The ILO/National Institute of Health

Training Workshop on Prevention of Pneumoconioses

(Using the ILO 2000 International classification of
Radiographs of Pneumoconioses)
KGH 26-29 October 2009, Lima, Peru

Asbestos-related Respiratory Diseases:

Epidemiological, Clinical and Radiological Aspects

Enfermedades Respiratorias Relacionadas al Asbesto:

Aspectos de Epidemiologia, Clínica y Radiología

K.G. Hering
Miners Hospital
Dortmund, Germany
 Asbestos

Definition: natural mineral fibres

Asbestos types e.g.: Chrysotile = „white asbestos“

Crocidolite = „blue asbestos“

Origin e.g.: • China

• Russia
Particles with • Südafrika
- a length > 5 µm • Canada
• Turkey
- a diameter < 3 µm • Italy
• Germany
- a length/diameter relation > 3:1 KGH-LIMA-10-2009
Properties of Asbestos

e.g.

heat resistency

tightness

high elasticity

flexibility

fibre

acid resistancy

insulation

easy to work with

low costs
KGH-LIMA-10-2009
 Asbestos consumption in Germany
KGH

5 50 60 60 60 60
75 175 190 150 60 35

200

180

160

140

120

100

80

60

40

20
BRD
0
1960
1970 DDR
1975
1980
1985
1990

KGH-LIMA-10-2009
Fibre concentration over the years
- effects of primary prevention -

KGH-LIMA-10-2009
Asbestos consumption and asbestos related
occupational diseases in Germany

(Hagemeyer et al., 2006) KGH-LIMA-10-2009

KGH

Lung-Cancer 1980 -2003 Mesothelioma 1980 -2003

European Forum: Enquiry Report, April 2006 KGH-LIMA-10-2009

 Expected Number of Deaths per Year in Europe (Peto 1999)

KGH

G.v.d.Laan
Falkenstein 2004
KGH-LIMA-10-2009
 General Ban on Asbestos Use

KGH Date Country

1984 Norway
1986 Denmark * and Sweden
1989 Switzerland
1990 Austria
1991 Netherlands
1992 Finland and Italy
1993 Germany
1996 France
1998 Belgium
1999 United Kingdom
2000 Ireland
2002 Spain and Luxembourg
2005 Greece and Portugal
* 1980 banned asbestos use, except asbestos-cement products KGH-LIMA-10-2009
PRODUÇÃO DE ASBESTO 1995
Fonte: Asbestos Institute, 1998
1200000

1000000 CIS

800000 Canada
Tons China
600000
Brazil
400000
Zimbabwe
200000 S. Africa

FUNDACENTRO, DMe/CST
CONSUMO DE ASBESTO 1994
Fonte: Asbestos Institute, 1998
700000

600000
CIS
500000
China
400000 Japan

300000 Brazil
Thailand
200000
India
100000

FUNDACENTRO, DMe/CST
 Asbestos related diseases with relation to
dose and latency

Asbestosis
Lung cancer
Dose

Plaques

Mesothelioma

10 20 30 40 Latency
Bohlig und Otto 1975
KGH-LIMA-10-2009
KGH-LIMA-10-2009
 Guidelines for Occupational Medical Examinations
KGH

• List of Guidelines – n = 46 plus 2 appendices

• Medical Examination – initial examination

follow-up examination
long-term follow-up exam.
• Medical Examination Schedule – general: personal & occupational history
special: target effects of specific exposure
supplementary: consultation, expertise
• Occupational Medical Assessment and Advice – no concern
short-term concern
long-term concern
• Supplementary Notes – Committee for Occupational Medicine

KGH-LIMA-10-2009
 Current strategy for the surveillance
of asbestos workers in Germany
KGH

• interval 2 - 3 years

• general and occupational history

• physical examination

• CXR (p.a.), classification according to ILO

• spirometry (to be repeated 3-times)

KGH-LIMA-10-2009
 Registered insured employees 2001
KGH

n = 564 000

5,1%
6,2% ZAs (420 000)

7,5% ODIN (38 000)

ZeBWis (42 000)

6,7% BONFIS (35 000)
74,5% BG 10 (29 000)
 ZAs/GVS  Asbestos dust 1972
 ODIN  Carcinogenics 1987
 BG 10  (Nuclear-)Powerplants 1989
 ZeBWis  Uranium-Mining 1992
 Bonfis  (Hard-Coal-)Mining 1995 KGH-LIMA-10-2009
 Surveillance examination „asbestos dust“

Quality problems (prevalence in B-reading):

Occupational history 13.5 %

Spirometry 12.8 %

ILO-Classification Lung 16.8 %

ILO-Classification Pleura 17.8 %

(Hagemeyer,2005) KGH-LIMA-10-2009
 Asbestos related lung fibrosis - asbestosis

Diagnosis:
Symptoms: cough, phlegm, dyspnoea
Examination: crackles lower fields
Lung function: restrictive pattern
Blood gas analysis: pO2 decrease during exercise
CXR: irregular opacities esp. lower fields

Course:
Progression after end of exposure possible

KGH-LIMA-10-2009
 Asbestos--related pleural thickening, e.g.
Asbestos
Pleural plaques

Diagnosis:
Symptoms: none
Examination: -
Lung function: no impairment (restrictive pattern)
Blood gas analysis: -
CXR: chest wall thickening, (en face)

