Burden of silicosis based on the Global Burden of Disease Study 2021: trend analysis of incidence, mortality, and disability-adjusted life years, and projections for the next 30 years

Introduction

Silicosis is a common occupational disease. It is a pneumoconiosis interstitial lung disease that is progressive and irreversible, and it is mainly caused by long-term exposure to high concentrations of free silica (SiO₂) (1). Depending on the duration of exposure to SiO₂, silicosis can be categorized as acute, accelerated, or chronic, with the chronic type being more common and the accelerated type being relatively rare. Patients commonly experience symptoms such as chest discomfort, difficulty breathing, mild fever, and nocturnal sweating. As the disease progresses, silicosis can lead to a variety of complications, with respiratory failure being the leading cause of death (2,3). A study by Faubry et al. found that other lung diseases occurring after SiO₂ exposure, such as lung cancer, tuberculosis, emphysema, and interstitial pulmonary fibrosis, increase the morbidity and mortality of silicosis (4). Despite the high morbidity and mortality of silicosis, the available treatment options are still very limited (5).

Globally, more than 2,000 people are diagnosed with silicosis each year, and there are more than 12,900 deaths annually, while the disability-adjusted life years (DALYs) for silicosis reached 650,000 in 2019 (6). Therefore, silicosis remains a global public health problem. It is estimated that around 230 million people are exposed to SiO₂ annually, of which 40.5 million work in the mining industry (7). A recent study showed that around 2 million people in the United States and Europe are exposed to SiO₂ each (8). Workers in South Africa are exposed to SiO₂ at concentrations ranging from 9% to 39% (9), and a study in southern Spain showed that from 2009 to 2018, a total of 106 people were diagnosed with silicosis (10). Furthermore, according to the Global Burden of Disease (GBD) Study 2019, approximately 12,900 deaths worldwide were attributed to silicosis, and the burden of silicosis was more pronounced in middle and middle–high regions (11).

There is still a lack of up-to-date literature on the global dynamics of silicosis analysis and surveillance. Therefore, we analyzed the overall trends in silicosis between 1990 and 2021 using data from the GBD database to provide more up-to-date information on its incidence and mortality. Moreover, the latest data on the DALYs of silicosis were predicted, and its trends for the next 30 years were projected and expressed as the average annual percent change (AAPC). We aimed to assess the global status of silicosis and its regional distribution characteristics, and to provide a scientific basis and rational recommendations for the development of effective prevention and control measures. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1341/rc).

Methods

Data source

Data from the GBD Study 2021 were analyzed secondarily. The study used existing data to assess the health costs of 371 diseases and injuries in 204 countries or regions by age and sex (12). The overall burden on health and socioeconomic factors that results in poor health, disability, and early mortality is known as the disease burden, and studying the consequences of the disease burden promotes the development of public health policy and the rational allocation of medical resources. The Bayesian meta-regression model (DisMod-MR 2.1), as the core estimation tool of the GBD, uses a mixed-effects method to analyze and integrate data across different age groups, time periods, and geographical regions. The model has the ability to correct data bias and fuse data from different sources to produce comprehensive and consistent estimates of the disease burden and disease trends (13). Estimates of silicosis are based primarily on systematic reviews, hospital records, and claims data reports. Demographic methods can then be applied to impute and supplement any missing data (14).

The sociodemographic index (SDI) is a comprehensive scale for assessing regional social and economic development. It considers factors such as the total fertility rate, the average number of years of education for residents aged ≥15 years, and the per capita income distribution. The SDI value ranges from 0 to 1. Based on the SDI value, 204 countries and regions were classified into five different development levels: low, low–middle, middle, middle–high, and high SDI regions (15). Based on data from the Global Health Data Exchange, we collected estimates of the silicosis incidence, mortality, and DALYs, as well as their 95% uncertainty intervals, based on the GBD 2021 data, and we used the International Classification of Diseases (ICD)-11 code CA60.0 to quantify the disease burden of silicosis (16). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Since this study is based on public data and does not involve any individual information, ethical approval is not required.

