Subscribe
Share
Share
Embed
Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
ATS_BEP_080726_EngineeredStone_First_Edit
Speaker: [00:00:00] You're listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society.
Erika: Welcome to another episode of the ATS Breathe Easy podcast. I'm your host, Dr. Erika Moseson, a pulmonary and critical care physician in Oregon and host of the Air Health, Our Health podcast. I have no financial disclosures. We are here today to discuss the silicosis in the artificial stone countertop industry, an official American Thoracic Society workshop report.
Joining me are Dr. Kristen Cummings and Dr. Maeve McMurdo, who will be introducing themselves.
Kristin: Hi, everyone. I'm Dr. Kristin Cummings. I'm an internist and occupational medicine physician, and I lead the Occupational Health branch at the California Department of Public Health, and I have no financial disclosures.
Maeve: And I'm Maeve McMurdo. I am a pulmonologist over at Cleveland. I [00:01:00] run our occupational lung disease clinic and see patients with silicosis on a pretty regular basis. And I also co-chair, vice-chair the ATS Environmental Health Policy Committee. And we've been talking a lot about silica, so I'm glad to be here.
Erika: Well, thanks for joining us. What are the key findings of the workshop report being released by ATS?
Kristin: So last year, ATS convened a group of experts to examine the issue of silicosis among countertop fabrication workers, and we were particularly interested in a material called artificial stone. And you may not have heard of artificial stone, but you've probably heard of quartz countertops.
That is what, um, this material is used, um, to make. It's a synthetic material that, um, consists of, um, crushed rock ground very finely, um, and then held together, essentially glued together with, um, with a resin, typically a polyester resin. And so this material is very durable. It comes in lots of different patterns and colors.
It's low [00:02:00] maintenance and reasonably priced. And so for all those reasons, the demand has really skyrocketed in the last 10 to 15 years. It's now the most popular countertop material in the United States. And, um, what we found in the workshop is that with that increase in demand and use of this material has come a really a global epidemic of silicosis among the workers, um, who are making the countertops.
Um, this disease, um, we found, um, has, has a distinct pattern compared to other, um, other silicosis that we see in other industries. So, um, I should back up and say that silicosis is a fibrosing lung disease, and, um, it's caused by inhaling, um, um, respirable-sized particles of, uh, crystal and silica. Um, silica is one of the most common, if not the most common, um, mineral in the Earth's crust, and so we encounter it in a lot of industries, mining, construction, um, boundaries.
And what we typically see in those industries is that it takes a long time from first exposure [00:03:00] to manifestation of disease. That's typically many years, if not decades. And so we think of silicosis, um, typically as a disease that's affecting people towards the end of their working life. What we found with artificial stone silicosis is that, um, there's-- the latency is much shorter, as few as three years, um, from first exposure to development of disease.
And so what we're seeing is that workers in their thirties and forties, really at the beginning of their working lives, are developing disabling lung disease And I think the other major finding, um, about this disease is, um, the accelerated time course. So we're seeing people, um, uh, diagnosed with silicosis and then develop, um, what we call progressive massive fibrosis, where small nodules have coalesced into large, um, masses and there's architectural distortion.
Um, and that condition, progressive massive fibrosis, um, has a high rate of progression to respiratory failure and, um, need for lung [00:04:00] transplant.
Maeve: Yeah, I think, you know, when you think about engineered stone and how silicosis behaves with engineered stone exposure, it's just so rapid. Like some of the patients I'm seeing are guys who are young, 20s, 30s with kids, who are gonna require lung transplant, who are disabled from their lung disease.
And we think about silicosis from things like mining, from construction, still really severe, can be fatal, but typically much, much slower in onset. Much more grumbling and so slowly progressive for a long time. This is much more rapid. It's progressing quickly, and even when the guys are out of exposure, so they're removed, they're still progressing.
So by the time we find it, we're-- it's often too late to really act, to actually do anything.
Erika: So what do we know about the burden of countertop silicosis in the US and globally?
Kristin: So one of the most striking findings for me to come out of this workshop was the number of [00:05:00] cases that have been reported. We were able to review the literature and found over six thousand cases worldwide, um, in the last, uh, s- several decades.
