Coal Mine Dust Lung Disease –An International Perspective. National Coalition of Black Lung and Respiratory Disease Clinics, Inc. September 26-28, Chicago, Illinois

Robert Cohen, MD, FCCPProfessor of Medicine

Northwestern University Feinberg School of Medicine

Clinical Professor - EOHS, University of Illinois

School of Public HealthChicago, Illinois

Disclosure of Funding Support Funded by the Alpha Foundation for the Improvement

of Mine Safety and Health Funded by HHS/HRSA/ORHP/BLCP & BLCE Employee of NIOSH/RHD Funded by USDOL/OWCP & MSHA Funded by Queensland, Australia DNRME Provide IME’s for Occupational Lung Disease

Pneumoconiosis – China, India, and Australia China

Largest Coal Producer and Consumer Highest rate of pneumoconiosis in the world Accounts for 85% of all reported occupational diseases.

No national surveillance system

India Second largest producer

No national surveillance system

Australia Myth that Black Lung was eliminated

State by state system of surveillance, dust control and monitoring No national surveillance system

World Coal Reserves in BTUs

Source: U.S. Energy Information Administration, International Energy Statistics.Note: Latest data available for the U.S. are 2009, international data are 2008

Coal Production in China – Metric Tons

China’s Coal Mines

China has about 10,760 coal mines (US had 1,885 in 2009) Plan to close 5,600 with production less than 90,000

tons/yr 90% are small mines (<300,000 tons) and make up only

36% of production Safety record worse than that of large mines. Death rates > than large mines –75% of fatalities

Chinese Coal Miners

China has 3,742,176 coal miners in 2010US 50,000 in 2017Chinese state owned mines – better dataChina has small private or

Township/Village Enterprises – less data, less regulated mines

The majority of miners are migrant peasants from rural areasMost vulnerable population

Chinese Miners

China 0.42 tons/miner hour – includes productivity of small mines

Australia – NSW – 4.76 tons/miner hourUS is 6.05 tons/miner hour

Chu C, Jain R, Muradian N, Zhang G. Statistical analysis of coal mining safety in China with reference to the impact of technology. Journal of the Southern African Institute of Mining and Metallurgy. 2016;116(1).

China’s Coal Mines

Regulation and Inspection carried out by State Administration of Worker Safety Combination of MSHA and NIOSH FunctionsOperates Hospitals, Institutes of Occ HealthResponsible for Inspections, EnforcementResponsible for Accident Investigations

National Center for International Exchange & Cooperation in Work Safety (SAWS)Works with MSHA

China – Pneumoconiosis Cases

Difficult to determine current national ratesLast national survey was 1992 then it was stopped

Prevalence of CWP was 6.49% at that timeNow only by company, mine, local or regional studies.

24,206 cases of pneumoconiosis in 2012China National Health and Family Planning

Commission Report: 2009-2013 – There were 105,000 cases of CWP

China – Pneumoconiosis Cases

Diagnosed by 3 radiologists using Chinese Diagnostic Criteria of Pneumoconiosis

Similar to ILO Standard Images88% of reported occupational disease is

pneumoconiosis48% of total reported cases of pneumoconiosis

are CWPReports from some newspapers state there are

70,000 new cases of Black Lung per year

CWP in China – Metanalysis of 11 Carefully Chosen Studies

173,646 dust exposed coal minersFrom 11 provinces in China

10,821 of them had CWPTotal prevalence 6.02%

Study from Hubei Province

Data from 2008-2013

Used annual reports of cases of CWP

3665 cases of pneumoconiosis 97% of these were silicosis and CWP

33% of cases occurred in miners with < 10 years of tenure

42% of cases from small and medium size enterprises

Xia Y, Liu J, Shi T, Xiang H, Bi Y. Prevalence of Pneumoconiosis in Hubei, China from 2008 to 2013. International Journal of Environmental Research and Public Health. 2014;11(9):8612-8621.

317 newly hired coal miners

132 conrols

Pre-employment then 15 follow up health surveys.

