Asbestos

Learning Objectives

▪ What is asbestos?

▪ Most important route of exposure

▪ Populations most heavily exposed

▪ Diseases associated with asbestos exposure

Learning Objectives

▪ Chest radiograph findings

▪ Pulmonary function test findings

▪ Other tests that can assist with diagnosis

▪ Primary treatment strategies

▪ Instructions for patients

Asbestos: Description

Asbestos is a generic term for a group of six

mineral silicates

Asbestos fibers are:

▪ Very strong
▪ Highly flexible
▪ Resistant to breakdown by acid, alkali,
water, heat, and flame
▪ Non-biodegradable
▪ Environmentally persistent
 Types of Asbestos

- Chrysotile - “White
asbestos”
Most
commonly - Amosite - “Brown
used: asbestos”
- Crocidolite - “Blue
asbestos” Asbestos fibers,
high magnification
“Blue Asbestos”-
Tremolite
(sometimes found in vermiculite)
Others:
Actinolite
Anthophyllite
 Uses of Asbestos
Asbestos has been used for centuries, but
greatly increased during and after World War II
in ship insulation and the following:

▪ Pipe insulation

▪ Surfacing insulating materials

Asbestos insulated pipe
▪ Reinforcement of materials

▪ Fireproofing

▪ Acoustic and decorative plaster

▪ Textiles

Use has greatly declined since the late 1970’s

Asbestos insulated boiler
 Examples of Uses of Asbestos

Sheet vinyl containing asbestos

Sprayed-on fireproofing material

These products may be found in

homes and buildings constructed
before 1981.
Vinyl asbestos flooring
 Damaged asbestos pipe insulation

This damaged pipe insulation is a health hazard to persons working around it,
handling it or removing it. Asbestos fibers are visible on the torn edges.
 Asbestos Mill Board

Asbestos millboard was used in the construction of walls and ceilings, especially
around furnaces and wood-burning stoves, where insulation and fire protection was
required.
Most varieties of asbestos millboard typically contained between 80% and 85%
asbestos.
Asbestos in gaskets
and fabric

Asbestos gaskets– may be round, flat or

impregnated with waterproof sealant

Asbestos fabric in HVAC system

Damaged asbestos gasket
Asbestos Roofing Material – used from 1920’s to 1970’s
 Cement-asbestos pipe (Transite)

Cement-asbestos pipe, sometimes called Transite, was used

underground and above ground in years past and may show up in
pipe replacement jobs, building demolition jobs or excavations.
Asbestos Ceiling Tile - used until about 1980

Tile close-up

Usually white and in 1’ by 1’ or 2’ by 4’ sizes

 Asbestos shingles and siding

Found in older houses – not to be confused with

newer asbestos-free cement siding. There is little
hazard unless disturbed.
The picture shows a siding replacement job with
broken green asbestos shingles, which would have
Removal done correctly released dust and fibers into the air if done incorrectly.
 Asbestos “Popcorn” Ceiling Material
Popcorn ceilings (also known as
acoustic ceilings) were popular in
many homes built from the late 1950s
through the early 80s.

Uncontrolled popcorn
ceiling removal job

Not all popcorn ceiling material contained

asbestos, but some did. Many types were
damaged ceiling material more easily dislodged than others.
 Asbestos in joint compound and plaster
Some joint compound contained up to 5% asbestos

Joint compound
Plaster with asbestos

See WRD 23.30 for guidance on employee exposure to joint compounds

Asbestos Exposure - General Overview

Many workers are exposed primarily in the

construction industry.
Asbestos removal and building renovation
& demolition have the greatest exposures.

Exposure in general industry:

- manufacture of asbestos products
- automotive brake and clutch repair
- Housekeeping and custodial work
Populations At Risk

Past Exposures
• Mechanics, construction workers,
shipyard workers, and military
personnel

• Secondary exposure in the

workplace

• Household contacts of workers Current Exposures

• Construction workers, mechanics
(brake pads)

• People in homes with friable

asbestos materials

• People in areas where asbestos-

bearing rock is disturbed
Asbestos Exposure Pathways

▪ Most common exposure pathway:

– Inhalation of fibers

▪ Minor pathways:
– Ingestion
– Dermal contact
 Asbestos is an Inhalation Hazard
Airborne asbestos fibers inhaled deep into the lung can
cause damage.

