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Original research

Trends in global, regional and national incidence of

pneumoconiosis caused by different aetiologies: an
analysis from the Global Burden of Disease
Study 2017
Peng Shi, Xiaoyue Xing, Shuhua Xi  ‍ ‍, Hongmei Jing, Jiamei Yuan, Zhushan Fu,
Hanqing Zhao

►► Additional material is Abstract

published online only. To view Key messages
Objectives  Pneumoconiosis remains a major global
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​ occupational health hazard and illness. Accurate data on
What is already known about this subject?
oemed-2​ 019-​106321). the incidence of pneumoconiosis are critical for health
►► Despite increasing recognition of
resource planning and development of health policy.
Department of Environmental pneumoconiosis as a contributor to poor health
Methods  We collected data for the period between
and Occupational Health, China outcomes, our literature searches identified
1990 and 2017 on the annual incident cases and
Medical University School a relative scarcity of data about the global
of Public Health, Shenyang, the age-­standardised incidence rates (ASIR) of
prevalence of pneumoconiosis.
Liaoning, China pneumoconiosis aetiology from the Global Burden of
Disease Study 2017. We calculated the average annual What are the new findings?
Correspondence to percentage changes of ASIR by sex, region and aetiology ►► The incidence patterns of pneumoconiosis
Professor Shuhua Xi, in order to determine the trends of pneumoconiosis.
Department of Environmental caused by different aetiologies were found to
and Occupational Health, China
Results  Globally, the number of pneumoconiosis have been heterogeneous across regions and
Medical University School cases increased by a measure of 66.0%, from 36 186 among countries.
of Public Health, Shenyang, in 1990 to 60 055 in 2017. The overall ASIR decreased ►► Asbestosis is increasing at a higher rate in some

copyright.
Liaoning 110122, China; by an average of 0.6% per year in the same period.
s​ hxi@​cmu.​edu.​cn high sociodemographic index (SDI) countries.
The number of pneumoconiosis cases increased across ►► Silicosis and coal workers’ pneumoconiosis
PS and XX contributed equally. the five sociodemographic index regions, and there was were found to have been reduced in middle SDI
a decrease in the ASIR from 1990 to 2017. The ASIR and low SDI regions.
Received 15 November 2019 of silicosis, coal workers’ pneumoconiosis and other
Revised 4 February 2020 pneumoconiosis decreased. In contrast, measures of the
Accepted 1 March 2020
How might this impact on policy or clinical
ASIR of asbestosis displayed an increasing trend. Patterns practice in the foreseeable future?
of the incidence of pneumoconiosis caused by different ►► Our novel findings shed new light on measures
aetiologies were found to have been heterogeneous for of the global disease burden of pneumoconiosis,
analyses across regions and among countries. and can be used to help develop increasingly
Conclusion  Incidence patterns of pneumoconiosis effective and targeted prevention strategies for
which were caused by different aetiologies varied pneumoconiosis.
considerably across regions and countries of the
world. The patterns of incidence and temporal trends
should facilitate the establishment of more effective up until 2018 was 97 500 and that 90% of reported
and increasingly targeted methods for prevention of occupational diseases were identified as pneumo-
pneumoconiosis and reduce associated disease burden. coniosis.4 Between 1975 and 2007 based on an
examination of a South African gold mine, the
proportions of white miners and black miners with
silicosis increased from 18% to 22% and from 3%
Introduction to 32%, respectively.5
Pneumoconiosis is inclusive of a group of serious Since the discovery of pneumoconiosis in the
occupational diseases associated with the inhalation 19th century, the prevention of occupational-­based
© Author(s) (or their of mineral dusts and corresponding reactions of hazards and diseases has been mainly focused on
employer(s)) 2020. No lung tissues.1 Pneumoconiosis can eventually induce control measures meant to help limit and reduce
commercial re-­use. See rights
and permissions. Published irreversible lung damage and has the potential to dust-­caused, occupational-­based hazards.6 The Joint
by BMJ. cause progressive and permanent physical disabil- International Labour Organization (ILO)/WHO
ities, and has afflicted tens of millions of workers Committee on Occupational Health established the
To cite: Shi P,
employed in hazardous occupations globally.2 In ILO/WHO Global Programme for the Elimination
Xing X, Xi S, et al.
Occup Environ Med Epub 2016, pneumoconiosis was found to have caused of Silicosis following the recommendations of the
ahead of print: [please include 21 488 deaths on a global scale.3 The National 1995 12th Session, which called on world leaders to
Day Month Year]. doi:10.1136/ Health Commission of China estimated that the take appropriate steps for better prevention of sili-
oemed-2019-106321 total number of reported occupational-­based cases cosis.7 However, the numbers of newly diagnosed
Shi P, et al. Occup Environ Med 2020;0:1–8. doi:10.1136/oemed-2019-106321 1
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Occup Environ Med: first published as 10.1136/oemed-2019-106321 on 18 March 2020. Downloaded from http://oem.bmj.com/ on April 10, 2020 at University of Birmingham. Protected by
pneumoconiosis cases have increased on a global scale during J92.0) were included in these estimates (online supplementary
the recent decades despite major types of public health measures box 1).
having been made to counter this problem. The aetiologies of
pneumoconiosis have been confirmed in previous epidemiolog-
ical studies.8–11 Therefore, the heterogeneous incidence pattern Statistical analysis
of pneumoconiosis is directly related to the level of exposure to The incidence rate is reported per 100 000 people, and is derived
relevant risk factors in different geographical regions. Knowing from the number of annual cases divided by the population size.
the patterns which influence pneumoconiosis incidence and In order to compare several populations with different age
temporal trends can help to facilitate rational allocation of structures, we used the GBD 2017 world standard population
healthcare resources and functions in order to promote accurate to calculate ASIRs and to quantify the trends in incidence of
and efficient prevention of pneumoconiosis. pneumoconiosis.14 We used the Joinpoint regression software
The Global Burden of Diseases, Injuries, and Risk Factors (V.4.7.0.0), developed by the National Cancer Institute, in order
Study (GBD) 2017 assessed 354 types of diseases and injuries to calculate measures of ‘AAPC of ASIR’, which is a summary
across 195 countries and territories, and has therefore provided of ASIR trends over a prespecified interval. These results are
a unique perspective to help understand the landscape of and presented as AAPC with corresponding 95% CI. The meaning of
the dynamics underlying pneumoconiosis.12 13 Thus, in the results based on AAPC has been reported in previous studies.15
current study, we sought to collect detailed information on the Briefly, if the AAPC and its 95% CI were both >0, the ASIR
incidence of pneumoconiosis caused by four major aetiologies was indicated to have had a corresponding increasing trend. In
from the GBD Study 2017. We further sought to present results contrast, if they were both <0, the ASIR was deemed to have
for annual incident cases, for age-­standardised incidence rate had a corresponding decreasing trend.
(ASIR), and to determine the average annual percentage change We used locally weighted regression and smoothing scatter-
(AAPC) of pneumoconiosis according to sex, across different plot regressions in order to analyse all ASIRs and SDIs at 21
regions, among different countries and among variable types geographical regions across the globe from 1990 to 2017 and to
of aetiologies, in order to determine trends in incidence of determine expected measures of relationships between them. We
pneumoconiosis. compared the observed measures of pneumoconiosis ASIR with
the expected levels in order to identify the state of development
in regions, whereas performance was determined to have either
Methods been better or lower than expected. Additionally, we assessed
Study data measures of the association between SDIs (2017) and AAPCs at
We collected annual incident cases and ASIRs of pneumoconi- the national level.
osis from the period spanning from 1990 to 2017 and according