Um, in the US, there are now more than six hundred cases that have been reported since the first case, um, in two thousand and fifteen. And I will say that for many reasons, we think that those numbers are actually, um, real underestimates. Um, a lot of workers are not getting, um, screened for this disease. Um, s- many do not have access to healthcare, so they don't have the opportunity to be diagnosed.
Um, if they are seen, um, their physician may not be familiar with silicosis or may not know to ask about countertop exposure. Um, and then even if the diagnosis is made, um, most countries lack a infrastructure for, um, disease surveillance for, for chronic disease like silicosis. And so, um, there isn't anyone tracking the, the numbers, um, at, at a, at a national level
Maeve: You know, Australia had a really similar situation to the [00:06:00] United States.
Engineered stone was being used widely and often in really unsafe conditions. Workers weren't aware they were being exposed and how dangerous this was, and they found that a significant proportion of actively working young workers working with this product had silicosis. You know, pause on the exact number.
I don't know if you remember, Kristen, but-
Kristin: Yes, it's at least 25%.
Maeve: Yeah. And so again, if you're not getting screened or you don't have regular healthcare access, this isn't being picked up. You know, I'm in Ohio, and we don't have the same sort of aggressive screening that California has, but there are a huge number of small mom-and-pop shops working with these products who may not be able to offer worker screening, may not be able to offer healthcare, and those workers aren't going to get diagnosed until they really become sick and end up in the hospital.
Erika: And what is the silica content of engineered stone, and how does this compare to naturally occurring stone?
Maeve: I mean, it's as high as close to 100%, like up to 90%, so this is [00:07:00] almost entirely crystalline silica. Natural stone's around 40%, 30%, so this is significantly higher. I think the challenge is, again, many workers were not really aware of how bad this stuff was, and even when they were aware, couldn't necessarily get around things like dry cutting.
Erika: Are there lower silica content alternatives?
Maeve: There are. I think California, again, is really leading the charge here. Australia too. But there are alternatives that are lower in silica, they're safer for workers. They are more expensive, and that's kind of been the challenge and the trade-off.
But a lot of companies now are going towards manufacturing lower silica content engin- or would you call them engineered stone? Engineered stone-adjacent products that fill the same role, have the same properties, but aren't gonna kill workers in the same way.
Erika: Is there a way to manufacture engineered stone with high silica content safely?[00:08:00]
Kristin: That, that's a great question. And I think, um, you know, going into the workshop, I think there was a general understanding among the, um, participants that dry cutting is particularly hazardous. So we know that when a- artificial stone is cut dry, it generates enormous amounts of, um, silica dust. And, um, there actually have been studies showing that a, a self-report of dry cutting is actually a risk factor for, for disease.
So we knew going into this that dry cutting was a hazard, and there are efforts in multiple, um, localities to ban dry cutting. Um, I think one of the things that was striking to me is that as we dug into the literature, we found that, um, even in shops that are trying to control dust with engineering controls, like using wet methods and ventilation, even in those settings, you will have overexposures to silica when you're using this product.
And I think that in part goes back to just how much of the [00:09:00] product is silica and how low, um, the threshold is for, um, for developing lung disease. So I can give you a couple of examples. Um, in the United States, there was a study in Georgia of about sixty, um, countertop workers who were using exclusively wet methods to cut.
And when the investigators sampled the air around these workers, they found that ab- over half of them were being ex- overexposed to silica, even with wet methods in place. And, um, Australia has really had a similar experience. When they first discovered this problem, they went out to shops, um, and tried to understand what was going on.
They found that, um, dry cutting certainly was causing, um, you know, high silica exposures. Um, and they, they had a comprehensive program to introduce wet methods to, um, teach employers and workers about what, um, technology is needed to control the exposure. And after a five-year program to implement, uh, this compliance, um, they found that more than half of the workers were still overexposed to [00:10:00] silica.
So I think there are really kinda two takeaways from that. One is that if engineering controls are not consistently, um, reducing exposures, then anyone using this material to make countertops needs to be in respiratory protection. They need to have a respirator that's well selected, that, um, has been fit tested and that's, um, well-maintained.
But I think, um, it also brought up for the group the idea of, um, substitution. You mentioned alternative, um, alternatives to artificial stone. When you have something that's so hazardous and, um, we can't control it, um, the exposures with, um, engineering controls, then that really leads you to, to look at, um, alternatives to this product
Speaker 5: Get the best of ATS 2026 on ATS Now.
