapore 339946 SINGAPORE John Foteliwale Deputy Commissioner of Labour (Ag) Labour Division P.O. Box G26 Honiara SOLOMON ISLANDS Le Van Trinh Director National Institute of Labour Protection 99 Tran Quoc Toan Str. Hoankiem, Hanoi VIETNAM

Nancy Leppink Chief of LABADMIN/OSH International Labour Office 4, route des Morillons CH-1211 Geneva 22 SWITZERLAND Evelyn Kortum Technical Officer, Occupational Health Interventions for Healthy Environments Department of Public Health and Environment World Health Organization 20, avenue Appia CH-1211 Geneva 27 SWITZERLAND Jorma Rantanen ICOH, Past President FINLAND Harri Vainio Director General Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki FINLAND