copyright.
to classifications of sex, geographical region and aetiology
(silicosis, asbestosis, coal workers’ pneumoconiosis and other Results
pneumoconiosis) from across 195 countries and territories. Globally, the incident cases of pneumoconiosis increased by a
The sociodemographic index (SDI) provides summary metrics measure of 66.0%, from 36 186 cases in 1990 to 60 055 cases
for lagged distributed income per capita; mean years of educa- in 2017. The ASIR was found to have decreased by an average
tion over the age of 15 years; and total fertility rate in women of 0.6% per year in the same period (from 0.86 per 100 000
under the age of 25 years. These metrics were used to estimate in 1990 to 0.75 per 100 000 in 2017; table 1). In 2017, the
a position on the development spectrum.12 The 195 countries incident cases and ASIR of pneumoconiosis were significantly
and regions were classified into broader groups of five regions higher in men than in women and were found to have peaked
according to the SDI value, including low, low-­middle, middle, in individuals aged 65–69 years, followed by the highest inci-
high-­middle and high SDI (online supplementary figure 1). dences in the 70–74 years age group and then by the 80+
Moreover, we divided the countries sampled across the world years age group (table 1, online supplementary figure 2). For
into 21 separate regions in terms of geography. We used data SDI regions, the number of pneumoconiosis cases was found
used from the GBD team in order to make estimates of pneu- to have increased (figure 1), and there was a decrease in the
moconiosis derived predominantly from three main sources.12 ASIR from 1990 to 2017 (table 1). For geographical regions,
The first source was based on resultant data from systematic except for three regions namely Central Europe, Eastern Europe
reviews, and these were usually from smaller-­scaled and rela- and Western Europe, the absolute numbers of pneumoconiosis
tively localised studies. The second source of data was derived cases increased (table 1). As for measures of the ASIR, except
from inpatient hospital reports, and the third source was based for six regions namely Southeast Asia, Oceania, Australasia,
on finely reported claims-­based data from the USA and Taiwan. high-­income North America, North Africa and Middle East,
A Bayesian meta-­regression model (DisMod-­MR V.2.1), as the and Western Sub-­Saharan Africa, the ASIR of pneumoconiosis
main method of estimation in the GBD, is a type of mixed-­ decreased (online supplementary figure 3). The most significant
effect model that borrows information across age, time and decrease was detected in Western Europe, and the most signifi-
locations, and which controls and adjusts biases in data, and cant increase was detected in Australasia (table 1).
synthesises multiple sources of data into unified estimates of At the national and territorial level, the highest ASIR in 2017
levels and trends. Final estimates are computed using the mean was observed in Taiwan (China), followed by Papua New Guinea
estimate across 1000 draws, and the 95% uncertainty inter- and then by China (figure 2A, online supplementary table 2).
vals are determined on the basis of the 25th and 975th ranked As for measures of the absolute number on a global scale, more
values across all 1000 draws. A detailed description of the like- than half of newly diagnosed pneumoconioses were recorded in
lihood used for estimation and a full description of improve- China in 2017 (32 205), followed by India (5160) and then the
ments made for DisMod-­MR V.2.1 are described among the USA (3324) (online supplementary table 2). The Netherlands
details within GBD 2017.12 All International Classification of and Belgium reported the largest decreases in pneumoconiosis
Diseases-10 codes pertaining to pneumoconiosis (J60–J65.0, ASIR between the measure in 1990 compared with the measure

