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SURVEILLANCE NEEDS AND CONTROVERSIES IN THREE OCCUPATIONS

M. L. Hopkins09/28/2023
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Medical surveillance is an ongoing need for employers and employees in
industries where exposure to chemicals, extreme heat, high radiation levels, or
other hazardous elements are part of the occupational landscape. Medical
surveillance is a program of medical examinations and tests designed to detect
and monitor potential health effects of these kinds of exposures, in conjunction
with employers’ safety-focused workplace practices and engineering controls.1

The appropriateness of employers’ current medical surveillance programs or the
need to revise or implement such an effort can fluctuate based on new rules
promulgated by regulators, increasing cases of adverse health incidents or
heightened awareness of hazardous exposures, and the emergence of new industries
or the growth of existing ones where hazardous exposures are a potential
concern.

This article examines three occupations (countertop fabrication, coal mining,
and electric vehicle battery production/recycling) in respect to the need for
medical surveillance and the controversies that can arise. Employers don’t need
to navigate the complexities of medical surveillance and regulatory compliance
alone. An occupational health provider is an essential partner for physical
exams, respirator clearance and respirator fit evaluations, and educating
employees about the vital importance of safety compliance.


COUNTERTOP FABRICATION – SILICOSIS RISK

Silicosis is a respiratory disease that leads to fibrotic changes (thickening or
scarring) that diminish lung function. It also can render individuals more
vulnerable to tuberculosis, lung cancer, chronic obstructive pulmonary disease
(COPD), and kidney disease.

Silicosis is caused by inhaling crystalline silica, which is found in quartz and
other types of stone, concrete, and mortar.2 In addition to stone countertop
fabrication, other occupations that pose a high risk of silica exposure include
jackhammering, sandblasting, cutting concrete and brick, ceramics manufacturing,
mining, and hydraulic fracturing.3

Engineered stone countertops are expected to overtake all other countertop
options in the U.S. by 2024.4  “Several recent studies have uncovered a high
prevalence of previously unrecognized silicosis in currently employed engineered
stone workers, indicating that efforts to decrease silica dust exposures in this
industry are inadequate, and also that many cases likely go undiagnosed,”
according to coauthors Hua, Rose, and Redlich in a July 2023 editorial published
in JAMA Internal Medicine.5


TO BAN OR NOT TO BAN ENGINEERED STONE?

Construction employees in Australia have won government consideration of a
national ban on engineered stone products six months earlier than expected. In
February 2023, health and safety ministers unanimously appealed to Safe Work
Australia, an occupational health and safety government agency, to prepare a
plan for “the world’s first total ban on engineered stone products in response
to rising rates of silicosis.”6

Regulators also are concerned in California, where several of cases of deadly
silicosis have been identified in among mostly immigrant workers, some in their
20s. While a surge in silicosis cases is newly being reported in the media, it’s
been a concern for a while. Studying the period from 2017 to 2019, Concentra’s
National Director of Medical Surveillance Services Ronda B. McCarthy, MD, and 21
other researchers working together first reported 18 cases of silicosis in the
stone fabrication industry in California, Colorado, Texas, and Washington,
including the first two fatalities in the U.S.7

Cal/OSHA, the state’s Occupational Safety and Health Administration (OSHA), in
May 2023 declared that a state ban on engineered stone products may be warranted
in the near future. Los Angeles County also is considering a proposal to
prohibit the sale and installation of fabricated stone containing silica.8

On September 25, the U.S. Department of Labor announced that OSHA has launched a
new initiative to enhance enforcement and provide compliance assistance to
protect workers in the engineered stone fabrication and installation industries.
The stated goal is to make sure the industry’s employers are following required
safety standards and providing workers with the protection required to keep them
healthy.

Two more occupations discussed in this article – coal mining and electric
vehicle battery production and recycling – also are experiencing developments
that may give rise to additional medical surveillance needs.


COAL MINING’S SILICOSIS THREAT SURGES

In Central Appalachia, coal workers’ pneumoconiosis has rebounded in the past
two decades after falling to a low point in the 1990s. Pneumoconiosis is an
umbrella term for lung diseases that develop from inhaling certain kinds of dust
particles, leading to fibrotic changes in the lungs.

