Lung disease a risk for engineered stone workers, sandblasters, miners

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. A lot of scientific research is incremental with its importance becoming evident over the years. Sometimes scientists uncover information that needs to be shared more urgently, and that's the case with some research into silicosis at Upstate. With me to talk about their findings are Dr. Jerry Abraham and Judith Crawford. Dr. Abraham is a professor of pathology and director of Upstate's environmental and occupational pathology. Dr. Crawford is a certified industrial hygienist and research associate at Upstate. Welcome back to "The Informed Patient," Drs., Abraham and Crawford

[00:00:47] Judith Crawford, PhD: Thank you.

[00:00:47] Jerrold Abraham, MD: Thank you.

[00:00:49] Host Amber Smith: Let's start with a definition of silicosis. Dr. Abraham?

[00:00:54] Jerrold Abraham, MD: Yes. Silicosis is one of the oldest recognized diseases related to exposure to something in somebody's job or environment. By definition, silicosis is the disease caused by inhalation of silica dust particles. It's usually a lung disease, resulting from inhaling, over periods of time, tiny particles of silica dust that injure the lung and cause a reaction, which can be different kinds of different severity.

[00:01:34] Host Amber Smith: So this isn't something that a person would be born with. It's an injury, it sounds like, or a disease that develops from breathing silica dust?

[00:01:43] Jerrold Abraham, MD: That's correct.

[00:01:46] Host Amber Smith: How long does silicosis take to develop? If you start breathing it, how long until you start having symptoms of silicosis?

[00:01:58] Jerrold Abraham, MD: Well, like many diseases related to inhaling harmful materials, it depends on how high the concentrations are that you inhale. Classically, silicosis develops with a few decades of exposure to silica in various occupations like mining or milling, in the past. But there are other forms that we'll talk about where it can develop within months to years and in between those different timeframes.

[00:02:33] Host Amber Smith: Is silica dust visible to the human eye, or does it have an odor? How would a person know they're breathing it in?

[00:02:41] Jerrold Abraham, MD: Well, it doesn't have any odor. And if the concentrations in the air are high enough, the air looks dusty, especially when there's light shining through it. It's like a dust. Particles scatter the light, and you can see it look much more dusty that way. Just like in a foggy environment, if you shine your headlights through it, you can see the fog, but if you turn the headlights off, you won't see it so much, even though it's still there.

So silica dust can be inhaled without you knowing it. If you're in a very dusty environment, you probably are aware you're in a dusty environment, but you would have no way to know that it's silica dust unless you were informed about the hazards. And that's one of the primary responsibilities in occupational health is to inform people. It's called a right to know. People should know what they're being exposed to, or prevent exposure to.

[00:03:35] Host Amber Smith: Are there specific symptoms a person might experience if they've developed silicosis?

[00:03:42] Jerrold Abraham, MD: Yes. As with most lung diseases, the main symptoms relate to breathing. So difficulty breathing or shortness of breath would be the most classical symptom someone would develop as they develop silicosis.

[00:03:59] Host Amber Smith: Can you talk about how silicosis is diagnosed?

[00:04:04] Jerrold Abraham, MD: Yes. One way it's diagnosed is with a chest x-ray that shows characteristic shadows, little round shadows in the lung, that are not 100% specific, but very suggestive for silicosis. And another way that it's diagnosed is not just based on an x-ray, but based on the physician taking a history of what the person was doing, how were they exposed to silica or other things, and to put it all together to see if that's a consistent picture before they make that diagnosis.

[00:04:41] Host Amber Smith: Are there treatments available for this, and is there any way to reverse the damage once it's occurred?

[00:04:49] Jerrold Abraham, MD: There's not really any good treatment. There can be treatment for complications. If you get damage to your lung and you get infections related to that, those can be treated. But the silica dust stays there and causes scarring in the lung, and it's not really possible at present to reverse that. That's the tragic part of it, and it's very simple. To prevent, if you don't inhale it, you aren't going to get that disease.

[00:05:20] Host Amber Smith: So it is preventable?

[00:05:23] Jerrold Abraham, MD: Yes. Maybe Dr. Crawford would want to talk about that a little bit.

[00:05:28] Judith Crawford, PhD: Yes. It's 100% preventable. It absolutely is. And employers are required under the OSHA (Occupational Safety and Health Administration) Act, to provide a safe and healthful work environment to their employees, and to protect workers. And there are regulations specifically for silica control on the books. And so those, the types of things that can be done to prevent silicosis are things like training of workers. And we talked about dust. Control of dust is absolutely huge for preventing disease and protecting the workers. And that includes things like wet methods.

