The current standard can be found at the OSHA Website: 29 CFR 1926.1153
(b) Definitions. For the purposes of this section the following
definitions apply: Action level means a concentration of airborne respirable crystalline
silica of 25 μg/m3, calculated as an 8-hour TWA. Assistant Secretary means the Assistant Secretary of Labor for
Occupational Safety and Health, U.S. Department of Labor, or designee. Director means the Director of the National Institute for
Occupational Safety and Health (NIOSH), U.S. Department of Health and Human
Services, or designee. Competent person means an individual who is capable of identifying
existing and foreseeable respirable crystalline silica hazards in the workplace
and who has authorization to take prompt corrective measures to eliminate or
minimize them. The competent person must have the knowledge and ability
necessary to fulfill the responsibilities set forth in paragraph (g) of this
section. Employee exposure means the exposure to airborne respirable
crystalline silica that would occur if the employee were not using a
respirator. High-efficiency particulate air [HEPA] filter means a filter that is
at least 99.97 percent efficient in removing mono-dispersed particles of 0.3
micrometers in diameter. Objective data means information, such as air monitoring data from
industry-wide surveys or calculations based on the composition of a substance,
demonstrating employee exposure to respirable crystalline silica associated
with a particular product or material or a specific process, task, or activity.
The data must reflect workplace conditions closely resembling or with a higher
exposure potential than the processes, types of material, control methods, work
practices, and environmental conditions in the employer's current operations. Physician or other licensed health care professional [PLHCP] means an
individual whose legally permitted scope of practice (i.e., license,
registration, or certification) allows him or her to independently provide or
be delegated the responsibility to provide some or all of the particular health
care services required by paragraph (h) of this section. Respirable crystalline silica means quartz, cristobalite, and/or
tridymite contained in airborne particles that are determined to be respirable
by a sampling device designed to meet the characteristics for
respirable-particle-size-selective samplers specified in the International
Organization for Standardization (ISO) 7708:1995: Air Quality—Particle Size
Fraction Definitions for Health-Related Sampling. Specialist means an American Board Certified Specialist in Pulmonary
Disease or an American Board Certified Specialist in Occupational Medicine. This section means this respirable crystalline silica standard, 29 CFR 1926.1153. (c) Specified exposure control methods. (1) For each employee engaged in a task identified on Table 1, the employer shall fully and properly implement the engineering controls, work practices, and respiratory protection specified for the task on Table 1, unless the employer assesses and limits the exposure of the employee to respirable crystalline silica in accordance with paragraph (d) of this section. Table 1 (Click Link to see entire table)2) When implementing the control measures specified in Table 1, each employer shall:(i) For tasks performed indoors or in enclosed areas, provide a means of
exhaust as needed to minimize the accumulation of visible airborne dust; (ii) For tasks performed using wet methods, apply water at flow rates
sufficient to minimize release of visible dust; (iii) For measures implemented that include an enclosed cab or booth, ensure
that the enclosed cab or booth: (A) Is maintained as free as practicable from settled dust; (B) Has door seals and closing mechanisms that work properly; (C) Has gaskets and seals that are in good condition and working properly; (D) Is under positive pressure maintained through continuous delivery of
fresh air; (E) Has intake air that is filtered through a filter that is 95% efficient
in the 0.3-10.0 µm range (e.g., MERV-16 or better); and (F) Has heating and cooling capabilities. (3) Where an employee performs more than one task on Table 1 during the course of a shift, and the total duration of all tasks combined is more than four hours, the required respiratory protection for each task is the respiratory protection specified for more than four hours per shift. If the total duration of all tasks on Table 1 combined is less than four hours, the required respiratory protection for each task is the respiratory protection specified for less than four hours per shift. (d) Alternative exposure control methods. For tasks not listed in
Table 1, or where the employer does not fully and properly implement the
engineering controls, work practices, and respiratory protection described in
Table 1: (1) Permissible exposure limit (PEL). The employer shall ensure that
no employee is exposed to an airborne concentration of respirable crystalline
silica in excess of 50 μg/m3, calculated as an 8-hour TWA. (2) Exposure assessment— (i) General. The employer shall
assess the exposure of each employee who is or may reasonably be expected to be
exposed to respirable crystalline silica at or above the action level in
accordance with either the performance option in paragraph (d)(2)(ii) or the
scheduled monitoring option in paragraph (d)(2)(iii) of this section. (ii) Performance option. The employer shall assess the 8-hour TWA
exposure for each employee on the basis of any combination of air monitoring
data or objective data sufficient to accurately characterize employee exposures
to respirable crystalline silica. (iii) Scheduled monitoring option. (A) The employer shall perform
initial monitoring to assess the 8-hour TWA exposure for each employee on the
basis of one or more personal breathing zone air samples that reflect the
exposures of employees on each shift, for each job classification, in each work
area. Where several employees perform the same tasks on the same shift and in
the same work area, the employer may sample a representative fraction of these
employees in order to meet this requirement. In representative sampling, the
employer shall sample the employee(s) who are expected to have the highest
exposure to respirable crystalline silica. (B) If initial monitoring indicates that employee exposures are below the
action level, the employer may discontinue monitoring for those employees whose
exposures are represented by such monitoring. (C) Where the most recent exposure monitoring indicates that employee
exposures are at or above the action level but at or below the PEL, the
employer shall repeat such monitoring within six months of the most recent
monitoring. (D) Where the most recent exposure monitoring indicates that employee
exposures are above the PEL, the employer shall repeat such monitoring within
three months of the most recent monitoring. (E) Where the most recent (non-initial) exposure monitoring indicates that
employee exposures are below the action level, the employer shall repeat such
monitoring within six months of the most recent monitoring until two
consecutive measurements, taken seven or more days apart, are below the action
level, at which time the employer may discontinue monitoring for those
employees whose exposures are represented by such monitoring, except as
otherwise provided in paragraph (d)(2)(iv) of this section. (iv) Reassessment of exposures. The employer shall reassess exposures
whenever a change in the production, process, control equipment, personnel, or
work practices may reasonably be expected to result in new or additional
exposures at or above the action level, or when the employer has any reason to
believe that new or additional exposures at or above the action level have
occurred. (v) Methods of sample analysis. The employer shall ensure that all
samples taken to satisfy the monitoring requirements of paragraph (d)(2) of
this section are evaluated by a laboratory that analyzes air samples for
respirable crystalline silica in accordance with the procedures in Appendix A
to this section. (vi) Employee notification of assessment results. (A) Within five working
days after completing an exposure assessment in accordance with paragraph
(d)(2) of this section, the employer shall individually notify each affected
employee in writing of the results of that assessment or post the results in an
appropriate location accessible to all affected employees. (B) Whenever an exposure assessment indicates that employee exposure is
above the PEL, the employer shall describe in the written notification the
corrective action being taken to reduce employee exposure to or below the PEL. (vii) Observation of monitoring. (A) Where air monitoring is
performed to comply with the requirements of this section, the employer shall
provide affected employees or their designated representatives an opportunity
to observe any monitoring of employee exposure to respirable crystalline
silica. (B) When observation of monitoring requires entry into an area where the use
of protective clothing or equipment is required for any workplace hazard, the
employer shall provide the observer with protective clothing and equipment at
