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IMPACTO DA EXPOSIÇÃO AO AMIANTO NAS DOENÇAS RELACIONADAS (DRA): A EXPERIÊNCIA DO CANADÁ��(The Health Impact of Asbestos: the Canadian Experience)

Paul A. Demers, Ph.D.

Occupational Cancer Research Centre, Ontario Health

Dalla Lana School of Public Health, University of Toronto

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Asbestos in Canada

Canada was once the worlds largest producer of asbestos
In the 1970’ & 1980’s use of asbestos began to be restricted and occupational exposure limits gradually dropped
By the early 1990’s mining outside of the province of Quebec stopped and in 2012 the last mine ceased operations
In 2018, Canada finally banned asbestos
However, the legacy of asbestos exposure will continue for many decades to come

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Asbestos in Canada: prevalence of exposure

Source: CAREX Canada (Asbestos Occupational Exposures)

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Asbestos in Canada: level of exposure

Source: CAREX Canada (Asbestos Occupational Exposures)

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https://www.odsp-ocrc.ca/

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https://www.odsp-ocrc.ca/

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Age-adjusted Mesothelioma Incidence Rates by Sex

British Columbia

Ontario

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Mesothelioma Incidence Rates by Sex: Ontario

Pleural

Peritoneal

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Ontario Mesothelioma Incidence Rates

Women

Men

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Mesothelioma Incidence in Ontario by Census Division 1992-2016

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Asbestos Workers Registry (AWR)

In 1986, Ontario Asbestos Workers Register was created to register people exposed to asbestos. It is a mandatory exposure registry that relies only on reported exposure information.
Linkage study: primary objective was to estimate the risk of cancer and non-malignant respiratory disease among workers in the AWR.

26,401 workers successfully linked to Ontario health records

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AWR Health Outcomes by Gender

	Male Incidence (n=25,479)			Female Incidence (n=823)
	Cases	SIR*	95% CI	Cases	SIR*	95% CI
All Cancer	3352	0.99	(0.95-1.02)	131	1.08	(0.90-1.28)
Lung Cancer	560	1.12	(1.03-1.22)	30	1.66	(1.12-2.36)
Mesothelioma	102	6.55	(5.34-7.96)	<6	19.3	(3.87-56.3)
All Respiratory Disease	16112	1.89	(1.86-1.91)	599	2.24	(2.06-2.42)
COPD	2214	2.34	(2.24-2.44)	107	2.62	(2.14-3.16)
Asbestosis	166	11.1	(9.46-12.9)	<6	1.21	(0.02-6.75)
Pulmonary Fibrosis	197	13.8	(11.9-15.9)	<6	9.15	(2.46-23.4)

* Standardized Incidence Ratio’s adjusted for 5-year age and calendar period.

As might be expected in any large population with asbestos exposure, the relative risk of mesothelioma was much higher than the general population, especially in women. However, the relative risk of lung cancer was only slightly elevated in men (12%), though more substantially elevated in women (66%). The relative risk of asbestosis was much higher than the general population (11 times higher in men, with too few cases among women to report). Interestingly, the risk of pulmonary fibrosis, which excludes asbestosis, silicosis and similar diseases, was also highly elevated (14 times higher in men, 9 times higher in women), which raises the possibility that some cases of asbestosis may be misdiagnosed. Perhaps the most surprising finding was a large excess of chronic obstructive pulmonary disease (COPD) among both men and women. COPD is often attributed to cigarette smoking, but the lack of a large excess of lung cancer makes that explanation unlikely.

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AWR Compared to Ontario Rates

	Construction (n=15,933)			Manufacturing (n=4,680)
	cases	SIR*	95% CI	cases	SIR*	95% CI
Lung Cancer	299	1.4	(1.3-1.6)	128	0.9	(0.8-1.1)
Mesothelioma	63	10.1	(7.8-13.0)	22	4.6	(2.9-6.9)
COPD	1310	3.1	(2.9-3.3)	505	1.8	(1.6-1.9)
Asbestosis	107	18.1	(14.8-21.9)	29	6.2	(4.2-9.0)
Pulmonary Fibrosis	102	11.6	(9.5-14.1)	53	17.5	(13.1-22.9)

* Standardized Incidence Ratio’s adjusted for sex & 5-year age & calendar period.