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Occup Environ Med: first published as 10.1136/oemed-2019-106321 on 18 March 2020. Downloaded from http://oem.bmj.com/ on April 10, 2020 at University of Birmingham. Protected by
Table 1  Incident cases and age-­standardised incidence rate of pneumoconiosis in 1990 and 2017, and its temporal trends from 1990 to 2017
1990 2017
1990–2017
Incident cases ASIR per 100 000 Incident cases ASIR per 100 000 AAPC
Characteristics n (95% UI) n (95% UI) n (95% UI) n (95% UI) n (95% CI)
Overall 36 186 (32 504 to 40 004) 0.86 (0.78 to 0.95) 60 055 (53 088 to 67 017) 0.75 (0.66 to 0.84) −0.6 (−0.6 to −0.5)
Sex
 Male 32 359 (28 959 to 35 915) 1.70 (1.52 to 1.88) 53 730 (47 417 to 60 282) 1.45 (1.28 to 1.62) −0.6 (−0.7 to −0.6)
 Female 3827 (3332 to 4377) 0.17 (0.15 to 0.19) 6324 (5456 to 7240) 0.15 (0.13 to 0.17) −0.7 (−0.8 to −0.6)
SDI
 High SDI 7070 (6437 to 7730) 0.55 (0.50 to 0.60) 11 333 (10 285 to 12 460) 0.52 (0.48 to 0.57) −0.2 (−0.3 to −0.2)
 High-­middle SDI 10 005 (8756 to 11 258) 1.03 (0.91 to 1.16) 15 973 (13 645 to 18 382) 0.90 (0.77 to 1.03) −0.6 (−0.7 to −0.5)
 Middle SDI 12 818 (11 367 to 14 412) 1.28 (1.13 to 1.44) 21 481 (18 865 to 24 497) 0.98 (0.86 to 1.12) −1.0 (−1.1 to −1.0)
 Low-m
­ iddle SDI 3930 (3551 to 4329) 0.67 (0.60 to 0.74) 7087 (6298 to 7936) 0.60 (0.53 to 0.67) −0.5 (−0.5 to −0.4)
 Low SDI 2020 (1817 to 2242) 0.62 (0.56 to 0.68) 3619 (3186 to 4098) 0.51 (0.45 to 0.57) −0.9 (−0.9 to −0.8)
Causes
 Silicosis 14 973 (12 402 to 17 714) 0.36 (0.30 to 0.42) 23 695 (19 069 to 28 969) 0.30 (0.24 to 0.36) −0.8 (−0.9 to −0.7)
 Asbestosis 4337 (3492 to 5494) 0.10 (0.08 to 0.13) 9397 (7652 to 11 637) 0.12 (0.10 to 0.15) 0.6 (0.5 to 0.6)
 Coal workers’ pneumoconiosis 9816 (7995 to 12 542) 0.24 (0.19 to 0.30) 15 080 (12 004 to 19 799) 0.19 (0.15 to 0.25) −0.9 (−0.9 to −0.8)
 Other pneumoconiosis 7061 (5956 to 8320) 0.17 (0.14 to 0.20) 11 883 (9900 to 14 278) 0.15 (0.12 to 0.18) −0.5 (−0.5 to −0.5)
Region
 East Asia 20 158 (17 620 to 22 838) 2.12 (1.86 to 2.41) 33 954 (29 050 to 39 105) 1.66 (1.43 to 1.91) −0.9 (−1.0 to −0.9)
 Southeast Asia 986 (850 to 1142) 0.36 (0.31 to 0.42) 2357 (2015 to 2744) 0.39 (0.34 to 0.46) 0.3 (0.2 to 0.4)
 Oceania 41 (36 to 46) 1.39 (1.24 to 1.57) 95 (81 to 112) 1.45 (1.24 to 1.69) 0.2 (0.1 to 0.3)
 Central Asia 167 (144 to 193) 0.34 (0.29 to 0.39) 229 (195 to 269) 0.30 (0.26 to 0.35) −0.5 (−0.5 to −0.5)
 Central Europe 1278 (1167 to 1404) 0.85 (0.78 to 0.93) 1150 (1015 to 1298) 0.59 (0.52 to 0.66) −1.5 (−1.6 to −1.4)
 Eastern Europe 1411 (1265 to 1581) 0.50 (0.45 to 0.55) 1213 (1046 to 1407) 0.37 (0.32 to 0.43) −1.2 (−1.3 to −1.1)
 High-i­ ncome Asia Pacific 1519 (1352 to 1705) 0.74 (0.66 to 0.82) 2509 (2176 to 2868) 0.54 (0.47 to 0.61) −1.3 (−1.4 to −1.2)
 Australasia 79 (68 to 92) 0.32 (0.28 to 0.37) 248 (217 to 280) 0.48 (0.42 to 0.54) 1.4 (1.3 to 1.5)

