Development of the “National Asbestos Profile” to Eliminate Asbestos-Related Diseases in 195 Countries

Worldwide, 230,000+ people die annually from asbestos-related diseases (ARDs). The World Health Organization (WHO) recommends that countries develop a National Asbestos Profile (NAP) to eliminate ARDs. For 195 countries, we assessed the global status of NAPs (A: bona fide NAP, B: proxy NAP, C: relevant published information, D: no relevant information) by national income (HI: high, UMI: upper-middle, LMI: lower-middle, LI: low), asbestos bans (banned, no-ban) and public data availability. Fourteen (7% of 195) countries were category A (having a bona fide NAP), while 98, 51 and 32 countries were categories B, C and D, respectively. Of the 14 category-A countries, 8, 3 and 3 were LMI, UMI and HI, respectively. Development of a bona fide NAP showed no gradient by national income. The proportions of countries having a bona fide NAP were similar between asbestos-banned and no-ban countries. Public databases useful for developing NAPs contained data for most countries. Irrespective of the status of national income or asbestos ban, most countries have not developed a NAP despite having the potential. The global status of NAP is suboptimal. Country-level data on asbestos and ARDs in public databases can be better utilized to develop NAPs for globally eliminating ARDs.


Introduction
A recent Global Burden of Disease (GBD) study estimated that each year more than 230,000 people die from diseases caused by occupational exposure to asbestos [1]. In 2006, the World Health Organization (WHO) declared that the most efficient way to eliminate asbestos-related diseases (ARDs) is to stop using all types of asbestos [2]. The following year, the WHO and the International Labor Organization (ILO) jointly formulated the National Program for the Elimination of Asbestos-Related Diseases (NPEAD) [3,4] to assist countries in establishing their respective national programs.
The National Asbestos Profile (NAP) was annexed to the NPEAD as a template to support the development of country profiles consisting of 18 items related to legislation,

Materials and Methods
We analyzed the status of information and data for 195 countries comprising 193 United Nations (UN) Member States [13] and two regional entities, Taiwan and Hong Kong. In our search of NAPs and related information, we explored the World Wide Web using English, German, French and Spanish. We also communicated with contacts of the coauthors, which included the current and former staff of international organizations, governments and non-government organizations. To determine the status of NAPs that corresponded to the countries, we applied the following criteria, which were ordinally categorized and mutually exclusive (Table 1): When a document was identified as a bona fide NAP, a copy was obtained by downloading or requesting it from the concerned parties.
Two authors (DA, KT) rated the NAP statuses and thereby grouped the countries into four categories: A (country that has a bona fide NAP), B (country that does not have a bona fide NAP but has a proxy NAP), C (country that has neither a bona fide nor proxy NAP but has relevant published information) and D (country that has no relevant information). A disagreement between the two raters was reconciled by rechecking their ratings and, if the disagreement persisted, having a third author (SF) act as the tiebreaking rater to establish the final rating (there were three instances).
As basic characteristics, we grouped the analyzed countries as high income, uppermiddle income, lower-middle income and low income based on the Income Classification of the World Bank [14]. Regions were based on the WHO region designation [15]. Regarding the status (banned or no-ban) and year of asbestos ban, we referred to the list of Current Asbestos Bans on the website of the International Ban Asbestos Secretariat [5].

Country Category Document Category Document Description
A "bona fide NAP" a single document that describes the national situation of asbestos and asbestos-related diseases (ARDs) in adherence to the NAP format published by the WHO/ILO 3 B "proxy NAP" a single document or multiple documents that describe the national situation of asbestos and ARDs but does (do) not satisfy the criterion for a bona fide NAP; * includes government statements and/or decrees, scientific articles and third-party organization reports C "relevant published information" information that does not satisfy the criteria for a bona fide or proxy NAP but refers to asbestos and/or ARDs; includes online information on asbestos as part of wider occupational health and safety policies, toxic chemical waste management policies, ARD case studies and media releases on asbestos and/or ARDs D "no relevant information" status that lacked any of the above * A proxy NAP was defined to be compatible in content with a bona fide NAP without satisfying the criterion of adhering to the NAP format published by the WHO/ILO.
To assess the availability of data that can be used to develop a NAP, we used the following: two sources of asbestos-related data, namely, (1) consumption of raw asbestos in the United States Geological Survey database (USGS) [16] and (2) import of asbestoscontaining material, textiles and friction material in the United Nations International Trade Statistics Database (UN Comtrade) [17]; and four sources of disease-related data, namely, (1) reported mortality of mesothelioma or asbestosis in the WHO Mortality Database (MDB) [18], (2) estimated incidence of mesothelioma in the GBD studies [1], (3) estimated mortality of mesothelioma in the WHO Global Health Estimates database (GHE) [19] and (4) reported or estimated mortality of mesothelioma in the WHO Global Cancer Observatory (GCO) [20].
All data sources were publicly available. Microsoft Excel Version 16 (Microsoft Corporation, Washington DC, USA) was used to compile and analyze all data. Table 2 shows the basic characteristics of 195 countries grouped by NAP status. Of them, 14 (7%) had a bona fide NAP (category A), 98 (50%) did not have a bona fide NAP but had a proxy NAP (category B), 51 (26%) had neither a bona fide nor proxy NAP but had other relevant published information (category C), and 32 (16%) had no relevant published information (category D). Of the 14 countries that had a bona fide NAP (category A), most were LMI countries (n = 8), followed by UMI countries (n = 3) and HI countries (n = 3), as per the national income status. In terms of region, seven, four and three countries were in the Western Pacific, South East Asia and Europe, respectively. In terms of asbestos ban status, five countries had bans, while nine did not. The NAP categories with the highest proportion of countries by income status were B (78%), B (52%), C (33%) and D (41%) in the HI, UMI, LMI and LI categories, respectively. Of the 32 countries that had no relevant published information (category D), the greatest proportion corresponded to LI countries, followed sequentially by LMI, UMI and HI countries.

