So, I'm June Sim. I'm an occupational physician based in Perth, Western Australia. I'm here today representing WorkSafe Western Australia. Apart from Dr. Ken, I don't know if many of you have been to Western Australia or Perth, and the Australians in the crowd, but we're in the west coast of Australia. People think that we're part of Sydney, but we're not. We're five hours flight away. We're in a beautiful part of the city where we're only half an hour from nice beaches surrounded by the Indian Ocean. I'm here to present to work today from WorkSafe Western Australia with the work I've done with Dr. Evelyn Lee, my colleague, who is also here and is in the crowd. So, feel free to have a chat to her as well. And we've both travelled from Western Australia, Perth, through London, had a brief holiday, and arrived here on Saturday. It's taken us over 24 hours to get here, but it's a pleasure to be here with you all. Thank you for being here. Thank you. I'm going to start with a video first, and hopefully it will play. The family of a Gold Coast stonemason who died from the fatal lung disease, silicosis, says the 36-year-old's death is just the tip of the iceberg. Anthony White is the first person to die from the disease in Queensland. A recent audit found almost 100 other workers have been diagnosed. Tom Falls reports. Anthony White worked as a stonemason for six years and was diagnosed with silicosis in 2017. A month later, he was in intensive care. I mean, they induced him into a coma for four days. He'd come out of it, and I've never seen him so scared. His brother says he rallied but died on Saturday. The 36-year-old became the face of a disease dubbed the new asbestosis. He wasn't a fan of being in the spotlight, but, you know, at the end of it, I believe he's saving lives. Two weeks ago, Shane Perata found out he's also contracted the disease. Myelin's mild, so mild silicosis. I don't know what mild silicosis really means yet. So I'm here to talk to you about the role of occupational physicians in the context of silica health monitoring, our role as an agent of change, of legislative change in this instance, and the value of occupational medicine in organisations, including government body. This is an important topic because we all have a role to play in prevention of disease through early identification and prevention of premature mortality. We also have a role to play in improving controls in the workplace, and particularly with the emergence of silicosis in the engineered stone industry. What I'll be talking to you about today is the health effects of silica, silica health monitoring in the West Australian context, and how this all led us and our experience to a time for change. So as I said, we'll be talking about silica in the context of engineered stone, and why is engineered stone topical? That's because the silica content in engineered stone is in excess of 95%. This is in comparison to natural stone, which has silica content of 5%, such as marble, and 60% in granite. So the amount of silica that's being released when it's being fabricated and cut is significantly higher. However, we should not forget that silica is also present in other more traditional industries, such as mining, boundaries, quarries, tunnelling, and the construction industry. So just a refresher on the effects of silica. There is the simple silicosis cases, and as you can see on this chest X-ray, there's diffused nodularity predominantly in the upper zones. Chronic silicosis takes several decades to develop. It's from continuous exposure to even low levels of silica. It typically occurs in individuals in their later parts of their lives, in their 50s onwards. And in comparison to this, you can get accelerated silicosis. And this is a chest X-ray of someone with progressive massive fibrosis, with conglomerates of nodularities, and also streaking of the bands. And that can develop as implied accelerated, so within 10 years of exposure, usually to high levels of silica. And it can occur in individuals who are younger, in their 30s onwards. So what is health monitoring? Health monitoring is a systematic monitoring of health workers' status after exposure to occupational chemicals or substances in the workplace, and it should occur at regular intervals. The aim of it is to detect early changes, and to do that, as occupational physicians, we need to understand the chemical properties of the substance, the exposures in the workplace, and hence, what interventions that we can recommend to workplaces. And the aim of this is to prevent serious harm or disease. Now that we know what health monitoring is, is it just something that we have to do, or is it something that is bigger than just a medical? It should always be part of an infrastructure process. And we've learned from this in terms of mine workers' health surveillance in Western Australia. So just to give you some context, mine workers' health surveillance was completed for mining medicals, as this implies, and the mining department was separate from the WorkSafe as a regulator at the time. It commenced in 1995, and as part of mine workers' health surveillance, individuals who either were commencing with the