RESPIRATORY HEALTH ISSUES IN THE ASIA-PACIFIC REGION

Asbestos use and asbestos-related diseases in Asia:

Past, present and future resp_1975 767..775

GIANG VINH LE,1 KEN TAKAHASHI,1 EUN-KEE PARK,1 VANYA DELGERMAA,1 CHULHO OAK,2
AHMAD MUNIR QURESHI3 AND SYED MOHAMED ALJUNID3

1
Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of
Occupational and Environmental Health, Iseigaoka 1-1, Yahatanishiku, Kitakyushu City, Japan, 2Department of
Internal Medicine, College of Medicine, Kosin University, Busan, Korea, and 3United Nations University,
International Institute for Global Health (UNU-IIGH), UKM Medical Center, Jalan Yaacob Latif, Bandar Tun
Razak, Kuala Lumpur, Malaysia

ABSTRACT
Background and objective: Although there are
growing concerns about the global epidemic of
asbestos-related diseases (ARD), the current status of
asbestos use and ARD in Asia is elusive.We conducted a
descriptive analysis of available data on asbestos use
and ARD to characterize the current situation in Asia.
Methods: We used descriptive indicators of per capita
asbestos use (kilograms per capita per year) and age-
adjusted mortality rates (AAMR, persons per million
population per year) by country and for the region,
with reference to the world.
Results: The proportion of global asbestos use attrib-
uted to Asia has been steadily increasing over the years
from 14% (1920–1970) to 33% (1971–2000) to 64%
(2001–2007). This increase has been reflected in the
absolute level of per capita use across a wide range of
countries. In contrast, 12 882 ARD deaths have been
recorded cumulatively in Asia, which is equivalent to
only 13% of the cumulative number of ARD deaths in
the world during the same period. The highest AAMR
were recorded in Cyprus (4.8), Israel (3.7) and Japan
(3.3), all of which have banned asbestos use.
Conclusions: There is a paucity of information con-
cerning the current situation of ARD in Asia. The
marked increase in asbestos use in Asia since 1970,
however, is likely to trigger a surge of ARD in the imme-
diate decades ahead.
Key words: asbestos, asbestosis, Asia, mesothelioma,
mortality.
Correspondence: Ken Takahashi, Department of Environmen-
tal Epidemiology, Institute of Industrial Ecological Sciences, Uni-
versity of Occupational and Environmental Health, Iseigaoka 1-1,
Yahatanishiku, Kitakyushu City, Fukuoka Prefecture 807-8555,
Japan. Email: ktaka@med.uoeh-u.ac.jp
Received 12 February 2011; invited to revise 9 March 2011;
revised 15 March 2011; accepted 17 March 2011 (Associate
Editor: Robert Young).
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
INTRODUCTION
The World Health Organization (WHO) recognizes
that asbestos is one of the most important occupa-
tional carcinogens, and the burden of asbestos-
related diseases (ARD) is rising. The WHO declared
the need to eliminate ARD and cease asbestos use.1
Recently the WHO upgraded its global estimate of
ARD to 107 000 annual deaths caused by asbestos-
related lung cancer, mesothelioma and asbestosis.2 A
2005 study of disease burdens due to occupational
carcinogens estimated a worldwide incidence of
43 000 mesothelioma cases, and 27 000 were attrib-
uted to the Asia-Pacific region.3 Despite Asia’s
growing importance in the world, objective analyses
concerning its asbestos use and ARD have been
scarce.
The asbestos situation in Asian countries was
described following a 2002 regional conference,
which was the first to discuss the theme.4 A striking
feature of the region was the persistent use of asbes-
tos in most, if not all, countries; however, important
changes have occurred since that time. Indeed,
Japan, which was a major asbestos user, experienced
the ‘Kubota Shock’ (media exposure of a cluster of
ARD victims impacting society)5 in 2005 and adopted
a total asbestos ban in 2006 (a prohibition in prin-
ciple was already in effect in 2004). In addition,
Korea promulgated a ban, in principle, in 2006 and
a total ban in 2009 after recognizing a surging
number of mesothelioma cases.6 Moreover, we are
aware that several south-east Asian countries are
considering asbestos bans, although this informa-
tion has not been documented. Thus, the asbestos
situation in Asia is volatile and warrants a careful
description.
A nation’s status with respect to asbestos and ARD
can be described in comparative terms using macro-
indicators such as per capita asbestos use and
age-adjusted mortality rates (AAMR). The volume of
Respirology (2011) 16, 767–775
doi: 10.1111/j.1440-1843.2011.01975.x