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 Western Europe 1735 (1529 to 1931) 0.28 (0.25 to 0.32) 1398 (1218 to 1594) 0.14 (0.13 to 0.16) −2.5 (−2.7 to −2.2)
 Southern Latin America 199 (179 to 223) 0.43 (0.39 to 0.48) 349 (299 to 404) 0.42 (0.36 to 0.49) −0.2 (−0.2 to −0.1)
 High-­income North America 1965 (1736 to 2221) 0.55 (0.49 to 0.63) 3724 (3294 to 4194) 0.62 (0.55 to 0.69) 0.5 (0.4 to 0.6)
 Caribbean 37 (32 to 44) 0.14 (0.12 to 0.16) 67 (55 to 79) 0.13 (0.11 to 0.16) −0.2 (−0.3 to −0.1)
 Andean Latin America 78 (69 to 86) 0.37 (0.34 to 0.41) 169 (140 to 206) 0.31 (0.26 to 0.38) −0.5 (−0.7 to −0.4)
 Central Latin America 753 (667 to 842) 0.79 (0.70 to 0.88) 1502 (1295 to 1721) 0.63 (0.54 to 0.72) −0.9 (−1.0 to −0.8)
 Tropical Latin America 506 (449 to 567) 0.53 (0.47 to 0.60) 966 (856 to 1084) 0.42 (0.37 to 0.47) −0.6 (−0.7 to −0.5)
 North Africa and Middle East 709 (621 to 809) 0.34 (0.30 to 0.38) 1711 (1496 to 1972) 0.36 (0.32 to 0.41) 0.2 (0.2 to 0.3)
 South Asia 3471 (3082 to 3891) 0.60 (0.53 to 0.66) 6307 (5427 to 7291) 0.48 (0.41 to 0.54) −1.0 (−1.1 to −0.9)
 Central Sub-­Saharan Africa 153 (136 to 172) 0.68 (0.62 to 0.75) 329 (287 to 375) 0.62 (0.55 to 0.70) −0.4 (−0.4 to −0.3)
 Eastern Sub-­Saharan Africa 468 (420 to 524) 0.60 (0.54 to 0.66) 888 (777 to 1013) 0.51 (0.45 to 0.59) −0.7 (−0.7 to −0.6)
 Southern Sub-­Saharan Africa 307 (276 to 341) 1.03 (0.92 to 1.14) 514 (444 to 590) 0.89 (0.77 to 1.02) −0.3 (−0.4 to −0.2)
 Western Sub-­Saharan Africa 166 (137 to 202) 0.16 (0.13 to 0.19) 376 (304 to 466) 0.17 (0.14 to 0.21) 0.2 (0.1 to 0.3)
AAPC, average annual percentage change of ASIR; ASIR, age-­standardised incidence rate; SDI, sociodemographic index; UI, uncertainty interval.

in 2017. In contrast, the largest increase in ASIR was observed in Silicosis

New Zealand (figure 2B, online supplementary table 2). Globally, 39% of the total pneumoconiosis cases (23 695)
The proportions of pneumoconiosis caused by specific aeti- were ascribed to silicosis in 2017 (figure 3, table 1). From
ologies at the global and regional level in 1990 and 2017 are the period ranging from 1990 to 2017, the ASIR of silicosis
presented in figure 3. Globally, approximately 40% of pneumo- displayed a decreasing trend. Silicosis cases increased and the
conioses were caused by crystalline silica, followed by coal dust, ASIR decreased in all SDI regions (figure 1, online supplemen-
asbestos and other causes. The proportions significantly changed tary table 1). For geographical regions, five regions namely
in some regions over time. For example, globally the propor- Central Europe, Eastern Europe, high-­ income Asia Pacific,
tion of asbestosis increased from 12% in 1990 to 16% in 2017, Western Europe and Caribbean all reported a decrease in sili-
while the proportion specific to coal workers’ pneumoconiosis cosis cases. Across the period from 1990 to 2017, the ASIR of
decreased from 27% to 25% during the same period. In the data silicosis displayed a minor increasing trend in Southeast Asia,
for Australia, the proportion of asbestosis increased from 46% North Africa and Middle East, and Western Sub-­Saharan Africa,
in 1990 to 78% in 2017, while the proportion for coal workers and indicated that AAPC of silicosis decreased in other regions
in this country for pneumoconiosis decreased from 27% to 8% (online supplementary table 1). At the national and territorial
during the same period. Similar results were observed in the level, the highest measure of ASIR in 2017 was observed in
high-­income North American data set. China, and the highest AAPC was found in Singapore, followed
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Figure 1  Pneumoconiosis cases caused by different aetiologies and by SDI regions from 1990 to 2017. CWP, coal workers’ pneumoconiosis; OP, other
pneumoconiosis; SDI, sociodemographic index.

