Occupational and 9/11 Exposures: Risk for Disease

Jacqueline Moline, MD, MSc, FACOEM, FACP

Director, Queens World Trade Center Clinical Center of Excellence

Vice President and Chair, Department of Population Health

North Shore University Hospital and Long Island Jewish Medical Center

Cases of mesothelioma each year in the US: roughly 3300

Cases of mesothelioma each year in the US appears to have peaked around the year 2000 and is now declining, thanks to strict regulation

Worldwide, though, cases of mesothelioma is increasing

In industrial nations, number of cases will peak this decade

In poorer countries, much higher numbers are expected due to lack of regulation, widespread use of asbestos commercially and in homes.

Mesothelioma: Trends

Price B, Ware A. Critical Reviews in Toxicology.

Aug2009, Vol. 39 Issue 7, p576-588 *age-adjusted

Incidence* of mesothelioma (per 100,00) for 17 states

Moolgavkar SH, Meza R, Turim J. Pleural and peritoneal

mesotheliomas in SEER: age effects and temporal trends, 1973-

2005. Cancer Causes Control. 2009 Aug;20(6):935-44.

Incidence of mesothelioma (per 100,00)

*age-adjusted

Price B, Ware A. Critical Reviews in Toxicology.

Aug2009, Vol. 39 Issue 7, p576-588

Incidence* of mesothelioma (per 100,00) for NY state

Projected Total Mesothelioma Cases through 2054

Price B, Ware A. Critical Reviews in Toxicology.

Aug2009, Vol. 39 Issue 7, p576-588

Construction Asbestos product manufacturing

(insulation, roofing, building materials)

Automotive repair shops (especially those that involve repair of brakes, clutches)

Mining companies Nonmetallic mineral stone

products Offshore rust removal

businesses Oil refineries Power plants Maritime companies

Sources of Asbestos Exposure: Industry

Shipbuilders, ship lines, and ship yards, repairing

Chemicals and other manufacturing

Railroads and Railways Yarn, thread, and fabric mills Trucking Plastic and rubber

manufactures Manufacturers of sand or

abrasives Steel manufacturers Tile cutters

Glazers Grinders Hod carriers Insulators Iron workers Laborers Libby vermiculite workers Longshoremen Painters Plumbers Pipefitters Auto Mechanics Plasterers Steamfitters Maintenance workers Operating engineers Drywallers Electricians Insulation workers Textile workers

Demolition Workers

Floor covering workers

Millwrights

Carpenters

Bricklayers

Laborers

Boilermakers

Furnace Workers

Building Inspectors

Merchant Marines

Welders and cutters

Janitors

Roofers

Refinery workers

Sheet metal workers

Shipyard workers

Tile setters

U.S. Navy personnel

Miners and millers

Sources of Asbestos Exposure: Occupation

Duct and home insulation Fire protection panels Fireplace artificial logs or ashes fuse box liners Gypsum wallboard Hair dryers Toasters Heater register tape and insulation Joint compounds Patching and spackling compounds Pipe or boiler insulation Pot holders and ironing board pads Sheet vinyl or floor tiles Shingles Textured acoustical ceiling Textured paints Underlayment for flooring and carpets Cement Pipes Elevator Brake Shoes Cement Wallboard HVAC Duct Insulation Cement Siding

Boiler Insulation Asphalt Floor Tile Breaching Insulation Vinyl Floor Tile Ductwork Flexible Fabric Connection Vinyl Sheet Flooring Cooling Towers Flooring Backing Pipe Insulation (corrugated air-cell, block, etc.) Construction Mastics (floor tile, carpet, ceiling tile, etc.) Heating and Electrical Ducts Acoustical Plaster Electrical Panel Partitions Decorative Plaster Electrical Cloth Textured Paints/Coatings Electric Wiring Insulation Ceiling Tiles and Lay-in Panels Chalkboards Spray-Applied Insulation

Roofing Shingles Blown-in Insulation Roofing Felt Fireproofing Materials Base Flashing Taping Compounds (thermal) Thermal Paper Products Packing Materials (for wall/floor penetrations) Fire Doors High Temperature Gaskets Caulking/Putties Laboratory Hoods/Table Tops Adhesives Laboratory Gloves Fire Blankets Joint Compounds Fire Curtains Vinyl Wall Coverings Elevator Equipment Panels Spackling Compounds

Other Sources of Asbestos Exposure

Sources of Asbestos from the Environment

Asbestos Fiber in the Lung

Direct use

Indirect use for insulation and auxiliary tools

Construction sector

Accidental and unaware exposures

Exposures to Asbestos – Four Macrocategories

Marinaccio et al; Int. J. Cancer 2012;130:2146-2154

Shipbuilding and repair

Asbestos cement industry

Railroad carriages construction and maintenance

Asbestos mining

Port handling

Asbestos textile industry

Friction materials production

Gaskets and packing production

Direct Use

Metal and engineering

Metallurgic

Oil refineries

Metal, food and drink industries

Sugar refineries

Organic and inorganic chemical plants

Wood processing

Power plants

Heat and steam generation

Tobacco

Leather tanning

Non-asbestos textile finishing

Glass and ceramic

Paper

Jewelry

Gas production

Navy and military defense work

Indirect Use

Spray-on asbestos

Ceilings

Floor tiles

Wallboard

Plaster/cement

Joint compound

Electrical work

Fire doors

Boilers

Steam pipes

HVAC

Sheet metal work

Caulk

Elevator work

Construction Sector – The Whole Industry!

