Autor : Rey Darío Raúl1-2
1 Consultant physician in Pulmonology, Hospital Gral. de Agudos Dr. E. Tornú
2 Director of the Bachelor’s Degree in Pulmonology, UBA (Universidad de Buenos Aires).
https://orcid.org/0000-0002-6586-2643
Correspondencia : Darío Raúl Rey E-mail: darioraul.rey@gmail.com
ABSTRACT
The
association of occupational exposure with respiratory diseases is well-known.
Non-occupational exposure has been recognized for over sixty years.
It
is necessary to differentiate two types of non-occupational asbestosis:
a)
Environmental (close or residential exposure).
b)
Domestic or home exposure.
Proximity
to a factory that uses asbestos is an important health risk.
The
environmental levels of this mineral can be dangerous when the clothes worn in
the workplace with exposure to asbestos are washed at home. Unaware workers
take their clothes home, and their homes could have high levels of asbestos.
Contaminated clothing should be left in the workplace.
Employees
and workers must be educated on the occupational risks and hazards, thus minimizing
the risk of developing a disease, especially one that can be prevented.
Key word: Home
asbestosis, Environmental asbestosis
RESUMEN
Es
ampliamente conocida la relación entre una ocupación laboral y
las enfermedades pulmonares. La exposición no ocupacional se reconoce
desde hace más de sesenta años.
Es
necesario diferenciar dos tipos de exposiciones en asbestosis no ocupacional:
a)
Ambiental (cercana o residencial).
b)
Exposición doméstica u hogareña.
La
vecindad a una fábrica, donde se utiliza amianto, representa un gran
riesgo para la salud.
Los
niveles del mineral en el medio ambiente pueden ser peligrosos cuando la ropa
usada en trabajos con amianto se lava en el hogar. Si debido al desconocimiento
llevaran su ropa a casa, los hogares de los trabajadores podrían
contener altos niveles de amianto. La ropa contaminada debe permanecer en el
lugar de trabajo.
Los
empleadores y los trabajadores deben ser educados sobre los riesgos y los peligros
de los riesgos laborales, lo que lleva a minimizar una enfermedad especialmente
prevenible.
Palabras
clave:
Asbestosis doméstica, Abestosis ambiental
Received: 09/16/2021
Accepted: 02/13/2022
INTRODUCTION
The
association of occupational exposure with the pulmonary diseases it may cause
is well-known, as well as the resulting severe health problem. The health of
the worker’s family may also be altered as a consequence of exposure to
dangerous substances in the workplace.
Their
health may be affected by toxic substances in the workplace, the community, and
at home. Industrial substances taken home by the worker are getting
increasingly involved as agents causing diseases in the family contacts.
The
most important vehicle for taking occupational substances home are the work
clothes, although there are some other personal objects that can be sources of
contamination at home.
The
non-occupational, non-work-related or take-home disease occurs when
dangerous substances are transported in contaminated clothes and infect the
household contacts.
Another
causal factor to consider is the fact of living near premises where industrial
safety and hygiene conditions are not suitably observed.
One
historical review stated that in the ‘60s arose the first publications
reporting a potential risk of disease related to asbestos in people who had
lived near industrial areas or mineral extraction sites, and also among the
workers’ families.
In
the ‘70s, there were reports that suggested the existence of asbestos-related
diseases in the household contacts of workers with occupational asbestos
exposure.
Between
1990 and 2011, additional cases of environmental exposure, both occupational
and non-work-related were published. There were many other reports about
workers with high or uncontrolled occupational exposure, decades ago.
Some
publications show the relationship between hazardous or contaminating
materials and familial diseases.
SOME FACTS ABOUT
ASBESTOS
In
the pre-Christian era, the non-flammable, fire-resistant properties of the asbestos
were already known. 100-150 years ago, it started to be used for industrial
purposes; since the 1950s, it gained a strategical position. Without the proper
respiratory protection, the inhalation of fibers or dust has enabled the
appearance of asbestosis, irreversible pneumoconiosis with fibrogenic and
carcinogenic action. Its negative prognosis is also related to this last effect
as cause of mesothelioma (MTM) and bronchopulmonary cancer.