Rising disease rates have been linked to higher levels of toxic silica as miners
must grind more rock to retrieve coal from thinner seams. In addition to the
general disease rate increase, more young miners are being diagnosed with
pulmonary massive fibrosis (PMF), a late-stage, chronic pneumoconiosis form.9

In response, the U.S. Mine Safety and Health Administration (MSHA) has proposed
tighter regulations. The new rule, which was published in the Federal Register
in July 2023, would lower the permissible exposure limit for respirable
crystalline silica from 100 to 50 micrograms per cubic meter of air in an
eight-hour shift.10

In addition to reducing the exposure limit, the proposed rule includes exposure
sampling and requirements for respiratory protection that reflect “the latest
advances in respiratory technologies and practices,” according to a MSHA news
release.11


ENFORCEMENT AND COMPLIANCE CONTROVERSIES

The proposed rule is generally welcomed by all parties in the coal mining
industry, but three areas are eliciting disagreements: the use of respirators;
sampling and reporting; and employee compliance.

Use of respirators

The National Mining Association, which represents mine operators, wants workers
to use respirators to comply with the proposed rule, similar to other
industries. The rule does allow the use of respirators, but only temporarily,
while mine operators implement engineering controls.12

The United Mine Workers of America and the American Thoracic Society have
summarized objections to wearing respirators, saying that they can be ill-suited
to extreme conditions in the mines and hinder communication between workers.
“Engineering controls are the best and preferred method of controlling miner
exposure to silica dust,” says Gary Ewart, an American Thoracic Society
spokesperson.13

Without inspectors present, miners are worried respirators might become mine
operators’ permanent solution of choice.14

Sampling and reporting

The proposed rule allows companies to self-report silica levels, with federal
inspectors conducting spot checks. Willie Dodson, Central Appalachian field
coordinator of an advocacy group for miners, is worried there may still be
leeway for some mine operators to manipulate the data they report.15

The claim may seem like a stretch, but an investigation of claims filed with the
U.S. Labor Department’s Black Lung Program from 2000 to 2013 is a reminder that
there can be vulnerabilities in surveillance and reporting. The investigation,
reported in the Annals of the American Thoracic Society in 2021, sought to
discover if there was any pattern between who paid for an X-ray and the
resulting radiologic classification (positive or negative for simple
pneumoconiosis or progressive massive fibrosis).

Researchers concluded that there was a strong association, “suggesting the
importance of eliminating financial conflict of interest in what should be an
objective determination of eligibility for Black Lung Workers’ Compensation
Benefits.”16

Employee compliance

Mine owners and operators who go to great lengths to protect miners from serious
lung disease can be frustrated in their efforts by employees who only
sporadically follow safe practices, including the use of personal protective
equipment (PPE), perhaps only when inspectors are present. Researchers have
reported these shortcomings in the Journal of Occupational and Environmental
Medicine.17

“To reliably reduce exposures, the correct type of respirator must be worn at
the correct time and must fit and function properly. Breakdowns can occur with
any of these steps. This is why engineering controls to reduce respirable dust
exposures to safe levels are preferred,” researchers said.18, 19


DRIVERS IN THE EV MARKET: FUNDING AND MINERALS

Increasing the number of electric vehicles on U.S. roads from about 2.5 million
currently to 44 million by 2030 is a key part of the push to reduce greenhouse
gas emissions to net-zero, according to the Rocky Mountain Institute, an
independent, non-partisan, and nonprofit organization that promotes clean
energy.20

The group estimates $175 billion will need to be invested in the next two or
three years to create an adequate supply chain for electric vehicle (EV) battery
production alone. Almost all EVs use lithium-ion batteries which contain five
critical minerals: lithium, nickel, cobalt, manganese, and graphite.21 Electric
vehicles require six times the mineral inputs of conventional cars, according to
the International Energy Agency.22


U.S. ‘CHARGED UP’ ABOUT EVS, EV BATTERIES

The push for more EVs is definitely “on,” as seen in increased funding by
companies and government to support electric vehicle production and supply
chain. The U.S. Department of Energy is planning to provide $12 billion for
automakers to retrofit existing manufacturing facilities to produce electric and
hybrid vehicles, as well as $3.5 billion for domestic battery manufacturing.23

Transport Topics, a logistics and trucking news publication, has reported that
Hyundai Motor Group and LG Energy Solution will spend an additional $2 billion
and hire 400 extra workers to make EV batteries at their electric vehicle plant
under construction in Georgia, bringing their total investment in the plant to
more than $7.5 billion and a planned workforce of 8,500.24


EXPOSURE RISK FOR EMPLOYEES

Hazardous exposures from EV minerals are possible during three stages – mining,
transporting new and spent batteries, and extracting/recycling battery
components.