768
asbestos used per capita (per capita asbestos use) is a
surrogate for the exposure level of a population, and
its trend over time has been used to characterize the
asbestos situation of various populations.7,8 In addi-
tion to other studies9,10 we have used per capita asbes-
tos use to estimate or predict ARD in different
populations, and this method has produced plausible
findings.11,12 In the present study, we conducted a
descriptive analysis of the available data to character-
ize the situation in Asia. We assumed that a country’s
past asbestos use influenced the present ARD rates,
and that present use of asbestos will influence future
ARD.
METHODS
We identified all countries that have available data
for either asbestos use and/or mortality data for
ARD. From a total of 185 countries identified, we
adopted the definition of Asia by the United Nations
Statistics Division13 and identified 47 countries that
belonged to Asia. These 47 Asian countries were
analysed in our study with reference to the 185
countries in the world.
We extracted all data on asbestos use from
a related report of the United States Geological
Survey (USGS).14,15 We adopted the USGS definition
of use (production plus import minus export),14 the
data for which were available by country in 10-year
intervals from 1920 to 1970, 5-year intervals from
1970 to 1995 and annually from 1995 to 2007. We
treated a reported negative value of asbestos use
(caused by storage, for example) as zero in the
present analysis. When necessary, we interpolated
values for asbestos use for the calendar years lacking
data.
Using the WHO Mortality Database,16 we identified
the number of deaths recorded as ‘mesothelioma
(C45, International Classification of Diseases, 10th
Revision, or ICD-10)’,17 or any subcategories thereof,
and ‘asbestosis (J61, ICD-10)’ between 1994–2008. We
separately counted numbers recorded for ‘malignant
neoplasm of the pleura (163, ICD-9)’17 as a condition
generally synonymous with mesothelioma of the
pleura. To investigate countries that did not report
data to the WHO, we used PubMed (http://www.
ncbi.nlm.nih.gov/pubmed) and other sources to
search for national frequency data published
in English (only 2 such references18,19 could be
identified).
National population data from 1920–2008 were
obtained from the WHO,16 the United States Census
Bureau20 and Lahmeyer,21 and the data were
prioritized for use in this order. We used the
indicators of per capita asbestos use (measured
in kilograms per capita per year (kg/capita per
year)) and AAMR (measured in cases per million
population per year) to analyse the national situa-
tions for asbestos and ARD, respectively. AAMR were
calculated using a direct age-adjustment method
with reference to the world population in the year
2000.22
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G Vinh Le et al.
Asbestos use data for Kazakhstan required special
treatment because of its political transition since
the era of the Soviet Union. Because data on asbes-
tos use for the Soviet Union between 1920–1990 in
the USGS database represented Russia and Kazakh-
stan combined,14 we apportioned the data from
this time period between Russia and Kazakhstan
according to the ratio of use recorded by Russia
and Kazakhstan between 1995–2007. In the present
analysis, only data for Kazakhstan were used
because Kazakhstan is categorized as a part of Asia
by the U.N. Note that the observed period for asbes-
tos use was 1920–2007 and that for ARD mortality
was 1994–2008 due to the availability of data in the
respective databases.
We compiled all data and conducted descriptive
statistics using Microsoft Excel (Microsoft Corpora-
tion, Redmond, WA, USA). We extracted the numbers
of deaths recorded in the WHO Mortality Database
and calculated the AAMR using SAS Version
9.1 (SAS Institute Inc., Cary, NC, USA). Graphs
were created with Sigmaplot Version 9.01 (Systat
Software Inc., San Jose, CA, USA), and maps were
drawn using MapInfo Professional Version 7.5 SCP
(Schlosser Geographic Systems, Inc., Seattle, WA,
USA).
RESULTS
Table 1 summarizes the asbestos situation of the 47
analysed countries as a region and by groups of
countries according to the availability of data for
asbestos use and ARD mortality: group A consisted
of 30 countries with available data for asbestos use
only, group B consisted of 15 countries with avail-
able data for both asbestos use and ARD mortality,
and group C consisted of two countries that only had
available data for ARD mortality. In Asia, the asbes-
tos use totaled 55.5 million metric tons (tons, here-
after) during the observed period of 1920–2007 (29%
of the world’s use). For the three consecutive periods
observed, Asia accounted for 14% (1920–1970), 33%
(1971–2000) and 64% (2001–2007) of the world’s
asbestos use. The annual mean volume of asbestos
use for each period was 0.1, 0.9 and 1.2 million tons
in group A, and 0.08, 0.4 and 0.1 million tons in
group B, respectively.
In terms of ARD, 12 882 ARD deaths (12 012 were
mesothelioma (ICD-10, C45)) have been recorded
cumulatively in Asia, which is equivalent to 12.5% of
ARD deaths (13.0% of mesothelioma (ICD-10, C45))
worldwide. Except for a single case of mesothelioma
and another case of malignancy of the pleura belong-
ing to group C, all cases belonged to group B:
mesothelioma in 10 countries, malignancy of the
pleura in four countries, asbestosis in five countries,
all of which were recorded in the WHO Mortality
Database, and mesothelioma in 1 country, which was
identified in the scientific literature (and not recorded
in the WHO Mortality Database).
Table 2 shows situations asbestos use and/or ARD
mortality by country. In terms of per capita asbestos
© 2011 The Authors
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Asbestos and related diseases in Asia 769