mining industry or continuing with the mining industry would undergo periodic mine workers' health surveillance. And this comprised of a respiratory questionnaire, occupational questionnaire, audiometry testing, and spirometry. Occasionally, they will have a chest X-ray, and this was then submitted to the Department of Mines. This was ceased in January 2013, after a number of epidemiological studies showed that it neither prevented or detected ill health at an early stage, and was found not to be helpful. Hence, the Department of Mines shifted this to become a risk-based approach. In reality, it was a corporate-driven process, where it was completed by lots of corporate practices, submitted to the Department of Mines, and not necessarily reviewed at any point for recommendations back to the mining companies. More recently, we have the experience of co-worker pneumoconiosis. This was an article that was published in the CDC, outlining that the prevalence of co-workers' pneumoconiosis in Australia was much lower than the United States. Should we be patching ourselves on the back in Australia, saying we don't have cases? There was some hypothesis that it was because of the coal shelves, and the way it was monitored, but the greater reality is we were not necessarily looking for cases. This came about in 2015, when the first case of co-workers' pneumoconiosis emerged in Queensland. That led to a parliamentary inquiry. If you're from Australia, we love parliamentary inquiries. This produced a report called Black Lung, White Lies, Matters Report, and it was found that there was catastrophic failures. Lots of medical providers were completing co-workers' health monitoring, but no action was taken. The workers were never informed of the results, the employers were never told what the outcome of it is, and whether remedial actions were required. There was no medical practitioner oversight of the program, so everyone was doing it individually at different practices. The results were submitted, but at a government or organisational level, no one looked at it. So those two examples outlines to us that it's not just about completing health monitoring. Behind that, you need to have an infrastructure for a process. And we're lucky in Western Australia, within the general industries, that we do have a process, and this process is legislated. So as part of our process and legislation, it says that employers need to engage a medical practitioner, send their workers to the medical practitioner for health monitoring, and it must be funded by the employer. In addition to that, we also outline what is a requirement of silica health monitoring. So it comprises of a questionnaire that the worker completes, which includes their medical history, respiratory questionnaire, as well as occupational exposure history. They then bring that to the medical practitioner, who goes through the questionnaire with them, and also complete a clinical examination. They have a spirometry done, which must meet ATS criteria, the American Thoracic Society criteria, and undergo a ILO chest X-ray read by a B reader. In addition to that, the other essential part of silica health monitoring component is that the medical practitioner completing it must analyse all that information they received and provide recommendations back to the worker, and medical counselling is an essential part of the health monitoring process. They will also have to provide a health monitoring report, and the health monitoring report must include information about the individual's suitability to return back to silica work, any remedial actions that the employer has to undertake, and initiate and complete appropriate referrals, and in the context of silica, typically to respiratory physicians. Not only do they have to do that, they have to provide that report to the employer, as I told you previously, but also to WorkSafe Western Australia. So the unique part of WorkSafe Western Australia is that we're the only regulatory body that insists on receiving all the health monitoring reports that have been completed. The other unique part is that there's myself and Dr Lee, who are occupational physicians embedded within the organisation, and that allows us to review all these health monitoring reports, look at trends, look at any concerns, and if there are, we let our director or the managers know, and they sent out the inspectors to the workplace, and when the inspectors go out to the workplace, they review the work processes, issue improvement notices if required. In addition to that, we have built good relationships with the medical practitioners completing health monitoring, and because of that, if they've got any concerns or would like to discuss cases, they will contact us, and that gives a direct and immediate response, and what we can do is quickly initiate an investigation without waiting for this paperwork to go through to us. So that's all well and good, but what does that mean in terms of silicosis or engineered stone silica health monitoring? So that's the Queensland alert that came out in 2018, and you met Mr Anthony White on the right of your screen earlier on in the video, who was the first man