Exposures and health effects

Of the five “critical minerals,” only lithium, nickel, and cobalt are mined in
the U.S., predominantly through open-pit mining or underground mining. A third
process involves extracting compounds from brine.25

There is no occupational exposure limit for lithium, but it is known to irritate
eyes, nose, throat, and lungs and may affect thyroid gland, kidney, and heart
function.26

The Centers for Disease Control and Prevention (CDC) says exposure to nickel can
harm the lungs, stomach, and kidneys and may lead to cancer. The level of
exposure and its effects depend on the dose, duration, and the work being done,
according to the CDC.27

OSHA’s permissible exposure limit for nickel is 1.0 milligram per cubic meter of
air in an eight-hour time weighted average (TWA) concentration.28

Cobalt can harm the eyes, skin, heart, and lungs, the extent to which again
depends on dose, duration, and the work being done.29 Chronic exposure to
cobalt-containing hard metal (dust or fume) can lead to a serious lung condition
called hard metal lung disease, a kind of pneumoconiosis from inhaling
respirable particles.30

OSHA has a permissible exposure limit for cobalt metal, dust, and fume of 0.1
milligram per cubic meter of air in an eight-hour time weighted average (TWA)
concentration.31

Transporting, extracting, and recycling

By 2027, 200,000 metric tons of batteries are expected to reach the end of their
life in powering electric and hybrid vehicles. Their destination at that point
is either to be transported to be discarded or to be collected so the mineral
components can be separated and recycled/reused. Separation involves mechanical
grinding or shredding of the battery before extracting the mineral components.
Either way, there are potential dangers and health risks, according to the
Congressional Research Service.32

“Most lithium-ion batteries when discarded would likely be ignitable and
reactive hazardous waste. Commercial establishments are responsible for
determining whether any waste they produce is hazardous waste, including
lithium-ion batteries at the end of their life,” says the U.S. Environmental
Protection Agency.33

“Lithium-ion batteries discarded by (small) businesses that generate less than
220 pounds of hazardous waste per month are considered very small quantity waste
generators and may be subject to reduced hazardous waste requirements,” the EPA
added.

Safe commercial transport of lithium-ion batteries depends on compliance with
hazardous materials regulations and good judgment, according to a safety
advisory issued by the Department of Transportation’s Pipeline and Hazardous
Materials Safety Administration in May 2022.34

Seeking to raise awareness of the dangers related to transporting lithium-ion
batteries, the safety advisory provides highlights of essential hazmat
regulatory information, discusses the general dangers, outlines what shippers,
carriers, and consumers should do when disposing or recycling EV batteries, and
points to additional information on preparing batteries for shipment.


HOW CONCENTRA CAN HELP

Employers are encouraged to partner with Concentra to develop an appropriate
medical surveillance service package. Each surveillance program is designed
based on the information the employer provides, such as employees’ job titles,
duration and frequency of exposure, anticipated exposure level, and respiratory
equipment or personal protective equipment used.

Collecting this information upfront helps Concentra provide best-in-class
healthcare to employees with hazardous exposures in their unique occupation and
workplace.