Statistical analysis

To minimize the interference caused by factors such as age and sex, and to facilitate meaningful comparisons across populations, we used the age-standardized rates (ASRs) to express the disease incidence, mortality, and DALYs. In this study, the AAPC was used to describe the average temporal trends in the age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR) from 1990 to 2021. Joinpoint regression software (version 5.2.0) was utilized to compute the AAPC values. Traditional regression models are mainly applicable to the evaluation of trend fitting on a global scale and are not able to show the characteristics of localized changes over the period under study. The Joinpoint regression model is suitable for describing trends in single disease morbidity or mortality rates by dividing the trend line into several segments and describing these segments in a continuous linear fashion, and it does not strictly require a trend to be present in the data series. We utilized the grid search method (GSM) to calculate all possible join points, selecting the one with the smallest mean squared error (MSE) as the optimal inflection point. Building on this, the optimal number of join points was determined using the Monte Carlo permutation test, allowing for a maximum of 5 join points and a minimum of 0 (17). The AAPC and its 95% confidence interval (CI) were used to express these results. In short, if the AAPC along with its 95% CI was >0, this indicated that the ASRs showed an increasing trend. Conversely, if the AAPC was <0, the ASRs were considered to show a decreasing trend. P<0.05 was considered statistically significant.

The Bayesian Age-Period-Cohort (BAPC) model integrates age, period, and cohort effects to analyze and predict disease trends, accounting for demographic changes (18). This model offers a nuanced approach to projecting disease trends by considering the complex interplay of demographic shifts over time (19). The BAPC model handles data uncertainty and complexity better than traditional models (20). A previous study has been conducted to project the incidence and prevalence of silicosis globally, but no studies have been conducted to project mortality and DALYs (21). Therefore, this study used the BAPC model to predict the future trends in silicosis over the next 30 years, aiming to provide guidance for the prevention and treatment of this condition. The BAPC and integrated nested Laplace approximation packages were used for BAPC model forecasting and visualization. To validate the stability of the prediction results, we performed a sensitivity analysis using the autoregressive integrated moving average (ARIMA) model. All statistical analyses were performed using R software (version 4.4.1).

Results

Global and regional burden of silicosis and disease trends

We analyzed the status of silicosis and the trends in the ASRs in 204 different countries and regions globally from 1990 to 2021. Globally, a decrease was observed in the ASIR, ASMR, and ASDR of silicosis (Figure 1A-1C). Similarly, there was an overall decreasing trend in AAPC for ASIR, ASMR, and ASDR (Figure 2A-2C). In 1990, the global ASIR of silicosis was 0.58/10⁵, and it decreased to 0.41/10⁵ in 2021, which was an overall decrease of 28.67%. The AAPC was −1.1% (−1.1% to −1.0%) (Table 1). In 2021, the medium SDI regions had the highest ASIR of 0.58/10⁵, while the low SDI regions had the lowest ASIR of 0.19/10⁵ (Table 1). The regional trend in ASIR showed that East Asia had the highest ASIR from 1990 to 2021 (Figure 3A). In terms of the ASMR, the global ASMR was 0.26/10⁵ in 1990 and 0.12/10⁵ in 2021, a decrease of 53.61%, with an AAPC of −2.5% (−2.7% to −2.3%) (Table 2). Unlike the ASIR, the lowest ASMR in 2021 was in the high SDI regions (0.05/10⁵), while the highest ASMR was in medium–high SDI regions (0.17/10⁵) (Table 2). In terms of the regional dominance of the ASMR from 1990 to 2021, East Asia ranked first (Figure 3B). In 1990, the global ASDR was 6.58/10⁵, and in 2021, the global ASDR was 3.03/10⁵, a decrease of 53.88% from 1990 to 2021, with an AAPC of −2.5% (−2.7% to −2.3%) (Table 3). In terms of the ASDR by SDI, in 2021, medium and high SDI regions had the highest ASDR of 4.19/10⁵, while high SDI regions had the lowest ASDR of 1.16/10⁵ (Table 3). The regional trend in the ASDR from 1990 to 2021 showed that East Asia had the highest ASDR (Figure 3C). Finally, the spatial distribution of the ASRs for silicosis in 2021 showed that the global ASIR was 0.41/10⁵, ASMR was 0.12/10⁵, and ASDR was 3.03/10⁵. The ASIR of China was 1.11/10⁵, ASMR was 0.31/10⁵, and ASDR was 8.35/10⁵, much higher than the global values (Figure 4A-4C).

Figure 1 Changes in the ASIR (A), ASMR (B), and ASDR (C) of silicosis among different SDI regions. ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASDR, age-standardized disability-adjusted life years rate; SDI, sociodemographic index.

