Asbestos Like Mineral Fiber Exposure and Turkey Asbestos Control Strategic Plan

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1 Asbestos Like Mineral Fiber Exposure and Turkey Asbestos Control Strategic Plan Dr. Muzaffer Metintas on behalf of Turkish Mesothelioma Working Group I state that I have no conflict of interest about this project.

2 Lung/pleural diseases which asbestos like mineral fiber causes Asbestos exposure Turkey Asbestos Control Strategic Plan Aim Method Mesothelioma risk in Turkey Asbestos exposure in rural area Erionite exposure in Turkey Discussion titles

3 Asbestos exposure Asbestos like mineral fibers cause lung / pleural diseases Malignant diseases. Mesothelioma. Lung cancer Benign diseases. Pleural plaques. Diffuse pleural fibrosis. Benign asbestos pleurisy. Rounded atelectasis. Asbestosis Metintas S.Respirology 2008;13: Metintas M. Eur Respir J 2005; 26: Metintas S. Chest 2002; 122: Metintas S. Int J Environ Health Res 2012; 22:

4 plevra Mesothelioma

5 Mesothelioma

6 Mesothelioma Lung Chest wall Mesothelioma Tumour disseminates to the near structers

7 Asbestos (70 80 %) Erionite SV 40 viral contamination Familial mesothelioma Nanotubes Mesothelioma risk

8 Mesothelioma risk

9 Mesothelioma risk Mesothelioma risk is increasing; Latent time of mesothelioma is between years. Environmental exposure to asbestos is still ongoing. Occupational exposure continues in the unregularly working environment There are countries where asbestos production continues. Other fibrous materials; nanotubes. Mazurek JM. CDC Weekley March 3, 2017 / 66 (8);

10 Mesothelioma risk

11 Asbestos Expsoure in Turkey Rural area Occupational Environmental

12 Asbestos exposure in rural area Dr. Mehmet Bayram arşivi

13 Asbestos exposure in rural area Metintas M. Eur Respir J 2005; 26:

14 Asbestos exposure in rural area * * * This soil deposits are called in Anatolia as white-soil or corak. *

15 Asbestos exposure in rural area * * Metintas M. Respir Med 1999;93:349. Selçuk ZT. Chest 1992;102:790.

16 Asbestos exposure in rural area Metintas M. Chest 2002; 122: Selçuk ZT. Chest 1992;102:790.

17 Asbestos exposure in rural area Metintas M. Chest 2002; 122: Selçuk ZT. Chest 1992;102:790. Mineral analysis of these white-soil samples identified contamination with mainly tremolite; tremolite-chrysotile; or various combinations of actinolite, anthophyllite, or chrysotile.

18 Asbestos exposure in rural area Incidence rates In Eskisehir cohort formed with 1886 villagers exposed to asbestos from birth through the use of white-soil in the 11 villages from rural part of Eskisehir: The annual mesothelioma incidence rates are per 100,000 for men and per 100,000 for women These values were about 88.3 times higher than expected in a nonasbestos exposed population for males and 799 times for females Metintas M. Chest 2002;122:2224. In occupational exposure series the same rates were between / 100,000 Letourneux M. Eur Respir Rev 1993;3:87.

19 Asbestos exposure in rural area Incidence rates In Diyarbakir from Southeast part of Turkey where many villages have natural white-soil deposits contaminated with asbestos fibres, mesothelioma incidence rate was 22.8 / 1, /year Senyigit A. Respiration 2000; 67: 610. Mesothelioma incidence rates for USA (2015): 10.9 / 1, /year Mazurek JM. CDC Weekley March 3, 2017 / 66 (8);

20 Asbestos exposure in rural area Exposure duration in a villager In general, occupational exposure durations are limited to about 2,000 h per year and start with employment. The exposure duration for a villager may be nearly 8,700 h per year, because the villager spends most of his time in the village and exposure starts at birth. For a 30 year-old man, the cumulative asbestos exposure duration will be more than 260,000 hours, as compared with 60,000 hours for the same duration (30-year working period) in an occupational setting. Dumortier P. Am J Respir Crit Care Med 1998;158:1815.

