Asbestos: use, bans and disease burden in Europe

Bull World Health Organ 2014;92:790–797 | doi: http://dx.doi.org/10.2471/BLT.13.132118 Research 790 Asbestos: use, bans and disease burden in Europe Takashi Kameda,a Ken Takahashi,a Rokho Kim,b Ying Jiang,a Mehrnoosh Movahed,a Eun-Kee Parkc & Jorma Rantanend Introduction The World Health Organization (WHO), joined by the Inter- national Labour Organization (ILO)1 and the United Nations Environment Programme, has called on countries throughout the world to eliminate asbestos-related diseases.2–4 WHO advises that the best way to eliminate such diseases is to stop using all types of asbestos.2 Although numerous countries have adopted national asbestos bans, many others continue to use asbestos at various levels. The use has declined 55% from its historical peak of 4.7 million metric tonnes per year in 1980,5 but more than 2 million metric tonnes per year are still used worldwide.6,7 WHO estimates that 107 000 global annual deaths are caused by mesothelioma, asbestos-related lung cancer and asbestosis.8 In 2005, occupational exposure to asbestos was estimated to cause 43 000 mesothelioma deaths9 and 7000 deaths due to asbestosis10,11 worldwide. Of those caused by mesothelioma, 7000 were attributed to Europe.9 However, the current and future burden of asbestos-related diseases in Europe has not been fully addressed, nor have such data been examined in relation to national asbestos bans. Through the Parma Declaration on Environment and Health, member countries of the WHO Regional Office for Europe agreed on the need to eliminate asbestos-related dis- eases.12 WHO and ILO specifically urged each country to for- mulate a national programme for eliminating asbestos-related diseases and develop a national asbestos profile3 as milestones for implementing the Parma Declaration by 2015.12 Asbestos use is a key item of a national asbestos profile. The volume of asbestos produced per person has been used to characterize the asbestos situation in various populations,13–15 and can serve as a surrogate for population-level exposure. In addition, a list of asbestos use per capita across countries and over time16 has been included in a recent monograph of the International Agency for Research on Cancer.17 Per capita asbestos use has also been employed to estimate and predict asbestos-related diseases in different populations.16,18–20 We conducted a descriptive analysis of national data on asbestos use and asbestos-related diseases in Europe account- ing for the status of national asbestos bans. Methods European countries were defined as the 53 countries in the European Region of WHO. Data on raw asbestos in these countries were obtained from the database of the United States Geological Survey5,6 and its updated data file (RL Virta, United States Geological Survey, personal communication, March 6, 2013). The definition of use – production plus import minus export – followed that of the United States Geological Survey.5 Data on asbestos use by country were available in 10-year intervals for 1920–1970, in 5-year intervals for 1970–1995 and annually for 1995–2012. We treated a reported negative value of asbestos use (e.g. reflecting storage from previous years) as zero. For years lacking data, reported data from the closest years were interpolated. We also retrieved informa- tion on the national status of asbestos bans21,22, ratification of the ILO Asbestos Convention23 and health system ranking.24 Data on asbestos-related diseases were extracted from the WHO mortality database;25 these included the number of deaths recorded as mesothelioma (International Classification Objective To analyse national data on asbestos use and related diseases in the European Region of the World Health Organization (WHO). Methods For each of the 53 countries, per capita asbestos use (kg/capita/year) and age-adjusted mortality rates (deaths/million persons/ year) due to mesothelioma and asbestosis were calculated using the databases of the United States Geological Survey and WHO, respectively. Countries were further categorized by ban status: early-ban (ban adopted by 2000, n = 17), late-ban (ban adopted 2001–2013, n = 17), and no-ban (n = 19). Findings Between 1920–2012, the highest per capita asbestos use was found in the no-ban group. After 2000, early-ban and late-ban groups reduced their asbestos use levels to less than or equal to 0.1 kg/capita/year, respectively, while the no-ban group maintained a very high use at 2.2 kg/capita/year. Between 1994 and 2010, the European Region registered 106 180 deaths from mesothelioma and asbestosis, accounting for 60% of such deaths worldwide. In the early-ban and late-ban groups, 16/17 and 15/17 countries, respectively, reported mesothelioma data to WHO, while only 6/19 countries in the no-ban group reported such data. The age-adjusted mortality rates for mesothelioma for the early-ban, late-ban and no-ban groups were 9.4, 3.7 and 3.2 deaths/million persons/year, respectively. Asbestosis rates for the groups were 0.8, 0.9 and 1.5 deaths/million persons/year, respectively. Conclusion Within the European Region, the early-ban countries reported most of the current asbestos-related deaths. However, this might shift to the no-ban countries, since the disease burden will likely increase in these countries due the heavy use of asbestos. a Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Iseigaoka 1-1, Yahatanishiku, Kitakyushu, Japan. b WHO Western Pacific Regional Office, Suva, Fiji. c Department of Medical Humanities and Social Medicine, Kosin University College of Medicine, Busan, Republic of Korea. d University of Jyväskylä, Jyväskylä, Finland. Correspondence to Ken Takahashi (email: ktaka@med.uoeh-u.ac.jp). (Submitted: 31 October 2013 – Revised version received: 19 June 2014 – Accepted: 29 July 2014 – Published online: 17 