Wet methods are very, very important where you have, like, water delivery systems to your power tools that will directly go on a saw blade, for example, to keep the dust down, vacuum type equipment that can also be attached to power tools, dust collection equipment. And so those controls are really important, as well as some you can control -- work time, the length or duration a worker can work.

The other types of things that, uh, can be used to protect workers are respiratory protection, and air testing is another type of activity that's really going to help document what type of exposures that workers might have. And then medical exams are also a part of it. So all those things need to be done when workers are exposed to silica.

[00:07:04] Host Amber Smith: Now the type of workers who might be exposed, would that be construction workers and coal miners?

[00:07:14] Judith Crawford, PhD: Those are two big groups, yes. I would say probably construction has more people potentially exposed. But there's also a lot of manufacturing industries that use silica. There's, for example, pottery, ceramics, brick, concrete manufacture, asphalt, jewelry -- silica is used in jewelry making -- and then the artificial stone -- we'll probably talk about later in this discussion -- but artificial stone countertops. But also sand is used, silica is used in foundry work and hydraulic fracturing, and so it's across the board in different industries, not just construction and mining.

[00:07:59] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking about a lung disease called silicosis with Dr. Jerry Abraham, who's a professor of pathology and director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, who's a certified industrial hygienist and research associate at Upstate.

The two of you, and colleagues, have a paper in the American Journal of Industrial Medicine that says there's an increase of accelerated and acute silicosis, something called PMF, and autoimmune diseases among coal miners and silica exposed countertop workers. How does accelerated and acute differ from regular silicosis?

[00:08:45] Jerrold Abraham, MD: Well, as I mentioned earlier, the main, classic kind of silicosis takes usually decades of exposure, a few decades of exposure, to develop. The terms "accelerated" and "acute" are largely related to the time it takes for them to show up.

So acute silicosis is the most severe and rapidly developing, and it's not like an acute pneumonia or something like that. Acute for something like silicosis means developing after months to just a year or two of exposure. And accelerated means it's in between. Usually it means it's developing in less than 10 years of exposure.

So the heaviest exposures, for example, an occupation that has resulted in acute silicosis is sandblasting using silica.

So in the U.S., sandblasting with silica sand is still allowed. Whereas, recognizing the hazards of it, that practice was banned completely in Britain in the 1940s. And in many other countries around the world, they don't even allow that. But it's still allowed here in the U.S., and you can see people doing sandblasting, driving down the highway or seeing people sandblasting buildings if you're out and about in most parts of the country. So that's still an ongoing hazard.

The main problem now with what's called accelerated silicosis is that people are being heavily exposed and not recognizing that they're getting silicosis. The disease is developing in their lungs with scarring and inflammation, but not recognized by the clinicians as silicosis, until it's further advanced. So there's a problem in reaching that diagnosis by clinical means, such as chest x-rays, for example. They often don't show it, even though the person may have pretty significant disease. You asked also about PMF. That's an abbreviation that stands for Progressive Massive Fibrosis. So, just as it sounds, it means large areas of scarring in the lung. They show up as big opacification or whitish areas on your chest x-ray. And those areas can be confused, for example, with lung cancers. So it requires the clinician getting the history of exposure and making sure they understand what the person has been going through, leading up to that point, to make that diagnosis.

[00:11:31] Host Amber Smith: So there's an increase in this type of silicosis, this more aggressive type, because of the sandblasting, is that right?

[00:11:41] Jerrold Abraham, MD: Maybe Dr. Crawford, you want to reply to that one?

[00:11:45] Judith Crawford, PhD: Well, I would say not necessarily. I think the increase in accelerated silicosis right now, across the world, is due to the artificial stone silica-containing countertops. So that's really where that's coming from. And also, in coal mining, in more recent times, that's increased more because it's harder and harder to mine coal. There's less of it easy to get at. And so, coal mining involves the actually chewing up a lot of the earth to get to the coal they want, or in other mining as well to get to whatever the mineral element that they're looking for. And so that means for the worker there's a greater exposure.

So I think that those are kind of two of the factors. We've got the equipment to chew through the earth, and the quartz countertops have a high concentration of silica. They're up to, like, 90% silica, so they're a very, very concentrated source.

[00:12:52] Host Amber Smith: So let's talk more about that type of silicosis that's among the workers who manufacture the artificial stone and engineered stone? How did this risk come to light?

[00:13:05] Judith Crawford, PhD: It really came to light with a lot of ill workers. That's how that came to light. And that's, unfortunately, the sad history of a lot of occupational disease. It's really not recognized until there's lots of sick, or dead bodies involved. So that's how that come to be known.

