Seven Challenges of Implementing Medical Surveillance under OSHAs New Respirable Silica Standard

OSHA’s silica standard addresses many aspects of workplace protection, including having a written plan, environmental monitoring, housekeeping, training and use of respirators.

OSHA’s newest major health protection standard (29 CFR 1926.1153) addresses respirable crystalline silica in construction, general industry, maritime, and hydraulic fracturing.1 Effective implementation dates range from June 2018 to June 2020, so health and safety professionals are actively designing and refining silica programs.

The silica standard addresses many aspects of workplace protection, including having a written plan, environmental monitoring, housekeeping, training and use of respirators.

Silica Exposure
The OSHA Directorate of Standards and Guidance estimates that 1.8 million workers in construction are at risk of overexposed to silica, plus another 320,000 workers in general industry. These workers represent a wide range of occupations and industrial sectors (See Table 1).2

Adverse Effects of Respirable Silica Exposure
Adverse effects of silica exposure are largely pulmonary. Most common is chronic obstructive pulmonary disease (COPD), such as chronic bronchitis and emphysema. Also common is lung cancer. The International Association for Research on Cancer (IARC) classifies silica in Group 1—a proven carcinogen to humans.3 Lung infections are triggered by the inflammatory effects of fine silica dust, resulting in atypical fungus infections of the lungs and activation of latent tuberculosis (TB), called “consumption” in Ramazzini’s era.

Most common symptoms are shortness of breath, cough (usually dry, but can produce sputum or blood), pleuritic chest pain on deep inspiration, and constitutional symptoms from secondary diseases such as fever from TB, or loss of appetite and weight loss from cancer. Additionally, silica exposure is associated with kidney disease and renal failure, as well as various kinds of autoimmune disorders, including lupus erythematosis.

Three kinds of silicosis reflect varying duration of exposure and resultant effects. Most common is chronic silicosis, a slow, but steadily progressive condition found among workers with more than 10 years of exposure. Accelerated silicosis comes from excessive exposure over five to 10 years. Since 2000, an epidemic of progressive massive pulmonary fibrosis has emerged among coal miners who must increasingly blast through underground rock to reveal lower concentrations of coal in smaller layer.

Short-term exposure to overwhelming amounts of respirable silica can cause acute silicosis. An example is severe lung disease among three people working for only a year as countertop cutters, in environments with neither proper ventilation nor respiratory protection.

Silica Standard Breaks New Ground
The respirable silica standard breaks new ground in many areas. One highlight is the referral of workers with significant pulmonary disease (based on examination and/or chest x-ray B reading) to a specialist in occupational medicine or pulmonary disease. It also is the first to require written employee authorization to communicate certain results to the employer.

The silica standard creates profound differences in the information provided in written medical opinions for the employee and the employer (See Table 2).

Appendix B, Medical Surveillance Guidelines, outlines silica’s health effects and details many aspects of the surveillance exam and medical report requirements.4 This appendix is a model of excellence that OSHA should emulate in updating old standards and issuing new ones.

Medical Surveillance Requirements
Workers above the exposure trigger (action level above the PEL of 50 mcg/cu M or Action Levels of 25 mcg/cu M) or those required to wear a respirator 30 or more days per year must be offered medical surveillance examinations every three years. The exams include several components:

  • Medical and work history
  • Pulmonary Function Testing, including FVC, FEV1, FEV1/FVC ratio (by a NIOSH-certified technician)
  • Chest X-ray (PA view) with ILO interpretation of small opacities, ground glass appearance (by a NIOSH-certified B-reader)
  • TB Test – initial exam only (skin or blood test)
  • Physical Exam by an examining physician or other licensed health care provider (PLHCP)
  • Other Tests as determined by the PLHCP, e.g., kidney function, CT scan of lung if chronic exposure
  • Two written medical reports issued within 30 days, one tailored to the employee, the second tailored to the employer

The medical and work history should address questions such as 1) prior, current and anticipated exposure to respirable silica, dust, or other respiratory irritants; 2) durations and levels of exposure, 3) use of personal protective equipment, 4) prior respiratory system dysfunction (e.g., shortness of breath, cough, asthma), 5) smoking status and history 6) history of tuberculosis or exposure, 7) prior positive TBC skin test, 8) history of kidney or autoimmune disease, and 9) availability of prior medical records.

The physical exam should include vital signs (blood pressure, pulse, temperature); careful examination of the chest (observation of breathing, chest structure, signs of cardio-pulmonary disease, listening to the chest for decreased breath sounds, rales, rhonchi, etc.); and observation of the fingers for cyanosis, edema, clubbing or other joint abnormalities.

