-->PONE-D-25-67182-->-->Disease Burden of Asbestos-Related Diseases in China (1990–2023) Based on GBD Estimates: A Call for Stronger Labor Protection Laws-->-->PLOS One

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PLOS One

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The article "Disease Burden of Asbestos-Related Diseases in China (1990–2023) Based on GBD Estimates: A Call for Stronger Labor Protection Laws" presents the results of a descriptive study of asbestos-related diseases. For clarity and to facilitate evaluation, I suggest highlighting the study's objectives. I believe you could choose between two expressions found in the introduction and phrase them as the objectives: "Updated analyses are essential for understanding current patterns, guiding prevention strategies, and informing occupational health policy," or "These findings aim to provide evidence for clinicians, epidemiologists, and policymakers to strengthen occupational disease prevention and improve asbestos-control policies in China." The objectives should also be included in the abstract.

Reviewer #2: Dear Authors,

Thank you for the opportunity to review your manuscript, “Disease Burden of Asbestos-Related Diseases in China (1990–2023) Based on GBD Estimates: A Call for Stronger Labor Protection Laws.” This is a timely and policy-relevant study addressing an important occupational and environmental health issue. Using updated Global Burden of Disease (GBD) 2023 data and Joinpoint regression, the manuscript provides a comprehensive assessment of long-term trends in asbestosis and asbestos-attributable cancers in China.

The manuscript is generally well-structured and clearly written. The use of age-standardized rates, sex-stratified analyses, and long-term trend modeling strengthens the contribution. The topic is highly relevant to occupational health policy and public health planning.

I commend you for:

• Addressing a major occupational health burden in a country with historically high asbestos production and use.

• Utilizing updated GBD 2023 data to provide current national-level estimates.

• Applying Joinpoint regression to identify meaningful temporal inflection points.

• Including sex- and age-specific analyses to better characterize vulnerable populations.

• Linking epidemiological findings to occupational health policy implications.

I believe the following revisions would strengthen the manuscript:

1. Clarify Methodological Transparency and Reproducibility

• Specify the exact GBD iteration/version and data download date used in the analysis.

• Clarify whether uncertainty intervals (95% UI) from GBD were incorporated into Joinpoint analyses or whether point estimates only were used.

• Describe the criteria for selecting the maximum number of joinpoints (e.g., permutation test, BIC).

• Indicate whether alternative model specifications or sensitivity analyses were conducted.

• Consider providing supplementary material detailing model specifications or R scripts to improve reproducibility.

2. Refine Interpretation of the Post-2020 “Rebound”

• The increase observed from 2020–2023 spans a short time window; please perform or discuss a sensitivity comparison between pre-2020 projected trends and observed post-2020 data.

• Discuss possible COVID-19-related data distortions, mortality coding changes, or modeling artifacts that may influence the apparent rebound.

• Avoid strong causal language implying regulatory insufficiency unless directly supported by additional evidence.

3. Clarify Cancer Attribution Methodology

• Provide a concise explanation of how GBD calculates asbestos-attributable burden (comparative risk assessment framework and population attributable fractions).

• Expand discussion of potential residual confounding (e.g., smoking for lung and laryngeal cancer).

• Emphasize the ecological nature of GBD modeling and its limitations for causal inference.

4. Moderate Policy Conclusions

• The manuscript does not directly evaluate regulatory enforcement, exposure intensity, compliance, or surveillance systems.

• Reframe policy implications as hypothesis-generating rather than definitive conclusions.

• Clarify that the study demonstrates descriptive burden trends rather than direct evidence of regulatory effectiveness.

5. Strengthen Age-Specific Interpretation

• Expand discussion of biological and occupational explanations for the secondary mesothelioma peak at 55–59 years in males.

• Consider discussing potential birth-cohort effects and latency-period differences.

Minor Edits

• Correct typographical errors (e.g., “Fugure” instead of “Figure”).

• Ensure consistent capitalization of terms such as “asbestos-attributable cancer.”

• Revise the Data Availability statement to clearly indicate that data are publicly available from GHDx with a direct URL.

• Clarify the rationale for ethics exemption given the use of publicly available secondary data.

• Simplify Tables 1 and 2 where possible and reduce excessive decimal precision in APC values.