no cost and shall ensure that the observer uses such clothing and equipment. (3) Methods of compliance— (i) Engineering and work practice
controls. The employer shall use engineering and work practice controls to
reduce and maintain employee exposure to respirable crystalline silica to or
below the PEL, unless the employer can demonstrate that such controls are not
feasible. Wherever such feasible engineering and work practice controls are not
sufficient to reduce employee exposure to or below the PEL, the employer shall
nonetheless use them to reduce employee exposure to the lowest feasible level
and shall supplement them with the use of respiratory protection that complies
with the requirements of paragraph (e) of this section. (ii) Abrasive blasting. In addition to the requirements of paragraph (d)(3)(i) of this section, the employer shall comply with other OSHA standards, when applicable, such as 29 CFR 1926.57 (Ventilation), where abrasive blasting is conducted using crystalline silica-containing blasting agents, or where abrasive blasting is conducted on substrates that contain crystalline silica. (e) Respiratory protection— (1) General. Where respiratory
protection is required by this section, the employer must provide each employee
an appropriate respirator that complies with the requirements of this paragraph
and 29
CFR 1910.134. Respiratory protection is required: (i) Where specified by Table 1 of paragraph (c) of this section; or (ii) For tasks not listed in Table 1, or where the employer does not fully
and properly implement the engineering controls, work practices, and
respiratory protection described in Table 1: (A) Where exposures exceed the PEL during periods necessary to install or
implement feasible engineering and work practice controls; (B) Where exposures exceed the PEL during tasks, such as certain maintenance
and repair tasks, for which engineering and work practice controls are not
feasible; and (C) During tasks for which an employer has implemented all feasible
engineering and work practice controls and such controls are not sufficient to
reduce exposures to or below the PEL. (2) Respiratory protection program. Where respirator use is required
by this section, the employer shall institute a respiratory protection program
in accordance with 29
CFR 1910.134. (3) Specified exposure control methods. For the tasks listed in Table 1 in paragraph (c) of this section, if the employer fully and properly implements the engineering controls, work practices, and respiratory protection described in Table 1, the employer shall be considered to be in compliance with paragraph (e)(1) of this section and the requirements for selection of respirators in 29 CFR 1910.134(d)(1)(iii) and (d)(3) with regard to exposure to respirable crystalline silica. (f) Housekeeping. (1) The employer shall not allow dry sweeping or
dry brushing where such activity could contribute to employee exposure to
respirable crystalline silica unless wet sweeping, HEPA-filtered vacuuming or
other methods that minimize the likelihood of exposure are not feasible. (2) The employer shall not allow compressed air to be used to clean clothing
or surfaces where such activity could contribute to employee exposure to
respirable crystalline silica unless: (i) The compressed air is used in conjunction with a ventilation system that
effectively captures the dust cloud created by the compressed air; or (ii) No alternative method is feasible. (g) Written exposure control plan. (1) The employer shall establish
and implement a written exposure control plan that contains at least the
following elements: (i) A description of the tasks in the workplace that involve exposure to
respirable crystalline silica; (ii) A description of the engineering controls, work practices, and
respiratory protection used to limit employee exposure to respirable
crystalline silica for each task; (iii) A description of the housekeeping measures used to limit employee
exposure to respirable crystalline silica; and (iv) A description of the procedures used to restrict access to work areas,
when necessary, to minimize the number of employees exposed to respirable
crystalline silica and their level of exposure, including exposures generated
by other employers or sole proprietors. (2) The employer shall review and evaluate the effectiveness of the written
exposure control plan at least annually and update it as necessary. (3) The employer shall make the written exposure control plan readily
available for examination and copying, upon request, to each employee covered
by this section, their designated representatives, the Assistant Secretary and
the Director. (4) The employer shall designate a competent person to make frequent and regular inspections of job sites, materials, and equipment to implement the written exposure control plan. (h) Medical surveillance— (1) General. (i) The employer shall
make medical surveillance available at no cost to the employee, and at a
reasonable time and place, for each employee who will be required under this
section to use a respirator for 30 or more days per year. (ii) The employer shall ensure that all medical examinations and procedures
required by this section are performed by a PLHCP as defined in paragraph (b)
of this section. (2) Initial examination. The employer shall make available an initial
(baseline) medical examination within 30 days after initial assignment, unless
the employee has received a medical examination that meets the requirements of
this section within the last three years. The examination shall consist of: (i) A medical and work history, with emphasis on: Past, present, and
anticipated exposure to respirable crystalline silica, dust, and other agents
affecting the respiratory system; any history of respiratory system
dysfunction, including signs and symptoms of respiratory disease (e.g.,
shortness of breath, cough, wheezing); history of tuberculosis; and smoking
status and history; (ii) A physical examination with special emphasis on the respiratory system; (iii) A chest X-ray (a single posteroanterior radiographic projection or
radiograph of the chest at full inspiration recorded on either film (no less
than 14 x 17 inches and no more than 16 x 17 inches) or digital radiography
systems), interpreted and classified according to the International Labour
Office (ILO) International Classification of Radiographs of Pneumoconioses by a
NIOSH-certified B Reader; (iv) A pulmonary function test to include forced vital capacity (FVC) and
forced expiratory volume in one second (FEV 1) and FEV 1/FVC
ratio, administered by a spirometry technician with a current certificate from
a NIOSH-approved spirometry course; (v) Testing for latent tuberculosis infection; and (vi) Any other tests deemed appropriate by the PLHCP. (3) Periodic examinations. The employer shall make available medical
examinations that include the procedures described in paragraph (h)(2) of this
section (except paragraph (h)(2)(v)) at least every three years, or more
frequently if recommended by the PLHCP. (4) Information provided to the PLHCP. The employer shall ensure that
the examining PLHCP has a copy of this standard, and shall provide the PLHCP
with the following information: (i) A description of the employee's former, current, and anticipated duties
as they relate to the employee's occupational exposure to respirable
crystalline silica; (ii) The employee's former, current, and anticipated levels of occupational
exposure to respirable crystalline silica; (iii) A description of any personal protective equipment used or to be used
by the employee, including when and for how long the employee has used or will
use that equipment; and (iv) Information from records of employment-related medical examinations
previously provided to the employee and currently within the control of the
employer. (5) PLHCP's written medical report for the employee. The employer
shall ensure that the PLHCP explains to the employee the results of the medical
examination and provides each employee with a written medical report within 30 days
of each medical examination performed. The written report shall contain: (i) A statement indicating the results of the medical examination, including
any medical condition(s) that would place the employee at increased risk of
material impairment to health from exposure to respirable crystalline silica
and any medical conditions that require further evaluation or treatment; (ii) Any recommended limitations on the employee's use of respirators; (iii) Any recommended limitations on the employee's exposure to respirable
crystalline silica; and (iv) A statement that the employee should be examined by a specialist
(pursuant to paragraph (h)(7) of this section) if the chest X-ray provided in
accordance with this section is classified as 1/0 or higher by the B Reader, or
if referral to a specialist is otherwise deemed appropriate by the PLHCP. (6) PLHCP's written medical opinion for the employer. (i) The
employer shall obtain a written medical opinion from the PLHCP within 30 days
of the medical examination. The written opinion shall contain only the
following: (A) The date of the examination; (B) A statement that the examination has met the requirements of this
section; and (C) Any recommended limitations on the employee's use of respirators. (ii) If the employee provides written authorization, the written opinion
