Discussion

To date, global efforts have been undertaken to eliminate pneumoconiosis for several decades, and the corresponding effects of control system have gradually emerged.4 The latest Global Burden of Disease (GBD) study has demonstrated that the ASIR of pneumoconiosis decreased worldwide from 1990 to 2017.2 However, present efforts to eliminate asbestosis might be insufficient in most countries in the world. The absolute number and ASIR of asbestosis increased globally between 1990 and 2017, especially in high-SDI regions. Moreover, the ASIR increased in all SDI regions in most recent years. One explanation is the historical legacy of extensive use of asbestos in industry, as well as the very long latency of asbestosis.5 According to a report from WHO, approximately 125 million people globally are currently exposed to asbestos in the workplace, and more than 90 000 workers die from asbestos-related diseases each year.6 So far, the use of asbestos has been completely banned in more than 50 countries, such as the European Union, South Africa and Australia, and the use has been restricted in some countries, including the USA, Canada and New Zealand.4 However, the asbestos is still widely used in some other countries, and the burden of asbestosis is still rising. A study in Canada found that the number of new asbestosis cases has increased by about 30% during the surveillance period from 1992 to 2004.5 Using data from the UK General Practice Research Database (a representative sample of the general population), we found that an overall increase was documented in asbestosis incidence in the UK between 1997 and 2008.7 Additionally, from 2001 to 2015, 17 220 asbestosis cases (1148 annually on average) were reported in Italy, and the overall adjusted hospitalisation rate was 25.2 per 1 000 000 residents.8 Consistent with previous studies, our results showed that the increasing ASIR and proportion of asbestosis occurred mainly in the developed regions, including high-income North America, Australasia and Western Europe. Another important reason for asbestosis elevation is that historical asbestos exposure limits in high-income countries may be not sufficient to protect workers from asbestosis.9 Based on the current situation, an international ban on asbestos mining and use is imminent and the International Labour Organization/WHO Joint Programmes for the Elimination of Asbestos-related Diseases should be revitalized.10 Given that most of the high-incidence countries listed here now have very effective asbestos control, and the high rates of asbestosis reported here reflect heavy and inadequately controlled exposures in the past, these results should be presented as a warning for the rest of the world.

This is the first study to systematically describe the characteristics of asbestosis incidence and the temporal trends. Several limitations of our study should be noted. First, we obtained the conclusion based on the data of GBD 2017; some patients who were not included in the data may have biased the results. However, GBD 2017 data sources cover a wide range and could provide clues for the incidence of asbestosis worldwide. Second, the quality of different primary data sources and assumptions are imperfect. However, the GBD estimates are updated each year with improvements in the modelling strategy and complementation of data sources. Taking the aforementioned into consideration, we found that integrating multiple health data sources could give a more accurate and complete picture of incidence trends of pneumoconiosis. Taken together, our findings, based on GBD 2017, could provide clues to the incident rates of asbestosis and warnings against complacency with respect to exposure control of asbestos.