Car mechanics

Brake mechanics

Heavy machine operators

Jute sack recycling

Dentists

Service industry employees where asbestos was in place

Talcum powder use

Laboratory workers

Researchers

Accidental and Unaware Exposure

50 year old advertising executive

In excellent overall health

Professional career spent in offices

No home renovations

Case #1

Full occupational history revealed college employment of note

Worked in an automobile manufacturing plant for three summers as a parts picker while in college

Father and brother also worked in same automobile plant

Parts: friction materials that contained asbestos

Case #1

54 year old dentist

Worked as dentist entire career, no other employment

Case #2

Crowns were made in dental school using the lost wax technique with asbestos containing dental tape

Similar exposures seen in jewelry industry using the same lost wax technique

Case #2

72 year old physician

In excellent health

Noticed shortness of breath while exercising

Diagnosed with mesothelioma

Case #3

Worked in a laboratory for years

Exposures from laboratory equipment

– Asbestos gloves

– Asbestos mesh

– Asbestos pads

– Insulation used around crucibles

Case #3

The asbestos fiber becomes coated with iron and calcium, which is why it is often referred to as a "ferruginous body" as seen here with an iron stain. Ingestion of these fibers by macrophages sets off a fibrogenic response via release of growth factors that promote collagen deposition by fibroblasts.

During work with asbestos

During work in the same space as others working with asbestos

On worker’s skin, hair, and clothing

In areas surrounding a mining operation

In areas of the world where construction or other human activity (such as gardening) results in disturbance of natural outcrops of asbestos-bearing rock

In homes and buildings where renovations or demolitions disturb asbestos-containing building materials

Methods of Exposure

Australian mesothelioma registry data

Rates steadily rising over past two decades

Most MM cases in men, but this type of exposure is much higher as a proportion in women

Men: increase from 3% to 8% from 1990s to 2005-2008

Women: increase from 5% of cases to over 35% of cases in same time period.

Incidence of Mesothelioma Increasing after Home Maintenance and Renovation

Most important non-occupational exposure

Exposure might be from performing the home renovations

Exposure might be from being present while renovations took place

Most instances, exposure might have lasted only a few days

Home Renovation as a Source of Asbestos

Pleural and parenchymal changes are significantly more prevalent in exposed households of asbestos workers

– 35% demonstrate pleural changes

– 17% demonstrate parenchymal changes.

Population surveys have identified higher rates of pleural abnormalities in locations where asbestos occurs naturally ranging from 2% and 17% of individuals.

Non-Occupational Environmental Asbestos Exposures

Shifting Gears: A Unique Exposure

Fallout from the World Trade Center disaster

Dust cloud from the WTC collapse. Source: NYPD

Lioy, Environ Health Perspectives, 2002;110:703-14

WTC Dust: Particle Composition

WTC Dust: Particle Size Large particles >> Small (respirable)

Alkaline pH (lye)

Larger the size, the more alkaline the pH

1-4% by mass were respirable particles PM2.5

Even large particles reached lower airways

– High concentrations – Mouth breathing

Particle Size (MMAD μm) 2.5 10 53 pH ~8.1 >10.0

Chen et al; Lancet 2002;360:S37-8.

Gavett et al; Environ Health Perspect 2003;111:981-91

WTC Dust: Particles, Gases and Fumes

Gypsum, calcite and crystalline silica

Diesel particulates and carbon monoxide

Glass, cellulose and crystalline asbestos fibers

Mercury and heavy metals

Volatile organics (benzene)

Semi-volatiles: PAHs, PCBs, Dioxins and Furans

Landrigan, Environ Health Perspectives,

2004; 112:731-9

Source Air Pollution

Constituents

Health Effects

Structural Collapse

Cement, ceiling tiles, drywall Calcium carbonate / Gypsum /

Vitreous Fibers

Airway and

pulmonary

irritation Calcium sulfate

Windows Glass fibers, Silicates

Fire retardant Asbestos Cancer

Combustion

Incomplete combustion -

plastics

Organic hydrocarbons Cancer

Diesel-powered rescue

equipment

Diesel exhaust Airway irritation,

cancer

WTC Dust: Known Health Effects

38 year old firefighter at Ground Zero from 9/11 – 9/24/01

Admitted with Pa02 of 53 mmHg, progressive dyspnea and cough

CT showed patchy ground glass densities, thickened bronchial walls and bilateral pleural effusions

Rom, et al Am J Respir Crit Care Med 2002; 166:797-800.

Acute Eosinophilic Pneumonia In a Firefighter

Chest CT. One-millimeter-thick section at the lung bases depicts patchy areas of consolidation (arrows). There is bronchial wall thickening and small pleural effusions (asterisks).

70% eosinophilia

Mineralogical analysis of lavage fluid

– Uncoated asbestos (chrysotile and amosite)

– Chromium

– Degraded fibrous glass

– Fly ash

– Metal particles

– Various silicates

Bronchoscopy Lavage Findings

Lancet 9/3/2011

Note: After correction for potential surveillance bias, Too few cases to achieve statistical power for any individual cancer analysis.

Lancet 9/3/2011

Cancer – WTC Covered Condition 10/12/12