shall also contain either or both of the following: (A) Any recommended limitations on the employee's exposure to respirable
crystalline silica; (B) A statement that the employee should be examined by a specialist
(pursuant to paragraph (h)(7) of this section) if the chest X-ray provided in
accordance with this section is classified as 1/0 or higher by the B Reader, or
if referral to a specialist is otherwise deemed appropriate by the PLHCP. (iii) The employer shall ensure that each employee receives a copy of the
written medical opinion described in paragraph (h)(6)(i) and (ii) of this
section within 30 days of each medical examination performed. (7) Additional examinations. (i) If the PLHCP's written medical
opinion indicates that an employee should be examined by a specialist, the
employer shall make available a medical examination by a specialist within 30
days after receiving the PLHCP's written opinion. (ii) The employer shall ensure that the examining specialist is provided
with all of the information that the employer is obligated to provide to the
PLHCP in accordance with paragraph (h)(4) of this section. (iii) The employer shall ensure that the specialist explains to the employee
the results of the medical examination and provides each employee with a
written medical report within 30 days of the examination. The written report
shall meet the requirements of paragraph (h)(5) (except paragraph (h)(5)(iv))
of this section. (iv) The employer shall obtain a written opinion from the specialist within 30 days of the medical examination. The written opinion shall meet the requirements of paragraph (h)(6) (except paragraph (h)(6)(i)(B) and (ii)(B)) of this section. (i) Communication of respirable crystalline silica hazards to employees—
(1) Hazard communication. The employer shall include respirable
crystalline silica in the program established to comply with the hazard
communication standard (HCS) (29
CFR 1910.1200). The employer shall ensure that each employee has
access to labels on containers of crystalline silica and safety data sheets,
and is trained in accordance with the provisions of HCS and paragraph (i)(2) of
this section. The employer shall ensure that at least the following hazards are
addressed: Cancer, lung effects, immune system effects, and kidney effects. (2) Employee information and training. (i) The employer shall ensure
that each employee covered by this section can demonstrate knowledge and
understanding of at least the following: (A) The health hazards associated with exposure to respirable crystalline
silica; (B) Specific tasks in the workplace that could result in exposure to
respirable crystalline silica; (C) Specific measures the employer has implemented to protect employees from
exposure to respirable crystalline silica, including engineering controls, work
practices, and respirators to be used; (D) The contents of this section; (E) The identity of the competent person designated by the employer in
accordance with paragraph (g)(4) of this section; and (F) The purpose and a description of the medical surveillance program
required by paragraph (h) of this section. (ii) The employer shall make a copy of this section readily available without cost to each employee covered by this section. (j) Recordkeeping— (1) Air monitoring data. (i) The employer
shall make and maintain an accurate record of all exposure measurements taken
to assess employee exposure to respirable crystalline silica, as prescribed in
paragraph (d)(2) of this section. (ii) This record shall include at least the following information: (A) The date of measurement for each sample taken; (B) The task monitored; (C) Sampling and analytical methods used; (D) Number, duration, and results of samples taken; (E) Identity of the laboratory that performed the analysis; (F) Type of personal protective equipment, such as respirators, worn by the
employees monitored; and (G) Name, social security number, and job classification of all employees
represented by the monitoring, indicating which employees were actually
monitored. (iii) The employer shall ensure that exposure records are maintained and
made available in accordance with 29
CFR 1910.1020. (2) Objective data. (i) The employer shall make and maintain an
accurate record of all objective data relied upon to comply with the
requirements of this section. (ii) This record shall include at least the following information: (A) The crystalline silica-containing material in question; (B) The source of the objective data; (C) The testing protocol and results of testing; (D) A description of the process, task, or activity on which the objective
data were based; and (E) Other data relevant to the process, task, activity, material, or
exposures on which the objective data were based. (iii) The employer shall ensure that objective data are maintained and made
available in accordance with 29
CFR 1910.1020. (3) Medical surveillance. (i) The employer shall make and maintain an
accurate record for each employee covered by medical surveillance under
paragraph (h) of this section. (ii) The record shall include the following information about the employee: (A) Name and social security number; (B) A copy of the PLHCPs' and specialists' written medical opinions; and (C) A copy of the information provided to the PLHCPs and specialists. (iii) The employer shall ensure that medical records are maintained and made available in accordance with 29 CFR 1910.1020. (k)Dates. (1) This section shall become effective June 23, 2016. (2) All obligations of this section, except requirements for methods of
sample analysis in paragraph (d)(2)(v), shall commence June 23, 2017. (3) Requirements for methods of sample analysis in paragraph (d)(2)(v) of this section commence June 23, 2018. (Top)Appendix A to § 1926.1153—Methods of Sample Analysis
This This appendix specifies the procedures for analyzing air samples for
respirable crystalline silica, as well as the quality control procedures that
employers must ensure that laboratories use when performing an analysis
required under 29
CFR 1926.1153 (d)(2)(v). Employers must ensure that such a
laboratory: 1. Evaluates all samples using the procedures specified in one of the
following analytical methods: OSHA ID-142; NMAM 7500; NMAM 7602; NMAM 7603;
MSHA P-2; or MSHA P-7; 2. Is accredited to ANS/ISO/IEC Standard 17025:2005 with respect to
crystalline silica analyses by a body that is compliant with ISO/IEC Standard
17011:2004 for implementation of quality assessment programs; 3. Uses the most current National Institute of Standards and Technology
(NIST) or NIST traceable standards for instrument calibration or instrument
calibration verification; 4. Implements an internal quality control (QC) program that evaluates
analytical uncertainty and provides employers with estimates of sampling and
analytical error; 5. Characterizes the sample material by identifying polymorphs of respirable
crystalline silica present, identifies the presence of any interfering
compounds that might affect the analysis, and makes any corrections necessary
in order to obtain accurate sample analysis; and 6. Analyzes quantitatively for crystalline silica only after confirming that
the sample matrix is free of uncorrectable analytical interferences, corrects
for analytical interferences, and uses a method that meets the following
performance specifications: 6.1 Each day that samples are analyzed, performs instrument
calibration checks with standards that bracket the sample concentrations; 6.2 Uses five or more calibration standard levels to prepare
calibration curves and ensures that standards are distributed through the
calibration range in a manner that accurately reflects the underlying
calibration curve; and 6.3 Optimizes methods and instruments to obtain a quantitative limit of detection that represents a value no higher than 25 percent of the PEL based on sample air volume. Appendix B to § 1926.1153—Medical Surveillance Guidelines
Introduction
The purpose of this Appendix is to provide medical information and
recommendations to aid physicians and other licensed health care professionals
(PLHCPs) regarding compliance with the medical surveillance provisions of the
respirable crystalline silica standard (29
CFR 1926.1153). Appendix B is for informational and guidance
purposes only and none of the statements in Appendix B should be construed as
imposing a mandatory requirement on employers that is not otherwise imposed by
the standard. Medical screening and surveillance allow for early identification of
exposure-related health effects in individual employee and groups of employees,
so that actions can be taken to both avoid further exposure and prevent or
address adverse health outcomes. Silica-related diseases can be fatal,
encompass a variety of target organs, and may have public health consequences
when considering the increased risk of a latent tuberculosis (TB) infection
becoming active. Thus, medical surveillance of silica-exposed employees
requires that PLHCPs have a thorough knowledge of silica-related health
effects. This Appendix is divided into seven sections. Section 1 reviews
silica-related diseases, medical responses, and public health responses.