• Improve readability of figure axis labels and harmonize color schemes across sex-stratified figures.

Overall, this is an important and well-executed descriptive epidemiological study with strong public health relevance. With the revisions outlined above, particularly regarding methodological clarity, cautious interpretation of post-2020 trends, and moderation of policy conclusions, the manuscript will make a meaningful contribution to the literature on asbestos-related disease burden and occupational health policy in China.

Best wishes,

Reviewer

Reviewer #3: This is a strong, data-rich, policy-relevant GBD-based trend analysis. The topic is appropriate for PLOS ONE, the methods are standard and reproducible, and the manuscript is generally well written. The long-time span (1990–2023) and the post-2020 rebound finding are clear strengths.

That said, the paper would benefit from methodological clarifications, tighter framing of novelty, and careful handling of causal/policy claims; especially since it relies entirely on modeled GBD estimates.

Major strengths of the paper include timeliness & novelty, which extends previous China analyses beyond 2019 to 2023, which is genuinely new. The post-2020 rebound is interesting and worth highlighting. In addition to that, the manuscript’s comprehensive scope, appropriate methodology, clear demographic stratification, and policy relevance makes it high-value output.

Below are my comments and suggestion that need to be addressed.

1. Over-interpretation of GBD Estimates

This is the biggest issue. The manuscript sometimes reads as if these are observed epidemiological data, not modeled estimates. Phrases like “temporary rebound occurred” risk implying causality.

My suggestion is that the authors should add clearer language in Methods and Discussion emphasizing that these are modeled estimates, not surveillance data; and Joinpoints indicate statistical trend changes, not real-world events

Example fix: “A statistically modeled increase was observed after 2020…”

2. Causal Language vs Descriptive Design

This is a descriptive trend analysis, yet the paper occasionally implies causation, such as “suggesting current asbestos control policies may be insufficient” and “underscores an urgent need for stricter bans”

The authors need to reframe to: “These findings support the need for…” and “These patterns are consistent with insufficient control…”

This keeps it aligned with PLOS ONE’s non-causal, evidence-neutral stance.

3. Justification for Including Ovarian Cancer

Ovarian cancer is controversial in asbestos literature. The GBD attribution is valid, but readers may question it. The rationale is only lightly mentioned.

I suggest adding 1–2 sentences in the Introduction or Methods clearly stating that ovarian cancer is included per GBD risk attribution framework, and cite WHO/ILO or GBD methodology papers more clearly.

4. Post-2020 Rebound: Competing Explanations Missing

The rebound after 2020 is interesting—but currently underexplained. Possible contributors not discussed include COVID-19-related diagnostic delays, death certification artifacts, model recalibration in GBD 2023, lagged mortality reporting

My recommendation is that, add a short paragraph acknowledging alternative explanations.

Below are minor Issues & Technical Points

= A few typos: “Fugure” => Figure (multiple times), “ASDYs” => ASDRs (line ~209).

= Some sentences are long and could be tightened in the Discussion.

= Tables 1 & 2 are dense but acceptable. Consider adding one summary figure highlighting all ARDs post-2020 trends, Or a small schematic timeline of key joinpoints

= The Discussion is well-referenced, logically structured, and consistent with results. But it could be sharper by separating global context vs China-specific interpretation, reducing repetition around latency explanation, and being more cautious with policy enforcement claims

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Disease Burden of Asbestos-Related Diseases in China (1990–2023) Based on GBD Estimates: A Call for Stronger Labor Protection Laws

PONE-D-25-67182R1

Dear Dr. Li,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Xingyu Xiong, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The suggestions made have been incorporated, for which I thank the authors of the article “Disease Burden of Asbestos-Related Diseases in China (1990–2023) Based on GBD Estimates: A Call for Stronger Labor Protection Laws.” I recommend its publication.

Reviewer #3: I recommend acceptance of the manuscript.

The authors have satisfactorily addressed all concerns raised in my previous review. In particular, the manuscript now more clearly acknowledges that findings are based on modeled GBD estimates rather than direct surveillance data, causal language has been appropriately moderated, the inclusion of ovarian cancer has been justified, and alternative explanations for the post-2020 increase have been discussed.

Great work! Congratulations to the authors!

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: No

Reviewer #3: No

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