September 2014 ) Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118 791 Research Disease burden related to asbestos use in EuropeTakashi Kameda et al. of Diseases, 10th Revision [ICD-10], C45)26 or any subcategory and asbestosis (ICD-10, J61) between 1994 and 2010. Asbestos-related lung cancers were precluded from our analysis because of difficulties in attributing causation. Separately, deaths recorded for malig- nant neoplasm of the pleura (ICD-9, 163), a condition generally synonymous with mesothelioma of the pleura, were counted between 1994 and 2009. To investigate countries that did not report data to WHO, we searched PubMed, governmental websites and other web- sites that we thought were credible27–30 for national frequency data on asbestos use and asbestos-related diseases. To calculate rates, national population data for 1920–2012 were obtained in the fol- lowing order – depending on data avail- ability and reliability – from WHO,25 the United States Census Bureau31 or Lahmeyer.32 To analyse asbestos use and asbes- tos-related diseases in each country, we calculated per capita asbestos use (kg/ capita/year) and age-adjusted mortal- ity rates (deaths/million persons/year), respectively. Age-adjusted mortality rates were calculated using a direct age- adjustment method with reference to the WHO world standard population.33 We analysed all countries individually, together and in groups based on national asbestos ban status, i.e. early-ban (ban adopted by 2000; n = 17 countries), late- ban (ban adopted 2001–2013; n = 17 countries), and no-ban (no ban adopted as of 2013; n = 19 countries). To provide continuity with data from currently existing countries, data on historical asbestos use from countries that had undergone political transitions (e.g. dissolution or unification) or had been combined with other countries or entities by the United States Geo- logical Survey (n = 14) were obtained as follows. First, in the United States Geological Survey database, data for the Soviet Union (1920–1990) represented Kazakhstan and the Russian Federation combined. We apportioned the data between Kazakhstan and the Russian Federation according to the ratio of use recorded by these countries between 1995 and 2012. Second, data for West and East Germany (1950–1985) were combined into Germany. Third, data for Czechoslovakia (1920–1990) were apportioned to the ratio of asbestos use recorded by the Czech Republic and Slovakia between 1995 and 2012. Similarly, the data for Montenegro and Serbia (1930–1990) were apportioned to the ratios recorded by Bosnia and Herzegovina, Croatia, Montenegro, Serbia, Slovenia and the former Yugo- slav Republic of Macedonia between 1995 and 2012. In the United States Geological Survey database, the data for Montenegro and Serbia (1999–2005) were combined; we apportioned the data to Montenegro and Serbia according to the sizes of the respective populations during this period. Finally, the com- bined data for Belgium and Luxembourg (1930–2005) were similarly apportioned to Belgium and Luxembourg. To exploit all available data, we assessed asbestos use from 1920–2012 and asbestos-related disease mortality from 1994 to 2010 (the disease category for mesothelioma was included in the WHO mortality database in 1994). The period for asbestos use was divided into 1920–1970, 1971–2000 and 2001–2012. An early cut-off point – 1970 – was chosen to allow a sufficient interval for observation of asbestos-related diseases and to be coherent with our previous studies.16,18,34,35 A later cut-off point – 2000 – was used to separate recent asbestos trends in both use and related diseases. Based on our earlier finding that 1.0 kg/capita/year of asbestos use cor- responded to 2.4 and 1.6-fold increases in mesothelioma deaths among men and women, respectively,18 we considered this level to be high. Asbestos use of 2.0 kg/capita/year was considered very high. For asbestos-related diseases, we considered age-adjusted mortality rate levels for mesothelioma and asbestosis exceeding those of the world average (5.2 and 0.8 deaths/million persons/ year, respectively) to be high. All data were compiled using Mi- crosoft Excel (Microsoft Corporation, Redmond, United States of America). Age-adjusted mortality rates were calculated using SAS Version 9.1 (SAS Institute, Inc., Cary, USA). Results Andorra, Monaco and San Marino did not report any data for any of the indi- cators during the whole study period. Table 1 shows asbestos use and related disease mortality and the national as- bestos ban status for each country. From 1920–1970, six countries recorded very high levels of asbestos use: Belgium, Cyprus, Denmark, Israel, Kazakhstan and Luxembourg. An additional 11 countries recorded high levels. From 1971–2000, the number of countries recording high and very high levels of use increased to 14 and 13, respectively. Between 2001 and 2012, most countries in Europe reduced their use, including those that previously used very high or high levels of asbestos: 43 countries used less than 0.5 kg/capita/year, of which 36 countries used less than 0.1 kg/capita/ year. In contrast, Kazakhstan, Kyrgyzstan and the Russian Federation recorded very high levels and Belarus, Ukraine and Uzbekistan reported high levels. For three consecutive periods Ka- zakhstan and the Russian Federation reported very high or high levels of asbestos use, while Kyrgyzstan, Ukraine and Uzbekistan recorded such levels for the two latter periods, and 11 countries did so for the two earlier periods. Deaths due to mesothelioma were reported by 36 countries during 3–17 years and by one country during 1–2 years, while 16 countries did not report at all. Deaths caused by asbes- tosis were recorded by 26 countries during 3–17 years, by seven countries during 1–2 years and 20 countries did not provide any reports. Among the 36 