who died of silicosis in Australia after being diagnosed two years prior. He was 36 years old. On the left of your screen is Mr Tahir Oskul. He also has progressive massive fibrosis, and he's our first transplantation case. So these two gentlemen filled our media pages and our newspaper articles and our TV screens with the emergence of silicosis, the new asbestosis, at the time. This also led to the alert where there were 78 stonemasons diagnosed with silicosis in Queensland, of which 43% had normal chest X-rays, 26%, more than a quarter, had progressive massive fibrosis, and the mean age was 34 years old. So why is that concerning? I'll just explain the process of engineered stone fabrication and installation. The typical process in the past was dry cutting and polishing, and as you can see from that photo, it generates significant amount of dust, and it's purely visible in the photo, and particularly if workplaces did not issue or provide respiratory protective equipment. Imagine the amount of dust that the workers are exposed to. With improved processes such as wet cutting or polishing, the visibility improves, but it doesn't necessarily mean there's no dust or exposure. So monitoring or workplace hygiene monitoring is required, and the workplace exposure standard currently is 0.05 milligrams per cubic meter. So what does this all mean? It's all well and good. We've got a process, we've got the alert, but what we saw in Western Australia is that we had not received a single silica health monitoring report from the engineered stone industry. WorkSafe WA then initiated a proactive enforcement campaign where they went out, where a team of specialised inspectors, including occupational hygienists, went out to visit these workplaces. The aim of it was to alert the workplaces, to educate, and to let them know what improvements were required. And they would issue improvement notices, which also included the requirement for the employer to engage a medical provider to complete health monitoring. So workers were being sent for silica health monitoring as a result of that initiative. Now we get to September 2019. By that stage, we've received 160 silica health monitoring. And as I told you before, chest x-rays were completed in all of them. Some of them had changes, and some of them had CT scans, particularly in the higher risk workers, and there were only eight silicosis cases. So we had one in 20 workers with silicosis. Is that good enough? Not really. When over the eastern states of Victoria, New South Wales, and Queensland, the estimate case numbers was one in four among engineered stone workers. We don't think, we didn't believe that our process was so much better and that we're immune from this issue. So just a revision about chest x-rays. This is a stone worker that's worked 20 years in the engineered stone industry. He had a ILO chest x-ray on the left of his screen, and it was reported normal with a ILO classification of 00. On your image on the right is the low dose CT scan of the same individual. And there is nodularities with ground glassing, indicative of simple silicosis. So this led us to think our health monitoring modalities may not necessarily be sufficient to detect silicosis and does not necessarily fulfill the requirements that we discussed earlier about the aim of health monitoring in general. So we wanted to explore CT scan of the chest, but there are some challenges. The first that always comes to mind is the radiation dose. So chest X-rays have radiation doses of about 0.1 millisieverts. The traditional high-resolution CT scan of the chest is four millisieverts. That's a significant increase in radiation dose. Do we submit people to that in a screening process? No. So we explored the possibility of ultra-low-dose CT chest. So ultra-low-dose CT chest, as most of you may be aware, is used for lung cancer screening, but in Western Australia, it's often used to monitor the progression of disease for those who have known asbestosis. So we spoke to our radiology colleagues, and they said, look, ultra-low-dose CT scan, good idea, but because of the proteinaceous properties of silica in silicosis, you're not gonna pick it up. So the radiation dose is great, but in terms of sensitivity, not great. Then they proposed a low-dose CT scan of the chest, where typically the scan radiation dose is under one millisievert, typically between 0.6 to 0.8 millisieverts. And this is achieved with the newer CT scanners and also the programming of the CT scanners. So that sounded like a more palatable idea for us. The next thing we had to consider is the availability. So as I said, Western Australia is the other side of Australia. We take up almost a third of Australia. We're four times the size of Texas, almost four times the size of Texas, with a population of a tenth of Texas. So we have a large mess of land area, but not necessarily the population across it. So we have areas that are sparsely populated in our regional areas, and it takes them about eight hours to drive or three days flying, depending on where you're coming from, to get to the city. So we needed to ensure that our workers, not only the ones in the city, have accessibility