Surveillance Needs and Controversies in Three Occupations

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.

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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.