Abstract

Résumé

Resumen

ملخص

摘要

Резюме

Introduction

The World Health Organization (WHO), joined by the International Labour Organization (ILO)¹ and the United Nations Environment Programme, has called on countries throughout the world to eliminate asbestos-related diseases.^2–4 WHO advises that the best way to eliminate such diseases is to stop using all types of asbestos.² Although numerous countries have adopted national asbestos bans, many others continue to use asbestos at various levels. The use has declined 55% from its historical peak of 4.7 million metric tonnes per year in 1980,⁵ but more than 2 million metric tonnes per year are still used worldwide.^6,7

WHO estimates that 107000 global annual deaths are caused by mesothelioma, asbestos-related lung cancer and asbestosis.⁸ In 2005, occupational exposure to asbestos was estimated to cause 43000 mesothelioma deaths⁹ and 7000 deaths due to asbestosis^10,11 worldwide. Of those caused by mesothelioma, 7000 were attributed to Europe.⁹ However, the current and future burden of asbestos-related diseases in Europe has not been fully addressed, nor have such data been examined in relation to national asbestos bans.

Through the Parma Declaration on Environment and Health, member countries of the WHO Regional Office for Europe agreed on the need to eliminate asbestos-related diseases.¹² WHO and ILO specifically urged each country to formulate a national programme for eliminating asbestos-related diseases and develop a national asbestos profile³ as milestones for implementing the Parma Declaration by 2015.¹² Asbestos use is a key item of a national asbestos profile. The volume of asbestos produced per person has been used to characterize the asbestos situation in various populations,^13–15 and can serve as a surrogate for population-level exposure. In addition, a list of asbestos use per capita across countries and over time¹⁶ has been included in a recent monograph of the International Agency for Research on Cancer.¹⁷ Per capita asbestos use has also been employed to estimate and predict asbestos-related diseases in different populations.^16,18–20

We conducted a descriptive analysis of national data on asbestos use and asbestos-related diseases in Europe accounting for the status of national asbestos bans.

Methods

European countries were defined as the 53 countries in the European Region of WHO. Data on raw asbestos in these countries were obtained from the database of the United States Geological Survey^5,6 and its updated data file (RL Virta, United States Geological Survey, personal communication, March 6, 2013). The definition of use – production plus import minus export – followed that of the United States Geological Survey.⁵ Data on asbestos use by country were available in 10-year intervals for 1920–1970, in 5-year intervals for 1970–1995 and annually for 1995–2012. We treated a reported negative value of asbestos use (e.g. reflecting storage from previous years) as zero. For years lacking data, reported data from the closest years were interpolated. We also retrieved information on the national status of asbestos bans^21,22, ratification of the ILO Asbestos Convention²³ and health system ranking.²⁴

Data on asbestos-related diseases were extracted from the WHO mortality database;²⁵ these included the number of deaths recorded as mesothelioma (International Classification of Diseases, 10th Revision [ICD-10], C45)²⁶ or any subcategory and asbestosis (ICD-10, J61) between 1994 and 2010. Asbestos-related lung cancers were precluded from our analysis because of difficulties in attributing causation. Separately, deaths recorded for malignant neoplasm of the pleura (ICD-9, 163), a condition generally synonymous with mesothelioma of the pleura, were counted between 1994 and 2009. To investigate countries that did not report data to WHO, we searched PubMed, governmental websites and other websites that we thought were credible^27–30 for national frequency data on asbestos use and asbestos-related diseases. To calculate rates, national population data for 1920–2012 were obtained in the following order – depending on data availability and reliability – from WHO,²⁵ the United States Census Bureau³¹ or Lahmeyer.³²

To analyse asbestos use and asbestos-related diseases in each country, we calculated per capita asbestos use (kg/capita/year) and age-adjusted mortality rates (deaths/million persons/year), respectively. Age-adjusted mortality rates were calculated using a direct age-adjustment method with reference to the WHO world standard population.³³ We analysed all countries individually, together and in groups based on national asbestos ban status, i.e. early-ban (ban adopted by 2000; n=17 countries), late-ban (ban adopted 2001–2013; n=17 countries), and no-ban (no ban adopted as of 2013; n=19 countries).