Course:
Progression after end of exposure possible

KGH-LIMA-10-2009
 Asbestos--related pleural findings
Asbestos

Diffuse pleural thickening with and without CPA blunting

Rounded atelectasis
Hyalinosis complicata
(Effusion)

KGH-LIMA-10-2009
Asbestos related lung and laryngeal cancer

Lung cancer:
- No preferred localization
- No preferred histological subtypes
- Latency > 20 years
- Asbestosis not obligatory for
recognition as occupational disease

Laryngeal cancer:
Very rare

KGH-LIMA-10-2009
 Lung cancer risk with relation to
smoking and asbestos

90 87.4
RR
80
80 without asbestos
70 with asbestos
70
60
60
relative risk

50.8
50
50
40 36.3
40
30
30
20
20 9.2 10.4
10 5.2 3.6
10 1
0
nonsmoker former smoker smoker < 20 cig./d smoker >= 20 cig./d
Nonsmoker exposure
KGH-LIMA-10-2009
 Asbestos related pleural mesothelioma

Diagnosis:
Symptoms: cough, chest pain, weight loss…
Examination: effusion
Lung function: restrictive pattern
CXR: chest wall thickening nodular
effusion

Course:
Mean survival time 8-12 months

KGH-LIMA-10-2009
 Asbestos issue international

USA
Number of possible claims 2.5 Mio.
Claims 20 billion $
Expected claims 200 billion $

prognosis:

Germany 40.000 deaths until 2025

France 100.000 deaths until 2030

KGH-LIMA-10-2009
 Cost of DGUV in Billion Euro 2008
KGH

Compensation

Rehabilitation

Total turnover
Σ 10.897.092.652 €
46,643,395,989 PEN
2007 2008
A = total turnover A = 8.169.797.375 A = 9.620.208.859
B = for rehabilitation B = 2.805.184.497 B = 3.275.335.939
C = for compensation C = 5.364.612.878 C = 5.452.604.959
KGH-LIMA-10-2009
Costs of asbestos related diseases

Analysis of costs (only: HVBG)

66,8
70
63,3 56,0
Share of costs [in %]

60
50
40
26,2
30
14,1 22,5 17,8 17,6 15,5
20
10
0,1 0,0 0,0
0
Asbestosis lung/larynx cancer mesothelioma

medical rehabilitation occupational rehabilitation

compensation insured compensation w idow s
 Costs of asbestos related diseases

Conclusion:
• total costs range from 0.6 to 0.8 billion € per year (minimum)
• most relevant expense factors are costs due to absence from
work and financial compensation
• uncertainties result from underreporting (especially:
under-claiming), not well known indirect costs and not known
costs of environmentally caused asbestos diseases

KGH-LIMA-10-2009
 CXR

Quality-Check: National-B-Reader-Group ca 15 Experts

KGH-LIMA-10-2009
 CXR quality

B-reader experience

Common mistakes
1%
4%
- Scapula 27.9%
34%
- underexposed 11.7%
- overexposed 7.3%
61% - CPW not shown 6.6%
- Underinflation 3.9%

+ +/- +/-- u Thank you for your attention!

KGH-LIMA-10-2009
KGH

Federation of Institutions for Central Federation of Public

Statutory accident insurance Sector Accident Insurers (BUK)
and prevention (HVBG)

2006/2007
German Statutory Accident Insurance (DGUV)

KGH-LIMA-10-2009
 Claims and recognised
asbestos related diseases

Number of claims with proofed underlying asbestos exposure and

number of recognised occupational diseases

asbestosis lung/larynx cancer mesothelioma

year occupational claimed, not occupational claimed, not occupational claimed, not
diseases recognised diseases recognised diseases recognised
1999 2115 779 620
2000 1757 704 652
1500 1671 123
2001 1940 767 683
2002 1927 754 735
97% 96% 95% of all German cases

(HVBG, 1999-2002)
 Results: Costs of asbestos
related diseases

Assessment of direct costs (Germany, projection, 1999 - 2002)

year asbestosis lung/larynx cancer mesothelioma

1999 36.408.566 € 100.884.080 € 88.221.680 €
2000 38.392.664 € 105.826.840 € 95.200.984 €
2001 40.579.027 € 120.950.180 € 108.275.531 €
2002 44.225.794 € 131.163.761 € 119.553.932 €
sum (1): 159.606.051 € 458.824.861 € 411.252.127 €
sum (2): 1.029.683.039 €
proofing claims* (n=17 355; 500 € per claim): 8.677.500 €
administration costs*: 12.000.000 €
prevention* (including ZAs about 11.000.000 €): 28.000.000 €
total: 1.078.360.539 €

* rough assessments, HVBG

Occupational History
Occupational History
 Surveillance examinations
Who?
KGH

Example Asbestos, silica dust, uranium miners

employee
employer Central registry
order for
examination

Occ. Health physicians

Pulmologists
Internal medicine

KGH-LIMA-10-2009
 Surveillance examinations
Who?
KGH

Example „other“ dusts, welding fumes

employer
if exposure > 6mg/m³ total dust
order for or > 1,5 mg/m³ inhalable dust
examination
or > 3 mg/m³ welding fumes

Occ. Health physicians

Pulmologists
Internal medicine

KGH-LIMA-10-2009