Results
Of the 195 countries, 65 (33%) countries had asbestos bans and 130 (67%) countries did not. In the group of 65 asbestos-banned countries, 5 (8%) had a bona fide NAP, 51 (78%) had no bona fide NAP but had a proxy NAP, and 9 (14%) had neither a bona fide nor proxy NAP but had other relevant published information. No asbestos-banned country lacked relevant published information. In the group of 130 no-ban countries, 9 (7%) had a bona fide NAP, 47 (36%) had no bona fide NAP but had a proxy NAP, 42 (32%) had neither a bona fide nor proxy NAP but had other relevant published information, and 32 (25%) had no relevant published information. Figure 1 shows 14 countries with a bona fide NAP by their year of NAP publication and national income category. The embedded table supplements information on the region, the status and year of asbestos ban, and the authoring group/organization. (Table 3) All NAPs were published in the 2010 decade. The five NAP-published countries that banned asbestos were Australia, Japan, Bulgaria, Germany and North Macedonia. Of them, North Macedonia published their NAP in the year of their asbestos ban; the other four countries published their NAPs 8-14 years after their ban. Multiple stakeholders (n = 9) were the most frequent authoring group, followed by government (n = 8) and non-government (n = 6) organizations (the total exceeds 14 due to some countries being counted in multiple categories). All NAPs were written in English or had an English version except for the NAP of North Macedonia, which did not have an English version.
Of the 195 countries, 65 (33%) countries had asbestos bans and 130 (67%) co did not. In the group of 65 asbestos-banned countries, 5 (8%) had a bona fide NAP, 5 had no bona fide NAP but had a proxy NAP, and 9 (14%) had neither a bona fide no NAP but had other relevant published information. No asbestos-banned country relevant published information. In the group of 130 no-ban countries, 9 (7%) had fide NAP, 47 (36%) had no bona fide NAP but had a proxy NAP, 42 (32%) had n bona fide nor proxy NAP but had other relevant published information, and 32 (25 no relevant published information. Figure 1 shows 14 countries with a bona fide NAP by their year of NAP pub and national income category. The embedded table supplements information on gion, the status and year of asbestos ban, and the authoring group/organization. ( All NAPs were published in the 2010 decade. The five NAP-published countr banned asbestos were Australia, Japan, Bulgaria, Germany and North Macedo them, North Macedonia published their NAP in the year of their asbestos ban; th four countries published their NAPs 8-14 years after their ban. Multiple stakehold 9) were the most frequent authoring group, followed by government (n = 8) and n ernment (n = 6) organizations (the total exceeds 14 due to some countries being c in multiple categories). All NAPs were written in English or had an English version for the NAP of North Macedonia, which did not have an English version.    Table 4 shows the relationship between the NAP category and the availability of data that can be used for a NAP. Asbestos data were available from two data sources: (1) the USGS database on raw asbestos consumption; and (2) the UN Comtrade data on asbestos-containing materials. The overall data availability was 85% (165/195) and 92% (179/195) of all countries, respectively. When stratified by NAP category, USGS data on raw asbestos consumption were available for 100% (14/14), 85% (83/98), 84% (43/51) and 78% (25/32) of category A, B, C and D countries, respectively. Similarly, UN Comtrade data on asbestos-containing materials were available for 100% (14/14), 93% (91/98), 90% (46/51) and 88% (28/32) of category A, B, C and D countries, respectively.
Disease data were available from four data sources: (1) the MDB data on reported mortality of mesothelioma or asbestosis; (2) the GBD data on the estimated incidence of mesothelioma; (3) the GHE data on estimated mortality of mesothelioma; and (4) the GCO data on reported or estimated mortality of mesothelioma. The overall data availability was 49% (96/195), 95% (186/195), 91% (178/195) and 69% (134/195) of all countries, respectively. When stratified by NAP category, data availability was generally better for categories A and B and worst for category D. For example, the MDB data on reported mortality of mesothelioma or asbestosis were available for 50% (7/14), 64% (63/98), 37% (19/51) and 22% (7/32) of countries in categories A, B, C and D, respectively. Table A1 lists the 14 bona fide NAPs and their references. Table A2 summarizes the data availability for each country across all six databases. Table A3 outlines the original NAP according each item (I-1 to I-18) to public data sources that can be utilized. Data for legislation-related items (I-1, I-15, I-16) were generally not available from international sources and thus needed to be sought from national sources. Data for asbestos-related items (I-2 to I-5) were generally available from the international databases mentioned above. Data for disease-related items (I-9 to I-12) were available from the international databases mentioned above. Although data for I-17 were generally not available from any source for most countries, data for I-18 were available in PubMed. Data for risk assessment (I-6 to I-8, I-13, I-14) were sometimes available from national sources.