To provide continuity with data from currently existing countries, data on historical asbestos use from countries that had undergone political transitions (e.g. dissolution or unification) or had been combined with other countries or entities by the United States Geological Survey (n=14) were obtained as follows. First, in the United States Geological Survey database, data for the Soviet Union (1920–1990) represented Kazakhstan and the Russian Federation combined. We apportioned the data between Kazakhstan and the Russian Federation according to the ratio of use recorded by these countries between 1995 and 2012. Second, data for West and East Germany (1950–1985) were combined into Germany. Third, data for Czechoslovakia (1920–1990) were apportioned to the ratio of asbestos use recorded by the Czech Republic and Slovakia between 1995 and 2012. Similarly, the data for Montenegro and Serbia (1930–1990) were apportioned to the ratios recorded by Bosnia and Herzegovina, Croatia, Montenegro, Serbia, Slovenia and the former Yugoslav Republic of Macedonia between 1995 and 2012. In the United States Geological Survey database, the data for Montenegro and Serbia (1999–2005) were combined; we apportioned the data to Montenegro and Serbia according to the sizes of the respective populations during this period. Finally, the combined data for Belgium and Luxembourg (1930–2005) were similarly apportioned to Belgium and Luxembourg.

To exploit all available data, we assessed asbestos use from 1920–2012 and asbestos-related disease mortality from 1994 to 2010 (the disease category for mesothelioma was included in the WHO mortality database in 1994). The period for asbestos use was divided into 1920–1970, 1971–2000 and 2001–2012. An early cut-off point – 1970 – was chosen to allow a sufficient interval for observation of asbestos-related diseases and to be coherent with our previous studies.^16,18,34,35 A later cut-off point – 2000 – was used to separate recent asbestos trends in both use and related diseases.

Based on our earlier finding that 1.0 kg/capita/year of asbestos use corresponded to 2.4 and 1.6-fold increases in mesothelioma deaths among men and women, respectively,¹⁸ we considered this level to be high. Asbestos use of 2.0 kg/capita/year was considered very high. For asbestos-related diseases, we considered age-adjusted mortality rate levels for mesothelioma and asbestosis exceeding those of the world average (5.2 and 0.8 deaths/million persons/year, respectively) to be high.

All data were compiled using Microsoft Excel (Microsoft Corporation, Redmond, United States of America). Age-adjusted mortality rates were calculated using SAS Version 9.1 (SAS Institute, Inc., Cary, USA).

Results

Andorra, Monaco and San Marino did not report any data for any of the indicators during the whole study period. Table 1 shows asbestos use and related disease mortality and the national asbestos ban status for each country. From 1920–1970, six countries recorded very high levels of asbestos use: Belgium, Cyprus, Denmark, Israel, Kazakhstan and Luxembourg. An additional 11 countries recorded high levels. From 1971–2000, the number of countries recording high and very high levels of use increased to 14 and 13, respectively. Between 2001 and 2012, most countries in Europe reduced their use, including those that previously used very high or high levels of asbestos: 43 countries used less than0.5 kg/capita/year, of which 36 countries used less than 0.1 kg/capita/year. In contrast, Kazakhstan, Kyrgyzstan and the Russian Federation recorded very high levels and Belarus, Ukraine and Uzbekistan reported high levels.

For three consecutive periods Kazakhstan and the Russian Federation reported very high or high levels of asbestos use, while Kyrgyzstan, Ukraine and Uzbekistan recorded such levels for the two latter periods, and 11 countries did so for the two earlier periods.