Section 2 outlines the components of the medical surveillance program for
employees exposed to silica. Section 3 describes the roles and responsibilities
of the PLHCP implementing the program and of other medical specialists and
public health professionals. Section 4 provides a discussion of considerations,
including confidentiality. Section 5 provides a list of additional resources
and Section 6 lists references. Section 7 provides sample forms for the written
medical report for the employee, the written medical opinion for the employer
and the written authorization. Recognition of Silica-Related Diseases
1.1. Overview. The term “silica” refers specifically to the compound
silicon dioxide (SiO 2). Silica is a major component of sand, rock,
and mineral ores. Exposure to fine (respirable size) particles of crystalline
forms of silica is associated with adverse health effects, such as silicosis,
lung cancer, chronic obstructive pulmonary disease (COPD), and activation of
latent TB infections. Exposure to respirable crystalline silica can occur in
industry settings such as foundries, abrasive blasting operations, paint
manufacturing, glass and concrete product manufacturing, brick making, china
and pottery manufacturing, manufacturing of plumbing fixtures, and many
construction activities including highway repair, masonry, concrete work, rock
drilling, and tuck-pointing. New uses of silica continue to emerge. These
include countertop manufacturing, finishing, and installation (Kramer et al.
2012; OSHA 2015) and hydraulic fracturing in the oil and gas industry (OSHA
2012). Silicosis is an irreversible, often disabling, and sometimes fatal fibrotic
lung disease. Progression of silicosis can occur despite removal from further
exposure. Diagnosis of silicosis requires a history of exposure to silica and
radiologic findings characteristic of silica exposure. Three different
presentations of silicosis (chronic, accelerated, and acute) have been defined.
Accelerated and acute silicosis are much less common than chronic silicosis.
However, it is critical to recognize all cases of accelerated and acute
silicosis because these are life-threatening illnesses and because they are
caused by substantial overexposures to respirable crystalline silica. Although
any case of silicosis indicates a breakdown in prevention, a case of acute or
accelerated silicosis implies current high exposure and a very marked breakdown
in prevention. In addition to silicosis, employees exposed to respirable crystalline
silica, especially those with accelerated or acute silicosis, are at increased
risks of contracting active TB and other infections (ATS 1997; Rees and Murray
2007). Exposure to respirable crystalline silica also increases an employee's
risk of developing lung cancer, and the higher the cumulative exposure, the
higher the risk (Steenland et al. 2001; Steenland and Ward 2014).
Symptoms for these diseases and other respirable crystalline silica-related
diseases are discussed below. 1.2. Chronic Silicosis. Chronic silicosis is the most common
presentation of silicosis and usually occurs after at least 10 years of
exposure to respirable crystalline silica. The clinical presentation of chronic
silicosis is: 1.2.1. Symptoms—shortness of breath and cough, although employees may not
notice any symptoms early in the disease. Constitutional symptoms, such as
fever, loss of appetite and fatigue, may indicate other diseases associated
with silica exposure, such as TB infection or lung cancer. Employees with these
symptoms should immediately receive further evaluation and treatment. 1.2.2. Physical Examination—may be normal or disclose dry rales or rhonchi
on lung auscultation. 1.2.3. Spirometry—may be normal or may show only a mild restrictive or
obstructive pattern. 1.2.4. Chest X-ray—classic findings are small, rounded opacities in the
upper lung fields bilaterally. However, small irregular opacities and opacities
in other lung areas can also occur. Rarely, “eggshell calcifications” in the
hilar and mediastinal lymph nodes are seen. 1.2.5. Clinical Course—chronic silicosis in most cases is a slowly
progressive disease. Under the respirable crystalline silica standard, the
PLHCP is to recommend that employees with a 1/0 category X-ray be referred to
an American Board Certified Specialist in Pulmonary Disease or Occupational
Medicine. The PLHCP and/or Specialist should counsel employees regarding work
practices and personal habits that could affect employees' respiratory health. 1.3. Accelerated Silicosis. Accelerated silicosis generally occurs
within 5-10 years of exposure and results from high levels of exposure to
respirable crystalline silica. The clinical presentation of accelerated
silicosis is: 1.3.1. Symptoms—shortness of breath, cough, and sometimes sputum production.
Employees with exposure to respirable crystalline silica, and especially those
with accelerated silicosis, are at high risk for activation of TB infections,
atypical mycobacterial infections, and fungal superinfections. Constitutional
symptoms, such as fever, weight loss, hemoptysis (coughing up blood), and
fatigue may herald one of these infections or the onset of lung cancer. 1.3.2. Physical Examination—rales, rhonchi, or other abnormal lung findings
in relation to illnesses present. Clubbing of the digits, signs of heart
failure, and cor pulmonale may be present in severe lung disease. 1.3.3. Spirometry—restrictive or mixed restrictive/obstructive pattern. 1.3.4. Chest X-ray—small rounded and/or irregular opacities bilaterally.
Large opacities and lung abscesses may indicate infections, lung cancer, or
progression to complicated silicosis, also termed progressive massive fibrosis. 1.3.5. Clinical Course—accelerated silicosis has a rapid, severe course.
Under the respirable crystalline silica standard, the PLHCP can recommend
referral to a Board Certified Specialist in either Pulmonary Disease or
Occupational Medicine, as deemed appropriate, and referral to a Specialist is
recommended whenever the diagnosis of accelerated silicosis is being
considered. 1.4. Acute Silicosis. Acute silicosis is a rare disease caused by
inhalation of extremely high levels of respirable crystalline silica particles.
The pathology is similar to alveolar proteinosis with lipoproteinaceous
material accumulating in the alveoli. Acute silicosis develops rapidly, often,
within a few months to less than 2 years of exposure, and is almost always
fatal. The clinical presentation of acute silicosis is as follows: 1.4.1. Symptoms—sudden, progressive, and severe shortness of breath.
Constitutional symptoms are frequently present and include fever, weight loss,
fatigue, productive cough, hemoptysis (coughing up blood), and pleuritic chest
pain. 1.4.2. Physical Examination—dyspnea at rest, cyanosis, decreased breath
sounds, inspiratory rales, clubbing of the digits, and fever. 1.4.3. Spirometry—restrictive or mixed restrictive/obstructive pattern. 1.4.4. Chest X-ray—diffuse haziness of the lungs bilaterally early in the
disease. As the disease progresses, the “ground glass” appearance of
interstitial fibrosis will appear. 1.4.5. Clinical Course—employees with acute silicosis are at especially high
risk of TB activation, nontuberculous mycobacterial infections, and fungal
superinfections. Acute silicosis is immediately life-threatening. The employee
should be urgently referred to a Board Certified Specialist in Pulmonary
Disease or Occupational Medicine for evaluation and treatment. Although any
case of silicosis indicates a breakdown in prevention, a case of acute or
accelerated silicosis implies a profoundly high level of silica exposure and
may mean that other employees are currently exposed to dangerous levels of
silica. 1.5. COPD. COPD, including chronic bronchitis and emphysema, has been
documented in silica-exposed employees, including those who do not develop
silicosis. Periodic spirometry tests are performed to evaluate each employee
for progressive changes consistent with the development of COPD. In addition to
evaluating spirometry results of individual employees over time, PLHCPs may
want to be aware of general trends in spirometry results for groups of
employees from the same workplace to identify possible problems that might
exist at that workplace. (See Section 2 of this Appendix on Medical
Surveillance for further discussion.) Heart disease may develop secondary to
lung diseases such as COPD. A recent study by Liu et al. 2014 noted a
significant exposure-response trend between cumulative silica exposure and
heart disease deaths, primarily due to pulmonary heart disease, such as cor
pulmonale. 1.6. Renal and Immune System. Silica exposure has been associated
with several types of kidney disease, including glomerulonephritis, nephrotic
syndrome, and end stage renal disease requiring dialysis. Silica exposure has
also been associated with other autoimmune conditions, including progressive
systemic sclerosis, systemic lupus erythematosus, and rheumatoid arthritis.