Discussion
A total of 14 (7% of 195) countries developed bona fide NAPs (category A). The development of a bona fide NAP showed no gradient by national income: LMI countries comprised the highest proportion (16%) of countries that published a bona fide NAP, followed by UMI (6%) and HI (5%) countries, with no bona fide NAP developed by an LI country to date. At the opposite extreme, 32 (16% of 195) countries had no relevant published information (category D), and this showed a gradient with the national income category: LI countries comprised the highest proportion with no relevant published information, followed sequentially by LMI, UMI and HI countries. Furthermore, a comparatively poorer status of NAPs (i.e., categories C and D combined) correlated with lower national income. Therefore, our study demonstrated that although the NAP status was generally related to the national income status, the development of a bona fide NAP was unrelated to the national income status in all but LI countries.
Ninety-eight (50% of 195) countries did not have a bona fide NAP but did have a proxy NAP (category B). As a proxy NAP was defined as being compatible in content with a bona fide NAP, they should be similar in their resources and information. It is thus reasonable to assume that the 98 countries (in category B) had the full potential (i.e., resources and information) to develop a bona fide NAP. A further 51 (26% of 195) countries had neither a bona fide nor proxy NAP but had other relevant published information (category C) and thus could have had some potential to develop a bona fide NAP. In effect, a combined 149 (76% of 195) countries had some or full potential to develop a NAP.
Two sources of data for asbestos and four sources of data for ARDs were available to develop a NAP. Importantly, these sources contained data for most of the countries, and there was a minimal gradient of data availability across the NAP categories (Table 4). A notable exception was the WHO MDB; this database compiles data reported by countries, and fewer than 50% of the countries were covered for mesothelioma mortality. However, estimated data can compensate for the lack of reported data, provided that a country indicates the nature of data that are incorporated in the NAP. The low number (n = 14) and proportion (7%) of all countries that had developed a bona fide NAP should thus be viewed in consideration of the wide availability of country-level data on asbestos and ARDs.
Mesothelioma is widely accepted as an indicator disease caused by asbestos exposure, with at least 80% specificity [21]; it is thus a key item for a NAP. Although more than 50% of the countries did not report mesothelioma deaths to the WHO, estimates are currently available for more than 90% of the countries in the two data sources (Table 4). Although many lower-income countries started to consume asbestos recently, some of them may not have reached the generally accepted latency period of 30-40 years for mesothelioma [21]. Moreover, many lower-income countries have not yet acquired the technology/infrastructure to diagnose and report mesothelioma and thus may be "missing" the disease burden. It is important for countries lacking mesothelioma data to utilize these estimates; that said, it is also important that they understand the method of imputation to derive the estimates (e.g., asbestos use is commonly imputed) as well as their limitations [10].
The regional distribution of the 14 NAP-published countries was skewed, with the majority situated in Asia (seven in the Western Pacific and four in South-East Asia), three in Europe and none in the Americas, Africa or Eastern Mediterranean ( Table 3). The regional preponderance may have been caused by a combination of "pull" and "push" factors. Possible pull factors are that Europe is the known current center of the ARD burden [22], and Asia has been implicated as the future "center" [23] of this burden due to its current heavy use of asbestos. Possible push factors include the WHO/ILO partnerships (e.g., the 2010 Parma Declaration on Environment and Health specified establishment of NPEAD for the member states of WHO-Europe [24]) and grass-roots initiatives on advocacy and technology transfer (e.g., the Asian Asbestos Initiative) [25]. On the other hand, proasbestos lobbies influence asbestos use in industrializing countries [6] and may present "opposing" factors. All these factors will impact the development (or lack thereof) of a NAP.
In terms of the relationship between the NAP category and asbestos-ban status, the proportion of countries having a bona fide NAP was similarly low in asbestos-banned (8% or 5/65) and no-ban (7% or 9/130) countries. The lack of association between the status of NAP and asbestos-ban is a positive finding because the acceptance of a NAP should not be limited to either asbestos-banned or no-ban countries. The NAP is an effective tool to outline the national situation on asbestos and ARDs. The development of a NAP benefits no-ban countries by informing the progress towards the adoption of an asbestos ban and benefits asbestos-banned countries by informing the progress in reducing exposure to in situ asbestos and transitioning to an asbestos-free society.
Most (56 [86%] of 65) of the asbestos-banned countries had either a bona fide NAP or a proxy NAP (i.e., categories A and B combined), while more than half (74 [57%] of 130) of noban countries had neither of the two (i.e., categories C and D combined). Asbestos-banned countries may build a "knowledge base" of experience, information and data, which accumulate over the various phases of asbestos use, ban and post-ban. This knowledge base is likely to be documented in various forms, including laws, regulations, advisories, status reports and official statistics. These countries can thus capitalize on the abundant experience and resources to develop their NAPs. In contrast, no-ban countries may have a less extensive "knowledge base", fewer resources and less experience.
For the 14 existing NAPs, multiple stakeholder authorship was common, and government representatives were often involved, with others or on their own. This finding corroborates the importance of employing multidisciplinary expertise with government representation in developing a NAP. Governments routinely collect information on industry and the labor force and collect (albeit to a lesser extent) surveillance data on asbestos and ARDs. General information on industry and the labor force constitutes baseline information and may be documented in the NAP to provide a national context. However, the highest priority should be given to incorporating national surveillance data on asbestos and ARDs. It is also important to observe that an equal disease incidence in men and women, rather than higher incidence in men due to occupational exposure to asbestos, could also alert countries to potential environmental exposure. Future studies are needed to review the use of ARD database information from this perspective.
The major limitations of this study are as follows: (1) We assessed the global status of the development of NAPs, not their utilization. For example, the NAP can be used to further develop a national action plan. Such a theme, however, is fundamentally different and warrants a separate study. (2) We cannot rule out the possibility that we missed identifying an existing bona fide NAP. (3) Our authors were involved in developing several NAPs (SF for the NAP of Japan; PT for the NAP of Australia; KT for the NAPs of Japan, Vietnam and Australia); although this experience may have added perspective and insight to the present work, we may not have been able to eliminate bias in judging a NAP as bona fide or not. The scope of this study is limited to mesothelioma and asbestosis and databases that use reported and/or estimated mortality. We highlight usable data sources from credible organizations that can be used to help and inform future NAPs. Despite being useful as an indicator of the asbestos burden, any database that uses estimates or country-level proxy data as a method has limitations. A strength of this study is that we were able to analyze the status of NAP development for most countries of the world and offer a framework for more countries to develop a NAP.