ATS Now is our new video platform that brings conference highlights, webinars, podcasts, and expert insights directly to you and tailored to your interests. Activate your account now to view more than one thousand [00:11:00] videos, including the best of ATS 2026. Access is free to ATS 2026 conference attendees through December 31st.
ATS members who are unable to attend ATS 2026 can access ATS Now for just fifty dollars USD, also through the end of this year. Visit ATSNow.thoracic.org to start your personalized learning journey today
Erika: Realistically, no. Um, it's not really a safe product to be manufacturing. Am I hearing that correctly?
I mean-
Maeve: Not much. Just pause it, 'cause not much manufacturing. You know, the manufacturer separate has its own risk, but it's really the working with. So you know, we think about people who are making the product, they're a separate group. But the guys who are actually on site who are buying the stone for manufacturers to use are the ones who are really getting the brunt of the exposure, which I think is a challenge.
You know, it's manufactured in pretty controlled conditions, but then it goes off site. And we [00:12:00] think about how a kitchen's installed, like you're typically cutting on site to cut the faucet hole, to kind of get it to fit, 'cause you measure and you measure and then you get on site and measurements are wrong or it can't get through the door.
Like, there are all these things that go into building a kitchen where it requires on-site cutting, and that's really where the challenge has been, is the, like, that's where people get exposed.
Erika: So it's the actual contractors and construction workers installing this that are at excess risk?
Maeve: Exactly. So manufacturing certainly, again, we could go into that, but where we're really seeing the problem is the guys who are on the ground doing the installation, doing the construction.
And again, a lot of those are those small mom and pop shops who might have two or three employees, who might have family working, who might have people working not necessarily under the table. And so things like fit testing, having a mask program, having a medical surveillance program, that just doesn't happen.
I mean, it's really hard to do for these [00:13:00] two, three-person operations.
Erika: Not to mention trying to do construction work wearing a respirator. I think we all worked in, you know, hot conditions with N95s is not ideal.
Maeve: Getting under a kitchen countertop to, like, install plumbing and work around plumbing while wearing, like, a full cartridge respirator is not easy.
Erika: It also makes you worry about the families moving into the homes. You know, I'm not sure what the dust disposal is like after an installation of new construction, but it also makes you worry about residual risk, though less elevated.
Maeve: Yeah, I think generally once it's installed it's pretty safe. The immediate installations, we see a lot of dust exposure.
That's gonna blow up pretty quickly, assuming you have decent ventilation and they're vacuuming, cleaning up, 'cause most families get cranky when you leave your kitchen covered in dust. Yeah. But yeah, it's really, you know, the workers are bearing the brunt of this by far.
Erika: Are other countries experiencing similar trends?
And if so, what steps have they taken?
Maeve: So like Kristen mentioned, Australia had a really similar problem to the United States. One in four [00:14:00] workers roughly had silicosis, which is a ridiculously high number. That's a complete failure of control. And they've been really aggressive about surveillance. They went out and they figured out how bad this problem was.
They offered a lot of screening. They made the process really straightforward for workers, and ultimately they found that there was no safe way to work with these products, so they banned them. They banned high, uh, crystalline silica engineered stone. And that's kind of what I think a lot of places are hoping for is, you know, this isn't a safe product.
It's not safe for the guys that are working with it, and no matter how good you are at following engineering controls and doing the right thing as a worker, it's a really dangerous product
Erika: What is the [00:15:00] state of California doing about the rise of silica disease in countertop fabricators and installers?
Kristin: We've been, um, conducting surveillance for artificial stone silicosis since 2019. Um, we're, we're not ourselves doing screening.
We're not going out and testing workers. But we are, um, receiving reports from physicians, from, um, employers, from other, um, community members where, um, cases have occurred, and we are investigating those and confirming them. And so, um, since 2019, we have confirmed more than six hundred cases in the state of California, and I can tell you that, um, these are happening in young workers.
The average age of diagnosis is forty-six, and the average age, um, at death is fifty-two. Um, thirty-two of these workers have died, um, so far, and we've had seventy-two, um, patients undergo lung transplant, um, for artificial stone silicosis in the state of California. And so those numbers, I think it's really important to [00:16:00] track that because it, it motivates, um, action.