Studies note an association between employees with silicosis and serologic
markers for autoimmune diseases, including antinuclear antibodies, rheumatoid
factor, and immune complexes (Jalloul and Banks 2007; Shtraichman et al.
2015). 1.7. TB and Other Infections. Silica-exposed employees with latent TB
are 3 to 30 times more likely to develop active pulmonary TB infection (ATS
1997; Rees and Murray 2007). Although respirable crystalline silica exposure
does not cause TB infection, individuals with latent TB infection are at
increased risk for activation of disease if they have higher levels of
respirable crystalline silica exposure, greater profusion of radiographic
abnormalities, or a diagnosis of silicosis. Demographic characteristics, such
as immigration from some countries, are associated with increased rates of
latent TB infection. PLHCPs can review the latest Centers for Disease Control
and Prevention (CDC) information on TB incidence rates and high risk
populations online (See Section 5 of this Appendix). Additionally,
silica-exposed employees are at increased risk for contracting nontuberculous
mycobacterial infections, including Mycobacterium avium-intracellulare
and Mycobacterium kansaii. 1.8. Lung Cancer. The National Toxicology Program has listed
respirable crystalline silica as a known human carcinogen since 2000 (NTP
2014). The International Agency for Research on Cancer (2012) has also
classified silica as Group 1 (carcinogenic to humans). Several studies have
indicated that the risk of lung cancer from exposure to respirable crystalline
silica and smoking is greater than additive (Brown 2009; Liu et al.
2013). Employees should be counseled on smoking cessation. Medical Surveillance
PLHCPs who manage silica medical surveillance programs should have a
thorough understanding of the many silica-related diseases and health effects
outlined in Section 1 of this Appendix. At each clinical encounter, the PLHCP
should consider silica-related health outcomes, with particular vigilance for
acute and accelerated silicosis. In this Section, the required components of
medical surveillance under the respirable crystalline silica standard are
reviewed, along with additional guidance and recommendations for PLHCPs
performing medical surveillance examinations for silica-exposed employees. 2.1. History. 2.1.1. The respirable crystalline silica standard requires the following: A
medical and work history, with emphasis on: Past, present, and anticipated
exposure to respirable crystalline silica, dust, and other agents affecting the
respiratory system; any history of respiratory system dysfunction, including
signs and symptoms of respiratory disease (e.g., shortness of breath,
cough, wheezing); history of TB; and smoking status and history. 2.1.2. Further, the employer must provide the PLHCP with the following
information: 2.1.2.1. A description of the employee's former, current, and anticipated
duties as they relate to the employee's occupational exposure to respirable
crystalline silica; 2.1.2.2. The employee's former, current, and anticipated levels of
occupational exposure to respirable crystalline silica; 2.1.2.3. A description of any personal protective equipment used or to be
used by the employee, including when and for how long the employee has used or
will use that equipment; and 2.1.2.4. Information from records of employment-related medical examinations
previously provided to the employee and currently within the control of the
employer. 2.1.3. Additional guidance and recommendations: A history is particularly
important both in the initial evaluation and in periodic examinations.
Information on past and current medical conditions (particularly a history of
kidney disease, cardiac disease, connective tissue disease, and other immune
diseases), medications, hospitalizations and surgeries may uncover health
risks, such as immune suppression, that could put an employee at increased
health risk from exposure to silica. This information is important when
counseling the employee on risks and safe work practices related to silica
exposure. 2.2. Physical Examination. 2.2.1. The respirable crystalline silica standard requires the following: A
physical examination, with special emphasis on the respiratory system. The
physical examination must be performed at the initial examination and every
three years thereafter. 2.2.2. Additional guidance and recommendations: Elements of the physical
examination that can assist the PHLCP include: An examination of the cardiac
system, an extremity examination (for clubbing, cyanosis, edema, or joint
abnormalities), and an examination of other pertinent organ systems identified
during the history. 2.3. TB Testing. 2.3.1. The respirable crystalline silica standard requires the following:
Baseline testing for TB on initial examination. 2.3.2. Additional guidance and recommendations: 2.3.2.1. Current CDC guidelines (See Section 5 of this Appendix)
should be followed for the application and interpretation of Tuberculin skin
tests (TST). The interpretation and documentation of TST reactions should be
performed within 48 to 72 hours of administration by trained PLHCPs. 2.3.2.2. PLHCPs may use alternative TB tests, such as interferon-γ release
assays (IGRAs), if sensitivity and specificity are comparable to TST (Mazurek et
al. 2010; Slater et al. 2013). PLHCPs can consult the current CDC
guidelines for acceptable tests for latent TB infection. 2.3.2.3. The silica standard allows the PLHCP to order additional tests or
test at a greater frequency than required by the standard, if deemed
appropriate. Therefore, PLHCPs might perform periodic (e.g., annual) TB
testing as appropriate, based on employees' risk factors. For example,
according to the American Thoracic Society (ATS), the diagnosis of silicosis or
exposure to silica for 25 years or more are indications for annual TB testing
(ATS 1997). PLHCPs should consult the current CDC guidance on risk factors for
TB (See Section 5 of this Appendix). 2.3.2.4. Employees with positive TB tests and those with indeterminate test
results should be referred to the appropriate agency or specialist, depending
on the test results and clinical picture. Agencies, such as local public health
departments, or specialists, such as a pulmonary or infectious disease
specialist, may be the appropriate referral. Active TB is a nationally
notifiable disease. PLHCPs should be aware of the reporting requirements for
their region. All States have TB Control Offices that can be contacted for
further information. (See Section 5 of this Appendix for links to CDC's
TB resources and State TB Control Offices.) 2.3.2.5. The following public health principles are key to TB control in the
U.S. (ATS-CDC-IDSA 2005): (1) Prompt detection and reporting of persons who have contracted
active TB; (2) Prevention of TB spread to close contacts of active TB cases; (3) Prevention of active TB in people with latent TB through targeted
testing and treatment; and (4) Identification of settings at high risk for TB transmission so
that appropriate infection-control measures can be implemented. 2.4. Pulmonary Function Testing. 2.4.1. The respirable crystalline silica standard requires the following:
Pulmonary function testing must be performed on the initial examination and
every three years thereafter. The required pulmonary function test is
spirometry and must include forced vital capacity (FVC), forced expiratory
volume in one second (FEV 1), and FEV 1/FVC ratio.
