Chapter 4 - Health services
Diagnoses and medical services
There is no curative treatment for the diseases caused by
exposure to coal dust and silica, in most cases early removal stops progressing
with minimal long term effects.[120]
4.1
Witnesses noted that there were problems with the
diagnoses of toxic dust-related ill health, particularly where there is a long
latency period, for example with crystalline silica and if other lifestyle
factors are involved, for example smoking. The Australian Lawyers Alliance (ALA)
commented:
I was surprised, when we surveyed our members, by the number of
potential exposures there were. I think it is a hazard and a problem that has
largely gone unrecognised because of problems with identification, diagnosis,
confusion with other lung conditions – including smoking related conditions and
so on – and I do not think we know the extent of the hazard.[121]
Inevitably, in relation to dust diseases, if there is smoking
difficulty will arise in determining what the contributions of the parts are.
Often that problem, we identify in our submission, leads to a failure to
identify the dust disease at all but, rather, have its ascription to tobacco
smoking or other problems than to relate it back to the exposure.[122]
4.2
The Australian Council of Trade Unions (ACTU) commented
that silicosis is difficult to detect in its early stages because of the
absence of symptoms and cited comments by Mr Richard Gun, Senior Lecturer,
Occupational and Environmental Health, University of Adelaide, that a miner
'who has been exposed to silica dust for five years can take little comfort
from a normal chest film, as it provides no guarantee that they will be free of
silicosis in another five years'.[123]
4.3
Professor Trevor
Williams commented that while classic
silicosis is likely to be accurately diagnosed:
...other consequences of silica exposure such as small airways
disease, emphysema, stomach and lung cancer may be attributed to other causes
such as asthma or exposure to cigarette smoke when in fact the predominate
cause may be silica dust. Patients may also be erroneously diagnosed as
idiopathic pulmonary fibrosis when their lung disease is due to fine particle
dust exposure such as silica.[124]
4.4
In the Regulation Impact Statement for crystalline
silica, the National Occupational Health and Safety Commission (NOHSC) noted
that health effects arising from respirable crystalline silica (RCS) exposure
are not obvious until the manifestation of illness. Once illness is manifest,
it is commonly not possible to identify when the RCS exposure occurred and at
what level. Problems with attributing adverse health effects to exposure
include:
-
the familiarity of RCS exposure. People who have
worked in dusty environments may not appreciate the risk of exposure to RCS as
the adverse health effects are not immediate;
-
as with asbestos and mesothelioma, irreversible
and cumulative lung damage caused by RCS is hidden, until it manifests as
illness; and
-
damage to the lungs can worsen after exposure
ceases.[125]
4.5
The need for an accurate diagnosis was acknowledged in
evidence. The Australian and New Zealand Society of Respiratory Science (ANZSRS)
noted that the critical factor is early identification of deteriorating lung
function. It stated that:
One of the difficulties in respiratory medicine is that the
lungs have a large reserve in function, about 33% that can be eroded before
there is any symptomatic evidence of deterioration. There is good evidence
linking excess loss of lung function to cumulative dust and fume exposure...Regular
lung function testing will provide early detection of loss of function well
before the results fall to 80% of predicted. This is important for people with
lung function at the high end of the reference range for whom a 20% fall is
very significant indeed.[126]
4.6
Coals Services stated that in the NSW coal mining
industry, accurate diagnosis of disease resulting from exposure to toxic dusts
is via the International Labour Organisation's international X-ray
interpretation system.[127] Cement
Concrete and Aggregates Australia (CCAA) noted it is accepted and recommended
internationally that the earliest and best indicators of any signs of effects
of RCS relate to scar tissue in the lung detectable by chest X-ray. Lung
function tests can also be used to measure the effect of silica in the lungs.
In the early stages of silicosis, the diagnosis may be uncertain, even with the
extensive medical diagnostic facilities available today such as computerised
tomography (CAT scanning) and lung biopsy. These services are widely available and
used in Australia.
However, CCAA did not see that such in-depth and invasive techniques as being
appropriate for health surveillance of workers.