Figure 2 Trend of ASRs by Joinpoint Regression (5 joinpoints), 1990–2021. (A) ASIR. (B) ASMR. (C) ASDR. The predictive mean is shown as solid line and the vertical dashed line indicates where prediction started. ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASDR, age-standardized disability-adjusted life years rate.

Figure 3 Age-standardized rates of silicosis globally and in 21 regions categorized by SDI from 1990 to 2021. (A) ASIR. (B) ASMR. (C) ASDR. For each region, the dots from left to right depict the estimated values for each year from 1990 to 2021. The blue line shows the expected incidence, mortality, and DALYs rate based on the SDI alone. ASR, age-standardized rate; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASDR, age-standardized disability-adjusted life years rate; SDI, sociodemographic index.

Figure 4 Age-standardized rates for silicosis in 204 countries and territories in 2021. A, ASIR. B, ASMR. C, ASDR. Abbreviations: ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; ASDR: age-standardized disability-adjusted life years rate.

Country-specific burden of silicosis in 2021

Globally speaking, the ASRs linked to silicosis in 2021 varied greatly among nations. In Kuwait, the ASIR was less than 0.004/10⁵, while in China, the ASIR was 1.11/10⁵. Of all countries, 38 had an ASIR below 0.05/10⁵, while seven countries (Kiribati, Paraguay, Portugal, Monaco, Chile, Democratic People’s Republic of Korea, and China) had an ASIR above 0.50/10⁵ (Figure 4A). Antigua and Barbuda had the lowest ASMRs. Sao Tome and Principe had the highest ASMRs (0.53/10⁵), followed by Chile, Mali, Eswatini, China, Lesotho, and Guinea-Bissau, all with ASMRs exceeding 0.30/10⁵ (Figure 4B). As shown by the ASDR, Kuwait had the lowest rate of silicosis, while Sao Tome and Principe had the highest, followed by Eswatini, Mali, and Lesotho (Figure 4C).

Burden of silicosis by age and sex

In all age groups, the incidence of silicosis and the ASIRs were greater in males than in females. The number of incident cases in both sexes increased with age until it began to decline in the 55–59-year age group, while it began to increase again in the 60–64-year age group, gradually declining again in the 65–69-year age group. The 70–74-year age group had the greatest number of incident cases in both sexes. The ASIR in males increased with age until it began to decline in the 90–94-year age group. In females, the ASIR increased with age (Figure 5A). In 2021, the highest ASIR among females was in the middle SDI region, while the highest ASIR among males was in the middle–high SDI region. The lowest ASIR among both males and females was in the low SDI region (Figure 1A).

Figure 5 Age-specific numbers and rates of silicosis by sex in 2021. (A) Crude incidence rate. (B) Crude mortality rate. (C) Crude DALYs rate. DALYs, disability adjusted life years; UI, uncertainty interval.

In all age groups, males exhibited a greater death count and a greater number of DALYs, along with a higher ASMR and ASDR, than females. The number of deaths and DALYs among males and females increased with age. The number of deaths among males did not begin to decline until the age of 75–79 years, and the number of DALYs did not begin to decline until the age of 55–59 years, after which it began to rise again at the age of 60–64 years and gradually declined in the 70–74-year age group. The number of female deaths did not begin to decline until the age of 80–84 years, and the number of DALYs did not begin to decline until the age of 70–74 years. The ASMR and ASDR increased with age in males. The ASMR began to decline after the age of 90–94 years, and the ASDR began to decline after the age of 85–89 years. The ASMR and ASDR in females increased with age (Figure 5B,5C). In 2021, females had the highest ASMR and ASDR in low SDI regions, while males had the highest ASMR and ASDR in middle–high SDI regions. Conversely, the lowest ASMR and ASDR were observed in both sexes in high SDI regions (Figure 1B,1C).