Testing must be administered by a spirometry technician with a current
certificate from a National Institute for Occupational Health and Safety
(NIOSH)-approved spirometry course. 2.4.2. Additional guidance and recommendations: Spirometry provides
information about individual respiratory status and can be used to track an
employee's respiratory status over time or as a surveillance tool to follow
individual and group respiratory function. For quality results, the ATS and the
American College of Occupational and Environmental Medicine (ACOEM) recommend
use of the third National Health and Nutrition Examination Survey (NHANES III)
values, and ATS publishes recommendations for spirometry equipment (Miller et
al. 2005; Townsend 2011; Redlich et al. 2014). OSHA's publication, Spirometry
Testing in Occupational Health Programs: Best Practices for Healthcare Professionals,
provides helpful guidance (See Section 5 of this Appendix). Abnormal
spirometry results may warrant further clinical evaluation and possible
recommendations for limitations on the employee's exposure to respirable
crystalline silica. 2.5. Chest X-ray. 2.5.1. The respirable crystalline silica standard requires the following: A
single posteroanterior (PA) radiographic projection or radiograph of the chest
at full inspiration recorded on either film (no less than 14 x 17 inches and no
more than 16 x 17 inches) or digital radiography systems. A chest X-ray must be
performed on the initial examination and every three years thereafter. The
chest X-ray must be interpreted and classified according to the International
Labour Office (ILO) International Classification of Radiographs of
Pneumoconioses by a NIOSH-certified B Reader. Chest radiography is necessary to diagnose silicosis, monitor the
progression of silicosis, and identify associated conditions such as TB. If the
B reading indicates small opacities in a profusion of 1/0 or higher, the
employee is to receive a recommendation for referral to a Board Certified
Specialist in Pulmonary Disease or Occupational Medicine. 2.5.2. Additional guidance and recommendations: Medical imaging has largely
transitioned from conventional film-based radiography to digital radiography
systems. The ILO Guidelines for the Classification of Pneumoconioses has
historically provided film-based chest radiography as a referent standard for
comparison to individual exams. However, in 2011, the ILO revised the
guidelines to include a digital set of referent standards that were derived
from the prior film-based standards. To assist in assuring that
digitally-acquired radiographs are at least as safe and effective as film radiographs,
NIOSH has prepared guidelines, based upon accepted contemporary professional
recommendations (See Section 5 of this Appendix). Current research from
Laney et al. 2011 and Halldin et al. 2014 validate the use of the
ILO digital referent images. Both studies conclude that the results of
pneumoconiosis classification using digital references are comparable to
film-based ILO classifications. Current ILO guidance on radiography for
pneumoconioses and B-reading should be reviewed by the PLHCP periodically, as
needed, on the ILO or NIOSH Web sites (See Section 5 of this Appendix). 2.6. Other Testing. Under the respirable crystalline silica
standards, the PLHCP has the option of ordering additional testing he or she
deems appropriate. Additional tests can be ordered on a case-by-case basis
depending on individual signs or symptoms and clinical judgment. For example,
if an employee reports a history of abnormal kidney function tests, the PLHCP
may want to order a baseline renal function tests (e.g., serum creatinine
and urinalysis). As indicated above, the PLHCP may order annual TB testing for
silica-exposed employees who are at high risk of developing active TB
infections. Additional tests that PLHCPs may order based on findings of medical
examinations include, but is not limited to, chest computerized tomography (CT)
scan for lung cancer or COPD, testing for immunologic diseases, and cardiac
testing for pulmonary-related heart disease, such as cor pulmonale. Roles and Responsibilities
3.1. PLHCP. The PLHCP designation refers to “an individual whose
legally permitted scope of practice (i.e., license, registration, or
certification) allows him or her to independently provide or be delegated the
responsibility to provide some or all of the particular health care services
required” by the respirable crystalline silica standard. The legally permitted
scope of practice for the PLHCP is determined by each State. PLHCPs who perform
clinical services for a silica medical surveillance program should have a
thorough knowledge of respirable crystalline silica-related diseases and
symptoms. Suspected cases of silicosis, advanced COPD, or other respiratory
conditions causing impairment should be promptly referred to a Board Certified
Specialist in Pulmonary Disease or Occupational Medicine. Once the medical surveillance examination is completed, the employer must
ensure that the PLHCP explains to the employee the results of the medical
examination and provides the employee with a written medical report within 30
days of the examination. The written medical report must contain a statement
indicating the results of the medical examination, including any medical
condition(s) that would place the employee at increased risk of material
impairment to health from exposure to respirable crystalline silica and any
medical conditions that require further evaluation or treatment. In addition,
the PLHCP's written medical report must include any recommended limitations on
the employee's use of respirators, any recommended limitations on the
employee's exposure to respirable crystalline silica, and a statement that the
employee should be examined by a Board Certified Specialist in Pulmonary
Disease or Occupational medicine if the chest X-ray is classified as 1/0 or
higher by the B Reader, or if referral to a Specialist is otherwise deemed
appropriate by the PLHCP. The PLHCP should discuss all findings and test results and any
recommendations regarding the employee's health, worksite safety and health
practices, and medical referrals for further evaluation, if indicated. In
addition, it is suggested that the PLHCP offer to provide the employee with a
complete copy of their examination and test results, as some employees may want
this information for their own records or to provide to their personal
physician or a future PLHCP. Employees are entitled to access their medical
records. Under the respirable crystalline silica standard, the employer must ensure
that the PLHCP provides the employer with a written medical opinion within 30
days of the employee examination, and that the employee also gets a copy of the
written medical opinion for the employer within 30 days. The PLHCP may choose
to directly provide the employee a copy of the written medical opinion. This
can be particularly helpful to employees, such as construction employees, who
may change employers frequently. The written medical opinion can be used by the
employee as proof of up-to-date medical surveillance. The following lists the
elements of the written medical report for the employee and written medical
opinion for the employer. (Sample forms for the written medical report for the
employee, the written medical opinion for the employer, and the written
authorization are provided in Section 7 of this Appendix.) 3.1.1. The written medical report for the employee must include the
following information: 3.1.1.1. A statement indicating the results of the medical examination,
including any medical condition(s) that would place the employee at increased
risk of material impairment to health from exposure to respirable crystalline
silica and any medical conditions that require further evaluation or treatment; 3.1.1.2. Any recommended limitations upon the employee's use of a
respirator; 3.1.1.3. Any recommended limitations on the employee's exposure to
respirable crystalline silica; and 3.1.1.4. A statement that the employee should be examined by a Board
Certified Specialist in Pulmonary Disease or Occupational Medicine, where the
standard requires or where the PLHCP has determined such a referral is
necessary. The standard requires referral to a Board Certified Specialist in
Pulmonary Disease or Occupational Medicine for a chest X-ray B reading
indicating small opacities in a profusion of 1/0 or higher, or if the PHLCP
determines that referral to a Specialist is necessary for other silica-related
findings. 3.1.2. The PLHCP's written medical opinion for the employer must include
only the following information: 3.1.2.1. The date of the examination; 3.1.2.2. A statement that the examination has met the requirements of this