Rusia,
China, Brazil and Kazakstán are great producers of this mineral. Rusia
is one of the largest asbestos consumers. Since 1999, it has banned its
industrialization; nevertheless, it is estimated that between 60% and 75% of
the asbestos used in the world comes from this nation2.
In
Argentina, the banning of asbestos and its derivatives is regulated and
legalized since 2003. In America: Brazil, Honduras, Chile and Uruguay have
banned it, too. Around the world: 58 countries have banned the use of
asbestos; most are European countries.
The
asbestos is classified in two groups: the amphiboles (its most representative
examples being “brown asbestos” or amosite, and “blue asbestos” or
crocidolite) and the serpentines (from which the chrysotile represents 90% of
industrial exploitation).
Apart
from the pathogenic effects already mentioned, asbestos inhalation causes many
exposure-response models such as round atelectasis, calcified pleural plaques
or a condition similar to pulmonary fibrosis3-8.
PATHOGENESIS OF
ASBESTOSIS
The
pulmonary disease associated with asbestos is complicated and not fully
understood.
The
size and appearance of the fiber, its environmental concentrations, chemical
composition and time of exposure may play a role both in the fibrogenesis and
the carcinogenesis.
In
order to establish the severity and the body’s response to the inhaled fibers
we should also take into account the host-related agents, his/her immune
status, smoking and pulmonary depuration mechanism.
Regarding
the degree of environmental concentration, time of exposure and respiratory
protection, asbestos can cause different clinical variants of the disease.
In
view of the above, the hazards of occupational exposure to asbestos are
well-known. Also, there are some studies that showed that non-work-related (or
environmental) manifestations increase the risk of MTM or lung cancer in the
general population9.
The incidence of MTM is 1.5/100,000 in men and 0.4/100,000 in women. In 2019,
3,209 cases were reported in U.S.A. From the classic study of Wagner, we are
aware about the causal relationship between this type of tumor and asbestos
exposure10, 11.
According to Melaiu, the incidence of the tumor in exposed workers is between
0.5% and 18%, whereas Sekido estimates that 20%-30% of cases of MTM were never
exposed to asbestos12,
13.
Non-Occupational
Asbestosis (NonOccupAsb)
Non-occupational
exposure has been recognized for over 60 years. Donovan et al carried out a
comprehensive review in 2012 about this topic, in which they evaluated more
than two-hundred articles, and found that 65% of the patients were relatives of
miners, electricians, shipyard workers or operators that make products with
asbestos. They also pointed out that 98% of lung biopsies of NonOccupAsb showed
amphiboles14.
A
thorough study conducted by Newhouse and Thomson in 1965 revealed that 52.6% of
83 pleural or peritoneal MTMs had history of non-work-related or domestic
exposure. They emphasized the evidence of living near an asbestos factory,
since 30.6% of the MTM cases lived less than 1 km from an industrial area (p
< 0.01)15.
In
1976, Selikoff et al researched 326 healthy household contacts, 25-30 years
after the beginning of a possible asbestos contamination, and found anomalies
in 35% of the chest X-rays16.
In
relation to the topic of this article, it is important to distinguish between
two classes of exposure in NonOccupAsb:
a)
Close exposure (or environmental or residential exposure).
b)
Domestic exposure (or home exposure).
Close exposure
Even
though the plaster collapses from natural processes, in the past, mortar with
asbestos was used to build walls and roofs as insulation and for aesthetic
purposes. So, as asbestos was used for the construction of buildings, both in
the past and now there still exists the possibility of exposure to this
mineral, and the affected person may not be aware of that. The findings on
calcified pleural plaques indicates possible previous asbestos exposure.
Cases of patients with MTM have been published, in which the only aspect that
could be researched was the place where the individuals had lived before or
where they are living now. Some examples are: office clerks, teachers and
employees17.
There
is extensive bibliography on this subject. In the ‘70s, Artviniki and Baris
studied 312 inhabitants of a town in Turkey and a control group. The results
showed 22 MTMs that corresponded to a high incidence of 6.5/1,000,000/year. The
research showed the presence of asbestos in building stones, fields, roads and
in the lung tissue of the citizens, as opposed to zero cases in the control
group18.