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Group	Asbestosis (HR 95% CI)	Mesothelioma (HR 95% CI)
Construction industry	2.5 (2.1-3.0)	2.0 (1.6-2.3)
General contractors	1.1 (0.8-1.6)	1.5 (1.1-2.0)
Special-trade contractors	3.1 (2.6-3.8)	2.1 (1.7-2.5)
Construction trades occupations	3.6 (3.1-4.3)	2.4 (2.0-2.8)
Construction electricians & repairmen	3.3 (2.4-4.6)	2.1 (1.4-3.2)
Carpenters and related occupations	2.0 (1.4-2.8)	1.7 (1.2-2.5)
Plasterers and related occupations	5.6 (3.4-9.3)	2.3 (1.1-4.9)
Insulators	35.2 (21.7-57.0)	25.8 (15.2-43.8)
Pipefitting and plumbing	8.2 (6.4-10.5)	5.9 (4.5-7.7)
DeBono NL et al, American Journal of Industrial Medicine 2021;64:476-487.

ODSS Results: Mesothelioma & Asbestosis in Construction

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Group	Asbestosis (HR 95% CI)	Mesothelioma (HR 95% CI)
Other Industry Sectors
Asbestos mines	25.4 (3.6-182)	240 (119-483)
Misc. non-metallic minerals products	8.4 (5.1-13.7)	6.5 (3.8-11.0)
Primary metals industries	2.4 (1.8-3.1)	1.8 (1.3-2.4)
Manufacture of industrial chemicals	5.7 (3.0-10.6)	3.9 (1.9-7.8)
Electric power	4.5 (3.2-6.4)	2.2 (1.4-3.5)
Education & related services	1.6 (1.2-2.1)	1.3 (1.0-1.8)
Other Occupations
Industrial, farm & construction mechanics	1.5 (1.0-2.1)	1.8 (1.3-2.4)
Stationary engine & utility equipment operators	1.5 (0.8-3.1)	2.5 (1.5-4.3)
DeBono NL et al, American Journal of Industrial Medicine 2021;64:476-487.

ODSS Results: Mesothelioma & Asbestosis

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Labrèche F et al. The current burden of cancer attributable to occupational exposures in Canada. Prev Med 2019;122:128-139.

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Burden of Occupational Cancer in Canada

New cancers each year:1,900 lung cancers, 430 mesotheliomas, 45 laryngeal cancers & 15 ovarian cancers
Digestive cancers more difficult to estimate
Many additional cases of asbestosis and other lung diseases

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Asbestos: Economic Burden

Healthcare & administrative

Caregiving & out-of-pocket

Output & productivity

Health-related quality of life

Lung Cancer

Mesothelioma

Average cost per case

Total Cost

$980K

$1.1 M

$1.9 billion

$480 million

5%

4%

9%

14%

3%

8%

82%

75%

Tompa E et al. The economic burden of lung cancer and mesothelioma due to occupational and para-occupational asbestos exposure. Occup Environ Med 2017;74:816-22.

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Asbestos Management

Purpose:

To explore best practices and identify potential gaps in asbestos management in Canada
To determine if there is a need for a national standard

Methods:

Review of scientific and grey literature
Environmental scan
Key informant interviews
Gap analysis and recommendations

Take a moment to establish common understanding of key terms:

CSA Group:

What is a standard?

Not a regulation.
Voluntary document - developed and approved through a defined consensus process involving a broad group of affected parties or their representatives
Available for use by an individual, private organization or government
Compliance is only mandatory when a standard is referenced by a government or a regulatory authority in their regulations

What is a National Standard?

A standard intended and approved for application across all Canadian jurisdictions (marketplaces), usually available in both French and English;

Methods:

Literature review – 8 databases

Environmental scan – regulations for managing and controlling asbestos exposure in 14 Canadian jurisdictions & 8 international jurisdictions

Key informant interviews – 31 stakeholders from across Canada and a range of asbestos management roles: regulators, employer and labour representatives, consultants, abatement contractors, NGO’s (e.g., Asbestos Free Canada, Saskatchewan Asbestos Disease Awareness Organization)

Gap analysis and recommendations – created 23 cross-cutting tables to summarize and compare key regulatory requirements across the 14 Canadian jurisdictions

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Multiple legislative & regulatory frameworks

Asbestos management

Public health

OHS

Environmental

Other

37 pieces of legislation

22 general
15 industry-specific

18 pieces of legislation

14 pieces of legislation

Transportation of Dangerous Goods
Employment Standards
Trades Certification
Building Codes
Home Inspection
Real Estate

2 pieces of legislation

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Key gaps & challenges identified

Multiple legislative and regulatory frameworks
Identification of asbestos and asbestos containing materials
Assessment and categorization of risk
Control of risk
Training and determination of competency
Management and disposal of asbestos waste
Asbestos in the residential and commercial sectors

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Obrigado!

Thank You!

Towards a cancer free workplace