Table 1 Asbestos use and asbestos-related diseases (ARD) in Asian countries and the world

Data availability [n of countries]

Asbestos only Both asbestos and ARD ARD only Asia [47]
Group A [30] Group B [15] Group C [2] (% of World) World [185]

Asbestos, recorded cumulative use (million metric tons)

During 1920–1970 5.1 [10] 3.9 [9] NA 9.0 [19] 65.4 [89]
<annual mean> <0.1> <0.08> (13.8)
During 1971–2000 25.6 [25] 11.6 [15] NA 37.2 [40] 113.7 [138]
<annual mean> <0.9> <0.4> (32.7)
During 2001–2007 8.4 [30] 0.9 [14] NA 9.3 [44] 14.6 [159]
<annual mean> <1.2> <0.1> (63.7)
Total 39.1 [30] 16.4 [15] NA 55.5 [45] 193.7 [169]
(28.7)
ARD, reported cumulative mortality during 1994–2008 (n of cases)
ICD-10, C45 NA 12,011 [10] 1 [1] 12,012 [11] 92,253 [83]
(13.0)
ICD-9, 163 NA 53 [4] 1 [1] 54 [5] 330 [12]
(16.4)
ICD-10, J61† NA 516 [5] 0‡ [NA] 516 [5] 9,943 [53]
(5.2)
Other data source§ NA 300 [1] 0¶ [NA] 300 [1] 868 [2]
(34.6)
Total NA 12,880 [15] 2 [2] 12,882 [17] 103,394 [98]
(12.5)

†
Countries recorded both J61 and C45 in WHO mortality database, except Suriname (J61 only).
‡
No record in WHO mortality database.
§
Published articles in English identified via Pubmed or other source of national data.
¶
Data cannot be identified.
NA, not applicable.