Analyze longitudinal data

Controlled for age, height, pack years, and dust exposure

Rapid initial loss in FEV1, then plateau and partial recovery

Consistent with other studies of initial losses due to dust exposure

Smokers lost greater amounts of FEV1

Young controls < 20 had continued lung growth

Dust exposed miners had declines in FEV1

Study of Tiefa Mine

CXR every 1 to 5 years depending on job

Used Chinese standard films for diagnosis

16,154 miners – 87% working, 9% retired, 4% deceased

CWP rates (positive at lowest category or greater) 0.37%, 12%, 18% in < 10, 10 to 20, and >20 tenure cohorts respectively

CWP related to duration of exposure and job

Cumulative Incidence of CWP by Job CategoryFig. 2. Cumulative incidence rates of CWP among coal miners with different occupational categories.

**indicate statistically significant difference (p<0.01) as compared with Mining by Log-rank test, ##compared with Helping, p<0.01.

Deaths in Coal Mining

80% of World Coal Mining Deaths are in ChinaDeath rate likely higher due to under-reporting

Avoid fines and mine closuresCorruption of small local mines

Rural areas less responsive to central regulation“Mountains are high and the emperor is out of sight”

Deaths in Chinese Coal Mine Industry Are Decreasing

Increased RegulationImproved LawsIncreased Public AwarenessClosure of small mines

Compensation for Death

Prior to 2004 ($1300 to $6400) Allowed operators to pay off families at slightly higher

rates if they agreed not to report

After 2005 ($25,000) Later instituted a fine of $130,000 to local

government agencies for each death. Resulted in incentive for government to be less

interested in prevention Resulted in incentive to negotiate with families to under-

report

China Safety Science Journal, Volume 14, Issue 8, p. 29; China Labor Bulletin, November 2006, Interview with Relatives of Coal Miners Died in Accidents.

China-Coal Mine Fatality Rates

India Coal Mine Fatality Rates

US Coal Mine Fatality Rates

Chinese Approach to the Treatment of pneumoconiosis

In the 1950s they focused on sanitaria which provided rest and recuperation and breathing exercises.

1960s Chinese medicines 1970s-80s anti-fibrotic medications From the midterm of 80s WLL was explored and was a

major part of treatment programs. Now moving away from WLL

Rehabilitation Center for Pneumoconiosis, State Administration of Coal Mine Safety, Beidaihe Sanatorium of Chinese Coal Miners

Beidaihe Sanatorium Whole Lung Lavage Program

Coal Mine Trust Fund (Created 2003) The China Treatment Foundation is funded at

approximately 115 Million RMBFunds approximately 50% of cases. Officially known as China Treatment

Foundation for Coal Worker’s PneumoconiosisEach contributing mine can select patients for

referral 50% of Cases funded privately

Cost of WLL is 10,000 RMB ($1,500)

Whole-lung lavage Fluid (WLLF)

Beidaihe Sanatorium Whole Lung Lavage Program

Performed 400 Cases in 201073% Stage I22% Stage II5% Stage III

5763 cases performed from 1991 to 2010

5716 cases (99.2%) for CWP Other diseases 47 (0.8%)

CWP in India

550,000 Coal Miners500 Coal minesHuge informal work force unorganized labor. Coal - Permissible exposure limit is 2.0 mg/m3 DGFASLI* – India’s NIOSH

Directorate General Factory Advice Service Labor Institutes

Coal Mining in India Coal Mines Nationalized in 1973 Mines act 1978

Provided for initial medical examination Provided for periodic medical examination every 5 years

Difficulty with diagnosis due to lack of standardized interpretation of radiographs and not widespread use of ILO standards.

1997 Study of Prevalence in Southeastern Indian Coal Fields 10 Areas, 72 mines Prevalence of CWP 1/0 or greater was 3%

Category 1 = 81%, Category 2 – 18%, Category 3 – 1%

Mining in Queensland

34 billion Tons Raw CoalBowen Basin8.7 Billion Tons Coking Coal

4 Billion Open Cut

3.7 – Underground

7000 Underground Coal Miners

25,000 Open Cut Coal Miners

Myth Of No Black Lung

1998 Review of Coal Workers’ Health Scheme concluded that pneumoconiosis was not a problem

Changed surveillance program into fitness for work program

Anyone could take CXRs and no standards for whom or how the images were classified

Images sent to the Department of Natural Resources and Mining – but not reviewed

No central data capture or processing

Data from New South Wales

US Investigators Use Australian Data to Question need for lower PEL

Joy GJ, Colinet JF, Landen DD. Coal workers’ pneumoconiosi prevalence disparity between Australia and the United States. Min Eng. 2012;64(7)

Queensland PEL

3 mg/m3

Ignored Data from Other Australian Sources

Study of pneumoconiosis mortality in Australia found that, of the 1,000 deaths attributed to pneumoconiosis between 1979 - 2002, only 6% were classified as CWP, with the number of fatalities decreasing steadily over time.