countries that recorded mesothelioma mortality for three years or more, 21 countries recorded high age-adjusted mortality rates led by Iceland, followed by Malta and the United Kingdom of Great Britain and Northern Ireland. Among the 26 countries that recorded asbestosis mortality for three years or more, 12 recorded high age-adjusted mortality rates, led by Malta, followed by Slovenia and Finland. During 1920–1970, 1971–2000 and 2001–2012, Europe used 31.2, 66.5 and 7.8 million metric tonnes of asbestos, respectively, accounting for 48%, 58% and 31% of the global use, respectively (Table 2). Europe recorded 71 686 deaths from mesothelioma (averaging 6786 deaths annually) corresponding to 56% of the global burden of such disease, and 5732 deaths from asbestosis (averaging 542 deaths annually) corresponding to 41% of the global asbestosis cases. Another 28 762 deaths were associated with mesothelioma, including deaths recorded as malignant neoplasm of the pleura in the WHO mortality database and those identified from scientific articles.27–30 In total, Europe registered 106 180 asbestos-related disease deaths, Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118792 Research Disease burden related to asbestos use in Europe Takashi Kameda et al. Table 1. Status of asbestos bans, asbestos use and related diseases, Europea, 1920–2012 Country Status of asbestos banb Average per capita asbestos use, kg/capita/yearc Age-adjusted mortality rate, per million people (no. of reported years)d 1920–1970 1971–2000 2001–2012 Mesotheliomae Asbestosisf Albania None – 0.37 0.00 – – Andorra None – – – – – Armenia None – 0.13 0.10 – – Austria Early 1.17 2.09 0.00 6.35 (9) 0.42 (8) Azerbaijan None – 0.39 0.41 – – Belarus None – 0.85 1.86 – – Belgium Early 3.08 3.02 0.00 9.34 (5) 1.26 (5) Bosnia and Herzegovina None 0.00 0.01 0.00 – – Bulgaria Late 0.14 1.31 0.02 1.21 (6) 1.41 (6) Croatia Late 0.78 3.57 0.39 7.58 (16) 0.94 (11) Cyprus Late 6.41 2.36 0.01 7.72 (7) 0.73 (1) Czech Republic Late 0.82 1.85 0.06 3.12 (17) 0.42 (12) Denmark Early 2.16 1.97 0.00 8.87 (13) 1.91 (13) Estonia Late 0.07 0.06 0.26 5.78 (14) 0.44 (1) Finland Early 1.49 0.86 0.03 8.96 (15) 2.39 (15) France Early 1.08 1.44 0.00 7.74 (10) 0.79 (10) Georgia None – 0.00 0.01 1.49 (8) 0.82 (2) Germany Early 1.17 2.18 0.00 7.04 (13) 0.71 (13) Greece Late 0.41 1.28 0.00 – – Hungary Late 0.78 2.36 0.03 3.01 (14) 0.24 (6) Iceland Early 1.29 0.30 0.01 24.58 (13) 4.59 (2) Ireland Early – 1.57 0.19 5.77 (4) 0.96 (3) Israel Early 3.19 0.56 0.01 4.72 (12) 0.43 (6) Italy Early 0.83 1.61 0.00 10.37 (5) 0.30 (5) Kazakhstan None 6.09 18.88 8.47 – – Kyrgyzstan None – 3.12 2.72 2.56 (7) – Latvia Late 0.26 0.66 0.08 5.68 (15) – Lithuania Late 0.05 0.14 0.00 3.53 (13) – Luxembourg Late 3.48 3.13 0.08 13.59 (12) 2.45 (2) Malta Late – – 0.00 21.33 (15) 6.31 (7) Monaco None – – – – – Montenegro None 0.35 0.95 0.02 5.31 (6) 0.81(3) Netherlands Early 0.84 0.87 0.00 15.91 (15) 0.49 (15) Norway Early 0.98 0.36 0.00 7.99 (15) 2.07 (15) Poland Early 0.39 1.72 0.00 2.19 (12) 0.16 (12) Portugal Late 0.27 1.06 0.11 1.97 (6) 0.19 (4) Republic of Moldova None – 0.84 0.06 4.20 (15) – Romania Late 0.62 0.76 0.24 2.19 (12) 0.12 (5) Russian Federation None 1.53 7.86 2.26 – – San Marino None – – – – – Serbia Late 0.25 0.80 0.01 2.99 (14) 0.50 (3) Slovakia Late 1.52 3.01 0.02 2.92 (17) 1.43 (9) Slovenia Early 1.70 6.78 0.00 9.11 (14) 2.81 (14) Spain Late 0.51 1.35 0.03 4.13 (12) 0.21 (12) Sweden Early 1.20 0.51 0.00 7.65 (14) 0.60 (14) Switzerland Early 1.12 1.31 0.03 – – Tajikistan None – 0.09 0.06 – – The former Yugoslav Republic of Macedonia None 0.92 3.33 0.02 2.30 (4) 0.42 (1) Turkey Late 0.08 0.58 0.07 – – Turkmenistan None – 0.65 0.65 – – Ukraine None – 1.54 1.97 – – United Kingdom Early 1.92 1.03 0.00 18.36 (11) 1.16 (11) Uzbekistan None – 1.45 1.75 0.46 (2) 0.03 (1) All NA 1.20 3.07 0.74 7.76 (17) 1.03 (17) NA: not applicable. a Countries that belong to the European Region of WHO. b Early: ban adopted by 2000; Late: ban adopted 2001–2013; None: no ban. c Values below 0.05 were given the value 0.00. d Time period 1994–2010. e International classification of diseases, 10th Revision, C45. f International classification of diseases, 10th Revision, J61. Takashi Kameda et al. Disease burden related to asbestos use in Europe Research 793Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118 accounting for 60% of the global burden. Europe also had higher age-adjusted mortality rates for mesothelioma (7.8 versus 5.2 deaths/million persons/year) and asbestosis (1.0 versus 0.8 deaths/ million persons/year) than the world- wide average. Mesothelioma deaths were reported to the WHO mortality database by 16/17 (94%) early-ban countries, 15/17 (88%) late-ban countries and 6/19 (32%) no- ban countries. Of the 71 686 mesothe- lioma deaths throughout Europe, 64 156 (89%), 7407 (10%) and 123 (< 1%) were in the early-ban, late-ban and no-ban groups, respectively. Countries in the early-ban, late-ban and no-ban groups reporting mesothelioma deaths had age- adjusted mortality rates (crude mortality rates) of 9.4 (16.5), 3.7 (4.7) and 3.2 (0.6) deaths/million persons/year, respec- tively. Asbestosis deaths were reported by 16/17 (94%) early-ban countries, 13/17 (76%) late-ban countries, and 4/19 (21%) no-ban countries. Of the 5732 as- bestosis deaths throughout Europe, 5385 (94%), 339 (6%) and 8 (< 1%) were in the early-ban, late-ban and no-ban groups, respectively. Countries in the early- ban, late-ban and no-ban groups that reported asbestosis had age-adjusted mortality rates (crude mortality rate) of 0.8 (1.4), 0.9 (0.3) and 1.5 (0.2) deaths/ million persons/year, respectively. The ratification rates of the ILO Asbestos Convention were higher in Europe than worldwide (38% versus 19%). Also the quality ranking for the health systems was higher in Europe (62% versus 28%). Within