to a CT scan. Most CT scanners in the regional areas are run by the government, so we had the opportunity to discuss with them, and we were told that the government was planning to upgrade the CT scanners in these regional areas within 18 months. So that reassured us a little bit better, that potentially accessibility was not gonna be so much of an issue. The next thing is cost. So your chest X-rays, or the whole health monitoring process, is paid for by the employer. Chest X-rays, because they're for occupational reasons, are not rebatable by Medicare or private health insurance, and it costs employers between $170 to $200 for each chest X-ray. High-resolution CT scans, at that point in time, cost between $550 to $600. That's a significant impost on employers. We engaged with two radiology providers, because they were the ones who returned our call, and they agreed to reduce the cost to $300. I guess they had the business foresight of this, and that made it more affordable for us and for the employers. The final thing we also have to consider is reporting of the CT chests, because again, from the lessons we've learned, there's no point in getting the test done, no one to look at it with the expertise. And we were told that in Western Australia, we had quite a few chest radiologists with expertise in reporting CT scans, as well as chest X-rays, and they would be more than capable of looking at this from a pneumoconiosis perspective. In the regional areas, it was not a concern, particularly now with technology, as a lot of the images can be transferred through computer systems for them to be read. So now that we've overcome some of these challenges, we put through a project, what we call the WorkSafe Silica Recall Project. We propose that a trial of low-dose HRCT scan is completed to detect silicosis in engineered stone workers, who are considered high-risk. We define high-risk as greater than five years of exposure within the engineered stone industry. Our proposal was that the government funds a hundred of these scans, and that a multidisciplinary team is engaged to discuss the cases and the scan results. And the multidisciplinary team consists of radiologists, respiratory physicians, and occupational physicians. This proposal went up to the executives. So you've got Ms. Sally North, who's our director of our department, who supported the idea. So did Mr. Darren Kavanagh, who's the commissioner for WorkSafe, and the man with the money, Mr. Ian Muntz, also put the tick for us, and we were given the money. But not only that, they also funded for an occupational medicine registrar to be employed as a resource to us, to assist in this project. So this all came about towards the end of 2019. The project was due to commence in March, 2020, after we recruited a registrar. But as we all know, the pandemic hit. So things were delayed, but our registrar was working in the background, collating the list of suitable candidates to enroll in this project. So she identified the high-risk workers, as I said, more than five years. She contacted the worker and the employer, explained to them about the process, about our project, and that the CT scans would be funded, and all they had to do was make the phone call and attend the scans. This was also followed with a letter or an email with the instructions. Workers were given six weeks to complete the scan. At the end of the six weeks, if they hadn't completed it, she would call them again and give them a further four weeks. So all the scans were completed between July and November, 2020. 103 people were contacted, and 90 people took up the offer. The 13 either refused outright, or did not attend the scans, after agreeing on the phone initially. So what do we do with the scan results? So once we have the CT scans, the results came back to us in the department. It's reviewed by my colleague, Dr. Lee, myself, and our registrar, Dr. Yap. And if there were no changes, the worker, the employer, and the initial medical practitioner that completed the health monitoring was notified. But if there were any abnormalities or changes, the multidisciplinary team meeting would then convene. We held eight multidisciplinary team meetings between August and November, 2020, with 74 cases discussed. If there were concerns, respiratory physician referrals were required, and the worker, employer, and the medical practitioner were notified, and then this was followed up. If there were no concerns, they were again notified with no further follow-ups apart from their periodic health monitoring. So what are the findings? As I said, 90 of the 103 took up the offer. When we looked at the chest X-rays, 87 of them had normal chest X-rays. No silicosis, only three had IO abnormalities of 1-0 or 1-1, and there were no silicosis cases. This is our results from the project. 