Occupational and 9/11 Exposures and Cancer Risk presented by Jacqueline Moline, MD, at the Mesothelioma Applied Research Foundation's conference in New York, NY on September 28, 2012. www.curemeso.org

1. 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

2. Mesothelioma: Trends
 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.

3. Incidence* of mesothelioma
(per 100,00) for 17 states
*age-adjusted Price B, Ware A. Critical Reviews in Toxicology.
Aug2009, Vol. 39 Issue 7, p576-588

4. Incidence of mesothelioma
(per 100,00)
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.

5. Incidence* of mesothelioma
(per 100,00) for NY state
*age-adjusted
Price B, Ware A. Critical Reviews in Toxicology.
Aug2009, Vol. 39 Issue 7, p576-588

6. Projected Total
Mesothelioma Cases through 2054
Price B, Ware A. Critical Reviews in Toxicology.
Aug2009, Vol. 39 Issue 7, p576-588

7. Sources of Asbestos Exposure:
Industry
 Construction  Shipbuilders, ship lines, and
 Asbestos product manufacturing ship yards, repairing
(insulation, roofing, building  Chemicals and other
materials) manufacturing
 Automotive repair shops  Railroads and Railways
(especially those that involve  Yarn, thread, and fabric mills
repair of brakes, clutches)  Trucking
 Mining companies  Plastic and rubber
 Nonmetallic mineral stone manufactures
products  Manufacturers of sand or
 Offshore rust removal abrasives
businesses  Steel manufacturers
 Oil refineries  Tile cutters
 Power plants
 Maritime companies

8. Sources of Asbestos Exposure:
Occupation
 Glazers  Demolition Workers
 Grinders  Floor covering workers
 Hod carriers  Millwrights
 Insulators  Carpenters
 Iron workers  Bricklayers
 Laborers  Laborers
 Libby vermiculite workers  Boilermakers
 Longshoremen  Furnace Workers
 Painters  Building Inspectors
 Plumbers  Merchant Marines
 Pipefitters  Welders and cutters
 Auto Mechanics
 Janitors
 Plasterers
 Roofers
 Steamfitters
 Refinery workers
 Maintenance workers
 Sheet metal workers
 Operating engineers
 Shipyard workers
 Drywallers
 Electricians  Tile setters
 Insulation workers  U.S. Navy personnel
 Textile workers  Miners and millers

9. Other Sources of Asbestos Exposure
Duct and home insulation Boiler Insulation Roofing Shingles
Fire protection panels Asphalt Floor Tile Blown-in Insulation
Fireplace artificial logs or ashes Breaching Insulation Roofing Felt
fuse box liners Vinyl Floor Tile Fireproofing Materials
Gypsum wallboard Ductwork Flexible Fabric Connection Base Flashing
Hair dryers Vinyl Sheet Flooring Taping Compounds (thermal)
Toasters Cooling Towers Thermal Paper Products
Heater register tape and insulation Flooring Backing Packing Materials (for wall/floor
Joint compounds Pipe Insulation (corrugated air-cell, penetrations)
Patching and spackling compounds block, etc.) Fire Doors
Pipe or boiler insulation Construction Mastics (floor tile, High Temperature Gaskets
Pot holders and ironing board pads carpet, ceiling tile, etc.) Caulking/Putties
Sheet vinyl or floor tiles Heating and Electrical Ducts Laboratory Hoods/Table Tops
Shingles Acoustical Plaster Adhesives
Textured acoustical ceiling Electrical Panel Partitions Laboratory Gloves
Textured paints Decorative Plaster Fire Blankets
Underlayment for flooring and Electrical Cloth Joint Compounds
carpets Textured Paints/Coatings Fire Curtains
Cement Pipes Electric Wiring Vinyl Wall Coverings
Elevator Brake Shoes Insulation Elevator Equipment Panels
Cement Wallboard Ceiling Tiles and Lay-in Panels Spackling Compounds
HVAC Duct Insulation Chalkboards
Cement Siding Spray-Applied Insulation