Conclusions
In conclusion, the global status of NAPs is suboptimal. Irrespective of the status of national income or asbestos ban, most countries of the world have not developed a NAP despite having the potential (i.e., resources and information) to do so. Among the few countries that have developed a bona fide NAP, LMI and UMI countries outnumber HI countries. Country-level data on asbestos and ARDs in public databases can be utilized to develop a NAP. All countries should develop their NAP and use it to monitor progress towards eliminating ARDs, learn from the experience of other countries and contribute to promoting the global elimination of ARDs.

Conflicts of Interest:
The authors declare no conflict of interest.        Table A3. Availability of Data in International and National Sources in Relation to Each NAP Item.

Items of National Asbestos Profile
International Sources National Sources, etc.  Risk Assessment I-6. Estimated total number of workers exposed to asbestos in the country I-7. Full list of industries where exposure to asbestos is present in the country and list of industries with the largest numbers of workers potentially exposed to asbestos I-8. Industries with high risk of exposure (where overexposure is documented as exceeding occupational exposure limits) and estimated total number of workers at high risk I-13. Estimates on the percentage of house stock and vehicle fleet containing asbestos I-14. Total number of workers eligible for compensation for asbestos-related diseases, such as asbestosis, lung cancer and mesothelioma (per year) and the numbers of individuals compensated yearly I-6, I-8: Industrial hygiene or occupational health data; I-7, I-13: Specific industry inventory; I-14:

Consumption of
Occupational disease compensation data.