Europe, the convention was ratified by 53% (9/17), 35% (6/17) and 26% (5/19) countries in the early-ban, late-ban and no-ban groups, respectively. Higher-ranking health systems were found in 100% (17/17), 53% (9/17) and 26% (5/19) of these groups, respectively (Table 2). Table 2. Asbestos use and related diseases, policies and health system rankings in Europea and worldwide, 1920–2012 Variable Europea World (n = 194)b Europe as % of the world Status of asbestos banc All (n = 53) Early (n = 17) Late (n = 17) None (n = 19) Population, million people (%) 392 (43.2) 224 (24.6) 292 (32.1) 908 (100) 6974 13.0 Asbestos use Cumulative asbestos use, million metric tons (%) 1920–1970 17.5 (56.2) 2.9 (9.2) 10.8 (34.6) 31.2 (100) 65.4d 47.7 1971–2000 17.2 (25.9) 6.6 (9.9) 42.7 (64.2) 66.5 (100) 113.8e 58.4 2001–2012 < 0.1 (0.3) 0.2 (2.5) 7.6 (97.2) 7.8 (100) 24.9f 31.4 Per capita asbestos use, kg/capita/year 1920–1970 1.2 0.5 1.8 1.2 0.64 NA 1971–2000 1.6 1.2 8.0 3.1 0.87 NA 2001–2012 < 0.1 0.1 2.2 0.7 0.33 NA Asbestos-related disease Mesothelioma (ICD-10, C45) Deaths, no. (no. of countries) 64 156 (16) 7407 (15) 123 (6) 71 686 128 635 (95) 55.7 Deaths, annual average (no. of years) 6270 (16) 590 (16) 19 (14) 6876 11 957 NA AAMR, per million persons 9.4 3.7 3.2 7.8 5.2 NA Mesothelioma, other data sourceg Deaths, no. (no. of countries) 26 885 (15) 1617 (10) 260 (3) 28 762 34 130 (53)h 87.3 Asbestosis (ICD-10, J61) Deaths, no. (no. of countries) 5385 (16) 339 (13) 8 (4) 5732 13 943 (60) 41.1 Deaths, annual average (no. of years) 493 (16) 43 (16) 5 (7) 542 1330 NA AAMR, per million persons 0.8 0.9 1.5 1.0 0.8 NA Asbestos-related diseases deaths, total no. (no. of countries) 96 426 (17) 9363 (16) 391 (8) 106 180 176 708 (105)h 60.1 Related policies and health systems Countries ratifying ILO Asbestos Convention, no. (% in country group) 9 (52.9) 6 (35.3) 5 (26.3) 20 (37.7) 35 (18.9)i NA (NA) Countries in top tertile of world ranking for health systems,j no. (% in country group) 17 (100.00) 9 (52.9) 5 (26.3) 33 (62.3) 54 (27.8) NA (NA) AAMR: age-adjusted mortality rate; ICD: International classification of diseases; ILO: International Labour Organization; NA: not applicable. a Countries that belong to the European Region of WHO. b Number of countries in the world was based on the WHO definition. c Early: ban adopted by 2000; Late: ban adopted 2001–2013, None: no ban. d Based on 88 countries. e Based on 138 countries. f Based on 157 countries. g Malignant neoplasm of pleura (ICD-9, 163) in the WHO mortality database and published articles identified via PubMed of other source of national data [China (Hong Kong Special Administrative Region and Taiwan), Switzerland and Viet Nam]. For Switzerland, we estimated the values from a figure in Swiss Accident Insurance Institution (SUVA), Medical Information, No.78, p.65. h Taiwan, China, was counted as a single entity here, but it was not included in the 194 countries defined by WHO. i Number of ILO Member States is 185. j The ranking was obtained from the World Health Organization.24 Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118794 Research Disease burden related to asbestos use in Europe Takashi Kameda et al. Discussion This descriptive analysis of data in the WHO mortality database shows that 56% of all mesothelioma deaths and 41% of all asbestosis deaths recorded worldwide occurred in Europe, which accommodates 13% of the world’s popu- lation. Combining these data with those from other sources showed that Europe accounted for 60% of the reported global deaths from asbestos-related dis- eases, excluding asbestos-induced lung cancer. During the periods 1920–1970 and 1971–2000, Europe used 48% and 58%, respectively, of all asbestos traded throughout the world. Europe can thus be characterized as the historical global centre of asbestos use and the current global centre of reported asbestos- related diseases. The three different ban groups had comparable population sizes but showed wide differences in the absolute numbers of asbestos-related disease deaths. The early-ban group reported the highest burden of asbestos related disease, while the no-ban group recorded the lowest. This could reflect differences in the re- porting of asbestos-related diseases, as the majority of early-ban and late-ban countries reported asbestos-related disease data, whereas most of the no- ban countries did not. The three groups also differed in the quality rankings of their health systems,24 prompting us to speculate that gaps may exist in the level of medical expertise and resources re- quired to diagnose and report asbestos- related diseases. Almost all countries (14/17) that used asbestos at very high or high levels during 1920–1970 also demonstrated high mortality rates from mesothelioma and/or asbestosis. Kazakhstan and the Russian Federation did not report such data to WHO and no other comparable data could be identified. Switzerland did not report data to the WHO, but a substantial mesothelioma burden was found in a scientific article reporting national data.28 Israel constituted the only identified exception to the relation- ship between asbestos use and asbestos- related diseases. We have shown earlier that the level of asbestos use correlates with the subsequent asbestos-related disease burden.18 The asbestos-related disease burdens observed in the early-ban and late-ban countries are thus likely to be proportional to their levels of earlier asbestos use. The lower asbestos-related disease mortality currently being re- corded by the no-ban group – despite higher levels of earlier asbestos use – is based on sparse data and likely reflects underdiagnosis and underreporting. Asbestos use can be influenced by national policies. Therefore, we assessed the ratification status of the ILO Asbes- tos Convention.23 The ratification rate was highest in the