Workers at Risk of Silicosis–Ongoing Overexposure and Lack of Medical Surveillance-Reply

In Reply

We agree with the comments from Wagner and Michaels regarding prioritization of disease prevention through increased resources for the federal Occupational Safety and Health Administration (OSHA) inspections.¹ Additionally, employers have a responsibility to uphold and implement the requirements of the 2016 Respirable Crystalline Silica Standard,² which Hodgson and Smith of OSHA detailed in their letter.

Hodgson and Smith state that the OSHA National Emphasis Program on Respirable Crystalline Silica in 2022³ provided clear evidence of exposure above the permissible exposure limit (PEL) among one-quarter of those sampled. Similarly, analysis of data from the California Special Emphasis Program (occupational exposure to respirable crystalline silica, cut stone, and stone product manufacturing) showed that from January 2019 to February 2020, 25% of individuals and 51% of shops sampled had exposures above the PEL.¹ This suggests that the existing 2016 OSHA silica standard² is not preventing overexposure. In recognition of this and the increasing number of cases of silicosis in the industry, the California Occupational Safety and Health Standards Board voted to enact an Emergency Temporary Standard for silicosis, after a petition submitted from the Western Occupational Environmental Medicine Association.⁴ The draft Emergency Temporary Standard includes a set of trigger tasks that requires provisions of the silica standard without the need for air sampling, eliminates dry cutting, and requires use of powered air-purifying respirators.

We would also like to applaud the expansion of a National Emphasis Program announced on September 24, 2023.³ This will require 8 OSHA regions to perform inspections of a minimum of 5 stone-cutting establishments per region during the next 12 months. Systematic data collection and analysis of this program will be critical to help understand the magnitude of the problem nationally.

We agree with Wagner and Michaels that identifying 52 cases is the tip of the iceberg and suggests many more cases are occurring nationwide. We agree that primary care and emergency practitioners are likely to be the first to encounter at-risk workers, and that they should consider a diagnosis of silicosis in the appropriate setting and report cases to their local public health officials and OSHA. Additionally, we believe that California’s policy of extending Medicaid coverage to undocumented immigrants has been imperative in allowing affected workers to access medical care, and therefore, for clinicians to identify cases.

To support clinician reporting in California, the California Department of Public Health (CDPH) disseminated a health advisory through the California Health Alert Network, informing public health officials and physicians statewide about the issue.⁵ The CDPH has also strengthened its silicosis surveillance system by including an online case reporting form for practitioners and using the Reportable Conditions Knowledge Management System to identify cases through electronic medical records across the state. Using these methods, the CDPH has identified more than 80 cases of silicosis among engineered-stone workers across the state to date. State public health departments should consider the development of silicosis surveillance systems similar to that of California.