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level rather than nationally, leading to inconsistent coverage and variable assessments of workers depending on their location. In the Veneto region of Italy, an active government-led screening program for quartz conglomerate workers identified 24 cases of silicosis among 45 screened, prompting recommendations to include high-resolution computed tomography( HRCT) and diffusion capacity( DLCO) testing in surveillance programs. 83 In contrast, in countries that lack active screening programs, diagnosis is often delayed, disease remains untreated, and the true prevalence is substantially underestimated. This variability underscores how the absence of standardized, universal screening perpetuates gaps in prevention and inequities for AS countertop industry workers around the world.
Public health surveillance for silicosis similarly suffers from inconsistencies and underreporting, particularly for vulnerable worker populations. In China, although silicosis is mandatorily reportable through a national registry, migrant workers, employees of small or unlicensed workshops, and under-resourced regions are often overlooked, leading to large discrepancies between official counts and the true disease burden. 7, 84 In the United States, surveillance infrastructure remains limited, with formal programs operating in only four states. 85 California’ s adoption of electronic case reporting in 2022, which automatically generates and sends case reports when silicosis diagnoses are entered into electronic health records, represents progress. 86 Yet, effectiveness depends on accurate clinical recognition and coding, both of which remain inconsistent.
5, 86, 87
Silicosis surveillance in Europe is fragmented, with only a few countries maintaining their own registry and reporting rules, often tied to compensation. Therefore, case definitions, diagnostic standards, and coverage vary widely; as a result, workers in systems with active case-finding( such as Spain, which has documented large AS clusters) are detected earlier, while those in countries relying on passive, compensation-linked reporting remain underdiagnosed and invisible in EU-level data. 88 These gaps in surveillance capacity and reporting systems contribute to systematic underestimation of disease prevalence, limiting the urgency of governments to respond to this accelerating occupational health crisis.
Without employer-based screening compliance, the public health surveillance systems rely on diagnoses made in clinical settings after prevention efforts have failed. Access to health care is a central barrier in addressing silicosis and other occupational diseases, particularly for marginalized workers. In the US, many AS workers do not have legal authorization and / or are underinsured, relying on emergency departments for care, which delays diagnoses and makes follow-up care infeasible. For example, in California, a state with relatively inclusive publicly funded healthcare insurance( Medicaid), 58 % of silicosis patients in one series were uninsured or held limited, emergency Medicaid coverage. 4, 89 Californian policy changes threaten to restrict immigrant access to full Medicaid further, compounding diagnostic and imaging access gaps. 90 Another challenge in California is the limited utilization of workers’ compensation for AS silicosis: of 114 AS silicosis cases reported to the state by 2024 for whom insurance status was known, just 8( 7 %) were designated as having received workers’ compensation payments. 87 Informal employment arrangements that impact eligibility and the lack of work-related presumption for silicosis may contribute to the low rate of workers’ compensation coverage for what is an exclusively occupational disease. In contrast, in Victoria, Australia, where workers’ compensation covers 87 % of workers, silicosis is presumed to be work-related, and workers with silicosis are entitled to compensation. AS countertop fabrication drove a 27-fold increase in workers’ compensation claims for silicosis, resulting in 428 claims received between 2015 and 2022. 81
Clinical Manifestations Forms of Silicosis
Silicosis occurs in three main forms depending on the duration and intensity of silica exposure: chronic, accelerated, and acute. 2, 91 Chronic silicosis generally develops after more than a decade of exposure, beginning with radiographic small nodular opacities that may evolve into severe scarring and architectural distortion. It is classically categorized into two phenotypic forms:( 1) simple silicosis and( 2) complicated silicosis, also termed progressive massive fibrosis( PMF).
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