early-ban group and lowest in the no-ban group, suggesting a possible influence. It is also plausible that ratification may not have influenced use, but rather reduced asbestos expo- sure. A directive of the European Union (EU) mandated that all member states ban asbestos from 2005.36,37 However, some individual EU countries began adopting bans as early as the 1980s. The EU countries thus achieved zero use at different time points. In contrast, two no-ban countries, Kazakhstan and the Russian Federation have both used and mined asbestos5,6 in recent years, at approximately 930 000 and 280 000 metric tonnes per year, respectively (RL Virta, United States Geological Survey, personal communication). Economic incentives in these countries may en- courage domestic and international asbestos use. Between 2001 and 2012, Europe used 7.8 million metric tonnes of as- bestos. This share (31% of global use) is still disproportionately high relative to the population of this region. However, the absolute use declined from 3.1 kg/ capita/year during 1971–2000 to 0.7 kg/ capita/year during 2001–2012. Also the level of use varies considerably by group. The early-ban and late-ban groups reduced their average use to less or equal to 0.1 kg/capita/year, respectively, whereas the no-ban group continued to use an average of 2.2 kg/capita/year. In the early-ban group the use varied between 0 and 0.19 kg/capita/year, which might be variable according to the extent of national exemptions. These are considerable reductions from the previously high levels of use observed between 1920 and 2000 in the early- ban group and between 1971 and 2000 in the late-ban group. In contrast the no-ban group recorded very high and high levels of asbestos use throughout the timeframe studied. The six countries with very high and high levels of use in the present century were all no-ban countries. Hence, although asbestos use was historically widespread and substan- tial across most of Europe, more recent use has been concentrated in the no-ban countries. We therefore speculate that the future burden of asbestos-related diseases will likely shift from the early- ban and late-ban countries towards the no-ban countries. We previously used similar meth- ods to analyse asbestos use and asbestos- related diseases in Asia.35 Although the previous and present findings can be roughly compared, some caution should be exercised. The earlier study adopted the United Nations Statistical Division definition of Asia, whereas the present study adopted the WHO definition of Europe, resulting in an overlap of 11 countries, including one early-ban country (Israel), two late-ban countries (Cyprus and Turkey), and eight no-ban countries (Armenia, Azerbaijan, Geor- gia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan). Also, the final years analysed for asbestos use and asbestos-related diseases in the earlier study were 2007 and 2008, respectively. A strength of this study is the use of quantitative data from public databases to describe the situations in many coun- tries. There were limitations, however, in the representation and comparability of the analysed data. For example, the data on use of asbestos were extrapo- lated for several countries that lacked specific data due to political transitions. In addition, data on the use of imported asbestos-containing products were not available. Moreover, as asbestos-related diseases are generally rare and difficult to diagnose, serious bias could have been introduced by countries having limited experience with asbestos-related diseases. In conclusion, Europe currently carries the majority of the global as- bestos-related disease burden as a con- sequence of heavy asbestos use during earlier decades. For countries that have stopped using asbestos, their asbestos- related disease burden will most likely decrease. In contrast, countries that still have not banned asbestos are likely to have a substantial burden of asbestos- related disease in the future due to their past and current high levels of asbestos use. As attempts to reduce exposure without a concurrent reduction in over- all use are insufficient to control risk,16,38 asbestos bans should be in place in all countries to eliminate asbestos-related diseases. ■ Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118 795 Research Disease burden related to asbestos use in EuropeTakashi Kameda et al. Acknowledgements We thank Dr Vlasta Dečković-Vukres, Croatian National Institute of Public Health, Zagreb, Croatia, for her input. Funding: This work was supported in part by the Japan Society for the Promotion of Science, the Asia-Africa Science Platform Program, an research grant from Univer- sity of Occupational and Environmental Health for the promotion of occupational health, and a project for the develop- ment of a toolkit for the elimination of asbestos-related diseases, commissioned by the Rotterdam Convention Secretariat. Competing interests: None declared. صخلم صخلم ابوروأ في ضرلما ءبعو رظلحاو مادختسلاا ؛)سوتسبسلأا( يرخصلا ريرلحا يرخصلا ريرلحا مادختسا نأشب ةينطولا تانايبلا ليلتح ضرغلا ةمظنلم بيورولأا ميلقلإا في ةلصلا تاذ ضارملأاو )سوتسبسلأا( .ةيلماعلا ةحصلا باسح مت ،ينسملخاو ةثلاثلا نادلبلا نم دلب لك في ةقيرطلا /غلك( )سوتسبسلأا( يرخصلا ريرلحا مادختسا نم درفلا بيصن /ةافو( رمعلا باستحاب ةححصلما تايفولا تلادعمو )ةنس/درف ،سوتسبسلأا ءادو ةطسوتلما مرو نع ةجمانلا )ةنس/ةمسن نويلم ةدحتلما تايلاولل يجولويلجا حسلما تانايب دعاوق مادختساب دعب نادلبلا فينصت متو .لياوتلا لىع ،ةيلماعلا ةحصلا ةمظنمو هدماتعا مت يذلا رظلحا( ركبلما رظلحا :رظلحا ةلاح بسح كلذ مت يذلا رظلحا( رخأتلما رظلحا ،)17 = ددعلا ،2000 ماع لولحب رظلحا مدعو ،)17 = ددعلا ،2013 لىإ 2001 نم ةترفلا في هدماتعا .)19 = ددعلا( درفلل بيصن لىعأ دوجو ينبت ،2012و 1920 يماع ينب جئاتنلا مدع ةعوممج في )سوتسبسلأا( يرخصلا ريرلحا مادختسا نم رظلحاو ركبلما رظلحا اتعوممج تللق ،2000 ماع دعبو .رظلحا لىإ )سوتسبسلأا( يرخصلا ريرحلل ماهمادختسا تايوتسم رخأتلما تظفاح مانيب ،لياوتلا لىع ،ةنس/درف/غلك 0.1 يواسي وأ نم لقأ /غلك 2.2 لدعمب ًادج لاع مادختسا لىع رظلحا مدع ةعوممج بيورولأا ميلقلإا لجس ،2010و 1994 يماع ينبو .ةنس/درف ،سوتسبسلأا ءادو ةطسوتلما مرو نع ةجمان ةافو ةلاح 106180 16 ماقو .يلماعلا ديعصلا لىع ةافولا تلااح نم % 60 لثمي وهو رظلحا يتعوممج في لياوتلا لىع ًادلب 17 ينب نم 15و ًادلب 17 ينب نم ةمظنم لىإ ةطسوتلما مرو تانايب نع غلابلإاب رخأتلما رظلحاو ركبلما نم 6 لاإ تانايبلا هذه نع غلابلإاب مقي لم ينح في ةيلماعلا ةحصلا تايفولا تلادعم تناكو .رظلحا مدع ةعوممج في ًادلب 19 ينب تاعومجلم ةبسنلاب ةطسوتلما مرو في رمعلا بسحب ةححصلما /ةافو 3.2و 3.7و 9.4 رظلحا مدعو رخأتلما رظلحاو ركبلما رظلحا سوتسبسلأا ءاد تلادعم تناكو .لياوتلا لىع ،ةنس/ةمسن نويلم لىع ،ةنس/ةمسن نويلم/ةافو 1.5و 0.9و 0.8 تاعومجلما ىدل .لياوتلا بيورولأا ميلقلإا لخاد ركبلما رظلحا نادلب تغلبأ جاتنتسلاا يرخصلا ريرلحاب ةلصلا تاذ ةنهارلا ةافولا تلااح مظعم نع نادلب لىإ رملأا اذه لوحتي نأ لمتحلما نم هنأ لاإ .)سوتسبسلأا( ببسب نادلبلا هذه في ضرلما ءبع دايدزا حجري ثيح ،رظلحا مدع .فيثك وحن لىع )سوتسبسلأا( يرخصلا ريرلحا مادختسا 摘要 石棉：欧洲地区的使用、禁令和疾病负担 目的 分析世界卫生组织（WHO）欧洲地区有关石棉 使用国家数据和相关疾病。 方法 对于 53 个国家中的每个国家，分别使用美国地 质调查局和 WHO 的数据库计算人均石棉使用（公斤 / 人 / 年）以及间皮瘤和石棉肺年龄调整死亡率（例 死亡 / 百万人 / 年）。按禁令状态将国家进一步分 类 ：较早禁用（2000 年之前禁止，n = 17），较晚禁用 （2001–2013 年禁止，n = 17），和未禁用（n = 19）。 结果 在 1920–2012 年之间，在未禁用组中发现人均石 棉使用量最高。2000 年之后，较早禁用和较晚禁用组 石棉用量水平有所减少，分别降至小于或等于 0.1 公 斤 / 人 / 年，而未禁用组保持着非常高的使用量，为 2.2 公斤 / 人 / 年。从 1994 年到 2010 年，欧洲区域登记 106 180 人死于间皮瘤和石棉肺，占全球同类死亡人数 的 60%。在较早禁用和较晚禁用组中，16/17 和 15/17 个国家分别向 WHO 报告间皮瘤数据，而未禁用组中 只有 6/19 的国家公布这些数据。较早禁用、较晚禁用 和未禁用组间皮瘤年龄调整死亡率分别为 9.4、3.7 和 3.2 例死亡 / 百万人 / 年。各个组的石棉肺死亡率分别为 0.8、0.9 和 1.5 例死亡 / 百万人 / 年。 结论 在欧洲地区，较早禁用国家是当前石棉相关的死 亡大多数案例的报告来源。然而，这种情况可能转移 到未禁用国家，因为这些国家的疾病负担可能会由于 大量使用石棉而增加 Résumé Amiante: utilisation, interdictions et charge de morbidité en Europe Objectif Analyser les données nationales sur l’utilisation de l’amiante et les maladies qui y sont associées, dans la région européenne de l’Organisation mondiale de la Santé (OMS). Méthodes Pour chacun des 53 pays, l’utilisation de l’amiante par habitant (kg/habitant/an) et les taux de mortalité selon l’âge (décès/ millions de personnes/an) dus au mésothéliome et à l’asbestose ont été calculés en utilisant les bases de données de l’USGS (United States Geological Survey) et de l’OMS, respectivement. Les pays ont ensuite été classés en fonction de leur statut d’interdiction: interdiction précoce (interdiction adoptée avant 2000, n = 17), interdiction tardive (interdiction adoptée entre 2001–2013, n = 17) et aucune interdiction (n = 19). Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118796 Research Disease burden related to asbestos use in Europe Takashi Kameda et al. Résultats Entre 1920 et 2012, l’utilisation la plus élevée d’amiante par habitant a été trouvée dans le groupe sans aucune interdiction. Après 2000, les groupes à interdiction précoce et à interdiction tardive ont réduit leurs niveaux d’utilisation de l’amiante à un niveau inférieur ou égal à 0,1 kg/habitant/an, respectivement, tandis que le groupe sans aucune interdiction a maintenu une utilisation très élevée de 2,2 kg/habitant/an. Entre 1994 et 2010, la région européenne a déclaré 106 180 décès causés par le mésothéliome et l’asbestose, représentant 60% de ces causes de décès dans le monde. Dans les groupes à interdiction précoce et à interdiction tardive, 16/17 et 15/17 pays, respectivement, ont fourni des données relatives au mésothéliome à l’OMS, alors que seuls 6/19 pays dans le groupe sans aucune interdiction ont fourni de telles données. Les taux de mortalité selon l’âge du mésothéliome pour les groupes à interdiction précoce, à interdiction tardive et sans aucune interdiction étaient de 9,4, 3,7 et 3,2 décès/million de personnes/an, respectivement. Les taux d’asbestose des mêmes groupes étaient de 0,8, 0,9 et 1,5 décès/ million de personnes/an, respectivement. Conclusion Au sein de la région européenne, les pays à interdiction précoce ont signalé la plupart des décès actuels liés à l’asbestose. Cependant, cela pourrait se déplacer vers les pays sans aucune interdiction, puisque la charge de morbidité augmentera probablement dans ces pays en raison de leur utilisation importante de l’amiante. Резюме Асбест: использование, запреты и бремя болезней в Европе Цель Проанализировать национальные данные Всемирной организации здравоохранения (ВОЗ) об использовании асбеста и связанных с ним заболеваний в Европейском регионе. Методы Для каждой из 53 стран были рассчитаны уровни использования асбеста на душу населения (кг/на душу населения/ год) и смертности, скорректированной по возрасту (смертей/млн человек/год), от мезотелиомы и асбестоза, используя базы данных Геологической службы США и ВОЗ соответственно. Далее страны были дополнительно классифицированы по статусу принятия запрета на использование асбеста: ранний запрет (принятый к 2000 г., n = 17), поздний запрет (принятый между 2001—2013 гг., n = 17) и отсутствие запрета (n = 19). Результаты За период 1920—2012 гг. самый высокий уровень использования асбеста на душу населения был зафиксирован в группе стран, где запрет отсутствует. После 2000 года страны с ранним и поздним принятием запрета сократили свои уровни использования асбеста до 0,1 кг/чел/год, в то время как в группе стран, не имеющих запрета, сохранялся очень высокий уровень использования, равный 2,2 кг/чел/год. В период с 1994 по 2010 гг. в Европейском регионе было зарегистрировано 106 180 смертей от мезотелиомы и асбестоза, что составляет 60% от таких смертей в мире. В группе стран с ранним и поздним запретом 16 из 17 и 15 из 17 стран, соответственно, сообщили в ВОЗ данные о заболеваемости мезотелиомой, в то время как в группе, не имеющей запрета, только 6 из 19 стран сообщили такие данные. Показатели смертности от мезотелиомы, скорректированные по возрасту, среди стран с ранним запретом, поздним