Deaths due to mesothelioma were reported by 36 countries during 3–17 years and by one country during 1–2 years, while 16 countries did not report at all. Deaths caused by asbestosis were recorded by 26 countries during 3–17 years, by seven countries during 1–2 years and 20 countries did not provide any reports. Among the 36 countries that recorded mesothelioma mortality for three years or more, 21 countries recorded high age-adjusted mortality rates led by Iceland, followed by Malta and the United Kingdom of Great Britain and Northern Ireland. Among the 26 countries that recorded asbestosis mortality for three years or more, 12 recorded high age-adjusted mortality rates, led by Malta, followed by Slovenia and Finland.

During 1920–1970, 1971–2000 and 2001–2012, Europe used 31.2, 66.5 and 7.8 million metric tonnes of asbestos, respectively, accounting for 48%, 58% and 31% of the global use, respectively (Table 2). Europe recorded 71686 deaths from mesothelioma (averaging 6786 deaths annually) corresponding to 56% of the global burden of such disease, and 5732 deaths from asbestosis (averaging 542 deaths annually) corresponding to 41% of the global asbestosis cases. Another 28762 deaths were associated with mesothelioma, including deaths recorded as malignant neoplasm of the pleura in the WHO mortality database and those identified from scientific articles.^27–30 In total, Europe registered 106180 asbestos-related disease deaths, accounting for 60% of the global burden. Europe also had higher age-adjusted mortality rates for mesothelioma (7.8 versus 5.2 deaths/million persons/year) and asbestosis (1.0 versus 0.8 deaths/million persons/year) than the worldwide average.

Table 2

Asbestos use and related diseases, policies and health system rankings in Europe^a and worldwide, 1920–2012

Variable	Europea				World (n=194)b	Europe as % of the world
	Status of asbestos banc			All (n=53)
	Early (n=17)	Late (n=17)	None (n=19)
Population, million people (%)	392 (43.2)	224 (24.6)	292 (32.1)	908 (100)	6974	13.0
Asbestos use
Cumulative asbestos use, million metric tons (%)
1920–1970	17.5 (56.2)	2.9 (9.2)	10.8 (34.6)	31.2 (100)	65.4d	47.7
1971–2000	17.2 (25.9)	6.6 (9.9)	42.7 (64.2)	66.5 (100)	113.8e	58.4
2001–2012	<0.1 (0.3)	0.2 (2.5)	7.6 (97.2)	7.8 (100)	24.9f	31.4
Per capita asbestos use, kg/capita/year
1920–1970	1.2	0.5	1.8	1.2	0.64	NA
1971–2000	1.6	1.2	8.0	3.1	0.87	NA
2001–2012	<0.1	0.1	2.2	0.7	0.33	NA
Asbestos-related disease
Mesothelioma (ICD-10, C45)
Deaths, no. (no. of countries)	64156 (16)	7407 (15)	123 (6)	71686	128635 (95)	55.7
Deaths, annual average (no. of years)	6270 (16)	590 (16)	19 (14)	6876	11957	NA
AAMR, per million persons	9.4	3.7	3.2	7.8	5.2	NA
Mesothelioma, other data sourceg
Deaths, no. (no. of countries)	26885 (15)	1617 (10)	260 (3)	28762	34130 (53)h	87.3
Asbestosis (ICD-10, J61)
Deaths, no. (no. of countries)	5385 (16)	339 (13)	8 (4)	5732	13943 (60)	41.1
Deaths, annual average (no. of years)	493 (16)	43 (16)	5 (7)	542	1330	NA
AAMR, per million persons	0.8	0.9	1.5	1.0	0.8	NA
Asbestos-related diseases deaths, total no. (no. of countries)	96426 (17)	9363 (16)	391 (8)	106180	176708 (105)h	60.1
Related policies and health systems
Countries ratifying ILO Asbestos Convention, no. (% in country group)	9 (52.9)	6 (35.3)	5 (26.3)	20 (37.7)	35 (18.9)i	NA (NA)
Countries in top tertile of world ranking for health systems,j no. (% in country group)	17 (100.00)	9 (52.9)	5 (26.3)	33 (62.3)	54 (27.8)	NA (NA)

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AAMR: age-adjusted mortality rate; ICD: International classification of diseases; ILO: International Labour Organization; NA: not applicable.

