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A RESURGENCE of dust-related lung diseases unseen in Australia for 40 years has prompted new medical guidance aimed at identifying at-risk patients early.
At least 411 Australians are living with silicosis, according to experts from the National Dust Disease Taskforce. Most of these cases have been diagnosed in the past 3 years and are linked to inhaling dust while cutting and polishing artificial stone used in kitchens and bathrooms.
Furthermore, lung diseases including “black lung” (coal workers pneumoconiosis) have recently re-emerged among coal industry workers in Australia, with more than 100 cases detected since 2015.
In a Perspective in the MJA, experts led by Associate Professor Deborah Yates, a board member of the Thoracic Society of Australia and New Zealand (TSANZ), urged health professionals to be vigilant for potential cases of dust-related lung disease.
“It was only after cases of severe disease were described by the medical profession (here, here and here), and after several cases had been referred for lung transplantation, that the resurgence of pneumoconiosis was identified,” they wrote.
“These events are a stark reminder that occupational lung diseases are still a real issue in Australia.”
Artificial stone silicosis differed from other types of silicosis, they said, in that it progresses more rapidly and is also associated with a higher rate of development of autoimmunity than classical silicosis.
They recommended to clinicians the TSANZ’s new position statement on respiratory surveillance for workers in the coal mining and artificial stone industries, released in October 2020 – the first national protocol of its kind in Australia.
Associate Professor Yates told InSight+ in an exclusive podcast the position statement reflects advances in respiratory surveillance technology.
“In the past, we were very reliant on chest x-rays … but they probably miss 30–40% of [pneumoconiosis] cases,” she said.
“[Computed tomography (CT)] scanning is now very much more available and has lower dose radiation than it ever did.
It’s a much better modality for looking at lungs. We’ve suggested CT scanning when there’s any doubts [raised by a patient’s symptoms or chest x-ray].
“We’ve also recommended more sophisticated lung function tests [DLCO—lung diffusing capacity], because it looks like spirometry is not sufficiently sensitive.”
Associate Professor Yates said early detection of pneumoconiosis and referral to a specialist occupational respiratory disorder team was vital.
“If you remove a person who is susceptible, who has high dust exposure, from dust exposure, their disease will be slowed and they may live their normal lifespan.”
The long latency period with dust-related lung diseases was a major challenge, Associate Professor Yates said, urging GPs to spend as much time as possible documenting individual workers’ occupational exposures to mineral dusts.
“If in 20 years’ time, the patient turns up and says, I was exposed to dust, and there’s an independent true record of that, it’s really helpful. The other thing is we don’t know what other diseases [in future] might also be due to dust inhalation.”
Associate Professor Yates warned fellow clinicians “not to attribute everything to smoking”.
“In terms of smoking-related emphysema, the contribution from smoking 20 cigarettes a day for 20 years is equivalent to being down underneath, in the mine, for 20 years,” she said.
Professor Fraser Brims, a respiratory physician at Sir Charles Gairdner Hospital and Curtin Medical School was a co-author of the TSANZ position statement. He is also part of the federal government’s National Dust Disease Taskforce.
Professor Brims said the regulation of dust-generating industries such as coal mining and stonemasonry was “patchy”, with variable interpretation of laws governing employers in different jurisdictions. Furthermore, support available to workers, employers and doctors through Work Health and Safety authorities varied from state to state.
“There have been a series of failures along the way, from employers not being aware of the regulations, to employees not being aware of the risks, to the regulators not adequately communicating,” he said.
Professor Brims said a major question for the Taskforce was what should be done for people who had left the industry and were no longer covered by their employer’s legal obligations.
“People just drop out and there’s nothing but a black hole for them,” he said. “There’s currently no [Medicare Benefits Schedule] rebate for their ongoing surveillance.”
Tracking down people who once worked in the industry was part of the challenge, he said.
“Other than public information campaigns to raise awareness for people to come forward, we really rely on GPs identifying those people who have worked in a sector where they were exposed.”
The Taskforce, chaired by chief medical officer Professor Paul Kelly, is due to make recommendations in June 2021 for a national approach to detecting and managing pneumoconioses and their future prevention. The federal government has already accepted the interim recommendations of the taskforce, including the creation of a national registry so that the true burden of disease may be understood.
Professor Christine Jenkins, head of the Respiratory Group at the George Institute for Global Health and also a member of the Taskforce told InSight+:
“The biggest mistake doctors dealing with dust-exposed workers can make is not realising how urgently patients with abnormalities or symptoms need to be referred.”
Professor Jenkins said the health workforce needed up-skilling to deal with the ongoing crisis, and CT and DLCO needed to be made more accessible in coal-mining centres in regional Australia. She added that the Taskforce would be releasing its own clinical guidelines, which could be expected to reflect similar positions to TSANZ’s.
“The problem has always been implementation,” Professor Jenkins said. “If we don’t see improvements in the stone industry – especially compliance with a ban on dry cutting – the Taskforce still has an appetite for a total product ban.”
The Taskforce has noted that many workers in the stone injury come from non-unionised workplaces – often very small businesses. Furthermore, many come from non-English speaking backgrounds and are additionally vulnerable because of job security concerns.
Dr Graeme Edwards, a Taskforce member who provided figures for this story, said 1500 workers had been formally screened from the engineered stonework sector, and 358 cases had met the diagnosis of silicosis in one of its forms – a crude prevalence of 24% before regulators started to regulate the industry.