44 CT scans were normal with no silicosis, and we had 38 with early abnormalities, which were defined as either parenchymal changes with ground glass appearance or plural changes, or medicinal changes with enlarged lymph nodes and calcifications and hyperdensity, and there were eight silicosis cases. All of them were asymptomatic. In addition to this, obviously the medical practitioners were already aware that we were completing the project, and some of their workers were attending a CT scan of the chest. So for the astute medical practitioners who had their thinking caps on, when they saw a worker that was coming in for new health monitoring and they thought that they had high risk, they were completing CT scan on these workers, and there were four additional silicosis cases. So at that stage, by the end of 2020, we had 20 confirmed silicosis cases, eight from the original before the project, eight from the project, and four of these additional ones. This then led to the legislative change that's currently in place. The legislation was passed in January 2021, and as part of the legislative change, we also define what a Lloyd-OCT scan is, because we do not want people to be exposed to excessive amounts of radiation. So it has to be less than one millisievert, it must encompass the whole of the lung, and the images must be of sufficient quality to be able to detect any changes. So how did all of this happen? It seemed like a very short timeframe, and we were able to achieve this. Just like everything, it requires pieces of a jigsaw to fit together. The media helped initially with the 2018 campaign, and had ongoing campaigns during that period. We had the government support for the funding of the project, but also interest in silicosis. Then we had the supporting data, with the information we were receiving from medical practitioners, the recall project, and the additional information, and our WorkSafe commissioner was highly interested to push the agenda through. This then resulted in the changes that we saw. So as a result of this, our traditional silica health monitoring components had changed from a chest X-ray to a CT scan. Since those changes, we've also revised our silica health monitoring guidelines that's available on our website. We've revised the health monitoring forms. We hold annual medical practitioners forum, which includes updates about silica health monitoring, but also other substances, and hence other health monitoring. But we've engaged and collaborated with medical specialists. We've increased their awareness of silicosis in the workplace environment. And we also engaged with WorkCover Western Australia. So WorkCover is a workers' compensation regulatory body, and they're separate to us, but what was happening was that what we did notice were there were significant numbers of cases of individuals with silicosis whose English is not their first language. They came from Chinese background, Filipinos, Afghanistan. So we worked with WorkCover WA to develop, to ask them to translate their workers' compensation material to those languages to assist these workers in making a workers' compensation claim. Just like everything, we shouldn't stop at that. We need to always continually improve. We need to understand from a medical perspective what the clinical management is, and this is still questionable. We know that people with silicosis should be removed from the workplace, but those with early changes, do you remove them? When do you remove them? How far along do you remove them? We don't know the answers yet, so we need to continue monitoring this space. In terms of workplace engagement, that is still ongoing. As a result of this, there was a workplace that had five workers in total, of which three had early changes and all silicosis. As a result, a specialized inspector, an occupational hygienist and I visited that workplace. It's obviously a small business with a medium footprint of a workshop. We walked into the workshop and there was the receptionist who is of Afghanistan background. She spoke reasonably good English. She called the employer and said, WorkSafe is here, can you show them around? He also spoke reasonably good English and he walked us around the place. From the reception area, we walked into the tea room. It seemed fairly basic, but there were two men sitting there covered with dust having their lunch. They did not speak much English at all and the employer had to translate for them. After we left them to continue their lunch, we walked back into the workshop area. It was a large workshop and there were machines and stone everywhere and there was supposedly wet cutting. But obviously, the men sitting in a lunchroom, you would question how much dry cutting was going on as well. We walked through, we had a look. In the dry cutting, we opened the sump up and it's cloudy. So they were obviously not cleaning or maintaining the sump, which meant that when they're dry cutting, oh, wet cutting, you're still releasing mist that contains silica, which could be inhalable. So processes like that, it's on a face value, it might be in place, but you do need to look deeper into the workplace itself. However, after that, I turned around and I was walking out and I noticed on the right-hand side, there were two children's bicycle next to the roller door. And I asked the employer, what are those bicycles doing there? And he said, oh, my children, they're under 10. After school, they'll come here, wait for me to finish work, and then we'll go home together. So from our perspective, visiting workplaces is not only improving controls, but it's also educating workers and employers. He was inadvertently exposing his young children to silica dust, thinking, you know, babysitting them, being a good father, being around, and he was, but he was exposing them to silica. So in summary, as occupational physicians, we do have a value to play in workplaces. We are an agent for change, and this is an example of legislative change, and our goal should be prevention, not only treating diseases. I'd like to acknowledge all these individuals who are part of this project and this journey with us, and open for questions. Yes, Tim. Thanks, June, that was a great presentation, great project. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Great presentation, great project. Is there still a place for spirometry then, in silicosis screening? Yeah, I mean, we still continue to do spirometry. We insist that the medical practitioners track the spirometry to see if there's any decline, and that's a really good question, because what we see is that these are young workers, and if you just look at a static spirometry, they're always gonna be normal, But when you often go back and look at a serial spirometry, there has been a gradual decline. But because they are the industrial athletes, as we like to call them, they're fit, young, healthy, their percentage predicted is often in the 120s, 130s. And it comes down to 100. And no one thinks any different. But in actual fact, it is a decline. Good morning. My name is Shlomo Moshe. I'm from Israel. I do a lot of research in the field of silicosis since we share the main problems. Two questions. The one about environmental monitoring of wet cutting. We have data not published yet from Israel which proves that it lowers the exposure in one magnitude of order, meaning that the exposure, instead of being 0.05, it's 0.005. Do you have any data on this subject? I don't have any data on that subject. But there is impending change in Australia to lower the workplace exposure standards. And there's a lot of talk about how that's going to be managed. And the second question, which I think is very important, is when to start the CT scanning and what should be the frequency? We had a medical committee on this subject in 2012. And then I recommended to start it after 15 years of exposure. Why? Because this is the accepted latent period for chronic silicosis. However, since that recommendation, we found cases after 10 years. I'm talking only about chronic silicosis. And now we have a case series of four cases of a latent period between four to eight years of chronic silicosis, which is not mentioned yet. Now, if you talk about accelerated silicosis, there is no point in a health monitoring. Because if you diagnose them as accelerated silicosis, it's too late. I'm talking about chronic silicosis. Now, the question is, when to start? After 10 years, 15 years, how do we differentiate between smokers and non-smokers? Most of them are smokers. And what are we looking for? Are we looking for chronic silicosis or lung cancer? And of course, what should be the frequency? Annually, once in two years, once in three years? We don't have an answer to this, but maybe you have. Yep. That's a good question. And well, I guess I anticipated it, so I've got a slide up here. So we actually have in our guidelines that this is for silica health monitoring. And we have a special category for engineered stone, because we acknowledge, as you say, progressive massive fibrosis. We're trying to pick this up earlier. And the level of silica exposure is quite significant. Our current guideline says that they have it every two years. And they don't have it at the start of working. They have to have exposure for two years before they have it. But in other industries, so whether it's natural stone or mining, it's every five years. Now, after saying that though, my colleague and I are planning to revise this, because we're still looking at the data that's coming in. And with improvement in workplace practices, is every two years too frequent? So maybe that we do have to continue that for people who are already in the industry. But those who have joined when the industrial practices have improved, we need to reduce or lengthen the frequency of that. And when do you start? Sorry? When do you start, after a thousand years? Yeah, so that's why we're needing to look at our data and go, what is a reasonable timeframe to extend that? And in terms of other industries, we've also looked at it, because like you say, what we know from, say, the mining industry, or typically, or the construction industry, the exposure's more chronic. And if we say five years, is that too early? And it might be that we don't start that till about seven, it depends on when they started the mining industry. So we need to do a risk stratification approach. And this is our project for this year. Can I ask another question? The last one. About diffusing capacity, you didn't mention it, you said only spirometry. And we know that diffusing capacity is much more sensitive than normal spirometry. You didn't say anything about that. Yeah, that's because that's only