^a Countries that belong to the European Region of WHO.

^b Number of countries in the world was based on the WHO definition.

^c Early: ban adopted by 2000; Late: ban adopted 2001–2013, None: no ban.

^d Based on 88 countries.

^e Based on 138 countries.

^f Based on 157 countries.

^g Malignant neoplasm of pleura (ICD-9, 163) in the WHO mortality database and published articles identified via PubMed of other source of national data [China (Hong Kong Special Administrative Region and Taiwan), Switzerland and Viet Nam]. For Switzerland, we estimated the values from a figure in Swiss Accident Insurance Institution (SUVA), Medical Information, No.78, p.65.

^h Taiwan, China, was counted as a single entity here, but it was not included in the 194 countries defined by WHO.

ⁱ Number of ILO Member States is 185.

^j The ranking was obtained from the World Health Organization.²⁴

Mesothelioma deaths were reported to the WHO mortality database by 16/17 (94%) early-ban countries, 15/17 (88%) late-ban countries and 6/19 (32%) no-ban countries. Of the 71686 mesothelioma deaths throughout Europe, 64156 (89%), 7407 (10%) and 123 (<1%) were in the early-ban, late-ban and no-ban groups, respectively. Countries in the early-ban, late-ban and no-ban groups reporting mesothelioma deaths had age-adjusted mortality rates (crude mortality rates) of 9.4 (16.5), 3.7 (4.7) and 3.2 (0.6) deaths/million persons/year, respectively. Asbestosis deaths were reported by 16/17 (94%) early-ban countries, 13/17 (76%) late-ban countries, and 4/19 (21%) no-ban countries. Of the 5732 asbestosis deaths throughout Europe, 5385 (94%), 339 (6%) and 8 (<1%) were in the early-ban, late-ban and no-ban groups, respectively. Countries in the early-ban, late-ban and no-ban groups that reported asbestosis had age-adjusted mortality rates (crude mortality rate) of 0.8 (1.4), 0.9 (0.3) and 1.5 (0.2) deaths/million persons/year, respectively.

The ratification rates of the ILO Asbestos Convention were higher in Europe than worldwide (38% versus 19%). Also the quality ranking for the health systems was higher in Europe (62% versus 28%). Within Europe, the convention was ratified by 53% (9/17), 35% (6/17) and 26% (5/19) countries in the early-ban, late-ban and no-ban groups, respectively. Higher-ranking health systems were found in 100% (17/17), 53% (9/17) and 26% (5/19) of these groups, respectively (Table 2).

Discussion

This descriptive analysis of data in the WHO mortality database shows that 56% of all mesothelioma deaths and 41% of all asbestosis deaths recorded worldwide occurred in Europe, which accommodates 13% of the world’s population. Combining these data with those from other sources showed that Europe accounted for 60% of the reported global deaths from asbestos-related diseases, excluding asbestos-induced lung cancer. During the periods 1920–1970 and 1971–2000, Europe used 48% and 58%, respectively, of all asbestos traded throughout the world. Europe can thus be characterized as the historical global centre of asbestos use and the current global centre of reported asbestos-related diseases.

The three different ban groups had comparable population sizes but showed wide differences in the absolute numbers of asbestos-related disease deaths. The early-ban group reported the highest burden of asbestos related disease, while the no-ban group recorded the lowest. This could reflect differences in the reporting of asbestos-related diseases, as the majority of early-ban and late-ban countries reported asbestos-related disease data, whereas most of the no-ban countries did not. The three groups also differed in the quality rankings of their health systems,²⁴ prompting us to speculate that gaps may exist in the level of medical expertise and resources required to diagnose and report asbestos-related diseases.

Almost all countries (14/17) that used asbestos at very high or high levels during 1920–1970 also demonstrated high mortality rates from mesothelioma and/or asbestosis. Kazakhstan and the Russian Federation did not report such data to WHO and no other comparable data could be identified. Switzerland did not report data to the WHO, but a substantial mesothelioma burden was found in a scientific article reporting national data.²⁸ Israel constituted the only identified exception to the relationship between asbestos use and asbestos-related diseases.