copyright.
in order by New Zealand and the American Samoa (online North Africa and Middle East, and Southeast Asia reported an
supplementary table 2). increasing ASIR of coal workers’ pneumoconiosis, whereby the
greatest increase was found in Oceania, and the AAPC of coal
Asbestosis workers’ pneumoconiosis decreased in other regions (online
In 2017, asbestosis accounted for nearly 16% (9397) of the total supplementary table 1). With respect to countries and terri-
number of pneumoconiosis cases (figure 3, table 1). Globally, the tories, the highest absolute numbers were observed in China
ASIR of asbestosis displayed an increasing trend from the period (10 287), and relatively high ASIRs in 2017 were observed in
spanning from 1990 to 2017, with an AAPC of 0.6 (table 1). This Taiwan (China), followed by China and North Korea, with the
was despite the incidence of pneumoconiosis due to asbestosis highest increase in ASIR observed in New Zealand, followed
being under 0.10 per 100 000 in 2017 in most countries. For SDI next in order by Taiwan (China) and Montenegro (online
regions, an increasing trend in asbestosis was observed in high supplementary table 2).
SDI regions and low-­middle SDI regions (online supplementary
table 1). For geographical regions, except for the two regions,
namely Eastern Europe and Western Sub-­Saharan Africa, the Other pneumoconiosis
absolute numbers of asbestosis cases increased in other regions. In 2017, other pneumoconiosis accounted for 20% (11 883) of
The greatest increase was found in Australasia (online supple- the total pneumoconiosis cases (figure 3, table 1). The global
mentary table 1). At the national and territorial level, the highest ASIR of other pneumoconiosis decreased by an average of 0.5%
rate in 2017 was observed in South Africa, followed by Swazi- (table 1) per year from the period spanning from 1990 to 2017.
land and the USA, and the highest increase in asbestosis ASIR
The ASIR of other pneumoconiosis remained stable in high SDI
was observed in Australia, followed in order by New Zealand
regions and was found to have decreased in other SDI regions
and Spain (online supplementary table 2).
(online supplementary table 1). For geographical regions, data
indicated that only five regions namely high-­ income North
Coal workers’ pneumoconiosis
America, Southeast Asia, Oceania, Andean Latin America, and
In 2017, coal workers’ pneumoconiosis accounted for 25% (15
080) of the total pneumoconiosis cases, despite only 78 coun- North Africa and Middle East reported an increasing ASIR of
tries and territories reporting coal workers’ pneumoconiosis other pneumoconiosis, and the greatest increase was found in
cases (figure 3, table 1). From the period spanning from 1990 high-­income North America, whereas AAPC of other pneumo-
to 2017, the ASIR of coal workers’ pneumoconiosis displayed coniosis was found to have decreased in other regions (online
a decreasing trend (table 1). The ASIR of coal workers’ pneu- supplementary table 1). At the national and territorial level, the
moconiosis decreased in all SDI regions over this period highest measures of ASIR were observed in Taiwan (China),
(online supplementary table 1). For geographical regions, only followed next in order by Papua New Guinea (online supple-
four regions namely Oceania, Western Sub-­ Saharan Africa, mentary table 2).

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Figure 2  The global disease burden of pneumoconiosis for both sexes assessed for 195 countries and territories. (A) The ASIR of pneumoconiosis in 2017.
(B) The AAPC of pneumoconiosis ASIR from 1990 to 2017. Countries with an extreme number of cases were annotated. ASIR, age-­standardised incidence
rate; AAPC, average annual percentage change of ASIR.