done in respiratory laboratories. And with the volume of workers, we can't expect all of them to go to a respiratory laboratory. So we're currently stuck to spirometry, which is an office spirometry that can be completed. But those people who we've changed, they typically see a respiratory physician and they do undergo that. Yes. Thank you. Hi. So this is a classic example of a change in working practices without adequate risk assessment. So this was a failure of risk assessment. And we see the same thing in the Indian subcontinent, as you know, with sandblasting denim. We've also seen an epidemic of silica-related lung disease. It's a failure of risk assessment, also a failure of regulation. The regulators have clearly not had a handle on this. So you've talked about the medical side. What lessons have the Australian regulators learned from this? And how are they going to change the way they regulate going forward? Yeah, so I can't speak for Australian regulators because each state have a different regulatory body. But in Western Australia, we try and keep our eyes out and ears out for any industries that are coming up. And they do try and be more proactive. This obviously is an example that we've missed the boat until the alerts came out. Hi, good morning. My name is Brian Quinn. I'm from New York State. Thank you for a great presentation. Question about the x-rays. Had you come across any x-ray findings that were read as sarcoidosis? Because we've seen a fair number of x-ray findings that they weren't consistent with classic silicosis, but were read as sarcoidosis in silica workers. Yeah, I don't think we had any. Actually, no, we did have a couple that was read as sarcoidosis. And then they would go on to have a HRCT. And then, yeah, and then confirm. It's hard to differentiate sarcoidosis from silicosis in some cases. So that's where the respiratory physicians will work on it and things like that. And it depends on their history and their previous exposures as well. TB is another one as well that we did come across during this study, that it was very difficult and they had to be referred back to a respiratory clinic. Thank you. Good morning. Carl Auerbach, Alberti, New York. Thank you for an excellent talk. It reminds us why we became occupational physicians. It reminds us of what we can do as occupational physicians. My question is, did you incorporate smoking, cessation smoking counseling in your program? Yes, we did, actually. Thanks for asking that. Yeah, so as part of the health monitoring or medical counseling that we spoke about, it is essential, well, often the medical practitioners would also advise them about smoking and reducing their lifestyle risk factors. And one of the other interesting thing when we did this project is we found quite a lot of individuals on the CT scans with coronary artery disease. And that's an incidental finding, not related to silica, but it was then fed back to the medical practitioners and the individuals were then referred to a cardiologist for follow-up as well. So you're right, we shouldn't ignore other factors and we try and encourage our medical practitioners to do the same. Good morning, Dr. Sim, and thank you very much. Most enlightening presentation. I'm Vanessa Gavinder. I have a special interest in occupational lung diseases in the mining industry in South Africa. So the advantage of being one of the last two questioners is that some of the questions have been answered, but I'm particularly interested in how you stratified for risk with regards to the silica dust measurement level. So the OVLs are set at 0.05, but at what levels are the different risk categories defined? So you did mention high risk, but if you can just expand a bit on what that high risk was, I understand it to be five years or more. And then that leads on to my next question, which is around in those additional workers, were they exposed to less than five years or at what levels of silica dust were they exposed to, the additional workers that you found silicosis in? Thank you. So the first part to your question, we do use, so in our existing legislation with general industries, if you have any exposure to silica, regardless of the workplace exposures limits, you should have silica health monitoring. However, in the mining industry, this is what they often use as the similar exposure group where's the cutoff to have undertake silica health monitoring. We have also undergone a general legislative change, not related to silica, but just generally that mining now aligns with us. But the question is, when do we put people through a CT scan, for example, and we're currently in discussion because the workplace exposure standards is dropping further and if it's 50% of the WES, then it's essentially triggering health monitoring on everyone. So we've been working with some mining companies to look at what we call the highest risk group where their workplace exposure level is the highest risk, have CT scans done on that particular group of workers and then from there, we can see if there are changes. Because if there is, that means we have to filter down to the next groups. But if there's not, then we can draw a clear