▪ Tiny breathable asbestos fibers are

deposited in the alveoli, the ending
small air sacs in the lungs. Pleura

▪ The body’s defense mechanisms

cannot break down the fibers.

▪ Asbestos fibers cause damage to

the lungs.
▪ The fibers may also travel to the
pleura, the membrane lining the Alveoli
outside of the lungs.
 Asbestos-related Diseases
▪ Respiratory diseases:
– Parenchymal asbestosis
– Asbestos-related pleural abnormalities
– Lung carcinoma
– Pleural mesothelioma

▪ Nonrespiratory diseases:
– Peritoneal mesothelioma
– Possibly, other extrathoracic cancers
– Rarely, cor pulmonale or constrictive
pericarditis
Pathogenesis

▪ Asbestos fibers induce pathogenic changes

via:
– Direct interaction with cellular macromolecules
– Generation of reactive oxygen species (ROS)
– Other cell-mediated mechanisms

▪ These changes can lead to cell injury, fibrosis,

and possibly cancer
▪ Asbestos is genotoxic and carcinogenic
Parenchymal Asbestosis

▪ Diffuse interstitial fibrosis with:

– Restrictive pattern of disease on pulmonary function
testing (but can see mixed pattern)
– Impaired gas exchange
– Progressive exertional dyspnea

▪ Radiographic changes: >10 years

▪ Latency period: 20-40 years
 Asbestosis Example
Photos © RAVANESI@2000

Joe Darabant, 1949, Joe, 1989.

covered with Forced to retire
chrysotile asbestos in 1974 at age 50
fibers. Worked for from poor health;
30+ years at the he died from
Johns-Manville Plant asbestosis in
in New Jersey, cutting 1990 at age 66.
asbestos shingles
and making asbestos
block and pipe-
covering materials.

Asbestosis is a serious chronic, progressive disease that can eventually lead to

disability or death in people exposed to high amounts of asbestos over a long
period. Asbestos fibers cause the lung tissues to scar; when the scarring
spreads, it becomes harder and harder to breathe. Symptoms include shortness
of breath, a dry crackling sound in the lungs while inhaling, coughing, and chest
pain. This condition is permanent and there is no effective treatment.
Asbestos-Related Pleural Abnormalities

▪ Four types of abnormalities:

– Pleural plaques
– Benign asbestos pleural effusions
– Diffuse pleural thickening
– Rounded atelectasis

▪ Mostly asymptomatic, though some can

cause dyspnea or cough
▪ Latency periods: 10-30 years
(shorter latency is for pleural effusion)
Lung Carcinoma

▪ Risk depends on:

– Level, frequency, and duration of exposure
– Time elapsed since exposure
– Age at time of exposure
– Smoking history (synergistic)
– Individual susceptibility factors (under investigation)

▪ Latency period: 20-30 years

Malignant Pleural Mesothelioma

▪ Tumor arises from the thin serosal

membrane surrounding the lungs
▪ Rapidly invasive
▪ Rare, although incidences are increasing
▪ Long latency period: Usually 30-40 years
 Mesothelioma Example Photo © RAVANESI@2000

Mesothelioma is a rare form of cancer Tumors protruding

through the right
of the pleura, the thin membrane rib cage.
lining the lungs. About 200 cases are
diagnosed each year in the U.S.
Virtually all cases are linked with
asbestos exposure.
The cancer is very invasive and
spreads quickly, eventually crushing
the lungs so that the patient cannot
breathe. It is painful and always fatal. Richard Pankowski, 1986.
Diagnosed in 1985 with pleural
It can be caused by very low mesothelioma; died 5 months later at
exposure and is not directly related to age 36. In college, he worked for less
the amount inhaled. This cancer may than a year at the Manville Plant in
take 30-40 years to develop. N.J. Father also worked at the plant
30+ years and died from asbestosis.
Richard’s exposure may have begun
when he was a child.
Malignant Peritoneal Mesothelioma