Predictions for silicosis over the next 30 years

The BAPC model was used to observe and predict the trends in the ASIR, ASMR, and ASDR of silicosis from 1990 to 2050. Figure 6 shows that the burden of silicosis is projected to gradually decrease from 2021 to 2050. In 2021, the global ASIR, ASMR, and ASDR for silicosis were 0.44/10⁵, 0.17/10⁵, and 4.26/10⁵, respectively. By 2050, the global ASIR, ASMR, and ASDR of silicosis are projected to decrease to 0.44/10⁵, 0.07/10⁵, and 1.95/10⁵, respectively. Also, we used the ARIMA model to make the predictions. Figure 7 shows that by 2050, the global ASIR, ASMR and ASDR for silicosis are projected to decrease to 0.37/10⁵, 0.00/10⁵ and 1.02/10⁵, respectively.

Figure 6 Trends in observed and predicted ASRs of silicosis from 1990 to 2050 by Bayesian Age-Period-Cohort model. (A) ASIR. (B) ASMR. (C) ASDR. ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASDR, age-standardized disabilityadjusted life years rate.

Figure 7 Trends in observed and predicted ASRs of silicosis from 1990 to 2050 by Autoregressive Integrated Moving Average model. (A) ASIR. (B) ASMR. (C) ASDR. ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; ASDR, age-standardized disability-adjusted life years rate.

Discussion

Silicosis is an important component of the global pneumoconiosis burden. This study reported the temporal trends in the ASIR, ASMR, and ASDR for silicosis from 1990 to 2021 across various regions, countries, age groups, and sexes. Since 1990, there has been an upward trend in the worldwide incidence of silicosis and in the number of deaths from silicosis, whereas the total number of DALYs has shown a downward trend. The global ASIR, ASMR, and ASDR of silicosis demonstrated downward trends. Across all age groups, males had a higher ASIR, ASMR, and ASDR than females. These results provide reliable and comprehensive estimates that may contribute to reducing the global burden of this disease.

The incidence of silicosis, along with silicosis-related deaths and DALYs, as well as the ASIR, ASMR, and ASDR, were greater in males than in females. This may be because industries such as road construction, demolition work, and concrete manufacturing pose a higher risk of silicosis development, and most people working in these industries are male (10). The number of deaths in males slightly increased, while the number of deaths in females significantly increased in 2021 compared to in 1990. This may be explained as follows. First, in some traditional industries, such as gold mining, males and females have the same risk of silicosis exposure (22). Second, a variety of new industries, such as jeans sandblasting, artificial stone production, and glass manufacturing, pose an equal risk of exposure to silicosis to both males and females (23-25). Workers in these industries, regardless of their sex, need to be adequately educated and informed about the potential risks of silicosis. In addition, medical personnel must be sensitized to the occupational history of silicosis in both sexes, which is essential for the early prevention and treatment of this condition. An inadequate understanding of the occupational history of silicosis in females leads to difficulties in early prevention, thus increasing the number of deaths (26). These factors may explain the rise in the number of female deaths and remind us to pay more attention to females in the fight against silicosis. The highest incidence, number of deaths, and DALYs among males and females were in the 65–69-, 75–79-, and 70–74-year age groups, respectively. Chronic silicosis has a latency period of up to several decades, which causes many patients to begin experiencing symptoms only after retirement or as they enter old age (27). Some studies have shown that silicosis mainly affects older workers, and that the 65–79-year age group has the highest risk of developing silicosis (28,29), which is consistent with our findings. This is also a warning that we need to strengthen the health management of silicosis in older workers and conduct regular health checks to detect potential health problems at an early stage.

Detailed studies of silicosis, a traditional occupational disease, were published more than a century ago, and effective occupational health interventions became available (30). The present study found that in 1990, the global incidence of silicosis was 24,000, and the number of deaths was 0.9 million, whereas by 2021, the incidence and number of deaths increased to 35,000 and 10,000, respectively. However, the ASIR, ASMR, and ASDR showed an overall decreasing trend, indicating that positive and effective measures have been taken globally to prevent and control silicosis. The global burden of silicosis is mainly borne by medium SDI and medium–high SDI regions. These regions have relatively well-developed industrial systems and have workplaces with crystalline silica occupational hazards, such as the mining and stone processing industries (31,32). Our study also found that the ASIR for silicosis is lowest in low SDI regions. The main reasons for this are closely related to the level of economic development, such as the lack of diagnostic techniques for silicosis, and an inadequate silicosis registration system (33,34).