Challenges of New OSHA Regulations
As with all new OSHA regulations, there is often confusion and uncertainty during planning and implementation. However, the silica standard raises more than a dozen significant challenges for employers, employees, and medical professionals. The following challenges have emerged from experience performing more than 2,000 silica medical exams for dozens of employers.

Here are seven challenges you may face when working with OSHA’s silica standard.

Challenge 1. Understanding the silica regulations: Safety managers frequently express confusion with OSHA’s new silica standard, as it differs significantly from prior standards. Areas of confusion include:

  • Which employees need silica medical exams
  • The information needed for the exam and the specific tests to be performed
  • Specific examination results the employer may and may not receive
  • Chest x-ray, B-Reading and TB skin test interpretation
  • Appropriate employee follow-up, especially with designated specialists
  • Payment for follow-up exams

To understand and interpret the new standard, employers should seek the guidance of experts who have experience in silica medical exams and respiratory protection.

Challenge 2. Employee refuses any part of exam: While a silica medical examination must be offered, employees can choose not to have the exam or any component of it. An employee can decline to complete the work and medical history, pulmonary function test, chest x-ray with B-Read, physical exam, TB skin test or referral to a broad-certified specialist for follow-up.

Although employees can refuse any OSHA-mandated test, it is important to note that employers have the option to make medical exams a mandatory “condition of employment.” When looking for a medical partner for silica exams, seek a company that aims to teach workers the value of each component of the silica medical exam and the benefit to their health.

Challenge 3. Training of licensed health care professionals: Given the confusion surrounding the new silica standard, it is difficult to find competent and knowledgeable silica examiners. Unfortunately, not all medical examiners understand OSHA regulations and fully comprehend their role in the process. In fact, many simply review history, perform physicals and complete forms. Examiners need guidance on potential hazards, information to search for in work and medical history, how to focus their physical exams, knowledge of the required tests and how to interpret results, and clear understanding of the written medical opinions they must prepare for the employee and the employer.

Challenge 4. B-reader licensing: There is confusion about the credentialing needed for NIOSH-certified B-Readers to review silica x-rays. OSHA has not provided guidance on whether B-Readers must hold licenses in each state where they conduct B-Reads. Some B-Readers are attempting to distinguish comprehensive “clinical review” from occupational “pneumoconiosis consultations” to avoid dealing with state licensure issues.

Challenge 5. Assistance finding qualified medical specialists for referral: After the silica medical examination, employers must “make available within 30 days an evaluation by a board-certified specialist in pulmonary disease or occupational medicine” for employees with work-related silica health issues. Locating properly qualified medical specialists presents difficulties. Employers should work with a partner who can provide assistance in finding suitable specialists when needed.

Challenge 6. Employee does not authorize release information to employer: Only with a signed release can employers access the critical employee information from the initial medical examinations (See Table 2). Information includes recommended limitations on employee exposure to respirable crystalline silica and a statement directing an examination by a board-certified specialist in pulmonary disease or occupational medicine for the employee.

Look for a partner that guides workers to understand the best options for their health. Health professionals should discuss with employees the implications of not authorizing their employer to receive vital information.

Challenge 7. Confusion about what medical information the employer may receive: Employers usually receive medical exam results relevant to occupational exposures. However, the silica standard excludes employers from receiving: medical test results, medical conditions that would place employee at increased risk from silica exposure and medical conditions that require further evaluation or treatment (See Table 2). Only with employee authorization may an employer receive a statement that a board-certified specialist in pulmonology disease or occupational medicine should examine the employee. Employers must understand how significantly the silica rules differ from other OSHA standards.

Conclusion
Navigating the complex landscape of OSHA regulations can be tricky. The new silica standards complicate this further. In fact, they can be more difficult to understand than previous rules. Employers should look for a compliance partner who has the experience, knowledge and insight that can help them navigate OSHA silica confusion and keep their workforce productive, safe and healthy.

REFERENCES
1 https://www.osha.gov/laws-regs/regulations/standardnumber/ 1926/1926.1153  
2 https://www.osha.gov/silica/factsheets/OSHA_FS-3683_Silica_Overview.html
3 https://monographs.iarc.fr/agents-classified-by-the-iarc/
4 https://www.osha.gov/silica/AppendixBtosect1926.1153.pdf

This article originally appeared in the January/February 2020 issue of Occupational Health & Safety.

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