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Respiratory disease mortality in the United Kingdom compared with EU15+ countries in 1985-2015: observational study

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4680 (Published 28 November 2018) Cite this as: BMJ 2018;363:k4680

Linked Opinion

Gaining patients’ perspectives on respiratory diseases

Re: Respiratory disease mortality in the United Kingdom compared with EU15+ countries in 1985-2015: observational study

We read with interest the article by Salciccioli et al demonstrating the high mortality rate from interstitial lung disease (ILD) in the UK. We would like to highlight our published research that may be relevant to this. This demonstrated a significant association between annual mortality due to idiopathic pulmonary fibrosis (IPF) and deaths due to mesothelioma.[1] Such a relationship is surprising and not easily explainable, as by definition IPF has no identifiable cause, whereas almost all mesothelioma deaths can be explained by historic asbestos exposure. Our study found that mortality from both conditions had risen steadily since the 1960s, in parallel with national asbestos imports with a 48-year time lag. We have therefore put forward the controversial hypothesis that the high mortality rate from IPF relates to the very high historic asbestos usage in the UK.

In a related piece of work, we compared WHO mortality data (2005-10) for ILD and mesothelioma for 31 European countries (data available from the European Lung White Book).[2] Again, there was a significant association between mesothelioma and IPF (Pearson correlation 0.52, p=0.003), but there was no significant association with two other common forms of interstitial lung disease (HP and sarcoidosis). Although limited by the available data on asbestos, we also found that there was a significant association between annual asbestos consumption (averaged over 1920-70) and IPF mortality (2005-10) for each country. (Pearson correlation 0.37, p=0.046.)

We have previously discussed our belief that a causative link between asbestos and IPF is a biologically plausible hypothesis,[1] summarised as follows:

1. Based on job title, occupational asbestos exposure was previously very common in the UK
2. Asbestos exposure causes pulmonary fibrosis in humans and in animal models
3. Little is known about individual susceptibility to fibrosis in asbestos-exposed workers
4. Recent research does not support a threshold of exposure for asbestosis in exposed workers
5. IPF is idiopathic and by definition has no identifiable cause
6. IPF is usually diagnosed in the UK based on radiology (histology is rarely available)
7. Diagnosing IPF requires the exclusion of known causes, including asbestosis
8. The radiological appearance of asbestosis and IPF are similar (neither the pattern of fibrosis, nor the presence or absence of pleural plaques can reliably differentiate the conditions)
9. Diagnosing asbestosis is reliant on accurate patient recall of previous asbestos exposure many years ago
10. Diagnosing asbestosis is reliant on a subjective decision by a clinician that there has been a “sufficiently high” lifetime asbestos exposure
11. IPF is likely to be diagnosed in individuals (whether or not they have worked with asbestos) if they cannot or do not meet the criteria in 9. and 10.

References:
1. Barber CM, Wiggans RE, Young C, Fishwick D. UK asbestos imports and mortality due to idiopathic pulmonary fibrosis. Occupational Medicine 2016;66:106–111
2. Barber CM, Wiggans RE, Fishwick D. Mortality due to IPF and mesothelioma in Europe – A link with historic asbestos use? European Respiratory Journal 2016;48: OA457

Competing interests: No competing interests

11 February 2019
Christopher M Barber
Consultant and Honorary Reader in Occupational Lung Disease
D Fishwick
Centre for Workplace Health
Science Division, Health and Safety Executive, Buxton, UK