--------------------------------------------------------------------------------

NOTES

 1.  “What is Medical Surveillance,” by Michelle Hopkins. Concentra. January 6,
     2020.
 2.  “Silica, Crystalline.” Occupational Safety and Health Administration.
     Accessed: August 30, 2023.
 3.  “Learn About Silicosis.” American Lung Association. Updated: November 17,
     2022.
 4.  “Severe Silicosis Outbreaks Among Engineered Stone Workers (Discoveries &
     Impact August 2023),” by Melanie Ho. Yale School of Medicine. August 10,
     2023.
 5.  Hua JT, Rose CS, Redlich CA. Engineered Sone-Associated Silicosis-A Lethal
     Variant of an Ancient Disease. JAMA Internal Medicine. Published online
     July 24, 2023.
 6.  “Australia moves to fast-track ban on silica stone benchtops that cause
     fatal lung disease,” by Paul Karp. February 28, 2023.
 7.  Rose C, Heinserling A, Patel K, McCarthy RB, et al. Severe Silicosis in
     Engineered Stone Fabrication Workers – California, Colorado, Texas, and
     Washington, 2017-2019. MMWR Morbidity and Mortality Weekly Report.
     September 27, 2019;68(38):813-818.
 8.  “California Fast-Tracks Rules to Protect Stonecutters from ‘Horrible
     Deaths,” by Farida Jhanvala Romero. KQED. July 22, 2023.
 9.  “Black Lung Resurgence Prompts New Mining Rules,” by Kris Maher. The Wall
     Street Journal. August 28, 2023.
 10. “Lowering Miners’ Exposure to Respirable Crystalline Silica and Improving
     Respiratory Protection: A rule proposed by the Mine Safety and Health
     Administration on July 13, 2023.” Federal Register. July 13, 2023.
 11. “Department of Labor will extend comment period for proposed changes to
     standards to better protect miners from hazardous silica dust levels.” Mine
     Safety and Health Administration News Release. August 10, 2023.
 12. “After decades of delays and broken promises, coal miners hail rule to slow
     rise of black lung,” by Leah Willingham and Matthew Daly. Associated Press.
     August 5, 2023.
 13. “New silica exposure rules aim to protect miners, but critics say they lack
     needed enforcement,” by Sarah Vogelsong. Virginia Mercury. August 14, 2023.
 14. “After decades of delays and broken promises, coal miners hail rule to slow
     rise of black lung,” by Leah Willingham and Matthew Daly. Associated Press.
     August 5, 2023.
 15. “After decades of delays and broken promises, coal miners hail rule to slow
     rise of black lung,” by Leah Willingham and Matthew Daly. Associated Press.
     August 5, 2023.
 16. Friedman LS, De S, Almberg KS, Cohen RA. Association between Financial
     Conflicts of Interest and International Labor Office Classifications for
     Black Lung Disease. Annals of the American Thoracic Society. October
     2021;18(10):1634-1641.
 17. Reynolds LE, Blackley DJ, Colinet JF, et al. Work Practices and Respiratory
     Health Status of Appalachian Coal Miners with Progressive Massive Fibrosis.
     Journal of Occupational and Environmental Medicine. November
     2018;60(11):e575-e581.
 18. Reynolds LE, Blackley DJ, Colinet JF, et al. Work Practices and Respiratory
     Health Status of Appalachian Coal Miners with Progressive Massive Fibrosis.
     Journal of Occupational and Environmental Medicine. November
     2018;60(11):e575-e581.
 19. Colinet J, Goodman G, Listak J, et al. Effective Control of Respirable Dust
     in Underground Coal Mines in the United States. Eighth International Mine
     Ventilation Congress held July 6–8, 2015 Brisbane, Australia: The
     Australasian Institute of Mining and Metallurgy; 2005. pp. 129–134.
 20. “The EV Battery Supply Chain Explained,” by Alessandra R. Carreon. Rocky
     Mountain Institute. May 5, 2023.
 21. “The EV Battery Supply Chain Explained,” by Alessandra R. Carreon. Rocky
     Mountain Institute. May 5, 2023.
 22. “Mineral-Rich Nations Want Piece of EV Pie,” by John Emont, Juan Forero,
     and Alexandra Wexler. The Wall Street Journal. July 3, 2023.
 23. “Shift to Electric Gets $12 Billion in Funds,” by Scott Patterson. The Wall
     Street Journal, September 1, 2023.
 24. “Hyundai, LG Invest $2 Billion More Into Georgia Battery Plant.” September
     1, 2023.
 25. “Critical Minerals in Electric Vehicle Batteries,” by Brandon S. Tracy,
     analyst in energy policy. Congressional Research Service. August 29, 2022.
 26. “Hazardous Substance Fact Sheet: Lithium.” NJ Health. Revised: June 2008.
 27. “Nickel.” Centers for Disease Control and Prevention. The National
     Institute for Occupational Safety and Health. Last reviewed: November 2,
     2018. Accessed: August 29, 2023
 28. “Nickel, Metal & Insoluble Compounds.” Occupational Safety and Health
     Administration. Accessed September 5, 2023.
 29. “Cobalt.” Centers for Disease Control and Prevention. The National
     Institute for Occupational Safety and Health. Last reviewed: June 24, 2019.
     Accessed: August 29, 2023.
 30. “The toll of the cobalt mining industry on health and the environment.” CBS
     News. March 6, 2018.
 31. “Cobalt Metal, Dust & Fume.” Occupational Safety and Health Administration.
     Accessed September 5, 2023.
 32. “Critical Minerals in Electric Vehicle Batteries,” by Brandon S. Tracy,
     analyst in energy policy. Congressional Research Service. August 29, 2022.
 33. “The EV Battery Supply Chain Explained,” by Alessandra R. Carreon. Rocky
     Mountain Institute. May 5, 2023.
 34. “A Safety Advisory Notice for Disposal and Recycling of Lithium Batteries
     in Commercial Transportation.” U.S. Department of Transportation. Pipeline
     and Hazardous Materials Safety Administration. May 2022.  






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