Australian Council of Trade Unions Assistant Secretary, Liam O’Brien, said in many states, health surveillance for stonemasons has been provided free of charge through a program run either by the health department or the state health and safety regulator.
“The problem with the current system is that once no longer working, workers will be put onto a workers compensation program only if they have a successful claim,” Mr O’Brien said.
“This is only valid for 2 years and many workers will have to rely on Medicare and social security payments. Support for those with chronic diseases caused by work is very poor and more needs to be done.”
The Royal Australian College of General Practitioners has produced a GP training tool on silicosis.
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why don”t we ban stone benchtops
Is prevention better than cure?
We need be cognizant that coal workers’ pneumoconiosis (CWP) and silicosis form a spectrum of occupational lung diseases that included mixed dust pneumoconiosis, dust-related diffuse fibrosis (which can be mistaken for idiopathic pulmonary fibrosis), and chronic obstructive pulmonary disease (COPD). The symptoms and manifestations of CWP vary depending on the composition of the inhaled dust, duration of exposure, stage of disease and host-related factors. Needless to say, CWP may develop into progressive massive fibrosis (PMF).
Now with us is the growing prevalence of trademan’s silicosis as mentioned in this Insight article.
One way in which CWP and tradesperson’s silicosis can be prevented is through a combination of hazard surveillance and health surveillance. Together, both of these methodologies form an occupational health surveillance system (OHSS).
As Kow and Aw [2003, 705] have advised, hazard surveillance has been defined as the process of assessing the distribution of, and the secular trends in use and exposure levels of hazards responsible for disease and injury. For this type of surveillance to be considered, a clear exposure-health outcome relation must already have been established.
Health surveillance per se can either involve periodic clinical and/or physiological assessment of individual workers and fitness-for-work assessments. The rationale for intermittent clinical and/or physiological assessment is to detect adverse health effects resulting from occupational exposures at as early a stage as possible, so that appropriate preventive measures can be instituted promptly [Kow and Aw 2003, 706].
Concomitant with the periodic clinical and/or physiological assessment of individual workers, there is need to introduce a programme of medical screening. Such a programme will ensure that radiological assessment will be performed according to evidence-based standards. How do we commit tradesmen in the private sector exposed to silica dust to undertake regular screening?
We need also consider the extent of fitness-for-work health assessments. These will vary with the nature and risk to the health of the individual occasioned by the actual work. It may be the case that certain of industrial dusts exacerbate workers with pre-existing lung illnesses such as asthma or COPD that is due to cigarette smoking. They may be carried out as a pre-placement health assessment, for rehabilitation and return to work following illness or injury, or cessation of work due to disability or ill health [AFOM 1998, 1]. Unfortunately, it is often the case that fitness-for-work health assessments are taken to be the periodical clinical and/or physiological assessment of individual workers. This has been the case within the coal mining industry in Queensland as was exposed in the Queensland Parliament’s 2017 ‘Black lung – White lies’ Report.
A centralised occupational lung disease register should be set up for Australia. It should provide accurate data necessary for surveillance, prevention and research. The benefits of an occupational disease register is demonstrated with the asbestos hazard. Australia has a national mesothelioma register namely, the Australian Mesothelioma Register [NOHSC, 2002]. Apart from occupational lung diseases, Australia would do well to establish a National Register of Occupational Diseases as happens in Finland. Such registers provide an important instrument for policy-making and programme development
Mandatory occupational health surveillance systems imposed by governments would allow for more reliable occupational health surveillance databanks as the number of undetected cases would be limited. Ideally, hazard surveillance data such as the average airborne exposure in any 8-hour work shift of a 40-hour work week (TWA or time-weighted-average) fed into State or national occupational health surveillance databanks would be informative as it would allow for dust exposure comparisons among industries and allow the assessment of risks of occupational dust diseases at different levels of exposure. It would also allow the process of periodic screening to be more transparent.
The issue for tradesman’s silicosis is measuring the amount of dust and the overall volume of exposure in a working day, let alone a working week. Just imagine how to monitor the volume of silica dust when refurbishing a domestic kitchen! This, perhaps, is an easier task in the factory setting where working with silica-containing materials is ongoing. I would also proffer that monitoring for dust exposure and setting up an occupational lung disease register would be difficult. Consequently, in the interim we must look to industry and to governments to ensure that appropriate measures are in place to prevent exposure to airborne dusts in the occupational setting. In terms of CWP, certainly in Queensland, even this task has proved difficult. Added to this dilemma is the fact that lagging indicators, such as disease statistics, rather than leading indicators, such as exposure monitoring, regular use of preventive technologies and periodic radiologic assessment, are perhaps relied on more in determining whether occupational health concerns are being adequately addressed. Yet, leading indicators are primarily designed to limit adverse exposures to inevitable health hazards caused by exposure to dusts in the work environment.
References
Kow, D. and T. C. Aw. 2003. Surveillance in occupational health. Occupational and Environmental Medicine. 60: pp 705-710. Available at PubMed.
NOHSC. National Occupational Health and Safety Commission. 2002. Possible applications of disease minimum data set to future activities relating to occupational disease. Canberra, ACT: NOHSC. Australian Government.
We need them.