We have shown earlier that the level of asbestos use correlates with the subsequent asbestos-related disease burden.¹⁸ The asbestos-related disease burdens observed in the early-ban and late-ban countries are thus likely to be proportional to their levels of earlier asbestos use. The lower asbestos-related disease mortality currently being recorded by the no-ban group – despite higher levels of earlier asbestos use – is based on sparse data and likely reflects underdiagnosis and underreporting.

Asbestos use can be influenced by national policies. Therefore, we assessed the ratification status of the ILO Asbestos Convention.²³ The ratification rate was highest in the early-ban group and lowest in the no-ban group, suggesting a possible influence. It is also plausible that ratification may not have influenced use, but rather reduced asbestos exposure. A directive of the European Union (EU) mandated that all member states ban asbestos from 2005.^36,37 However, some individual EU countries began adopting bans as early as the 1980s. The EU countries thus achieved zero use at different time points. In contrast, two no-ban countries, Kazakhstan and the Russian Federation have both used and mined asbestos^5,6 in recent years, at approximately 930000 and 280000 metric tonnes per year, respectively (RL Virta, United States Geological Survey, personal communication). Economic incentives in these countries may encourage domestic and international asbestos use.

Between 2001 and 2012, Europe used 7.8 million metric tonnes of asbestos. This share (31% of global use) is still disproportionately high relative to the population of this region. However, the absolute use declined from 3.1 kg/capita/year during 1971–2000 to 0.7 kg/capita/year during 2001–2012. Also the level of use varies considerably by group. The early-ban and late-ban groups reduced their average use to less or equal to 0.1 kg/capita/year, respectively, whereas the no-ban group continued to use an average of 2.2 kg/capita/year. In the early-ban group the use varied between 0 and 0.19 kg/capita/year, which might be variable according to the extent of national exemptions. These are considerable reductions from the previously high levels of use observed between 1920 and 2000 in the early-ban group and between 1971 and 2000 in the late-ban group. In contrast the no-ban group recorded very high and high levels of asbestos use throughout the timeframe studied. The six countries with very high and high levels of use in the present century were all no-ban countries. Hence, although asbestos use was historically widespread and substantial across most of Europe, more recent use has been concentrated in the no-ban countries. We therefore speculate that the future burden of asbestos-related diseases will likely shift from the early-ban and late-ban countries towards the no-ban countries.

We previously used similar methods to analyse asbestos use and asbestos-related diseases in Asia.³⁵ Although the previous and present findings can be roughly compared, some caution should be exercised. The earlier study adopted the United Nations Statistical Division definition of Asia, whereas the present study adopted the WHO definition of Europe, resulting in an overlap of 11 countries, including one early-ban country (Israel), two late-ban countries (Cyprus and Turkey), and eight no-ban countries (Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan). Also, the final years analysed for asbestos use and asbestos-related diseases in the earlier study were 2007 and 2008, respectively.

A strength of this study is the use of quantitative data from public databases to describe the situations in many countries. There were limitations, however, in the representation and comparability of the analysed data. For example, the data on use of asbestos were extrapolated for several countries that lacked specific data due to political transitions. In addition, data on the use of imported asbestos-containing products were not available. Moreover, as asbestos-related diseases are generally rare and difficult to diagnose, serious bias could have been introduced by countries having limited experience with asbestos-related diseases.

In conclusion, Europe currently carries the majority of the global asbestos-related disease burden as a consequence of heavy asbestos use during earlier decades. For countries that have stopped using asbestos, their asbestos-related disease burden will most likely decrease. In contrast, countries that still have not banned asbestos are likely to have a substantial burden of asbestos-related disease in the future due to their past and current high levels of asbestos use. As attempts to reduce exposure without a concurrent reduction in overall use are insufficient to control risk,^16,38 asbestos bans should be in place in all countries to eliminate asbestos-related diseases.

Acknowledgements

Funding:

Competing interests:

References