[00:13:25] Host Amber Smith: And that's a risk for the people who are making these countertops. It's not a risk once they're installed in a home, is that right?

[00:13:34] Judith Crawford, PhD: Correct. Once it's installed in the home, you're not going to easily be able to get any silica off that. It's really completely contained within the countertop. But the fabricating it, the cutting it and drilling it and sanding it and polishing it, that produces a tremendous amount of, almost, as I said, 90% silica dust. So it's very, very hazardous.

[00:13:58] Host Amber Smith: So, Dr. Abraham, can you tell us about the work you're doing here in Syracuse that's tied to California?

[00:14:06] Jerrold Abraham, MD: Yes, as Dr. Crawford was just mentioning, the recognition of this terrible disease has come from places around the world where there's been this manufacture of these beautiful countertops that many people love to have in their kitchens, without knowing the workers producing them have been exposed to unacceptable risk.

And in California alone, there's probably close to 100 patients who have been recognized as having severe disease. Some of them fatal, some of them so severe as the patients need lung transplants to survive. And these are young, young men, often immigrants working legally, in small shops where their conditions are just horrendously dusty. And some have developed this disease after five or 10 years. Some, I think, as little as three or four years, where they become so short of breath, and they go to the doctor, and the doctor who's examined them has said, "you have severe disease, and you need a lung transplant if you're going to survive." So it, it is that kind of severity.

And many of the people that need lung transplants can't get them because lung transplants are not readily available, and they're, the whole procedure costs millions of dollars, probably, on the average, for a lung transplant with a long-term follow up and maintenance clinically. So it's just tragic that this is happening with a disease that should be totally prevented.

How we got involved was that, as a pathologist who's been interested in silicosis and other occupational diseases for years, many years ago, actually starting in 1980, I began seeing sand blasters with silicosis from another epidemic that was in Texas, which is the subject of that paper that we recently published. But because of that experience and expertise, I've also been asked to look at the lungs -- some from patients who have had lung transplant surgery in California, and some who have unfortunately died, and at autopsy I've been asked to look at their lungs to confirm the type of disease and the severity, and assist the families, basically, with filing claims for compensation. So my involvement has been through the claims of these families, and we're also conducting research on the type of silica and the amount of silica and other dusts in their lungs.

But we know, from all the experience we've had and others have had, that the silica is the main cause and could have been prevented if the exposure had not taken place. I should mention that we haven't used the word quartz much, but silica and quartz are often used interchangeably. So quartz is one of the common types of silica. So people are more familiar with quartz. Some of those countertops are called quartz countertops. Other countertops that are not this artificial or engineered stone are granite, and those can also contain a high content of silica, but not in the 90% range that Dr. Crawford mentioned that occurs in these artificial stone materials.

[00:17:49] Host Amber Smith: You're listening to Upstate's "The informed Patient" podcast. I'm your host, Amber Smith. I'm talking about silicosis with Dr. Jerry Abraham, who's a professor of pathology and the director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, who's a certified industrial hygienist and research associate at Upstate.

So we talked about the people in California, but this is a problem beyond the workers in California, is that right, Dr. Abraham?

[00:18:19] Jerrold Abraham, MD: Yeah, most definitely. It's a global problem. There's a huge epidemic in Australia that's been widely publicized to the point where Australia has taken the regulatory step to try to ban the use of these artificial stone products altogether. That has yet to happen in the U.S. But other countries that are able to do more rapid reaction to public health problems have looked into that. And there have been cases in many parts of Europe and China and Israel, and other parts of the U.S., not just California.

[00:18:57] Host Amber Smith: Is the industry looking at newer ways to manufacture countertops that don't put workers at such risk for silicosis, and other diseases?

[00:19:07] Judith Crawford, PhD: I think that's happening. What I've heard is that the attempt is to try to reduce the quantity of silica in the countertop, and so that it's not going to be as hazardous. And I don't know where that actually stands, but it seems like a very good idea so that it could be used without being so hazardous.

[00:19:29] Host Amber Smith: OK. Back to the original people who got silicosis, the coal miners, are they still being exposed on the job? Dr. Abraham?

[00:19:39] Jerrold Abraham, MD: I'm not directly involved in the regulations and enforcement, but I know disease in coal miners has increased, and a lot of it has been reportedly related to lax enforcement of respiratory protection and ventilation. As the industry shrinks, it's maybe cutting corners. There's a lot of expertise on that that I don't have. But certainly it's possible to protect coal miners. There are standards for exposures in coal mines, to coal dust and to general dust, as well as to silica. And it's obvious, one of the conclusions that come out of studies that are going on of coal miners' lungs is that they're getting silicosis. So obviously the protection has been inadequate.