запретом и отсутствием такового составили 9,4, 3,7 и 3,2 смертей/млн. человек/год соответственно. Уровни асбестоза для этих групп составили 0,8, 0,9 и 1,5 смертей/млн. человек/год соответственно. Вывод В Европейском регионе страны с ранним запретом сообщили о большинстве смертей, связанных с асбестом. Подобные показатели, тем не менее, могут распространиться на группу стран с отсутствием запрета, так как, вероятно, что в связи с интенсивным использованием асбеста бремя болезней в этих странах увеличится. Resumen Amianto: uso, prohibiciones y carga de morbilidad en Europa Objetivo Analizar los datos nacionales sobre el uso del amianto y las enfermedades relacionadas a este en la región europea de la Organización Mundial de la Salud (OMS). Métodos Para cada uno de los 53 países, se calculó el uso del amianto por cápita (kg/cápita/año) y las tasas de mortalidad ajustadas por edad (muertes/millón de personas/año) causadas por mesotelioma y asbestosis a través de, respectivamente, las bases de datos de la Encuesta Geológica de los Estados Unidos y la OMS. Además, los países se clasificaron según el estado de prohibición: prohibición temprana (prohibición adoptada en el año 2000, n = 17), prohibición tardía (prohibición adoptada entre 2001–2013, n = 17) y sin prohibición (n = 19). Resultados El grupo sin prohibición presentó el mayor uso de amianto por cápita entre 1920–2012. A partir del año 2000, los grupos con prohibiciones tempranas y tardías redujeron sus niveles de uso de amianto a menos de o igual a 0,1 kg/cápita/año, respectivamente, mientras que el grupo sin prohibición mantuvo un uso muy elevado de 2,2 kg/cápita/año. Entre 1994 y 2010, la Región de Europa registró 106 180 muertes por mesotelioma y asbestosis, lo que representa el 60 % de este tipo de muertes en todo el mundo. Los grupos con prohibiciones tempranas y tardías, 16/17 y 15/17 países respectivamente, comunicaron los datos de mesotelioma a la OMS, mientras que solo 6/19 países del grupo sin prohibición facilitaron dicha información. Las tasas de mortalidad ajustadas por edad para el mesotelioma en los países con prohibiciones tempranas y tardías y sin prohibición fueron de 9,4, 3,7 y 3,2 muertes/millón de personas/año, respectivamente, y las tasas de asbestosis, de 0,8, 0,9 y 1,5 muertes/millón de personas/año, respectivamente. Conclusión En la Región de Europa, los países con la prohibición temprana notificaron el mayor número de las muertes actuales relacionadas con el amianto. Sin embargo, esto podría cambiar a los países sin prohibición, ya que es probable que la carga de la enfermedad aumente en dichos países debido al gran uso de amianto. Bull World Health Organ 2014;92:790–797| doi: http://dx.doi.org/10.2471/BLT.13.132118 797 Research Disease burden related to asbestos use in EuropeTakashi Kameda et al. References 1. Thirteen session of the Joint ILO/WHO Committee on occupational health. Report of the Committee. Geneva: International Labour Office; 2003 Dec. Report No.: JCOH/2003/D.4. Available from: http://www.icohweb.org/ site_new/multimedia/asbestos/Enclosure_5.pdf [cited 2014 Aug 4]. 2. Elimination of asbestos-related diseases. Geneva: World Health Organization; 2006. Available from: http://www.who.int/occupational_ health/publications/asbestosrelateddiseases.pdf [cited 2014 Aug 4] 3. Outline for the development of national programmes for the elimination of asbestos-related diseases. Geneva: International Labour Organization/ World Health Organization; 2007. Available from: http://www.who.int/ occupational_health/publications/Out_NPEAD_ENG.pdf [cited 2014 Aug 4]. 4. Report of the Conference of the parties to the Rotterdam Convention on the prior informed consent procedure for certain hazardous chemicals and pesticides in international trade on the work of its fourth meeting; 2008 Oct 27–31; Rome, Italy. New York: United Nations; 2008. 5. Virta RL. Worldwide asbestos supply and consumption trends from 1900 through 2003. Circular 1298. Reston: United States Geological Survey; 2006. p. 80. 6. Mineral industry surveys. World asbestos consumption from 2003 through 2007. Reston: United States Geological Survey; 2009. 7. Stayner L, Welch LS, Lemen R. The worldwide pandemic of asbestos-related diseases. Annu Rev Public Health. 2013;34(1):205–16. doi: http://dx.doi. org/10.1146/annurev-publhealth-031811-124704 PMID: 23297667 8. Asbestos: elimination of asbestos-related diseases. Fact sheet N°343. Geneva: World Health Organization; 2010. Available from: http://www.who. int/mediacentre/factsheets/fs343/en/index.html [cited 2013 Aug 28]. 9. Driscoll T, Nelson DI, Steenland K, Leigh J, Concha-Barrientos M, Fingerhut M, et al. The global burden of disease due to occupational carcinogens. Am J Ind Med. 2005;48(6):419–31. doi: http://dx.doi.org/10.1002/ajim.20209 PMID: 16299703 10. Driscoll T, Nelson DI, Steenland K, Leigh J, Concha-Barrientos M, Fingerhut M, et al. The global burden of non-malignant respiratory disease due to occupational airborne exposures. Am J Ind Med. 2005;48(6):432–45. doi: http://dx.doi.org/10.1002/ajim.20210 PMID: 16299701 11. Fingerhut M, Driscoll T, Nelson DI, Concha-Barrientos M, Punnett L, Pruss- Ustin A, et al. Contribution of occupational risk factors to the global burden of disease–a summary of findings. Scand J Work Environ Health. 2005; Suppl. 1:58–61. 12. Parma declaration on environment and health. Copenhagen: World Health Organization Regional Office for Europe; 2010. Available from: http://www. euro.who.int/en/who-we-are/policy-documents/parma-declaration-on- environment-and-health [cited 2013 Aug 28]. 13. Tossavainen A. Global use of asbestos and the incidence of mesothelioma. Int J Occup Environ Health. 2004;10(1):22–5. doi: http://dx.doi.org/10.1179/ oeh.2004.10.1.22 PMID: 15070022 14. LaDou J. The asbestos cancer epidemic. Environ Health Perspect. 