21 Turkey Asbestos Control Strategic Plan

22 Doç.Dr. Nazan Şen Prof.Dr. Toros Selçuk Prof.Dr. Şule Akçay Prof.Dr. Gaye Ulubay Doç.Dr. Ülkü Yılmaz Öğr.Gör.Dr. Nilgün Yılmaz Demirci Doç.Dr. Engin Tutkun Prof.Dr. Ömer Özbudak Prof.Dr. Mehmet Karadağ Prof.Dr. Arzu Mirici Prof.Dr. Sibel Özkurt Prof.Dr. Abdurrahman Şenyiğit Doç.Dr. Abdurrahman Abakay Prof.Dr. Figen Deveci Prof.Dr. Gamze Kırkıl Prof.Dr. Selma Metintaş Doç.Dr. Güntülü Ak Prof.Dr. Hasan Bayram Prof.Dr. Levent Elbeyli Doç.Dr. Sebahat Genç Prof.Dr. Önder Öztürk Prof.Dr. Hasan Fevzi Batırel Prof.Dr. Sedat Altın Turkey Asbestos Control Strategic Plan Doç.Dr. Mehmet Bayram Doç.Dr. Dilek Ernam Uz.Dr. Özkan Kaan Karadağ Doç.Dr. Ahmet Erbaycu, Doç.Dr. Dursun Tatar Doç.Dr. Berna Eren Kömürcüoğlu Doç.Dr. Hasan Kahraman Prof.Dr. Mehmet Bilgin Doç.Dr. Hakan Büyükoğlan Prof.Dr. Adil Zamani Yrd.Doç.Dr. Umran Toru Doç.Dr. Talat Kılıç Prof.Dr. Nurhan Köksal Prof.Dr. Zehra Seyfikli Doç.Dr. Serdar Berk Doç.Dr. Murat Gültekin Dr. Hüseyin İlter Dr. Ezgi Hacıkamiloğlu 41 researchers; 22 universities, 4 educational hospitals, 1 general hospital, 2 occupational hospitals.

23 Turkey Asbestos Control Strategic Plan Epidemiyoloji: Prof.Dr. Selma Metintaş Epidemiyoloji: Doç.Dr. Tevfik Pınar Epidemiyoloji: (M) Yrd.Doç.Dr. Talat Bahçebaşı Mineraloji: Prof.Dr. Selahattin Kadir Mineraloji: Prof.Dr. Hüseyin Yalçın Kenji Morinaga, MD, PhD, Professor Gunnar Hillerdal, MD, PhD, Professor Sverre Langård,MD, Senior Researcher Eun-Kee Park, Ass. Prof.

24 Turkey Asbestos Control Strategic Plan 3 November 2012, Ankara: Meeting on Methods of Project

26 Turkey Asbestos Control Strategic Plan İstanbul Samsun Çanakkale Bursa Bilecik Çankırı Çorum Tokat Eskişehir Ankara Yozgat Sivas Kütahya İzmir Afyon Denizli Isparta Burdur Antalya Konya Kayseri K Maraş Malatya Elazığ Diyarbakır Adıyaman Adana Gaziantep Şanlıurfa 98.3 % of all mesothelioma cases diagnosed in these 32 provinces Hatay Cities where Turkish Mesotehlioma Working Group was organized. Cities where Turkish Mesotehlioma Working Group controlled.

27 Turkey Asbestos Control Strategic Plan Year Male Female Total , , , ,221 TOTAL 3,241 2,376 5,617 Men/women ratio 1.36, Mean age of the patients 62 yrs, Incidence in Turkey: 2.33 / 100,000 / person-year Incidence in the risky rural area: 79 / 100,000 / person-year Incidence in the past exposure 26 / 100,000 / person-year

28 Turkey Asbestos Control Strategic Plan Status Number Mean age Standard Minimum Maximum years deviation Alive 2, Dead 3, Total 5, Mean survival of the dead cases was 11.4, median as 8 month. Living in rural area Number Mean age years Yes 3, No 1, Standard deviation

29 Turkey Asbestos Control Strategic Plan RR according to the patients birth places RR (95%CI) > 8 RR (95%CI) > 8-5 RR (95%CI) > RR (95%CI) >

30 Turkey Asbestos Control Strategic Plan Tekirdağ Yalova Çanakkale Balıkesir Manisa İzmir Aydın Muğla Bursa Kütahya Uşak Denizli Kocaeli Bilecik Burdur Sakarya Eskişehir Afyon Antalya Düzce Isparta Bolu Ankara Konya Kastamonu Sinop Çankırı Çorum Samsun Amasya Yozgat Kırşehir Kayseri Nevşehir Aksaray Mersin Niğde Adana Hatay Tokat Sivas K Maraş Gaziantep Gümüşhane Bayburt Malatya Adıyaman Erzincan Tunceli Elazığ Şanlıurfa Bingöl Diyarbakır Erzurum Muş Bitlis Siirt Ardahan Kars Ağrı Van Hakkari Türkiye Mezotelyoma Çalışma Grubu nun organize olduğu iller. Türkiye Mezotelyoma Çalışma Grubu nun kontrol ettiği ek iller. Mezotelyoma olgusu doğumu olan diğer köylerin bulunduğu iller. Mezotelyoma olgusu doğumu olan ancak toprak analizine gerek görülmeyen iller. Following the analysis of the cases born and lived in rural areas, 1,236 villages in 58 provinces were determined as "villages required to be examined in terms of asbestos exposure risk".