▪ “Doughy” feeling on abdominal palpation

▪ Male: female incidence is 1.5:1 (compared to
5:1 with pleural tumor)
▪ Rapidly invasive and rapidly fatal
▪ Often associated with high-dose asbestos
exposures
▪ Rare
 Lung Cancer
Lung cancer causes the largest number of deaths from asbestos exposure.
The risk greatly increases in workers who smoke.
 Other Cancers
Evidence suggests that ingesting
asbestos can also cause cancers in the:

▪ esophagus
▪ larynx
▪ oral cavity
▪ stomach
▪ colon
▪ kidney
Fibers can enter the mouth and be swallowed.
Poor hygiene, leaving food/drinks out in
contaminated areas, and carelessness can result in
the ingestion of asbestos.
Cardiovascular Conditions

▪ Cor pulmonale
– Secondary to chronic lung disease
– Mainly with severe parenchymal asbestosis

▪ Constrictive pericarditis
– Secondary to asbestos-associated disease
– Very rare
Risk Factors

▪ Nature and extent of exposure:

– Concentration of asbestos fibers
– Duration of exposure
– Frequency of exposure

▪ Cigarette smoking
Diagnosis

▪ Medical evaluation of all patients should include:

– Assessment of clinical presentation
– Exposure history
– Medical history
– Physical examination
– Chest radiograph and pulmonary function tests
▪ Radiologic and laboratory testing can include:
– CT or HRCT
– BAL
– Lung biopsy (rarely needed)
Clinical Presentation

Disease Signs and Symptoms

Parenchymal • Insidious onset of
Insidious onset of dyspnea
dyspnea on
on exertion
exertion
Asbestosis Fatigue
• Fatigue
Asbestos-Related • Usually: None
Pleural • Sometimes: Progressive dyspnea and intermittent
Abnormalities chest pain (depending on the type of pleural
abnormality)
Lung Cancer Usually: None (until later stages)
Sometimes: Fatigue, weight loss, or chest pain
Mesothelioma Usually: None (until later stages)
Sometimes: Dyspnea, chest pain, and fatigue
Patient History

Medical History
Exposure History

• Work history • History of smoking

• Source, intensity, duration, and • History of other
frequency of exposure conditions
• Time elapsed since first exposure
• Workplace dust measurements or
description of exposure scenario
• Use of personal protective equipment
• Paraoccupational exposures
• Sources of environmental exposure
Link to Taking an Exposure History CSEM and other publications in this series:
http://www.atsdr.cdc.gov/HEC/CSEM/csem.html
Physical Examination

▪ Focus on lungs, heart, digits, and extremities

▪ Pulmonary auscultation to detect bibasilar

inspiratory rales
(not always present)

▪ Observation of other signs, such as clubbing

of the fingers and cyanosis
Pulmonary Function Tests

Disease Pulmonary Function Test Findings

Parenchymal • Reduction in FVC; normal FEV1/FVC Ratio
Asbestosis • Reduction in FEF (25%-75%)
• Restrictive pattern with decreased DLCO
• Or, mixed obstructive/restrictive pattern
(reduced FEV1/FVC associated with
reduced FVC)

Asbestos-Related • Often normal

Pleural • Reduced FVC can be associated with
Abnormalities diffuse pleural thickening
Chest Radiograph Findings:
Parenchymal Asbestosis

▪ Small, irregular oval

opacities
▪ Interstitial fibrosis
▪ “Shaggy heart
sign”

List of certified B Readers: http://www.cdc.gov/niosh/pamphlet.html

Chest Radiograph Findings:
Asbestos-Related Pleural Abnormalities

▪ Pleural plaques
– Areas of pleural thickening
– Sometimes with calcification

▪ Pleural effusions
▪ Diffuse pleural thickening
– Lobulated prominence of
pleura adjacent to thoracic margin
(over ¼ of chest wall)
– Interlobar tissue thickening

▪ Rounded atelectasis
– Rounded pleural mass
– Bands of lung tissue radiatingutwards
Chest Radiograph Findings:
Lung Cancer