line of when these things are done, yeah. The second part to your question, can you repeat that? Because... Yes, on those additional cases. Oh, yeah. Yes, from your recall study. Yeah, so they were most definitely people that have been working in excess of five years. I don't have the statistics on me, but they have had significant exposures, yeah. I guess I was leading up to other additional risk factors, which would be good to understand. Yeah. So we can stratify the workers better, but thank you very much for your responses. Thanks. Just a wonderful presentation and great questions. My name's Kathy Fagan, I'm in Ohio. I have more of a comment. When I was at OSHA, I was on our silica team that created the standard. And... I might start crying. The huge epidemic that's been discovered in engineered stoneworkers in California, we failed those workers. Our silica standard has failed those workers. When I was at OSHA, one of the things that you have that we don't in the standard is WorkSafe. We actually asked NIOSH if they could do that. And they said they don't have the funding to do it. So it was never part of the standard. And so my one question to everybody is, should we really push to ban high silica content engineered stone? Thanks for your comment. Yep. Thank you for the presentation. My question is, it's related to my practice. You know, I do X-ray and then we send it to be reading. And the be reader will send back the reading. And if there is any abnormalities on the chest X-ray or be reading on the spirometry, you know, that's when we think about doing CT scan. I mean, we don't just do CT scan on everybody. I don't think there is OSHA guidelines that says you have to do CT scan, you know, a certain period of time or every year or every two years. You know, where did the data come from to do CT scan every two years as you do there? Also, do you do be reading or not? So tell me, am I doing something wrong? Because I don't do CT scan on everybody. Yeah, so this only applies in Western Australia because it's a legislative change that we've had. We do not do chest X-rays anymore for silica health monitoring, but we do for asbestos. So it's only specific to silica. And it's also specific to certain circumstances where we have considered what are the risks, as I explained before. In terms of OSHA requirement and things like that, because we don't do chest X-rays, we don't have be readers that have to report on it. And the other point is that it doesn't have to be abnormal to pick up silicosis, the chest X-rays or the spirometries. We're seeing them in cases where, you know, in our project, there were normal chest X-rays and they have silicosis. David Weissman from NASH. I'd also like to echo everybody else on just the wonderful presentation and the wonderful work that you've done. I have one question. Are you planning to do any studies to compare the diagnostic performance of ultra low-dose CT to low-dose CT? Very good question. We actually funded another project that does look at ultra low-dose CT and not to be CT scans, but with chest X-rays. And we are waiting for the outcome of that study. So that's in the pipeline with another group of researchers. Well, thank you. And also I'd like to echo Kathy Fagan's comment, which is, it's really a cautionary tale, your experience with coal miner surveillance in Australia, where there was a system where there was medical surveillance, but there was no reporting to the government at all of the results of that surveillance. And that's what we have with our current silica rule. And so if there are folks here from the US that are in the audience, if you have cases of silicosis, please report them to your state health departments. Please let people know. We know there are a lot of cases of artificial stone silicosis in the US that just aren't being recognized. And that needs to be brought to light. The other thing is that MSHA has on its regulatory agenda a new silica rule for miners. And when that proposed rule is posted, please comment on it. And please demand that there be a mechanism for reporting of cases that are identified by surveillance. I think that that's really important. So thank you so much. Thank you. And I'll just say, I know we're over time, but not all states take those reports, right? Not all states actually take silicosis reporting, but all should. And we should have the money and the surveillance structure in the US so that that could happen. ACOM can push for that. Well, on that note, we're gonna close. But I think we've talked about silica today and silicosis cases. But this is to also illustrate that as occupational physicians, you don't always have the luxury that Dr. Lee and I have sitting within a government body. But it doesn't mean that you can't influence change and you can't collegiate and look at your cases together to then inform your regulators. So I would encourage you to do that. And those that are in the early years of their career, that you have a role in all of this. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

June Sim

silica

silicosis cases

health monitoring

CT scans

legislative changes

occupational diseases

prevention

early detection