ASIRs, AAPCs and SDIs the ASIR of pneumoconiosis across all the years from 1990 to
The GBD regions of East Asia, Oceania, Southern Sub-­Saharan 2017. However, there were significant differences in the trends
Africa, Central Europe, Central Latin America, high-­income Asia of incidence across the world. This can be illustrated briefly by
Pacific and high-­income North America had higher observed the observance of a significant decrease in the trends of pneu-
ASIRs due to pneumoconiosis than was expected based on moconiosis ASIR in middle SDI and low SDI regions, which
their SDI. Regions with better-­than-­expected pneumoconiosis were primarily dominated by the reductions in silicosis and coal
ASIRs included the Caribbean, Western Europe, Western Sub-­ workers’ pneumoconiosis. Conversely, in high SDI regions, there
Saharan Africa, Central Asia, Andean Latin America, North was a minor decreasing trend in pneumoconiosis ASIR, which
and Middle Eastern Africa, and Southeast Asia (figure 4A). As was mostly attributed to a dramatic decrease in silicosis and an
shown in figure 4B, data indicated that there was a significantly increase in asbestosis. The pattern of incidence of exposure to
negative association between AAPCs and SDIs in 2017 when the risk factors was heterogeneous16 17; however, if we had only
SDI value was above 0.7. In contrast, when SDI was limited to looked at the total number or the rate of pneumoconiosis cases as
below 0.7, the association disappeared. A detailed result of the a whole, important findings and actual trends of individual types
correlation between AAPC, ASIR and SDI, by specific aetiology, of pneumoconiosis may have been missed, and such dynamics
is provided in online supplementary figures 4 and 5. can lead to complications in efforts to prevent pneumoconiosis
across the world. Therefore, knowing the exact patterns of inci-
Discussion dence of pneumoconiosis and corresponding temporal trends is
In this study, we comprehensively analysed trends in the inci- critical for the accurate prevention of pneumoconiosis.
dence of pneumoconiosis caused by four aetiologies at the global, These findings are in agreement with those from previous
regional and national levels. Globally, there was a decrease in research suggesting that crystalline silica remains the most
Shi P, et al. Occup Environ Med 2020;0:1–8. doi:10.1136/oemed-2019-106321 5
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Occup Environ Med: first published as 10.1136/oemed-2019-106321 on 18 March 2020. Downloaded from http://oem.bmj.com/ on April 10, 2020 at University of Birmingham. Protected by
Figure 3  Contribution of the different types of pneumoconiosis to the absolute measures of incident cases of pneumoconiosis by region in 1990 and
2017. CWP, coal workers’ pneumoconiosis; OP, other pneumoconiosis; SDI, sociodemographic index.

important risk factor for pneumoconiosis.18 Although silicosis have had relatively fast growth in some high and high-­middle
had higher ASIRs in both high and middle SDI regions, including SDI countries, including Singapore and New Zealand. Addition-
East Asia (mainly China) and Oceania, they have been declining ally, in recent years, an increasing level of attention has been
overall during the recent decades. A possible explanation for this paid to rapidly emerging problems related to silicosis, including

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finding might be that the prevention of pneumoconiosis through shorter latency periods, that is, 4–10 years, which are associated
specific steps and increasing awareness of self-­protection have with occupational exposure to silica dust generated by manu-
greatly improved during these decades. For example, in order facturing, finishing and installation of artificial stone.19 20 It is
to strengthen surveillance for this and other types of occupa- possible that as a result, peaks in the rates of this new silicosis
tional diseases, the Network Direct Report System of Occupa- epidemic might be observed in the next 3–5 years, most notably
tional Diseases was constructed in 2006 in China.2 6 Surprisingly, perhaps in Israel, Spain and Australia.20 21
a significantly negative association was found between AAPCs Asbestosis was found to have had higher numbers of cases
and SDIs when measures of the SDI were above 0.7 in sili- and ASIRs in high SDI regions, including Australasia (mainly
cosis, although the rate of incidence of silicosis was found to Australia) and high-­income North America. Mining, processing

Figure 4  (A) ASIR and the expected value based on the SDI, by regions from 1990 to 2017. The black line represents the expected value of an incidence
rate based on a LOESS regression of all years of available estimates by GBD locations and by their SDI value. (B) Measures of correlation between AAPC
and SDI in 2017. Circles represent countries and territories available on GBD data. The relative size of circles increased correspondingly with increases in the
cases of pneumoconiosis in 2017. The blue line represents the expected value of AAPC based on a LOESS regression of all years of available estimates by
SDI value in 2017. ASIR, age-­standardised incidence rate; AAPC, average annual percentage change of ASIR; GBD, global burden of disease; LOESS, locally
weighted regression and smoothing scatterplots; SDI, sociodemographic index.