We
must focus on the study of the Constantopoulos group, who researched and
published the results obtained in four Greek towns for twenty years. Baseline
results revealed that 45.5% of the inhabitants had pleural calcifications
increasing with age up to 81% in persons older than 70 years. The
identification of amphiboles both in soil samples and lung biopsies was enough
to consider it as the causative agent of that disease.
In
1985, seven cases of MTM were diagnosed in the population, meaning 280 times
higher than expected increase (1/1,000,000/year).
It
was related to an asbestos-containing type of lime used to whiten the walls of
the houses. Since it was less and less used, the incidence of MTM has been
reduced to 33% of the expected incidence.
In
2017, the group published a new study that showed that, after having
interrupted the use of lime, only two inhabitants presented minimum
calcifications, and the tomographic studies of 22 young adults were negative19-22.
Proximity
to a factory that uses asbestos is an important health risk. In Northern Italy,
there was a fiber cement factory between 1932 and 1993. The rate of MTM in
Lombardy exposed a high impact of asbestos exposure on the incidence of the
tumor among workers, their families, and people who lived in close proximity.
Between
2000 and 2016, 39 cases of MTM were found among workers’ household members
(4.24 expected) and 91 cases in inhabitants (7.43 estimated), in individuals
who had never had occupational or non-work-related exposure. The total number
of excess cases (including factory workers) was approximately 194 (17.24
expected).
Even
though the premises were closed, the incidence of MTM associated with the
factory is still high for the workers, their families and the neighbours23.
In
Barcelona, there was a fiber cement factory between 1907 and 1997. 1,107 cases
of NonOccupAsb were diagnosed between 1970 and 2006 with values of 9.5/100,000
among neighbors of the area and 35.5/100,000 among the people living near the
premises. The prevalence of NonOccupAsb was 91/100,000 in inhabitants of the
area and 353.4/100,000 in people living near the factory, with 8.4% for MTM and
86.5% for non-malignant masses, assuming a serious conflict for workers and the
population24.
In
their interesting article, Reid et al research the deaths of an Australian
female population between 1950-2004 without occupational asbestos exposure,
and found 455 deaths, 30 of them from MTM. The risk of death was excessive for
all types of cancer, and MTM in particular was associated with handling or
washing the work clothes of the local mine workers. Thus, the former
inhabitants of this population who had been exposed to asbestos at home or in
their environment showed excess of mortality from cancer, including MTM25.
We
can deduce that there is strong evidence of a higher risk of MTM among subjects
whose exposure is of non-occupational or domestic origin. The risk of MTM as a
consequence of living near an industry that uses asbestos (deposits, mineral
processing plants, mills) is certainly confirmed. NonOccupAsb explains around
20% of the MTMs in industrialized countries26.
The
magnitude of the problem can be reduced through the adequate regulation of the
workplace and increased awareness amongst healthcare professionals.
Controlling diseases of familial occurrence depends mostly on raising awareness
among the population and the participation of the authorities.
Find
attached two personal comments regarding the NonOccupAsb of close exposure:
Case
1: FP, 80 years old, non-smoker. No dyspnea. Transferred due to “abnormalities
in chest CT”. Numerous pleural calcifications observed in both hemithorax. Never
worked with asbestos directly, but had non-occupational exposure to the mineral
for fifteen years, (administrative manager at the repair shop of the AFIP
[Federal Administration of Public Revenue, for its acronym in Spanish]) (Figures
1 and 2).
Case
2 JB, 53 years old. Transferred due to “lung tumor”. Non-smoker. Chest CT:
round atelectasis and calcifications in diaphragmatic pleura. Twenty years
ago, he worked as office clerk in an office with insulation roofs. The roofs
were destroyed after a storm, so he lived for a long time in contact with
environmental pollution (Figures 3 and 4).
Domestic exposure
When
someone washes the clothes used in jobs exposed to asbestos, the levels of the mineral
in the home environment may account for several hundred fibers per milliliter.
As a result, the homes of the workers could contain high levels of asbestos if
they unknowingly take their clothes home27.
In
1992, Dodoli et al reviewed 39,650 death certificates of Livorno (1975-1988)
and 45,900 of La Spezia (1958-1988), and found 262 cases of pleural MTM. Most
cases were workers of the boat building industry.