use, five countries recorded high values (defined as
exceeding 1.0 kg/capita per year) between 1920–1970:
Cyprus (7.6), Kazakhstan (5.8), Israel (3.2), Lebanon
(2.1) and Singapore (1.5). Thirteen countries recorded
high values between 1971–2000: Kazakhstan (18.4),
U.A.E. (3.4), Kyrgyzstan (3.1), Cyprus (2.4), Japan (2.2),
Thailand (1.7), Korea (1.5), Uzbekistan (1.5), Malaysia
(1.4), Singapore (1.3), Saudi Arabia (1.2), Lebanon
(1.1) and Kuwait (1.0). Five countries recorded high
values between 2001–2007: Kazakhstan (11.4), Kyr-
gyzstan (4.2), U.A.E. (3.5), Thailand (2.1) and Uzbeki-
stan (1.9). Among these countries, Kazakhstan was
the only country listed with high values during all
three consecutive periods. Cyprus and Lebanon had
high values for the two earlier periods and Kyrgyzstan,
U.A.E., Thailand and Uzbekistan had high values for
the two latter periods. Four countries increased their
use over the three periods: Thailand, China, India and
Indonesia. In total, most Asian countries (28/47 or
60%) increased asbestos use during the observation
period (Table 2 and Fig. 1).
In terms of ARD, 17 and 7 countries reported data
for at least 1 year for mesothelioma and asbestosis
deaths, respectively (the numbers of countries report-
ing data for at least 3 years are 11 and 5, respectively).
Among countries reporting data for at least 3 years,
the AAMR (cases per million population per year) for
mesothelioma were highest for Cyprus (4.8), Israel
(3.7) and Japan (3.3). It should be noted that the
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
AAMR values for Bahrain and Macau, which were the
two countries in group C, were each based on a single
case in a single year.
Figure 2 illustrates temporal trends of asbestos
use in combination with or without mesothelioma
mortality (depending on data availability of the latter)
in selected countries. Peak asbestos use in Japan
exceeded 2.0 kg/capita per year between 1970–1990,
which was followed by a linear increase of mesothe-
lioma mortality since 1995 and the rate has recently
approached 4 per million population per year. In
Korea, asbestos use reached a peak just below 2.0 kg/
capita per year between 1975–1995, which was fol-
lowed by an increase in mesothelioma mortality that
has slowly risen since 1995 and recently approached 1
per million population per year. Singapore recorded a
sharp, transient peak of asbestos use around 1975
(approaching 4.0 kg/capita per year), which was fol-
lowed by an increase in mesothelioma mortality
leaping from less than 0.5 to recently around 2.0 per
million population per year. Asbestos use in Thailand
increased in the 1960s, exceeded 1.0 kg/capita per
year in 1975 and peaked at around 3.0 kg/capita per
year in 1996. Recently the level of asbestos use in
Thailand has fluctuated. China and India have shown
increased asbestos use approaching 0.5 and 0.3 kg/
capita per year, respectively, and the slopes have
recently accelerated. Thailand, China and India,
however, lack national data on mesothelioma.
Respirology (2011) 16, 767–775
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770 G Vinh Le et al.

Table 2 Age-adjusted mortality rate (AAMR) of asbestos-related diseases (ARD) between 1994–2008 and per capita
asbestos use (kg/capita per year) in Asian countries

Asbestos use† AAMR (n of reporting years)