6 Shi P, et al. Occup Environ Med 2020;0:1–8. doi:10.1136/oemed-2019-106321

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Occup Environ Med: first published as 10.1136/oemed-2019-106321 on 18 March 2020. Downloaded from http://oem.bmj.com/ on April 10, 2020 at University of Birmingham. Protected by
and transportation of raw asbestos are high-­risk occupations for as largely reflecting past exposures, and this aspect requires
asbestosis.22–24 Moreover, economic issues surrounding asbestos further analysis.
and the financial implications from growing worldwide legal
implications have largely affected changes in the incidence of
Conclusions
asbestosis.23–26 For example, mainly due to the ban on the use of
In summary, pneumoconiosis continues to be one of the major
asbestos in Europe for about the last 30 years,22 we found that
and significant occupational health-­related hazards and subse-
the incidence of asbestosis has decreased significantly. Despite
quent illnesses in the world. On one hand, although the world
these promising advances and our positively oriented results,
has attained great achievements in the prevention of silicosis
questions remain, such as when we found that the Netherlands
and coal workers’ pneumoconiosis, these remain as important
reported the largest decrease in pneumoconiosis ASIR between
health problems in some countries and territories. On the other
1990 and 2017 while the ASIR of asbestosis increased during the
hand, asbestosis is increasing at a higher rate in some high SDI
same period. Australia is one of the countries with the highest
countries. The novel findings reported herein help to shed new
incidence of asbestos-­related lung disease in the world, and the
light on the global disease burden of pneumoconiosis. Our hope
ban on the importation of asbestos was issued only in 2004.
is that these estimates of pneumoconiosis incidence and their
Lessons taken from Australia might have important implications
longer-­term trends will help public health officials, scholars and
for countries currently still using asbestos, whereby reducing
policymakers to better assess and identify more effective and
asbestos use, implementation of careful monitoring, and
targeted pneumoconiosis prevention and intervention strategies
improving the levels of management, diagnosis, treatment and
at national and international scales in order to reduce the burden
compensation for asbestosis cases can further the prevention of
of disease from pneumoconiosis.
asbestosis and accelerate progress towards ‘Sustainable Develop-
ment Goal 8’, which promotes ‘full and productive employment
Acknowledgements  We appreciate the work by the Global Burden of Disease
and decent work for all’. Study 2017 collaborators. We express our gratitude to the reviewers and editor of
In 2017, coal workers’ pneumoconiosis accounted for 25.11% the journal for their valuable comments for improvement of the paper.
of the total pneumoconiosis cases, despite only 78 countries and Contributors  All authors contributed to the study concept and design. PS wrote
territories reporting coal workers’ pneumoconiosis cases. Corre- the first draft of the report. PS, XX, HJ, JY, ZF and HZ did the collection and analysis.
spondingly, coal workers’ pneumoconiosis had the highest abso- PS, XX and SX reviewed and revised the manuscript before submission. All authors
lute numbers in China, while the ASIR was also found to have approved the final submitted version.
been decreasing over the last couple of decades. In contrast, in Funding  This work was supported by the National Natural Science Foundation of
New Zealand, Taiwan (China) and Montenegro, there has been China (NSFC) (81673207 and 81373023).
an increasing trend. Government-­based operations and progres- Disclaimer  This manuscript has been posted to Research Square as a pre-­
sive coal mining companies have recently chosen to put more print (https://www.​researchsquare.​com/​article/​df29da45-​60d0-​43cc-​a6b1-​

copyright.
4b5d18231674/​v1).
energy and money into production safety with respect to trade-­
offs between ‘visible and immediate accidents’ and ‘invisible and Competing interests  None declared.
chronic lung diseases’, which can seriously damage coal miners’ Patient consent for publication  Not required.
lives and health.27–30 Provenance and peer review  Not commissioned; externally peer reviewed.
Apart from silicosis, asbestosis and coal workers’ pneumo- Data availability statement  Data are available in a public, open access
coniosis, diseases such as aluminosis, berylliosis, siderosis and repository. The data sets generated and/or analysed during the current study are
stannosis were integrated into the category of ‘other types of available in the Global Health Data Exchange (GHDx) query tool (http://​ghdx.​
pneumoconiosis’ in the 2017 GBD study.13 From 1990 to 2017, healthdata.​org/​gbd-​results-​tool).
the overall ASIR of other types of pneumoconiosis showed a ORCID iD
minor decreasing trend. However, a study showed that, although Shuhua Xi http://​orcid.​org/​0000-​0003-​4232-​7258
23% of pneumoconiosis cases are attributed to other pneumoco-
niosis, most are actually due to silicosis, asbestos or coal workers’
References
pneumoconiosis and related to incomplete coding in the source 1 Worth G. [Roentgenologically demonstrable changes in pneumoconiosis (author’s
data.3 Therefore, we should consider the findings in light of the transl)]. Prax Klin Pneumol 1979;33:622–6.
totality of evidence which has provided these specific types of, 2 Zhang Z, Zhao Y, Sun D. China’s occupational health challenges. Occup Med
and other forms of, data on the incidence of pneumoconiosis. 2017;67:87–90.
3 GBD 2016 occupational chronic respiratory risk factors collaborators. Global and
It should be noted that our study has several limitations.
regional burden of chronic respiratory disease in 2016 arising from non-­infectious
First, the GBD 2017 measures are probably underestimates of airborne occupational exposures: a systematic analysis for the global burden of
cases and ASIRs associated with pneumoconiosis, and because disease study 2016. Occup Environ Med 2020;77:142–50.
the quality and quantity of data used in modelling to deter- 4 The Lancet. Improving occupational health in China. Lancet 2019;394:443.
mine the accuracy and robustness of GBD estimation of a 5 Nelson G. Occupational respiratory diseases in the South African mining industry.
Glob Health Action 2013;6:19520.
number of cases are not perfect.12 13 For example, clinical data 6 Han L, Yao W, Bian Z, et al. Characteristics and trends of pneumoconiosis in the
records have been demonstrated to have selection biases based Jiangsu Province, China, 2006–2017. Int J Environ Res Public Health 2019;16:437.
on the subsets of the population who have access to health- 7 Mandrioli D, Schlünssen V, Ádám B, et al. WHO/ILO work-­related burden of disease
care.31 Further, data reported by some countries and territo- and injury: protocol for systematic reviews of occupational exposure to dusts and/
or fibres and of the effect of occupational exposure to dusts and/or fibres on
ries are based on only diagnosed cases, and the low frequency
pneumoconiosis. Environ Int 2018;119:174–85.
of occupational-­oriented health checks as well as the narrow 8 Leung CC, Yu ITS, Chen W. Silicosis. Lancet 2012;379:2008–18.
range of diseases defined within the occupational diseases list. 9 Morgan J. Black lung is still a threat. Lancet Respir Med 2018;6:745–6.
Thus, there are still a high number of unreported and undiag- 10 Culver DA. Beryllium disease and sarcoidosis: still besties after all these years? Eur
nosed cases. Second, we have not performed a detailed analysis Respir J 2016;47:1625–8.
11 Furuya S, Chimed-­Ochir O, Takahashi K, et al. Global asbestos disaster. Int J Environ
of the occupational risk factors for our pneumoconiosis-­related Res Public Health 2018;15. doi:10.3390/ijerph15051000
results. Additionally, although reflecting a certain and identifi- 12 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global,
able trend, the results for pneumoconiosis should be considered regional, and national incidence, prevalence, and years lived with disability for 354