Um, and so, um, our regulatory agency in the state, Cal OSHA, um, saw those data, and they, um, concluded that their, uh, regulations on silica were not, um, uh, protective enough. And so over, over the past few years, they've introduced, um, several new, um, what we call standards or regulations, um, requiring, for instance, um, use of a powered air purifying respirator, so a very, uh, a high level of respiratory protection.
They have banned, um, dry cutting, and they're actually requiring employers to offer chest CT screening every three years. Um, with all of that, um, they have, um, continued to see, um, high exposures in workplaces across the state when they go to inspect. And so as of, um, May of this year, um, uh, Cal OSHA has undertaken a, a rulemaking process, um, to, um, prohibit the use of, um, artificial stone that has more than one percent crystalline silica, um, [00:17:00] for, um, for fabrication and installation.
So that process is, is getting underway, um, and will, will be a major step in California to address the epidemic.
Erika: And what should concerned listeners of this podcast know about what they can do locally to help reduce the burden of this disease?
Maeve: Most importantly, when you're getting your kitchen countertop done, don't use engineered stone.
Like, your money is the easiest way to have action in some cases, and not buying engineered stone is the best way to keep at least one worker safe. But more broadly, I'd say as an occupational pulmonologist, I really encourage people to think about taking an occupational history and thinking about silicosis.
A lot of the guys that I see did not get diagnosed or had a delayed diagnosis because people weren't necessarily aware of what they're exposed to and what this was. I think that's true across the board. In California, in Australia, this wasn't necessarily recognized right away because people weren't thinking silicosis because Why would you?
It's silicosis. It's gone away, right? And unfortunately, it really hasn't. It's [00:18:00] bad. And so if you can recognize it and make the diagnosis, that helps both the worker, your patient, but also that workplace who probably has other workers who are exposed, who may not know that what they're doing to keep their workers safe isn't working.
And so you can really have a positive action, not just on your patient, but on a whole workforce if you just think about it and make that diagnosis and kind of follow it through.
Kristin: I would add th- those are terrific recommendations made. But I would add that, um, in California, as of, um, last summer, we added silicosis to our list of reportable diseases and conditions.
And so now it's required by law if, um, a healthcare provider makes the diagnosis that they report it to public health authorities. And I think that has given us a fuller picture of, of the scope of the problem. Um, not every state has silicosis as a notifiable or reportable disease, but, um, physicians can contact their, um, their public health, um, uh, local public health department to find out, um, uh, if they can share, if they [00:19:00] can report the information.
Um, and then there's also, um, uh, the opportunity to contact OSHA with, um, with patient's permission, um, because if, if you find one case, certainly there are others in the workplace that are having similar exposures.
Erika: Well, it sounds like we could all be reaching out to our individual states to see if they could take a, um, a page from the playbook in California and try to be working across the country to make sure to keep people as safe as possible in the workplaces.
Maeve: Look, I think it goes a long way. The-- I think I put a plug for, you know, OSHA offers a consultation service. So for employers who are worried their workers are exposed, and a lot of employers are trying to do the right thing. They're trying to keep their workers safe. It's just that it's hard and there's a lot of information out there.
OSHA will come to the workplace and they say they provide free consultation. They'll help you make things safer. You will not get penalized. They work with you, not against you. And so it's a really great resource that a lot of workers em-employers don't know about. It's not something [00:20:00] particularly doctors think about, but it can be a really nice thing to suggest and kind of bring up in a clinic visit.
If you know that your patient, for example, owns a business or has a really good employer who wants to help them, that's a nice resource that exists and it's free and it's underutilized.
Erika: Well, I want to thank both of you very much for joining us here today and for your excellent workshop report. Um, what conclusions do you want people to take home from this episode of the ATS Breathe Easy podcast?
Maeve: I think if anything, that silicosis has not gone away. Engineered stone is hurting workers and is dangerous. There is no safe way to work with engineered stone There are safer products and there are low silica engineered stone products that can be used. But if anything, just think about it, recognize it, make the diagnosis, share the diagnosis, and help us kind of stop us in its tracks and keep workers safe.
Erika: All right. Well, thank you both very much for your time [00:21:00] and for contributing to the ATS.
Kristin: Thank you for having us
Speaker: Thank you for joining us today. To learn more, visit our website at thoracic.org. Find more ATS Breathe Easy podcasts on Transistor, YouTube, Apple Podcasts, and Spotify. Don't forget to like, comment, and subscribe so you never miss a show