10. Sources of Asbestos
from the Environment

11. Asbestos Fiber in the Lung

12. Exposures to Asbestos –
Four Macrocategories
Direct use
Indirect use for insulation and auxiliary tools
Construction sector
Accidental and unaware exposures
Marinaccio et al; Int. J. Cancer 2012;130:2146-2154

13. Direct Use
Shipbuilding and Port handling
repair Asbestos textile
Asbestos cement industry
industry Friction materials
Railroad carriages production
construction and Gaskets and packing
maintenance production
Asbestos mining

14. Indirect Use
 Metal and engineering  Tobacco
 Metallurgic  Leather tanning
 Oil refineries  Non-asbestos textile
 Metal, food and drink finishing
industries  Glass and ceramic
 Sugar refineries  Paper
 Organic and inorganic  Jewelry
chemical plants  Gas production
 Wood processing  Navy and military defense
 Power plants work
 Heat and steam generation

15. Construction Sector – The Whole Industry!
Spray-on asbestos Fire doors
Ceilings Boilers
Floor tiles Steam pipes
Wallboard HVAC
Plaster/cement Sheet metal work
Joint compound Caulk
Electrical work Elevator work

16. Accidental and Unaware Exposure
Car mechanics Talcum powder use
Brake mechanics Laboratory workers
Heavy machine Researchers
operators
Jute sack recycling
Dentists
Service industry
employees where
asbestos was in place

18. Case #1
50 year old
advertising executive
In excellent overall
health
Professional career
spent in offices
No home
renovations

19. Case #1
Full occupational Father and brother also
history revealed college worked in same
employment of note automobile plant
Worked in an Parts: friction materials
automobile that contained asbestos
manufacturing plant for
three summers as a
parts picker while in
college

20. Case #2
54 year old dentist
Worked as dentist
entire career, no
other employment

21. 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

22. Case #3
72 year old physician
In excellent health
Noticed shortness of breath while exercising
Diagnosed with mesothelioma

23. Case #3
Worked in a laboratory for years
Exposures from laboratory equipment
– Asbestos gloves
– Asbestos mesh
– Asbestos pads
– Insulation used around crucibles

24. 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.

25. Methods of Exposure
 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

26. Incidence of Mesothelioma Increasing after
Home Maintenance and Renovation
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.

27. Home Renovation as a
Source of Asbestos
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

28. Non-Occupational Environmental
Asbestos Exposures
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.

29. Shifting Gears: A Unique Exposure
Fallout from the
World Trade Center disaster

34. Dust cloud from the WTC collapse. Source: NYPD

46. WTC Dust: Particle Composition
Lioy, Environ Health Perspectives, 2002;110:703-14

47. 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

48. 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

49. WTC Dust: Known Health Effects
Source Air Pollution Health Effects
Constituents
Structural Collapse
Calcium carbonate / Gypsum /
Cement, ceiling tiles, drywall
Vitreous Fibers Airway and
pulmonary
Calcium sulfate irritation
Windows Glass fibers, Silicates
Fire retardant Asbestos Cancer
Combustion
Incomplete combustion - Organic hydrocarbons Cancer
plastics
Diesel-powered rescue Diesel exhaust Airway irritation,
equipment cancer

50. Acute Eosinophilic Pneumonia
In a Firefighter
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.

51. 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).

52. Bronchoscopy Lavage Findings
70% eosinophilia
Mineralogical analysis of lavage fluid
– Uncoated asbestos (chrysotile and amosite)
– Chromium
– Degraded fibrous glass
– Fly ash
– Metal particles
– Various silicates

53. Lancet 9/3/2011

54. Lancet 9/3/2011
Note: After correction for potential surveillance bias, Too few cases to
achieve statistical power for any individual cancer analysis.

55. Cancer – WTC Covered Condition
10/12/12