4.7
CCAA submitted that:
...the only rational approach to diagnosis of silicosis and other
pneumoconioses (occupational dust diseases) is to follow established
international criteria for these diagnoses. To do otherwise would be to prevent
any contribution of Australian information to international efforts to control
occupational lung disease and distort Australian health information. Australia
has been an important contributor to work in this area of UN agencies such as
the International Labour Organisation and World Health Organisation.[128]
CCAA commented that the present international
recommendations on diagnosis of silicosis and screening of workers potentially
exposed to silica dust are appropriate for use in Australia.
These are presently established in Australia
under Hazardous Substances Regulations and NOHSC Guidelines on Health
Surveillance (1995). These are consistent with comparable economies including
the USA, UK
and Western Europe. CCAA also stated that as silicosis
and other toxic dust diseases are at such low levels in Australia,
that no additional or special facilities are warranted in the context of public
health priorities.[129]
4.8
Witnesses pointed out that as some patients would not
be accurately diagnosed with diseases arising from toxic dust, further research
is required to fully understand the extent of diseases caused by fine dust.[130] The ACTU recommended that government
adequately fund research into improving medical tests for dust diseases,
particularly silica and asbestos related diseases, with a focus on early
detection and commented:
At the moment I think that we struggle. We do not have research
into early detection, nor do we have enough research dollars going towards
looking for cures. They are very difficult and long-term projects, but the
longer we leave it the greater the number of workers who will die, so money
needs to be pushed into those areas, especially if you consider the long
latency period of toxic dust diseases.[131]
4.9
The Construction, Forestry, Mining and Energy Union (CFMEU)
noted that the medical profession was for many years reluctant to accept white
asbestos (Chrysotile) as a carcinogen or cause of lung disease. The CFMEU saw an
urgent need for an effective education program to ensure this is not repeated
with crystalline silica.[132]
4.10
Dr Thomas
Faunce, Senior
Lecturer at the Medical School
and Law Faculty, Australian National
University stated:
The message that is coming through from people like Richard
[White], if I could break it down, is that there are potentially enormous
numbers of Australians out there who have something wrong with them. They know
something is wrong with them, they know they have worked in an industry where
they have been exposed to something, whether it is silica or nanotechnology in
the future, but they just do not know where to go. They go to the GPs, but the
GPs do not have the expertise to diagnose it so they pass them off and say,
'You’ve got a bit of smoking,' a bit like the High Court did. Richard
is saying that you want some centre where people know that, if they have
something like this, if they have a history of industrial exposure, they can go
there and get to the bottom of the problem quickly. I have mentioned
enforcement standards and the importance of having medical centres of
excellence.[133]
Employee health surveillance
4.11
There was discussion in evidence on the need for health
surveillance of employees exposed to toxic dust. Witnesses noted the importance
of monitoring of workers who are exposed to toxic dust so that loss of lung
function can be detected before symptoms are noticeable.[134] The ANZSRS commented:
...monitoring should be part and parcel of everybody going into an
environment where there is a risk of exposure. There is no point waiting until
exposure has occurred and deleterious changes have occurred. It is too late. We
have to monitor everybody and get measurements on people when they are fit and
healthy, not just when they are starting to get sick. The starting point is
very critical.[135]
4.12
WHS noted that research has indicated that workers
exposed to respirable crystalline silica who are regularly monitored present, on
average, for compensation at a less severe stage of disease.[136]
4.13
Mr Bruce
Ham noted the need for a register of workers
and to have them undertake pre-employment and periodic health assessments:
'this does not prevent disease, but permits some understanding of the
occurrence of disease and progression of disease in current workers'.[137]
4.14
The ACTU supported regular screening in industries
where workers are exposed to toxic dust and suggested that as well as a lung
capacity test, chest X-rays every two years of workers in those industries should
be considered.[138] The ACTU also
raised particular concerns about practices in sandblasting and recommended that
government establish a screening program for all former workers from the
sandblasting industry for dust diseases at no cost to the workers:
I think that the government and business need to take the lead
on this and provide those workers with, if not peace of mind, at least
detection of the disease if it has affected them. We are talking about
thousands of workers here. I would suggest that it needs to be a government
initiative and it needs to be done now.[139]
4.15
The States and Territories have all adopted hazardous
substances regulations based on the national model regulations produced by the
Commonwealth in 1994. The model regulations set out the requirements for health
surveillance where:
-
an employee is at risk from one of the 16 listed
hazardous substances (including asbestos, crystalline silica and vinyl
chloride); and
-
an employee could be exposed to a hazardous
substance and there is a disease or health effect that can be caused by that
exposure; there is a reasonable likelihood that the disease or health effect
could occur under the conditions of work; and there are valid ways of detecting
the disease or health effect.