section; and 3.1.2.3. Any recommended limitations on the employee's use of respirators. 3.1.2.4. If the employee provides the PLHCP with written authorization, the
written opinion for the employer shall also contain either or both of the
following: (1) Any recommended limitations on the employee's exposure to
respirable crystalline silica; and (2) A statement that the employee should be examined by a Board
Certified Specialist in Pulmonary Disease or Occupational Medicine if the chest
X-ray provided in accordance with this section is classified as 1/0 or higher
by the B Reader, or if referral to a Specialist is otherwise deemed
appropriate. 3.1.2.5. In addition to the above referral for abnormal chest X-ray, the
PLHCP may refer an employee to a Board Certified Specialist in Pulmonary
Disease or Occupational Medicine for other findings of concern during the
medical surveillance examination if these findings are potentially related to
silica exposure. 3.1.2.6. Although the respirable crystalline silica standard requires the
employer to ensure that the PLHCP explains the results of the medical
examination to the employee, the standard does not mandate how this should be
done. The written medical opinion for the employer could contain a statement
that the PLHCP has explained the results of the medical examination to the
employee. 3.2. Medical Specialists. The silica standard requires that all
employees with chest X-ray B readings of 1/0 or higher be referred to a Board
Certified Specialist in Pulmonary Disease or Occupational Medicine. If the
employee has given written authorization for the employer to be informed, then
the employer shall make available a medical examination by a Specialist within
30 days after receiving the PLHCP's written medical opinion. 3.2.1. The employer must provide the following information to the Board
Certified Specialist in Pulmonary Disease or Occupational Medicine: 3.2.1.1. A description of the employee's former, current, and anticipated
duties as they relate to the employee's occupational exposure to respirable
crystalline silica; 3.2.1.2. The employee's former, current, and anticipated levels of
occupational exposure to respirable crystalline silica; 3.2.1.3. A description of any personal protective equipment used or to be
used by the employee, including when and for how long the employee has used or
will use that equipment; and 3.2.1.4. Information from records of employment-related medical examinations
previously provided to the employee and currently within the control of the
employer. 3.2.2. The PLHCP should make certain that, with written authorization from
the employee, the Board Certified Specialist in Pulmonary Disease or
Occupational Medicine has any other pertinent medical and occupational
information necessary for the specialist's evaluation of the employee's
condition. 3.2.3. Once the Board Certified Specialist in Pulmonary Disease or
Occupational Medicine has evaluated the employee, the employer must ensure that
the Specialist explains to the employee the results of the medical examination
and provides the employee with a written medical report within 30 days of the
examination. The employer must also ensure that the Specialist provides the
employer with a written medical opinion within 30 days of the employee
examination. (Sample forms for the written medical report for the employee, the
written medical opinion for the employer and the written authorization are
provided in Section 7 of this Appendix.) 3.2.4. The Specialist's written medical report for the employee must include
the following information: 3.2.4.1. A statement indicating the results of the medical examination,
including any medical condition(s) that would place the employee at increased
risk of material impairment to health from exposure to respirable crystalline
silica and any medical conditions that require further evaluation or treatment; 3.2.4.2. Any recommended limitations upon the employee's use of a
respirator; and 3.2.4.3. Any recommended limitations on the employee's exposure to
respirable crystalline silica. 3.2.5. The Specialist's written medical opinion for the employer must
include the following information: 3.2.5.1. The date of the examination; and 3.2.5.2. Any recommended limitations on the employee's use of respirators. 3.2.5.3. If the employee provides the Board Certified Specialist in
Pulmonary Disease or Occupational Medicine with written authorization, the
written medical opinion for the employer shall also contain any recommended
limitations on the employee's exposure to respirable crystalline silica. 3.2.5.4. Although the respirable crystalline silica standard requires the
employer to ensure that the Board Certified Specialist in Pulmonary Disease or
Occupational Medicine explains the results of the medical examination to the
employee, the standard does not mandate how this should be done. The written
medical opinion for the employer could contain a statement that the Specialist
has explained the results of the medical examination to the employee. 3.2.6. After evaluating the employee, the Board Certified Specialist in
Pulmonary Disease or Occupational Medicine should provide feedback to the PLHCP
as appropriate, depending on the reason for the referral. OSHA believes that
because the PLHCP has the primary relationship with the employer and employee,
the Specialist may want to communicate his or her findings to the PLHCP and
have the PLHCP simply update the original medical report for the employee and
medical opinion for the employer. This is permitted under the standard, so long
as all requirements and time deadlines are met. 3.3. Public Health Professionals. PLHCPs might refer employees or
consult with public health professionals as a result of silica medical
surveillance. For instance, if individual cases of active TB are identified,
public health professionals from state or local health departments may assist
in diagnosis and treatment of individual cases and may evaluate other
potentially affected persons, including coworkers. Because silica-exposed
employees are at increased risk of progression from latent to active TB,
treatment of latent infection is recommended. The diagnosis of active TB, acute
or accelerated silicosis, or other silica-related diseases and infections
should serve as sentinel events suggesting high levels of exposure to silica
and may require consultation with the appropriate public health agencies to
investigate potentially similarly exposed coworkers to assess for disease
clusters. These agencies include local or state health departments or OSHA. In
addition, NIOSH can provide assistance upon request through their Health Hazard
Evaluation program. (See Section 5 of this Appendix) Confidentiality and Other Considerations
The information that is provided from the PLHCP to the employee and employer
under the medical surveillance section of OSHA's respirable crystalline silica
standard differs from that of medical surveillance requirements in previous
OSHA standards. The standard requires two separate written communications, a
written medical report for the employee and a written medical opinion for the
employer. The confidentiality requirements for the written medical opinion are
more stringent than in past standards. For example, the information the PLHCP
can (and must) include in his or her written medical opinion for the employer
is limited to: The date of the examination, a statement that the examination
has met the requirements of this section, and any recommended limitations on
the employee's use of respirators. If the employee provides written
authorization for the disclosure of any limitations on the employee's exposure
to respirable crystalline silica, then the PLHCP can (and must) include that
information in the written medical opinion for the employer as well. Likewise,
with the employee's written authorization, the PLHCP can (and must) disclose
the PLHCP's referral recommendation (if any) as part of the written medical
opinion for the employer. However, the opinion to the employer must not include
information regarding recommended limitations on the employee's exposure to
respirable crystalline silica or any referral recommendations without the
employee's written authorization. The standard also places limitations on the information that the Board
Certified Specialist in Pulmonary Disease or Occupational Medicine can provide
to the employer without the employee's written authorization. The Specialist's
written medical opinion for the employer, like the PLHCP's opinion, is limited
to (and must contain): The date of the examination and any recommended
limitations on the employee's use of respirators. If the employee provides