Silicosis represents a type of pneumoconiosis that results from prolonged exposure to elevated levels of SiO₂ (35). SiO₂ is present in many industries, such as the mining, metallurgy, and porcelain industries (36). Recently, several studies have reported other workplaces that pose a risk of SiO₂ exposure, such as artificial stone production for indoor building materials, which contain high concentrations of SiO₂ ranging from 85% to 93% (37,38). The results of one study showed that young workers using artificial stone became an important emerging population for silicosis (39). In addition, exposure to working environments where manufactured stone is processed is the main reason for the recent increase in the number of silicosis cases, especially in Spain, Australia, and Israel (8). Cohort studies from Australia have found that artificial stone has become a new cause of silicosis, with a prevalence rate of 28.2%, which has led to artificial stone being banned by the Australian government (40,41). Despite the long history of silicosis prevention and treatment, attention needs to be paid to the emergence of new exposure conditions, such as artificial stone production, denim sandblasting, and jewelry manufacturing (10,42). A retrospective cohort study found that the level of silicosis-associated lung function decline in workers using artificial stone was more than five-times that of workers using non-artificial stone (43). The above studies suggest that although the pathogenic form of silicosis is constantly changing, the main cause of silicosis has never changed; in essence, the cause is always SiO₂.

Currently, there is a great global effort to prevent and control silicosis, but it is still a public health problem and a priority target requiring prevention and control in developing countries. A report from India noted a high local prevalence rate, mainly identified through regular medical check-ups for workers and the development of a national health program to prevent and control silicosis (44). Meanwhile, educational and training interventions have been used in some countries and regions to improve dust control and the use of respiratory protective equipment (3). Socioeconomic development also affects the occurrence of silicosis, with a lack of control of SiO₂ in some areas and workplaces not equipped with appropriate protective equipment (45). A study from Zambia found that mining workers had basic knowledge of SiO₂ protection, but their employers did not provide appropriate protective equipment (46). The emergence of new exposure scenarios, such as denim garment sandblasting and jewelry production, means that some workers may be unaware of the hazards, resulting in prolonged exposure (47). Meanwhile, the present study on the spatial distribution characteristics of the ASRs of silicosis in 204 countries and regions around the world found that developing countries, such as China, Chile, Paraguay, and South Africa, had higher ASIRs, ASMRs, and ASDRs than the respective rates at the global level. The study showed that the proportion of cases of silicosis diagnosed in a mobile mine in Zimbabwe was 21% (48). Furthermore, the onset of silicosis may contribute to the emergence of additional respiratory conditions, including tuberculosis and lung cancer (49,50). A systematic evaluation and meta-analysis by Ehrlich et al. 2021 showed that silicosis significantly increased the risk of developing tuberculosis, and that this increase in risk was already evident at milder levels of silicosis (51). Another study showed that silicosis leads to the development of lung cancer and exacerbates the formation of pulmonary fibrosis (52). Although progress has been made in the global fight against silicosis, it remains a major public health problem in developing countries, and there is a need to reduce its incidence through better education, training, regulation, and provision of appropriate protective equipment. A better understanding of its association with other respiratory diseases is also needed.

Limitations

This study has several key limitations that should be considered. First, the data on silicosis were mainly obtained from the GBD 2021 database, which is a global database that collects data from many different sources. This means that there may be inconsistencies among the data, as they may be affected by the collection and reporting methods used in different regions, which could lead to biases in the study results. Second, because some symptoms of silicosis may be similar to the symptoms of other pulmonary diseases, this could have led to the true number of cases being underestimated. Finally, the data on silicosis relied on calculations from surveillance data, which may be subject to lag. Although the GBD provides valuable global health data, we must be cautious when interpreting the results of studies on silicosis and consider the potential impact that these limitations may have on data interpretation and policymaking.

Conclusions

Silicosis continues to be a significant public health issue, and it presents a potentially serious health burden on a global scale. Although the ASRs exhibited a downward trend globally from 1990 to 2021, the number of incident cases, mortality, and DALYs increased significantly in females. Therefore, effective preventive and curative measures should be implemented to address the challenges posed by silicosis, increase the attention paid to silicosis in females, reduce its global burden, and protect the lives and health of workers.

Acknowledgments

The authors thank the GBD Project collaborators for sharing their data publicly, allowing relevant analysis and interpretation.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1341/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1341/prf

Funding: The research reported in this publication was funded by Corps Guiding Science and Technology Program Projects (grant number 2023ZD019).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1341/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). As this study is based on public data and does not involve any individual information, ethical approval was not required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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