33 ANKET İl ismi: Köyün ismi: İlçe: Muhtar ismi: 1. Köyünüzde bu broşürde gösterilen toprak var mı: Evet ( ) Hayır ( ) 2. Köyünüzde bu broşürde gösterilen toprakla sıvalı ev var mı: Evet ( ) Hayır ( ) 3. Köyünüzde bu toprakla çatısı örtülü oda dam var mı : Evet ( ) Hayır ( ) 4. Köyünüzde bu broşürde gösterilen toprak eskiden kullanıldı mı: Evet ( ) Hayır ( )

34 Education of technicians Turkey Asbestos Control Strategic Plan

37 Turkey Asbestos Control Strategic Plan Asbest teması riskli olduğuna karar verilen 1,236 köy, 1018 inden örnek alındı.

41 Turkey Asbestos Control Strategic Plan Asbestos exposure was stated to continue in a total of 379 villages.

42 Turkey Asbestos Control Strategic Plan According to the cases from rural area, the total population exposed to asbestos in rural area was estimated as 571,460 until ,068 villagers will continue to be exposed to asbestos after 2013.

43 Expected mesothelioma cases in rural area in next 20 years 15,450 2,511 A total of 17,961 cases is expected in next 20 yrs if problem is not solved.

44 Expected lung cancer cases in rural area in next 20 years Lung cancer: In population exposed to asbestos: 5,737, In population who continue to exposure: 1,322

45 Cappadocia is a miraculous natural area in the central part of Anatolia Erionite exposure and mesothelioma

46 Erionite exposure and mesothelioma Three villages in Cappadocia have extreme number of mesotheliomas. Of the 96 deaths among the villagers lived in Karain or Karain/Stockholm born between , 69 of them (72%) were due to mesothelioma. In these villages researchers who had worked since 1970s detected that erionite fibers were responsible of mesothelioma epidemic. Karain village Metintas M. Eur Respir J 1999; 13: 523±526

47 Erionite exposure and mesothelioma For Karain villagers living in Stockholm (erionite exposed) AAMIRs were per 100,000 for men per 100,000 for women Metintas M. Eur Respir J 1999;13:523. For Karain villagers living in Karain(erionite exposed) AMIRs were 639 per 100,000 for men 1267 per 100,000 for women Metintas M. Archives of Environmental & Occupational Health 2010; 65: Mean cumulative exposure of erionite in Karain: 8.7 f/ml-yr for women with a 44 yrs of median exposure 6.9 f/ml-yr for men with a 47 yrs of median exposure; p < 0.001

48 Erionite exposure and mesothelioma Issues. Fiber levels and types to which villagers exposed. Immigrations. Stones which used in construction of houses

49 Erionite exposure and mesothelioma Artvinli M. Arch Environ Health 1982;37:177. Baris I. Lancet 1981;1:984.

50 Erionite exposure and mesothelioma Genetic tendency While to discuss the genetic theory, we should take attention immigrations in Karain cohort. * *

51 Erionite exposure and mesothelioma Characteristics of women who immigrated as brides to Karain since 1930 Characteristics Died of Mesothelioma N=11 Died from other causes N=5 Living N=48 Age of death, year X±SD Mean age of the living Age of moving to Karain, year X±SD F=1.525; p= ±13.8 ( ) ±8.7 (14-44) 70.0±15.51 ( ) ±6.8 (12-30) ±15.6 (21-96) 20.6±6.6 (12-47) Years of living in Karain, X±SD F=9.216; p= and above 38.7±9.1 (20-51) (18.2) 4 (36.4) 4 (36.4) 1 (9.1) 47.0±16.8 (25-71) (20.0) 0 2 (40.0) 2 (40.0) 22.1±16.9 (0-67) 10 (20.8) 13 (27.1) 14 (29.2) 5 (10.4) 1 (2.1) 5 (10.4)

52 Erionite exposure and mesothelioma Karain houses - stones People from many civilisations lived in the caves which were carved inside these rocks Turkish villagers do not use these caves, they are living in the houses which were built with different stones mined from near the village.

53 Erionite exposure and mesothelioma There are a lot of types of stones used to built houses.

54 Erionite exposure and mesothelioma Stones: Örencillik Akkuşak Akköy Su kayası Kayataşı Ürgüp Metintas M. Archives of Environmental & Occupational Health 2010; 65: 86-93

55 Erionite exposure and mesothelioma

56 Conclusion Mineral fibre exposure, especially asbestos, is an important health problem in Turkey. This risk urgently requires to take preventive efforts. We have no knowledge about occupational exposure to asbestos in urban area of Turkey We have no knowledge about environmental exposure to asbestos in urban area of Turkey Erionite exposure is very important for mesothelioma, however exposure is declining.