▪ Same findings as those of other lung cancer

etiologies
Chest Radiograph Findings:
Mesothelioma

▪ Pleural effusions

▪ Pleural mass

▪ Diffuse pleural
thickening
Other Tests

▪ CT and HRCT

▪ BAL and lung biopsy

▪ Colon cancer screening

Disease Management

Asbestos-associated
Disease Treatment Strategy
Parenchymal • Stopping additional exposure
Asbestosis and • Careful monitoring to facilitate early diagnosis
Asbestos-Related • Smoking cessation
Pleural Abnormalities
• Regular influenza and pneumococcal vaccines
• Pulmonary rehabilitation as needed
• Disability assessment
• Aggressive treatment of respiratory infections
Lung Cancer and • Early diagnosis
Mesothelioma • Surgery
• Chemotherapy
• Radiation
Communication with the Patient

▪ Obtain patient’s employer contact information to

facilitate occupational exposure prevention
(OSHA mandates
PPE and medical surveillance)
▪ Counsel patient regarding smoking cessation
▪ Have patient consult you for health changes
▪ Provide and review patient education and
instruction sheet with patient
Case report

Asbestos
Peritoneal mesothelioma from
asbestos in hairdryers
Health history

A 49-year-old female was evaluated in May 2004 for a routine Papanicolaou

smear. As a result of decreased bone density, she was referred to a
rheumatologist.

A blood test revealed an elevated sedimentation rate, prompting a work-up for

malignancy including a computed topography (CT) of the abdomen.

There were no reports in her medical records of abdominal abnormalities on

physical examination.

Radiological studies revealed multiple lesions in the abdominal cavity, leading

to an exploratory laparotomy, revealing several masses in the peritoneal cavity.

The largest was a 7-cm mass adherent to the splenic flexure of the colon.
Other lesions were noted adjacent to the stomach, intestine, diaphragm,
omentum, liver, and adrenal gland.
Peritoneal mesothelioma from
asbestos in hairdryers
Health history

Immunocytochemistry analysis: sections revealed an epithelial malignancy

exhibiting a spectrum of differentiation consistent with well-differentiated
malignant mesothelioma. Large and small irregular glandular spaces lined by
small mesothelial-like epithelial cells focally on the peritoneal surfaces were
essentially indistinguishable from benign hyperplastic mesothelium.

The histology revealed a poorly differentiated malignant neoplasm with

epithelial and mesothelial expression.

Salient mesothelioma immune-histological markers were positive including

CAM 5.2, EMA, Calretinin (a marker of mesothelial cells), and CD5 (a marker
positive in mesothelioma).

The CA 125 was normal at 19 and the clinical picture and histology were not
indicative of ovarian cancer.

She was diagnosed with peritoneal mesothelioma in August 2004.

Peritoneal mesothelioma from
asbestos in hairdryers
Health history

The patient underwent surgical debulking and chemotherapy treatment with

cisplatin and AlimtaH. In April of 2005, she had a second cycle of
chemotherapy with Alimta. The tumor responded to chemotherapy.

After treatment, the patient was inactive with impaired memory, emotional
distress, insomnia, nausea, loss of appetite, and frequent pain. Her symptoms
were typical of peritoneal mesothelioma.

The patient had a history of smoking cigarettes for 20 years, but had no
serious health problems prior to her cancer diagnosis.
She died in late 2006.
Peritoneal mesothelioma from
asbestos in hairdryers
Occupational history

The subject worked as a cosmetologist and makeup artist in New York from
1976 to 1992 and used a hairdryer every day. She worked 8–14 hours a day, 4–
5 days a week, not altering the products she used between 1976 and 1985.
The patient used a blow dryer 1–2 feet away from her face, close enough to feel
the expulsion of hot air from the dryer. She reported that the air was strong
enough to blow her hair and bangs away from her face.

The hairdryer was on and off throughout the day, in use for periods of 15–20
minutes for 8–14 hours a day, 4–5 days a week. The patient only used the
models of hairdryers that contained asbestos (Conair, General Electric, Gillette)
from 1976 to 1982.