Country Group 1920–1970 1971–2000 2001–2007 Mesothelioma‡ Asbestosis§

1 Afghanistan A — — 0.00 — —
2 Armenia A — 0.13 0.08 — —
3 Azerbaijan A — 0.39 0.70 — —
4 Bahrain C — — — 3.46 (1) —
5 Bangladesh A — 0.01 0.02 — —
6 Bhutan A — — 0.33 — —
7 Brunei A — — 0.00 — —
8 China A 0.07 0.24 0.39 — —
9 Cyprus B 7.60 2.41 0.12 4.79 (4) —
10 Georgia B — 0.00 0.01 0.33 (3) 0.38 (2)
11 Hong Kong B 0.02 0.04 0.20 1.19 (7) 0.20 (5)
12 India A 0.04 0.13 0.20 — —
13 Indonesia A 0.01 0.16 0.17 — —
14 Iran A 0.25 0.74 0.66 — —
15 Iraq A 0.07 0.06 0.00 — —
16 Israel B 3.19 0.56 0.02 3.67 (10) 0.13 (5)
17 Japan B 0.80 2.23 0.17 3.25 (14) 0.12 (14)
18 Jordan A — — 0.00 — —
19 Kazakhstan¶ A 5.84 18.40 11.44 — —
20 Kuwait B — 1.04 0.00 0.00 (1)†† —
21 Kyrgyzstan B — 3.12 4.24 0.56 (6) —
22 Lebanon A 2.10 1.12 0.01 — —
23 Macau C — — — 3.61 (1)†† —
24 Malaysia B 0.89 1.37 0.38 0.21 (6) —
25 Maldives A — 0.00 0.00 — —
26 Mongolia B — 0.14 0.11 1.71 (1)†† —
27 Myanmar A 0.04 0.04 0.01 — —
28 Nepal A — 0.00 0.00 — —
29 North Korea A — 0.12 0.07 — —
30 Oman A — 0.34 0.54 — —
31 Pakistan A — 0.05 0.03 — —
32 Philippines B 0.07 0.04 0.03 0.21 (5) 0.08 (5)
33 Qatar A — — 0.36 — —
34 Republic of Korea B 0.32 1.45 0.28 0.62 (12) 0.03 (7)
35 Saudi Arabia A — 1.15 0.01 — —
36 Singapore B 1.52 1.31 0.10 1.12 (13)†† —
37 Sri Lanka B — 0.37 0.81 0.27 (1)†† —
38 Syria A — 0.27 0.04 — —
39 Taiwan B 0.29 0.96 — 1.14 (12)‡‡ —
40 Tajikistan A — 0.09 0.12 — —
41 Thailand A 0.45 1.72 2.05 — —
42 Turkey A 0.08 0.58 0.14 — —
43 Turkmenistan A — 0.63 0.42 — —
44 United Arab Emirates A — 3.43 3.46 — —
45 Uzbekistan B — 1.45 1.89 0.30 (2) 0.03 (1)
46 Vietnam A — 0.36 0.65 — —
47 Yemen A — 0.01 0.00 — —

†
Data were interpolated for some years and then the weighted average per capita asbestos use was calculated.
‡
C45, ICD-10.
§
J61, ICD-10.
¶
See text for calculation method of Kazakhstan.
††
163, ICD-9.
‡‡
National data represented only death count for all ages so crude mortality rate was calculated.
A, asbestos use only; B, both asbestos and ADR; C, ARD only; —, data not available.

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Asbestos and related diseases in Asia 771

Figure 1 Asbestos use among Asian countries between 1920–1970 (A), 1971–2000 (B) and 2001–2007 (C). Asbestos use
(kg per capita per year) ( ) >1.0, ( ) 0.1 to 1.0, ( ) <0.1, ( ) data not available.

Table 3 highlights the national policy situations in DISCUSSION

Asia related to asbestos use with reference to the
world. Only 3 (6%) Asian countries have ratified the
International Labour Organization (ILO) Asbestos
Convention23 compared with 17% of countries world-
wide. Thirteen (28%) Asian countries have adopted
asbestos bans, which is a similar percentage to the
number of countries that have adopted asbestos bans
worldwide (30%).
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
Before 1970, Asian countries only accounted for a
minor proportion (14%) of global asbestos use. This
historical situation should be reflected, at least par-
tially, in the current situation of ARD, for which only
17 (36%) of the 47 analysed countries recorded ARD
deaths. Interestingly, only about 13% of global ARD
deaths have occurred in Asia. These figures are low for
Respirology (2011) 16, 767–775
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772 G Vinh Le et al.

