Page 14 of 50 been deemed necessary to protect workers. 66 Going further, the United Kingdom and Europe banned silica sandblasting and transitioned to safer alternatives, most commonly almandine garnet, a naturally occurring mineral abrasive with low free crystalline silica content. 66
According to the Hierarchy of Controls, the persistence of overexposures despite the application of engineering measures and use of respiratory protection suggests inherent limitations in the current control framework. When engineering controls are unable to maintain exposures below established limits, dependence on respirators becomes necessary, even though this represents the least effective tier of protection and introduces complexity. Respiratory protection places the onus of exposure reduction on the individual worker, can increase the physical demands of the work, and introduces challenges in terms of comfort, visibility, and communication. Within the United States, when respirators are required, OSHA mandates that the employer develop and implement a written respiratory protection program administered by a suitably trained program administrator. The program must include procedures for: respirator selection; medical evaluation; fit testing for tight-fitting respirators; proper use under routine and emergency conditions; respirator maintenance and storage; employee training that includes instruction on donning and doffing; and regular evaluation of the effectiveness of the program. 67
Collectively, the evidence indicates that the hazard may not be adequately controlled using existing process controls or personal protective equipment alone. As such, the elimination of AS or substitution with less hazardous materials is a more effective control measure that appears higher on the hierarchy( Figure 4) and should be considered for this high-risk work, as was done in Australia in July 2024.
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Gaps in Medical Screening and Public Health Surveillance
Programs for medical screening and public health surveillance for AS silicosis are inconsistent worldwide. For the purposes of this document, screening refers to the medical evaluation of asymptomatic exposed workers to detect silicosis at the individual level, whereas surveillance involves systematic collection and reporting of cases at the population or industry level to monitor trends and guide prevention( refer to Box 1). Regulatory requirements vary substantially between and within countries, and even where standards exist— such as OSHA-mandated medical examinations in the United States or California’ s requirement for computed tomography( CT) scanning— employer compliance remains very low. 5 In addition to compliance, regulatory enforcement by OSHA is challenged by being understaffed and under-resourced. 72 Only 5 % of California fabricators report receiving screenings, 73 and most cases are diagnosed after symptoms emerge, 4 reflecting systemic failures in early detection. Even in a voluntary industry-supported survey of stone fabrication shops, only 46 % reported periodic medical screening; of these, only 64 % included spirometry and 57 % chest imaging. 29 Additionally, there is an over-reliance on less sensitive chest radiography( chest x-ray) rather than chest CT scans, as discussed in more detail below.
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Cited barriers to screening include limited awareness of regulatory requirements, financial burdens on employers, the prevalence of informal working arrangements, and shortages of accessible screening sites. Small workplaces complicate governmental public health surveillance systems as businesses often have fewer than 10 employees. 4, 6, 62, 77 – 79 As such, the financial burden of screening falls on small businesses with tight margins, whose employers are often unable to fund a medical monitoring program.
Industry-wide, government-funded medical screening programs for AS silicosis have been provided in very few countries. In New Zealand, the Accelerated Silicosis Assessment Pathway( ASAP) provides free specialist evaluations for artificial countertop workers, with over 220 screened and 26 cases identified by 2024. 80 Australia has developed the most extensive screening initiatives for AS workers, which have identified hundreds of workers with silicosis. 8, 20, 71 For example, in Victoria and Queensland, government-led screening programs have successfully detected large numbers of early silicosis cases. In the Victorian screening program, 117 out of 544 workers( 21.5 %) were diagnosed, including 21 with PMF; participation in the program led to a rise in workers’ compensation claims and costs. 8, 75, 81, 82 However, these programs are administered at the state
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