written authorization, the written medical opinion can (and must) also contain
any limitations on the employee's exposure to respirable crystalline silica. The PLHCP should discuss the implication of signing or not signing the
authorization with the employee (in a manner and language that he or she
understands) so that the employee can make an informed decision regarding the
written authorization and its consequences. The discussion should include the
risk of ongoing silica exposure, personal risk factors, risk of disease
progression, and possible health and economic consequences. For instance,
written authorization is required for a PLHCP to advise an employer that an
employee should be referred to a Board Certified Specialist in Pulmonary
Disease or Occupational Medicine for evaluation of an abnormal chest X-ray
(B-reading 1/0 or greater). If an employee does not sign an authorization, then
the employer will not know and cannot facilitate the referral to a Specialist
and is not required to pay for the Specialist's examination. In the rare case
where an employee is diagnosed with acute or accelerated silicosis, co-workers
are likely to be at significant risk of developing those diseases as a result
of inadequate controls in the workplace. In this case, the PLHCP and/or
Specialist should explain this concern to the affected employee and make a
determined effort to obtain written authorization from the employee so that the
PLHCP and/or Specialist can contact the employer. Finally, without written authorization from the employee, the PLHCP and/or
Board Certified Specialist in Pulmonary Disease or Occupational Medicine cannot
provide feedback to an employer regarding control of workplace silica exposure,
at least in relation to an individual employee. However, the regulation does
not prohibit a PLHCP and/or Specialist from providing an employer with general
recommendations regarding exposure controls and prevention programs in relation
to silica exposure and silica-related illnesses, based on the information that
the PLHCP receives from the employer such as employees' duties and exposure
levels. Recommendations may include increased frequency of medical surveillance
examinations, additional medical surveillance components, engineering and work
practice controls, exposure monitoring and personal protective equipment. For
instance, more frequent medical surveillance examinations may be a
recommendation to employers for employees who do abrasive blasting with silica
because of the high exposures associated with that operation. ACOEM's Code of Ethics and discussion is a good resource to guide PLHCPs
regarding the issues discussed in this section (See Section 5 of this
Appendix). Resources
5.1. American College of Occupational and Environmental Medicine (ACOEM): ACOEM Code of Ethics. Accessed at: http://www.acoem.org/codeofconduct.aspx
Raymond, L.W. and Wintermeyer, S. (2006) ACOEM evidenced-based statement on
medical surveillance of silica-exposed workers: Medical surveillance of workers
exposed to crystalline silica. J Occup Environ Med, 48, 95-101. 5.2. Center for Disease Control and Prevention (CDC) Tuberculosis Web page: http://www.cdc.gov/tb/default.htm
State TB Control Offices Web page: http://www.cdc.gov/tb/links/tboffices.htm
Tuberculosis Laws and Policies Web page: http://www.cdc.gov/tb/programs/laws/default.htm
CDC. (2013). Latent Tuberculosis Infection: A Guide for Primary Health Care
Providers. Accessed at: http://www.cdc.gov/tb/publications/ltbi/pdf/targetedltbi.pdf
5.3. International Labour Organization International Labour Office (ILO). (2011) Guidelines for the use of the ILO
International Classification of Radiographs of Pneumoconioses, Revised edition
2011. Occupational Safety and Health Series No. 22: http://www.ilo.org/safework/info/publications/WCMS_168260/lang-en/index.htm
5.4. National Institute of Occupational Safety and Health (NIOSH) NIOSH B Reader Program Web page. (Information on interpretation of X-rays
for silicosis and a list of certified B-readers). Accessed at: http://www.cdc.gov/niosh/topics/chestradiography/breader-info.html
NIOSH Guideline (2011). Application of Digital Radiography for the Detection
and Classification of Pneumoconiosis. NIOSH publication number 2011-198.
Accessed at: http://www.cdc.gov/niosh/docs/2011-198/
NIOSH Hazard Review (2002), Health Effects of Occupational Exposure to
Respirable Crystalline Silica. NIOSH publication number 2002-129: Accessed at http://www.cdc.gov/niosh/docs/2002-129/
NIOSH Health Hazard Evaluations Programs. (Information on the NIOSH Health
Hazard Evaluation (HHE) program, how to request an HHE and how to look up an
HHE report). Accessed at: http://www.cdc.gov/niosh/hhe/
5.5. National Industrial Sand Association: Occupational Health Program for Exposure to Crystalline Silica in the
Industrial Sand Industry. National Industrial Sand Association, 2nd ed. 2010.
Can be ordered at: http://www.sand.org/silica-occupational-health-program
5.6. Occupational Safety and Health Administration (OSHA) Contacting OSHA: http://www.osha.gov/html/Feed_Back.html
OSHA's Clinicians Web page. (OSHA resources, regulations and links to help
clinicians navigate OSHA's Web site and aid clinicians in caring for workers.)
Accessed at: http://www.osha.gov/dts/oom/clinicians/index.html
OSHA's Safety and Health Topics Web page on Silica. Accessed at: http://www.osha.gov/dsg/topics/silicacrystalline/index.html
OSHA (2013). Spirometry Testing in Occupational Health Programs: Best
Practices for Healthcare Professionals. (OSHA 3637-03 2013). Accessed at: http://www.osha.gov/Publications/OSHA3637.pdf
OSHA/NIOSH (2011). Spirometry: OSHA/NIOSH Spirometry InfoSheet (OSHA
3415-1-11). (Provides guidance to employers). Accessed at http://www.osha.gov/Publications/osha3415.pdf
OSHA/NIOSH (2011) Spirometry: OSHA/NIOSH Spirometry Worker Info. (OSHA
3418-3-11). Accessed at http://www.osha.gov/Publications/osha3418.pdf
5.7. Other Steenland, K. and Ward E. (2014). Silica: A lung carcinogen. CA Cancer J
Clin, 64, 63-69. (This article reviews not only silica and lung cancer but
also all the known silica-related health effects. Further, the authors provide
guidance to clinicians on medical surveillance of silica-exposed workers and
worker counselling on safety practices to minimize silica exposure.) References
American Thoracic Society (ATS). Medical Section of the American Lung
Association (1997). Adverse effects of crystalline silica exposure. Am J
Respir Crit Care Med, 155, 761-765. American Thoracic Society (ATS), Centers for Disease Control (CDC),
Infectious Diseases Society of America (IDSA) (2005). Controlling Tuberculosis
in the United States. Morbidity and Mortality Weekly Report (MMWR),
54(RR12), 1-81. Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm
Brown, T. (2009). Silica exposure, smoking, silicosis and lung
cancer—complex interactions. Occupational Medicine, 59, 89-95. Halldin, C.N., Petsonk, E.L., and Laney, A.S. (2014). Validation of the
International Labour Office digitized standard images for recognition and
classification of radiographs of pneumoconiosis. Acad Radiol, 21,
305-311. International Agency for Research on Cancer. (2012). Monographs on the
evaluation of carcinogenic risks to humans: Arsenic, Metals, Fibers, and Dusts
Silica Dust, Crystalline, in the Form of Quartz or Cristobalite. A Review of
Human Carcinogens. Volume 100 C. Geneva, Switzerland: World Health
Organization. Jalloul, A.S. and Banks D.E. (2007). Chapter 23. The health effects of
silica exposure. In: Rom, W.N. and Markowitz, S.B. (Eds). Environmental and
Occupational Medicine, 4th edition. Lippincott, Williams and Wilkins,
Philadelphia, 365-387. Kramer, M.R., Blanc, P.D., Fireman, E., Amital, A., Guber, A., Rahman, N.A.,
and Shitrit, D. (2012). Artifical stone silicosis: Disease resurgence among
artificial stone workers. Chest, 142, 419-424. Laney, A.S., Petsonk, E.L., and Attfield, M.D. (2011). Intramodality and
intermodality comparisons of storage phosphor computed radiography and
conventional film-screen radiography in the recognition of small
pneumonconiotic opacities. Chest, 140, 1574-1580. Liu, Y., Steenland, K., Rong, Y., Hnizdo, E., Huang, X., Zhang, H., Shi, T.,
Sun, Y., Wu, T., and Chen, W. (2013). Exposure-response analysis and risk
assessment for lung cancer in relationship to silica exposure: A 44-year cohort
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Sample Forms
Three sample forms from Appendix B of the Silica Standard are provided. The first is a sample written medical
report for the employee. The second is a sample written medical opinion for the
employer. And the third is a sample written authorization form that employees
sign to clarify what information the employee is authorizing to be released to
the employer. |