Figure 1 Continued

Figure 2 Trends in asbestos use

with/without mesothelioma (C45,
ICD-10) mortality in selected Asian
countries. (a) Japan, (b) Korea, (c)
Singapore (163, ICD-9), (d) Thailand,
(e) China, (f) India. ( ) asbestos
use, ( ) missing data on asbestos
use was interpolated, ( ) age-
adjusted mortality rates for
mesothelioma.

Respirology (2011) 16, 767–775 © 2011 The Authors

Respirology © 2011 Asian Pacific Society of Respirology

Asbestos and related diseases in Asia
Table 3 Ratification status of the International Labour
Organization (ILO) Asbestos Convention† and adoption of
asbestos ban‡ in Asia and the world
Asia World
[n of countries] (n = 47) (n = 185)
Ratification status of ILO 6.4% (3‡/47) 17.3% (32/185)
Asbestos Convention†
Adoption of asbestos 27.7% (13¶/47) 29.7% (55/185)
ban§
†
ILO Convention No. 162.23
‡
Cyprus, Japan, Korea.
§
Source: International Ban Asbestos Secretariat.24
¶
Bahrain, Brunei, Cyprus, Israel, Japan, Jordan, Korea,
Kuwait, Mongolia, Oman, Qatar, Saudi Arabia, Turkey.
a region with a combined population of 3.7 billion, or
61% of the world’s population in the year 2000.
The asbestos situation has changed drastically
since Asian countries increased their share to 33% of
the world’s use between 1971–2000, which reached
64% after the turn of the century. Although the delin-
eating year of 1970 was chosen arbitrarily, it repre-
sents a widely accepted latency time of 30–50 years
for ARD,25,26 particularly mesothelioma, to develop at
the individual (case) level after asbestos exposure.
The year 1970 is also in line with our earlier findings at
the national level, that asbestos use between 1960–
1969 correlated with ARD mortality rates around the
year 2000.11 In addition, cumulative asbestos use
before 1970 predicted the recent cumulative number
of mesothelioma deaths.27 Thus we hypothesize that
the increased asbestos use observed after 1971 will
begin to take its toll.
In the present study, we observed characteristic
trends within groups and in individual countries.
Group B countries (i.e. countries with available data
for asbestos and ARD) had substantially reduced
asbestos use since 2001 (the average annual mean was
0.1 million tons), whereas group A countries (i.e. coun-
tries with available data for asbestos only) had sub-
stantially increased asbestos use during the same
period (the average annual mean was 1.2 million tons).
Similar trends were observed at the level of individual
countries, which suggested that countries reduced
their asbestos use after realizing the burden of ARD.
Although the reduction of asbestos use may correlate
with a country’s own acquisition of ARD data, the
‘lessons’ of other countries are not easily learned.
Western countries that used large volumes of asbes-
tos eventually experienced an epidemic of ARD,28
typically mesothelioma. At the national level, this
experience can be demonstrated graphically as the
‘double-peak’ curve,29,30 in which the ARD epidemic
curve follows the asbestos-use curve after several
decades.6 Several Asian countries are now following
this pattern: Japan (most typical; Fig. 2A), Korea
(typical; 2B), Singapore (possible; 2C) and Israel (pos-
sible; not shown). In these countries, the initial, rising
segment of the presumed ARD curve coincides with
the final waning segment of the asbestos-use curve.6
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
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773
Furthermore, the slopes of the rising segments of both
curves appear similar in their respective countries.
These findings suggest that countries will experience
ARD even after asbestos use is significantly decreased
and in a manner reflective of historical asbestos use.
It is highly unlikely that ARD are absent in countries
that have used large volumes of asbestos but do not
report the related numbers.27,31 In Asia, this problem is
especially relevant to China (Fig. 2E) and India (2F),
where levels of asbestos use have increased but are
still at moderate levels (lower than 1 kg/capita per
year). However, the moderate values are due to their
large populations, and the actual level of use is
high31,32 (e.g. in 2007, China and India used 626 000
and 302 000 tons, respectively; data not shown),
which could potentially expose many people to
asbestos. Recently we estimated the number of
mesothelioma cases in countries where the disease is
unreported by assuming that the cumulative number
of mesothelioma cases is related to the cumulative
asbestos use. These estimates suggested that China
and India have already ‘missed’ 5100 and 2200 cases,
respectively.27 Although high per capita use will likely
lead to high disease rates, moderate per capita use in
populous countries should not be underestimated.
The asbestos file of the USGS compiles information
on the production (mining), trade and use of asbestos
by country and has been referenced widely to assess
asbestos-related situations in the world. It is possible,
however, that the USGS data on asbestos use are not
as complete for less-developed countries, especially
in the earlier years. According to the USGS, Vietnam
and Mongolia first used asbestos in 1998. In a recent
scientific meeting to promote international coopera-
tion for the elimination of ARD in Asia, however,
national representatives reported contradicting infor-
mation: Vietnam established its first asbestos-cement
factory in the mid 1960s33 in the province of Dong Nai,
and Mongolia started to import asbestos in the early
1960s for application in power plants.34 These reports
are yet to be documented in the scientific literature,
but they suggest that some historical information is
not well documented.
Political actions by countries as countermeasures
for asbestos use were assessed in terms of the ratifi-
cation status of the ILO Asbestos Convention23 and
adoption of asbestos bans.24 Although the ratification
status of asbestos bans in Asia is similar to the rest of
the world, the ratification status is lower. Interestingly,
the three Asian countries taking both political actions
(i.e. Cyprus, Japan and Korea) have recently experi-
enced the burden of ARD. Previously, we reported on
early indications suggesting that the adoption of
bans may contribute to a subsequent reduction
in mesothelioma mortality at national levels.12 A prac-
tical recommendation to Asian countries is to not
only ban asbestos use as soon as possible, but also to
minimize exposure to asbestos and to ratify the ILO
Asbestos Convention.
The strength of the present study was that it was a
comparative assessment of a wide range of countries,
based on data in public databases, which has been
widely referenced and complemented by scientific
literature. In addition, the present study applied
Respirology (2011) 16, 767–775