Shi P, et al. Occup Environ Med 2020;0:1–8. doi:10.1136/oemed-2019-106321 7

 Workplace

Occup Environ Med: first published as 10.1136/oemed-2019-106321 on 18 March 2020. Downloaded from http://oem.bmj.com/ on April 10, 2020 at University of Birmingham. Protected by
diseases and injuries for 195 countries and territories, 1990-2017: a systematic 22 Accinelli RA, López LM. [Asbestos, an epidemic that still needs to be controlled]. Gac
analysis for the global burden of disease study 2017. Lancet 2018;392:1789–858. Sanit 2017;31:365–7.
13 GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national 23 Leong SL, Zainudin R, Kazan-­Allen L, et al. Asbestos in Asia. Respirology
deaths, prevalence, disability-­adjusted life years, and years lived with disability for 2015;20:548–55.
chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis 24 Hoy RF, Brims F. Occupational lung diseases in Australia. Med J Aust 2017;207:443–8.
for the global burden of disease study 2015. Lancet Respir Med 2017;5:691–706. 25 Rosner D. Deregulating safety: the case of the effort to ban asbestos. Milbank Q
14 Hankey BF, Ries LA, Kosary CL, et al. Partitioning linear trends in age-­adjusted rates. 2017;95:257–60.
Cancer Causes Control 2000;11:31–5. 26 Poyatos G, Diego Roza C. Asbestos and the law. Arch Bronconeumol 2017;53:5–6.
15 Liu Z, Jiang Y, Yuan H, et al. The trends in incidence of primary liver cancer caused 27 Perret JL, Plush B, Lachapelle P, et al. Coal mine dust lung disease in the modern era.
by specific etiologies: results from the global burden of disease study 2016 and
Respirology 2017;22:662–70.
implications for liver cancer prevention. J Hepatol 2019;70:674–83.
28 Han S, Chen H, Harvey M-­A, et al. Focusing on Coal Workers’ Lung Diseases: a
16 Fernández Álvarez R, Martínez González C, Quero Martínez A, et al. Guidelines for the
Comparative Analysis of China, Australia, and the United States. Int J Environ Res
diagnosis and monitoring of silicosis. Arch Bronconeumol 2015;51:86–93.
Public Health 2018;15. doi:10.3390/ijerph15112565
17 Perlman DM, Maier LA. Occupational lung disease. Med Clin North Am
2019;103:535–48. 29 Mazurek JM, Wood J, Blackley DJ, et al. Coal Workers’ Pneumoconiosis-­
18 Mazurek JM, Wood JM, Schleiff PL, et al. Surveillance for Silicosis Deaths Among Attributable Years of Potential Life Lost to Life Expectancy and Potential Life Lost
Persons Aged 15-44 Years - United States, 1999-2015. MMWR Morb Mortal Wkly Before Age 65 Years - United States, 1999-2016. MMWR Morb Mortal Wkly Rep
Rep 2017;66:747–52. 2018;67:819–24.
19 Hoy RF, Baird T, Hammerschlag G, et al. Artificial stone-­associated silicosis: a rapidly 30 Blackley DJ, Reynolds LE, Short C, et al. Progressive massive fibrosis in coal miners
emerging occupational lung disease. Occup Environ Med 2018;75:3–5. from 3 clinics in Virginia. JAMA 2018;319:500–1.
20 Kirby T. Australia reports on audit of silicosis for stonecutters. Lancet 2019;393:861. 31 Stanaway JD, Shepard DS, Undurraga EA, et al. The global burden of dengue:
21 Leso V, Fontana L, Romano R, et al. Artificial stone associated silicosis: a systematic an analysis from the global burden of disease study 2013. Lancet Infect Dis
review. Int J Environ Res Public Health 2019;16:568. 2016;16:712–23.

copyright.

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