A new hairdryer was purchased every year as a result of burned out motors.
The patient used hairdryers until 1992, a total of 16 years.
Peritoneal mesothelioma from
asbestos in hairdryers
Occupational history

The subject was involved in a legal case in which the defendant ruled out any
other asbestos exposures.

The subject experienced no exposure from relatives working in the asbestos

industry. An evaluation on her residence and job histories also revealed no
asbestos exposure. She lived in New York, New York; West Hartford,
Connecticut; and Santa Monica, California.

None of these locations were near an asbestos factory, mine.

Outside of her career as a cosmetologist and makeup artist, the subject worked
behind a deli counter and in beauty supply sales. Neither occupation exposed
her to asbestos.
Peritoneal mesothelioma from
asbestos in hairdryers
Occupational history

Asbestos was used as an insulator in the hood-type and the hand-held blow
dryers during 1970

Asbestos release from hairdryers was discovered

by accident when a photographer used a hairdryer
to dry film and noted white flecks on the film.
The CPSC issued a recall and convinced the
manufacturers of hair dryers to voluntarily remove
asbestos from this product.
 How do asbestos fibers get in the air?
Physical disturbance of asbestos-containing
materials can suspend fibers in the air.

Asbestos is most hazardous

when it is “FRIABLE”.

▪ Friable: can be easily

crumbled or crushed by hand,
releasing fibers into the air

▪ Very small fibers stay in the

Photo of friable asbestos
air for long periods
▪ Damaged or deteriorated
ACM increases friability Non-friable ACM (floor and ceiling
tiles, house siding, fire doors, etc.)
won’t release fibers unless disturbed
or damaged in some way.
 Evaluating Asbestos Hazards
Type of Material
– What is the asbestos content (greater than
1%)?
– Is it friable or non-friable?
– What is the location – is it isolated or
accessible to workers?
Condition of Material
– Is it intact with no damage?
– Is it in poor condition – damaged, disturbed
or no longer intact?
Activity
- Are employees working in the area where asbestos is found?
- Will the material be cut, sawed, grinded, sanded drilled,
broken, removed, replaced or otherwise disturbed?
 General asbestos safety and health requirements

If workers will be exposed to asbestos on the job, employers

must take measures to minimize their exposure by:

▪ doing exposure evaluation, air monitoring and

record keeping

▪ providing training on the hazard of asbestos

▪ providing a medical surveillance program and

keeping exposure records

▪ developing an Exposure Control Program

 Asbestos Limits in the Air

Asbestos Permissible
Exposure Limits (PEL)

◼ 0.1 fibers per cubic

centimeter of air (0.1 f/cc)
8-hour time weighted average

◼ 1.0 f/cc 30-minute short-term

exposure limit

Air monitoring equipment Asbestos in the air at these levels

on a worker would be invisible to the naked eye.
 Exposure Evaluation & Monitoring
▪ You must conduct periodic air monitoring of
workers when:
– levels in the air are likely to be at or
above the PEL
– conducting an “asbestos project”*
– There are change in process, controls,
work practices or workers

▪ Notify affected employees of results of air

monitoring results.

▪ Maintain exposure monitoring records for

duration of employment + 30 years.

* “asbestos project” means work on any building, ship, or other facility

that releases or is likely to release asbestos fibers into the air.
 Exposure Control
Asbestos exposure must be controlled by one or more of the
following engineering and work practices:

Local exhaust ventilation

with HEPA filter system
HEPA-filtered vacuums
Enclosure or isolation
Wet methods of handling
Prompt disposal
Regular housekeeping

HEPA filter = high efficiency

particulate air filter
 More Exposure Control Requirements
(depending on the type of asbestos abatement work done)

Worker training
- Provide initially and annually
- Cover hazards, work practices, &
safety procedures
- Program elements of Rule

Worker protection
- PPE: respirator, gloves, head and
foot protection, coveralls
- Hygiene facilities:
decontamination, change room