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quantitative indicators to the data (e.g. AAMR and
per capita use). Our study had several limitations,
however, including the representation and compara-
bility of the original extracted data. The use of asbes-
tos may not have been fully grasped for each country
and ARD are known to be generally rare and difficult
to diagnose. The most serious bias could have been
the data validity in countries with limited experience
in diagnosing ARD and underreporting is probably
the most dominant problem.27 Hence, our findings
should be viewed as an underrepresentation of the
actual situation.
In conclusion, our analyses of available data in
public databases and the literature revealed a paucity
of information on ARD in Asia. This finding is likely
related to the fact that asbestos use was not high until
around 1970, but it is also compounded by the poor
political will to improve national situations and the
lack of resources to diagnose ARD. Most importantly,
asbestos use in Asia has increased drastically since
1970 and has reached formidable levels in terms of
per capita use and absolute volumes. A surge of ARD
in Asia should be anticipated in the coming decades.
Asian countries should not only cease asbestos use
but also prepare themselves for an impending epi-
demic of ARD.
ACKNOWLEDGEMENTS
This work was supported in part by the JSPS (Japan
Society for the Promotion of Sciences), the AA (Asia
Africa) Science Platform Program, and a Project for
the Development of a Toolkit for the Elimination of
Asbestos-Related Diseases, commissioned by the Rot-
terdam Convention Secretariat.
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