Compensation data showed that there were 750 new cases of pneumoconiosis (including CWP, asbestosis and silicosis) with 92 deaths in 2003 between 2001 and 2003.

Review of respiratory component of the medical assessment of Qld coal mine workers

Draft scope of the reviewMonash University

Malcolm Sim, Deborah Glass, Mina Roberts, Ryan Hoy

University of Illinois at Chicago

Robert Cohen, Leonard Go, Kirsten Almberg

Coal mine workers’ health scheme

Regular medical assessments Nominated Medical Advisers (NMA)Many organ systems, not just lungs Lung component includes lung conditions,

symptoms, lung function test and chest x-ray X-ray only for those ‘at risk of dust exposure’ Aim is early detection of coal dust lung disease Report on health assessment - NMA

Objectives of the review

Investigate whether the current design and operation of the lung component of the scheme is optimal to effectively detect early CMDLD

If not, recommend changes to improve identified deficiencies and identify what is needed to increase capacity in Qld

Australian Federal Government

Queensland Parliament InvestigationReport Issued May 2017

What has been accomplished since Monash/UIC Report CXR surveillance system comparable to NIOSH

Dual read and adjudication with up to 3 additional reads

Sponsored NIOSH Couse for B-Readers 13 Australian Radiologists Certified

Contract with Australian Provider for CXR surveillance

Training course for NMAs and EMOs Online, Webinars, and in person Workshops

Register for NMAs and EMOs

Spirometry Training Course Developed.

Data on CXR Reads to DateN=20,968

Age Number<30 4184

30-39 597140-49 510550-59 385860-69 141070+ 99

Data on CXR Reads to DateN=20,968

Category NumberNegative 20,417

1/0 1401/1 951/2 21≥2/1 6

A,B,C PMF 4

ILO Classifications by Age and Category

Age Group

Category <30 (n ,%) 30-39 (n ,%) 40-49 (n ,%) 50-59 (n ,%) 60-69 (n ,%) 70+ (n ,%)

Negative 4178 99.9 5945 99.7 5044 98.9 3735 97.1 1344 95.4 89 89.9

Category 1 4 0.0 18 0.3 54 1.0 105 2.7 63 4.5 10 10

≥ Category 2 0 0 1 0.017 0 0 4 0.01 1 0.07 0 0

PMF 0 0 0 0 1 0.0002 2 0.05 0 0 0 0

Total 4182 5964 5099 3846 1408 99

China – Dust Level Regulations

PC-TWA’s Crystalline Silica – 0.3 mg/m3 (US now 0.05 mg/m3 down from 0.1 mg/m3

Ji Y, et. Al. International Journal of Mining Science and Technology. 2016;26(2):199-208.

China and Australia Dust Sampling

Dust Regulations in Australia

Country / Region Concentration mg/m3

US (MSHA) 1.5 as of August 2016China 3.5QLD 3 (shift adjusted)NSW 2.5

BHP Billiton Corporate 2 (shift adjusted)NIOSH recommended 1.0

New South Wales Dust Limits

International Pneumoconiosis – Lessons Learned Medical surveillance is essential to monitor disease trends – especially with

changes in production and industrial processes. Medical surveillance is important to assess efficacy of primary preventive

strategies. Voluntary programs such as those in the US likely underestimate the

problem. Programs that only survey active miners will miss disease in retired/former

workers due to disease latency. Fitness for work programs without quality control and centralized analysis of

data will miss disease. Secondary Prevention may not work unless there are strong protections of

workers rights

U Shaped Curve of Concern in Public Health

New York City TB Rate/100,000 Pop1969-1989

Prevalence (%) of PMF among Appalachian Working Miners >25 years tenure. 1974-2012

From: Cohen, RA et. al. AJRCCM 2016, 194(6):773-775

q