4.16
The health surveillance must be performed under the
supervision of a legally qualified medical practitioner who is adequately
trained in the tests or procedures necessary. In the case of the listed
hazardous substances, the type of surveillance is specified including medical tests.
For example, the requirements for crystalline silica are occupational and
medical history, demographic data, completion of a standardised respiratory
questionnaire, standardised respiratory function test and chest X-ray. For
those working with asbestos, the health surveillance is to be conducted every two
years and every five years for crystalline silica. The employee is advised of
the results and the health surveillance records must be kept by the employer as
a confidential record for at least 30 years.[140]
4.17
The Department of Employment and Workplace Relations
(DEWR) noted that when the health surveillance guidelines were first released
NOHSC worked with physicians to make them aware that the information was
available.[141]
4.18
In some industries health surveillance for workers
coming into contact with hazardous substances is well established. In NSW and Queensland
there is provision for a centralised health surveillance program for the coal
mining industry.[142] For example, Coal
Services noted that periodic medicals are undertaken about every three to five
years, and at every second medical an X-ray is taken for coal miners in NSW. Coal
Services pointed to the success of their program by referring to the USA
where, although the threshold level for coal dust is lower than in New
South Wales, the incidence of pneumoconiosis is
costing the American coal industry $US1 billion per annum in workers'
compensation.[143]
4.19
In NSW, the Dust Diseases Board is able to test for a
range of possible diseases including asbestosis and silicosis. The service is
provided free of charge to NSW workers who fall under the Dust Diseases Board
compensation protocol. In addition, the Board offers an on-going commercial
screening service to industry to facilitate compliance with occupational health
and safety legislation. Workers can be screened at the Respiratory Assessment
Centre in Sydney
or on the Lung Bus. The Lung Bus provides respiratory assessment services
'on-site' for up to 64 employees per day.[144]
4.20
CCAA also stated that the cement, concrete and
aggregates industry also conducted regular screening as required by regulation.
The industry tended to undertake screening four yearly rather than five yearly
to ensure that all employees are examined. However, CCAA went on to state that
the five year time frame is based on the national exposure standards. If an
employee was in an industry where there was very high exposure, for example, sandblasting
with exposures around 15 or 20 mg/m3
the worker may need an X-ray every six months.[145]
4.21
The Minerals Council of Australia (MCA) informed the
Committee that companies generally considered legislative requirements to be
the minimum and most companies completed additional health assessments.[146]
4.22
However, in other sectors, for example the building
industry, workers are not likely to be regularly tested or do not have a centralised
scheme for the data collected. The problem is exacerbated as in some industries
workers change employers frequently. The Australian Manufacturing Workers Union
(AMWU) commented that while certain regulations require that health
surveillance be carried out, it is 'patchy and has its difficulties, in that it
is only related to a couple of particular issues, like asbestos and if the
silica levels are up at a particular rate'.[147]
4.23
A further problem noted by the CFMEU is the lack of a
central repository for the records so that they could be accessed easily.[148] The Minerals Council of Australia
also noted the mining industry had identified a need for a central data scheme
so that data can be analysed to establish trends and allow following of
individuals. The MCA further commented:
There is limited exposure data held electronically and little or
no correlation between health information and exposure data either at the
Government or company level. The limited exposure data that is currently
collected in an electronic dataset makes it difficult to establish a
relationship between occupational exposure and disease particularly when there
may be lifestyle factors that also affect the likelihood of disease. The data
currently held in electronic data sets limits both the following of individuals
and the identification of tends. If electronic data capture is to be widely
established, consideration needs to be given to privacy concerns, costs and
resources and the potential use of information for litigation.[149]
4.24
The ANZSRS also commented on the need for high quality
testing and monitoring. Those doing the testing need to be highly trained and
the equipment used needed to be regularly checked and calibrated for quality
assurance. However, the Society indicated that 'it is well established that the
quality of spirometry performed in the primary care sector is not good'. The
ANZSRS also recommended that lung function reports contain certain information
including flow/volume and volume/time graphics and must be of sufficient size
that all information is easily read and can form part of a permanent record.[150] The ANZSRS concluded:
It is in the area of serial monitoring that quality assurance
plays a very critical role. The physician reviewing the test results must be
able to have absolute confidence that the tests have been performed to the same
standard every time. The data quality must be independent of any changes in
equipment, changes of staff or the time since the person doing the testing has
had refresher training. Only with these guarantees can the physician concerned
know that any changes are due to changes in the patient's profile. Furthermore, it is the serial changes that
are crucial to successful early detection and management of any disease process
that may result from workplace exposure. Negative trends can be apparent even
though the absolute measures are still within the reference ranges.
