1. South West Public Health Observatory South West Regional Public Health Group Mesothelioma clusters and mode of exposure in the South West of England Sean McPhail, Annika Evans, Andy Pring and Julia Verne South West Public Health Observatory sean.mcphail@swpho.nhs.uk

2. South West Public Health Observatory South West Regional Public Health Group Mesothelioma & asbestos Pleura of lungs (mostly) More than 80% of mesothelioma cases related to asbestos 20-60 years between exposure and symptoms Survival is usually less than 2 years Possible routes of exposure – –Occupational –Environmental –Items in home –Exposure from family member

3. South West Public Health Observatory South West Regional Public Health Group Mesothelioma in the UK JT Hodgson et al, Brit. J. Can. 92, 587-593 (2005) Female cases approximately 12% of total

4. South West Public Health Observatory South West Regional Public Health Group Industry in the South West of England Population based cancer registry 6.6 million people Shipyard Other

5. South West Public Health Observatory South West Regional Public Health Group Mesothelioma in the South West of England – modelling the number of cases Age – period – cohort model gives good agreement to data.

6. South West Public Health Observatory South West Regional Public Health Group Mesothelioma – male 99.8% deviation by ward 0.01p 13 000Pop 38n 2.4RR <0.001p 311 000Pop 763n 2.2RR <0.001p 147 000Pop 432n 2.6RR Plymouth Swindon Portsmouth & Southampton “Satscan” Clustering tool Deaths 1980-2005 Clear effect after 40+ years of population mixing! M. Kulldorff, Comm. Stat: Theo. & Meth. 26:1481-1496 (1997)

7. South West Public Health Observatory South West Regional Public Health Group Mesothelioma – female 99.8% deviation by ward 0.41p 78 000Pop 27n 2.3RR Bristol 0.134p 198 000Pop 55n 1.9RR Portsmouth & Southampton Deaths 1980-2005 Elevated rates in Portsmouth and Southampton No unusual level of cases in Plymouth Plymouth

8. South West Public Health Observatory South West Regional Public Health Group Male and female rates 29:1 male:female ratio in Plymouth, 12:1 in Southampton Consultation with Trade Union Congress revealed that, uniquely, the Devonport dockyard in Plymouth operated a workers laundry service.

9. South West Public Health Observatory South West Regional Public Health Group Occupations of Mesothelioma Deaths - Female f Females 0 10 20 30 40 50 60 70 % Agriculture, forestry & mining Construction Dockyard Education, health & retail Financial & Professional Transport, communication manufacturing & energy Regional Occupations of All People MalesFemales 0 10 20 30 40 50 60 70 % 0 10 20 30 40 50 60 70 % <1% of females in “High risk” groups No evidence for occupational exposure for female patients

10. South West Public Health Observatory South West Regional Public Health Group Occupations of Mesothelioma Deaths - Male f Agriculture, forestry & mining Construction Dockyard Education, health & retail Financial & Professional Transport, communication manufacturing & energy Regional Occupations of All People MalesFemales 0 10 20 30 40 50 60 70 % 0 10 20 30 40 50 60 70 % Males Husbands 0 10 20 30 40 50 60 70 % 0 10 20 30 40 50 60 70 % Males do show evidence of occupational exposure And so do husbands of female patients

11. South West Public Health Observatory South West Regional Public Health Group Evidence toward clothing –exposure model % in High risk occupations (95% CI) Male patients 43 (40-46) Female patients 1 (1-1) Husbands 23 (17-29) Husbands of female patients have higher exposure Additional evidence for exposure through clothing … though limitations of death certificate occupation data All males 9 (9-9) All females 1 (1-1)

12. South West Public Health Observatory South West Regional Public Health Group Summary/conclusions Difference in male/female ratio between different clusters is striking Occupational data is suggestive of a clothing- exposure route Justifies launching patient based study to better examine potential exposure routes

13. South West Public Health Observatory South West Regional Public Health Group Thank you sean.mcphail@swpho.nhs.uk