Whether it can be perfect is unlikely, but it certainly can be better, because what the studies with the National Institute for Occupational Safety and Health, or NIOSH, have shown is that the severity of disease in coal miners dipped chronologically as regulations were put into place after the 1970s. And then in the last decade or two, there's been an increase in severity of disease in coal miners. Again, some for the reasons that Dr. Crawford mentioned with changing mining technology and more rock exposure as they mine thinner seams of coal. So instead of 90% coal and 10% rock, they might be mining 10% coal and 90% rock because they're able to separate the coal, which is what they want. And the miners have consequently had greater exposures.

[00:21:32] Host Amber Smith: Well, let me ask you, the lung tissue of the sand blasters from Texas, from the 1980s and 1990s, does that look like the lung tissue from the people in California that have developed this, working on artificial stone?

[00:21:49] Jerrold Abraham, MD: There's a lot of overlap. Some look a little bit different because the sand blasters exposure was a little bit different than some of the countertop workers. But in the end, some of the sand blasters have died from severe silicosis, and some of the countertop workers have died or needed transplants from the severe silicosis, and that at that point the pathology -- what a pathologist would see when they examine the lungs after after surgery or autopsy -- and in the microscope would often be indistinguishable. They would look like severe, fatal unsurvivable silicosis.

One of the things, though, that's important is that the pathology examination has been able to show that there's an earlier stage where it can be diagnosed by the pathologist before it shows up on the chest X-ray as the little round nodules classical for silicosis. And it's hoped that from the studies that we did from the people years ago with the sandblasting and what we're doing now with the people working on artificial stone, that it'll enhance awareness among physicians to look harder for this disease, where, as I mentioned, it can't be seen when it's so early, sometimes, on a chest x-ray, but can be seen with different methods such as a high resolution CT (computerized tomography) scan, for example. That can show the disease even when the chest X-ray may not show it yet.

So that's a way, if it's identified earlier, at least those people can be removed from the workplace before they have further exposure. But it won't be reversible, at present.

[00:23:48] Host Amber Smith: Well, it sounds like a health crisis in real time. So, what is your message to physicians and public health providers?

[00:23:55] Jerrold Abraham, MD: Well, the main thing is for the clinicians to spend the time needed to get a good occupational history: what does your patient do? What have they done? They might have done something for 10 years and now have a desk job. So you have to go back and get a full occupational history. And as physicians get busier and busier and use more electronic methods, that history is less and less often adequately taken. So that's a lesson to patients to tell their physicians what they've been exposed to or what their family members have been exposed to, and to the physicians to keep in mind that the person with pretty much any disease, but especially lung diseases, may have an environmental or occupational contributing cause.

[00:24:48] Host Amber Smith: And Dr. Crawford, what is important for the workers? Someone who has a job that might expose them to silica or quartz, what do they need to know?

[00:24:59] Judith Crawford, PhD: If someone's exposed on their job, to silica, as I said before, they need to know that it's the employer's responsibility to protect them, and they should be seeing things in their workplace, they should have heard about this. They should be seeing things like control measures for the silica, respiratory protection, written control plans, people testing the air, medical exams, things like that may be appropriate. And if they're absent, they need to be asking about that and saying, "am I at risk?"

And if the employer doesn't do that, then they should be calling OSHA, osha.gov. Call them. Talk to them about it. They can help.

[00:25:43] Host Amber Smith: Well most of these workers need to be wearing masks to be safe?

[00:25:47] Judith Crawford, PhD: Not necessarily. Not necessarily. Depends on, again, these other controls that we have, the local controls on power equipment. And depending on how well those work, they may not need respiratory protection at all. Or if there's a short length of time that they use this equipment, again, with controls, then they may not need respiratory equipment. But some of the jobs, for example, sand blasters, they really always need respiratory protection.

[00:26:18] Host Amber Smith: Isn't sandblasting done outdoors, though?

[00:26:23] Judith Crawford, PhD: It can be definitely outdoors, but they can still be exposed. They can still be overexposed. So yes. Other sand blasting can be done in an enclosed cabinet, indoors too. But even outdoors, they require respiratory protection.

[00:26:41] Host Amber Smith: Well, that's really good to know.

I thank you both for making time for this interview.

[00:26:46] Judith Crawford, PhD: Thanks for having us.

[00:26:48] Jerrold Abraham, MD: Thank you for having us.

[00:26:50] Host Amber Smith: My guests have been Dr. Jerry Abraham, a professor of pathology and director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, a certified industrial hygienist and research associate at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.

[00:27:37] Host Amber Smith: