Asbestos ban policies and mesothelioma mortality in Greece

Our plain-English summary of Asbestos ban policies and mesothelioma mortality in Greece, by E. Gogou, C. Hatzoglou, D. Siachpazidou, et al (BMC Public Health, 2024).

The study

• Authors: E. Gogou, C. Hatzoglou, D. Siachpazidou, S.G. Zarogiannis, K.I. Gourgoulianis
• Journal: BMC Public Health
• Published: 2024;24(1):1177
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant mesothelioma is a rare form of cancer that mostly affects the pleura and has a strong link to asbestos exposure. Greece banned the use of asbestos in 2005, however, the public was already aware of this substance in the 1980s. This research aims to present an overview of Greece's mesothelioma age-standardized mortality rates (ASMR) from 1983 to 2019 by age, gender, and geographic region and to determine whether the actions to ban asbestos impacted these rates.

Methods: Data were retrieved by the Hellenic Statistical Authority (HSA) from death certificates that mentioned mesothelioma as the cause of death from 1983 to 2019 with details on the residence, gender, and age. Statistical analysis was performed using PRISM 6.0 software, a two-way ANOVA test, Trend analysis was conducted using Joinpoint Regression Program 5.0 software. The linear and non-linear model was used to calculate the age-standardized rates of annual percentage change (APC) and its 95% confidential interval (95% CI).

Results: From 1983 to 2019, 850 total mesothelioma deaths were recorded, the majority of whom were males (634). A rate of 74.6% accounts for males and 25.4% for females, and the ratio of Males: Females was 3:1. Males' ASMR and the whole population's ASMR reached their highest levels in 2011 (0.93/100000person-years and 0.53/100000person-years, respectively). To look for potential changes between the first two decades of the 21st century, we compared the mean ASMR of each geographic region in Greece between two different 10-year subperiods (2000-2009 and 2010-2019). Except for Epirus, all regions of Greece had elevated regional ASMRs, particularly in those with the highest asbestos deposits. Notably, the ASMR in Epirus decreased from 0.54/100000person-years (2000-2009) to 0.31/100000person-years (2010-2019). After 2011, the ASMR for men and the general population stabilized. This stability is important since mesothelioma in men is associated with occupational asbestos exposure. The intriguing discovery of a lower ASMR in Epirus emphasizes the need to raise awareness of the condition and implement effective public health measures.

Conclusions: In Greece, the annual ASMR for males and the whole population reached its highest level in 2011, which is positive and encouraging and may be a sign that the rate will stabilize during the following years. Moreover, this study showed that the actions made in the 1980s regarding public awareness and surveillance directly impacted the decrease in Epirus rates. Future research, continual awareness, information, and recording are needed to monitor the mesothelioma epidemic. The possible benefit of a mesothelioma registry and the epidemiological surveillance of asbestos-related diseases, particularly mesothelioma mortality, need to be addressed.

Trial Registration: Not applicable.

© 2024. The Author(s).

In plain English

The authors analysed mesothelioma deaths recorded on Greek death certificates from 1983 to 2019, supplied by the Hellenic Statistical Authority. The certificates did not give the tumour's site, so all sites were counted together, and no individual's asbestos exposure was measured. There were 850 deaths, 634 (74.6%) of them in males, and most were in people aged 60 to 79. Age-standardized death rates rose across 1983–1999, 2000–2009 and 2010–2019. Rates for males and for the whole population peaked in 2011 (0.93 and 0.53 per 100,000 person-years) and stayed below those levels afterward, while the female rate kept rising until 2019. From 2000–2009 to 2010–2019, rates rose in every region except Epirus, where they fell from 0.54 to 0.31 per 100,000 person-years. That fall was not statistically significant. In Epirus, inhabitants of Metsovo had whitewashed walls with asbestos-contaminated soil, which has not been used since 1985. The authors concluded that 1980s public awareness and surveillance actions directly affected the decrease there. They noted that some deaths may have been missed, especially before 1990.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: National mortality trend study using death certificates. Age-standardized mortality rates were calculated by year, gender, age and region, with joinpoint trend analysis.
• Who was studied: All deaths in Greece from 1983 to 2019 whose death certificate mentioned mesothelioma (any site): 850 deaths, 634 of them males. Residence, gender and age were recorded. Regional rates covered eight regions of Greece for 2000–2019. Rates were standardized to the European standard population (2018 update).
• Exposure: No individual exposure was measured. The authors related the rates to Greek asbestos production (peak in 1996, stopped in 1999) and to Greece's 2005 ban on all forms of asbestos. In Epirus, they pointed to the use in Metsovo of asbestos-contaminated soil ('luto') to whitewash interior walls. The article describes the local rock as containing mainly chrysotile but also tremolite and anthophyllite. Luto has not been used since 1985.
• Main results:
  • Of the 850 deaths, 74.6% were in males and 25.4% in females (male to female ratio 3:1).
  • Most mesothelioma deaths were in people aged 60 to 79.
  • The male rate and the whole-population rate were highest in 2011 (0.93 and 0.53 per 100,000 person-years). Afterward they stayed below those values.
  • The female rate continued to rise until 2019.
  • For males, the mean rate rose from 0.13 (1983–1999) to 0.43 (2000–2009) to 0.67 (2010–2019) per 100,000 person-years (P less than 0.001).
  • For the whole population, the mean rate rose from 0.09 to 0.25 to 0.40 per 100,000 person-years across the three sub-periods (p less than 0.001).
  • For the whole population, the annual percent change over 1983–2019 was 8.09, which was statistically significant.
  • For males, the annual percent change was 15.08 in 1983–2000 and 3.92 in 2001–2019.
  • In Epirus, the rate fell from 0.54 per 100,000 person-years (2000–2009, the highest regional rate in that decade) to 0.31 (2010–2019). This difference was not statistically significant.
  • In 2010–2019, rates above the national rate of 0.40 per 100,000 person-years were seen in Attiki (printed here as 0.65) and Sterea Ellada (0.59).
• The authors' conclusion: The authors concluded that 1980s public awareness and surveillance actions directly affected the decrease in Epirus rates. They expected rates in Greece to steady before decreasing. They also called for a mesothelioma registry and continued surveillance.
• Limitations the authors state:
  • Death certificates gave descriptive data rather than ICD codes.
  • The site of the mesothelioma was not specified, so all sites were combined.
  • Recording methods were less advanced before 1990, so some deaths may have been missed.
  • Mesothelioma may be under-reported on death certificates.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Malignant Mesothelioma, Pleura, Asbestos Exposure, Death Certificate, Discovery.

Related studies

• Mesothelioma Mortality Rates in Greece for the Period 2005-2015 Is Increased Compared to Previous Decades — E. Gogou, C. Hatzoglou, et al. (2019)
• Mesothelioma mortality in Greece from 1983 to 2003 — E. Gogou, T. Kerenidi, et al. (2009)
• Malignant mesothelioma in Metsovo, Greece, from domestic use of asbestos: 30 years later — A. Gogali, C. Manda-Stachouli, et al. (2012)
• Metsovo lung: pleural calcification and restrictive lung function in northwestern Greece. Environmental exposure to mineral fiber as etiology — S.H. Constantopoulos, J.A. Goudevenos, et al. (1985)
• Malignant pleural mesothelioma from nonoccupational asbestos exposure in Metsovo (north-west Greece): slow end of an epidemic? — K. Sakellariou, V. Malamou-Mitsi, et al. (1996)
• Metsovo lung outside Metsovo. Endemic pleural calcifications in the ophiolite belts of Greece — S.H. Constantopoulos, P. Theodoracopoulos, et al. (1991)

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