2004;112(3):285–90. doi: http://dx.doi.org/10.1289/ehp.6704 PMID: 14998741 15. Harington JS, McGlashan ND. South African asbestos: production, exports, and destinations, 1959–1993. Am J Ind Med. 1998;33(4):321–6. doi: http://dx.doi.org/10.1002/(SICI)1097-0274(199804)33:4<321::AID- AJIM2>3.0.CO;2-X PMID: 9513639 16. Nishikawa K, Takahashi K, Karjalainen A, Wen CP, Furuya S, Hoshuyama T, et al. Recent mortality from pleural mesothelioma, historical patterns of asbestos use, and adoption of bans: a global assessment. Environ Health Perspect. 2008;116(12):1675–80. doi: http://dx.doi.org/10.1289/ehp.11272 PMID: 19079719 17. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 100 C. A review of human carcinogens: arsenic, metals, fibres and dusts. Lyon: International Agency for Research on Cancer; 2012. 18. Lin RT, Takahashi K, Karjalainen A, Hoshuyama T, Wilson D, Kameda T, et al. Ecological association between asbestos-related diseases and historical asbestos consumption: an international analysis. Lancet. 2007;369(9564):844–9. doi: http://dx.doi.org/10.1016/S0140- 6736(07)60412-7 PMID: 17350453 19. Antao VC, Pinheiro GA, Wassell JT. Asbestosis mortality in the USA: facts and predictions. Occup Environ Med. 2009;66(5):335–8. doi: http://dx.doi. org/10.1136/oem.2008.039172 PMID: 19017689 20. Tse LA, Yu IT, Goggins W, Clements M, Wang XR, Au JS, et al. Are current or future mesothelioma epidemics in Hong Kong the tragic legacy of uncontrolled use of asbestos in the past? Environ Health Perspect. 2010;118(3):382–6. doi: http://dx.doi.org/10.1289/ehp.0900868 PMID: 20064790 21. Current asbestos bans and restrictions [Internet]. London: International Ban Asbestos Secretariat; 2013. Available from: http://www.ibasecretariat.org/ alpha_ban_list.php [cited 2014 Apr 2]. 22. Chronology of national asbestos bans [Internet]. London: International Ban Asbestos Secretariat; 2013. Available from: http://www.ibasecretariat.org/ chron_ban_list.php [cited 2014 Apr 2]. 23. Ratifications of C162–Asbestos Convention (No. 162). Geneva: International Labour Organization; 1986. Available from: http://www.ilo.org/dyn/ normlex/en/f?p=NORMLEXPUB:11300:0::NO:11300:P11300_INSTRUMENT_ ID:312307:NO [cited 2014 Sep 9]. 24. The world health report 2000 – Health systems: improving performance. Geneva: World Health Organization; 2000. Available from: http://www.who. int/whr/2000/en/ [cited 2014 April 2]. 25. Health statistics and health information systems. WHO mortality database [Internet]. Geneva: World Health Organization; 2012. Available from: http:// www.who.int/healthinfo/statistics/mortality_rawdata/en/index.html [cited 2013 Aug 28]. 26. The International statistical classification of diseases and health related problems ICD-10. Volume 1. Tabular list. Geneva: World Health Organization; 1992. Available from: http://www.who.int/classifications/icd/ icdonlineversions/en [cited 2014 Aug 4]. 27. Lee LJ, Chang YY, Wang JD. Impact of malignant mesothelioma in Taiwan: a 27-year review of population-based cancer registry data. Lung Cancer. 2010;68(1):16–9. doi: http://dx.doi.org/10.1016/j.lungcan.2009.05.016 PMID: 19535165 28. Rüegger M, Marcel J. Malignant tumors caused by asbestos: recognition as occupational diseases. In: Medical Information No. 78. Lucerne: Swiss accident insurance institution (SUVA); 2007. pp. 64-70. Available from: https://wwwepp1.suva.ch/webshop/4C/4CA34F620AA94329E10080000A6 3035B.pdf [cited 2014 Aug 4]. French. 29. Ngoan T, Lua NT, Hang LT. Cancer mortality pattern in Viet Nam. Asian Pac J Cancer Prev. 2007;8(4):535–8. PMID: 18260724 30. Hong Kong cancer registry [Internet]. Hong Kong: Hospital Authority; 2014. Available from: www3.ha.org.hk/cancereg/statistics.html [cited 2013 August 28]. 31. International Data Base [Internet]. Washington: United States Census Bureau; 2012. Available from: http://www.census.gov/population/ international/data/idb/informationGateway.php [cited 2013 Aug 28]. 32. Lahmeyer J. Population statistics: historical demography of all countries, their divisions and towns [Internet]. Utrecht: Populstat; 2006. Available from: http://www.populstat.info/ [cited 2013 Aug 28]. 33. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. Geneva: World Health Organization; 2001. 34. Park EK, Takahashi K, Hoshuyama T, Cheng TJ, Delgermaa V, Le GV, et al. Global magnitude of reported and unreported mesothelioma. Environ Health Perspect. 2011;119(4):514–8. doi: http://dx.doi.org/10.1289/ ehp.1002845 PMID: 21463977 35. Le GV, Takahashi K, Park EK, Delgermaa V, Oak C, Qureshi AM, et al. Asbestos use and asbestos-related diseases in Asia: past, present and future. Respirology. 2011;16(5):767–75. doi: http://dx.doi.org/10.1111/j.1440- 1843.2011.01975.x PMID: 21449920 36. The Human and Financial Burden of Asbestos in the WHO European Region. Meeting report; 2012 Nov 5-6; Bonn, Germany. Copenhagen: World Health Organization Regional Office for Europe; 2013. Available from: http://www. euro.who.int/__data/assets/pdf_file/0003/194133/RB-Asbestos-Mtg- Report-Bonn-2012.pdf [cited 2014 Aug 4]. 37. Commission Directive 1999/77/EC of 26 July 1999 on adapting to technical progress for the sixth time. Annex I to Council Directive 76/769/EEC on the approximation of the laws, regulations and administrative provisions of the Member States relating to restrictions on the marketing and use of certain dangerous substances and preparations (asbestos). Official J Eur Communities. 1999;L 207:18–20. Available from: http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri=OJ:L:1999:207:0018:0020:EN:PDF [cited 2014 Sep 9]. 38. The Helsinki Declaration on Management and Elimination of Asbestos- Related Diseases. Rome: International Commission on Occupational Health; 2014. Available from: http://www.icohweb.org/site_new/multimedia/ news/pdf/20%20March%202014%20Final%20Signed%20Declaration%20 for%20website.pdf [cited 2014 June 11].