Decontamination shower
 Communication of Hazards

• Warning Signs
− for regulated areas
− visible before entering

• Warning Labels
− attached to all products and
their containers

AVOID BREATHING
AIRBORNE ASBESTOS Entrance to regulated area
FIBERS
 Building/Facility Owner Responsibilities
▪ Determine presence, location, and quantity of asbestos
containing material.
▪ Inform employers, employees, and others who may be
impacted.
▪ Have a “Good Faith” inspection done before starting any
bidding or construction/maintenance work.
▪ Permit only certified individuals to perform work that may
release asbestos fibers into the air.
▪ Submit “Notice of Asbestos Abatement Project” to
L & I when project involves 48 sq. ft. or 10 linear feet of
pipe.
 Construction/Maintenance Activities
To avoid a situation illustrated in the photo below, the regulations
cover any construction or maintenance activity releasing or likely
to release asbestos fibers into the air including:
renovation demolition
remodeling asbestos removal and disposal

Covers work done in:

➢ buildings
➢ structures
➢ mechanical piping equipment
and systems
➢ ships
➢ other facilities
Loose asbestos debris from demolition project
 "Good Faith" Inspection/Survey
• Required for all construction and maintenance in
buildings that may contain asbestos:
– Must be done by an EPA-accredited AHERA
building inspector

– documented written report

– not required if assumed

and treated as asbestos

 Possible fines of $250/day if not

done or poorly done
 Both building owner and
contractor can be cited!
 Construction/Maintenance Activities
Asbestos training certification of workers is required when
asbestos levels in the air are above the PELs

Required for removal or

encapsulation of any materials
containing 1% asbestos or
more.

Covers contractors, supervisors,

workers depending on type/size
of work.

Additional training may be

required depending on type/size Asbestos abatement area contained and
of work. enclosed
 Custodial/Light maintenance work
Housekeeping and building maintenance activities may expose
workers to asbestos fibers if ACM/PACM is disturbed.

Activities of concern:
• sweeping
• vacuuming
• cleaning
• changing lights Damaged asbestos pipe insulation

Materials of concern:
• vinyl asbestos tile
• popcorn ceiling
• exposed piping

Asbestos debris on floor • exposed fireproofing

 Custodial/Light maintenance work

Dry dust or sweep

surfaces, ceilings,
walls, or floors

Disturb ACM when

replacing light bulbs, etc.
DO NOT:

Pin or hang pictures,

plants, or objects on Sand asbestos floor
walls or from ceilings tiles or backing
covered with asbestos material
materials
 Custodial/Light maintenance work

DO: Dust with a damp cloth

Use only a HEPA-filtered

vacuum to clean up
asbestos debris

Wet mop
floors
 Specific requirements for other work

Automotive brake and clutch

inspection, disassembly, repair, and
assembly operations
(View requirements – WAC 296-62-07745)

Roofing, flooring, siding and gaskets

as found in WAC 296-62-07712(10)

Custodial/Light maintenance
Employees who perform housekeeping activities
during and after construction activities are covered
by asbestos construction work requirements in
WAC 296-62-07723.
 DOSH Asbestos Regulations

RCW 49.26 – Asbestos Safety Act

WAC 296-62-077 Part I-1 Occupational

Health-Asbestos
WAC 296-65 Asbestos Certification &
Training
WAC 296-155-160 Construction
regulations which refer to WAC 296-62-077
 Environmental Regulations (EPA)

▪ AHERA (Asbestos Hazard

Emergency Response Act )

▪ NESHAPS (National Emission

Standards for Hazardous Air
Pollutants)
State environmental agencies:
– Washington State Department of Ecology
– Local Air Pollution Authorities (SCAPCA)
– Washington State Department of Health, County Health
Departments
 Further Information

• DOSH – asbestos webpage

OSHA – asbestos webpage

• Environmental Protection Agency –

asbestos webpage

• Department of Ecology – asbestos waste

webpage
 DOSH Consultation Services
Safety & health program review and
worksite evaluation

• By employer invitation only

• Free
• Confidential
• No citations or penalties
• Letter explains findings
• Follow-up all serious hazards
For assistance, you can call one of our consultants. Click below for local L & I office locations:

http://www.lni.wa.gov/wisha/consultation/regional_consultants.htm