Regarding
non-occupational asbestos exposure, thirteen cases of MTM were found in women
who had washed the clothes of their relatives and six possible cases due to the
installation of fire-resistant or insulation materials in the domestic
environment, which allowed us to think that the cases could be more common than
expected28.
A
publication of Rake et al researched the home and work history of 622
individuals with MTM and 1,420 controls. The results showed that the risk of
life was the same for both genders in non-exposed individuals, but it doubled
in the family contacts of workers exposed to asbestos. In 38% of women and 86%
of men, it could be attributed to asbestos exposure both at home and in the
workplace29.
Italy
has a MTM record, so it is possible to update and know the number of cases,
its incidence, its prevalence and its relationship with the jobs and types of
exposure. D’Agostin et al studied the characteristics of MTM in Veneto, which
could only be attributed to the asbestos brought home by the workers,
especially those who worked in shipyards. The study was carried out by means of
a standardized medical-work interview and a questionnaire.
35
MTMs were attributed to home exposure (including two workers’ sons). Workers’
exposure to asbestos occurred mainly in the shipyards. The mean latency time
was 59 years, and the spouses had a significantly shorter interval between the
exposure and appearance of the disease, thus confirming that domestic
concentration increases the risk of MTM in women without history of occupational
exposure to asbestos30.
In
the study of Hilbert et al, asbestos workers and their families underwent a
chest X-ray and answered questionnaires regarding personal hygiene and
possible access to mineral exposure. The assessment of the X-rays was done in
accordance with the International Labor Organization (ILO) Guides31.
118
workers and 122 household contacts participated in the study. 53% of workers
showed radiographic alterations, and this number was reduced by 2% in household
contacts.
The
high prevalence of pleural alterations and the pulmonary interstice in workers
didn’t correspond with similar changes in household contacts, and this was the
result of the individual hygiene behavior of most workers.
The
use and habitual washing of work clothes in the workplace, as well as having a
bath before leaving the premises are important factors that could contribute
to reducing possible home contamination and preventing adverse results in the
worker’s family32.
Case
3 Personal comment regarding domestic NonOccupAsb: NC, 63 years old.
Woman. Smoker, 40 packs/year, consulted because of chronic bronchitis
progression. Auscultation: velcro-type crackles in the bases. Chest CT:
extensive honeycombing associated with pleural calcifications. During her
childhood and adolescence, she cleaned her shoes and those of her siblings with
an asbestos burlap (the burlap had been taken home by her father, an electrician
working in a sugar mill) (Figures 5 and 6).
PREVENTION
It
is extremely important to ensure that contaminated clothes remain in the workplace.
The IOSHA (Industrial Occupational Safety and Health Administration)
regulations require among other things, that employers provide the workers with
work clothes, proper environmental ventilation, showers and dressing rooms.
Occupational
physicians and health and safety professionals have a significant role in the
detection and prevention of occupational or environmental diseases. The
anamnesis related to the type of work, environmental characteristics and the
way in which the task is performed, knowledge of the risks and taking them home
are all elements of prime importance for identifying occupational and
non-occupational diseases.
It
is also important to know about previous tasks, since they may be related to
the current disease.
Demolitions
can release fibers containing dispersed asbestos. Perkins et al published a
study about air monitoring in buildings to be demolished to check the presence
of asbestos. They also controlled the personnel involved and the air of the
area around the sites. In general, there weren’t asbestos fibers, and real
exposure to this element was frequently below the limit of detection. The
buildings were washed with fire hose water during demolition, requiring great
amounts of liquid; undoubtedly, this contributed to the results obtained33.
Nicholson et al evaluated asbestos concentrations in damaged
buildings, in the surroundings of those buildings, and in the homes of workers
who worked with asbestos. Of the 89 air samples, 43 exceeded 50 ng/m3, showing the
need of promoting corrective measures or proper surveillance34.
Occupational exposure is extremely important. State or provincial
organizations, occupational physicians or industrial hygiene and safety
engineers or technicians who intervene in the workplace can be consulted to
know the degree of occupational exposure and limits allowed by law.
Through primary care both the employer and the worker can be
educated on the risks they face and also the para-occupational etiology
hazards, with the purpose of minimizing a specially preventable disease.
Conflict
of interest
Authors declare there isn’t any conflict of interest in relation
to this publication.
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