The need for consistency of approach is becoming increasingly
important as the workforce becomes more mobile.
Data from one area should be able to be compared with data from another
area in the interest of gaining long term trending and separating pre-existing
trends from current trends.[151]
4.25
Witnesses commented that pre-employment screening was
important. Pre-employment screening was necessary to establish a baseline for
the employee and to establish if there are any existing conditions that may
make an employee more susceptible than usual to hazards in the workplace.[152] Witnesses advocated the need for a
lung function test and a chest X-ray. The ANZSRS commented that spirometry
should be seriously considered as a minimum in pre-employment screening where
there are work place exposure risks. The ANZSRS added that pre-employment
spirometry would also help address the questions of contributions to airway and
parenchymal lung dysfunction due to volitional practices, such as smoking, from
workplace exposure to dusts.[153]
4.26
While acknowledging the need for health monitoring, the
AMWU warned that too much effort on health surveillance often means that the
focus on control at source and stopping the problem before it affects employees
is lost:
The problem that may well be showing up in certain sectors in
terms of silicosis is not because we did not know the problem was there. We
have known about silicosis...for over 50 years. The concern is that if you put a
lot of effort into surveillance but then do nothing about it, what is the
point? You are just picking up a lot of 'had it' lungs.[154]
4.27
Mr John
Edwards raised with the Committee the
problems of detecting Chronic Beryllium Disease (CBD). Mr
Edwards noted that blood testing using the
Beryllium Blood Lymphocyte Proliferation Test (BELPT) had only recently become
available at the John Hunter
Hospital in Newcastle.
Some airline workers commenced testing in mid February 2006.[155]
Employee records
4.28
A number of witnesses discussed the issue of employee
records. CCAA noted that under the hazardous substances regulations the
employer is responsible for keeping the records. However, records are made
available to workers in the concrete industry on request.[156] Coal Services also commented that
it held the records of health testing on all coal miners who enter the NSW coal
mining industry and those who present for health surveillance screening
assessments:
We hold onto those X-rays, but we make them available. If an
individual wants to have access to them, say, to discuss them with his GP, we
provide them. The reason we hang onto them is that people in the coalmining
industry tend not to leave. They get paid a lot of money, and it is very
difficult for them to earn as much money doing something else. So if we are
going to measure the health of an individual over a period of time, we need
access to these X-rays to contrast where they were 10 years ago with where they
are today.[157]
4.29
However, some witnesses suggested that employees should
hold their own records. The ANZSRS, for example commented:
If they change job or anything else, that data goes with them.
It is serial history. With the increasing mobility in the work force, that is
very important.[158]
Conclusions
4.30
The early diagnosis of dust-related disease is
difficult. Dust-related disease may be confused with other lung conditions or
may be attributed to lifestyle factors such as smoking. There also appears to
have been slow acceptance that exposure to crystalline silica causes health conditions
other than silicosis. However, early diagnosis is important to limiting the
extent of disease and ensuring that adequate treatment is provided.
4.31
While there are guidelines in place to ensure that employees
working with toxic dust receive adequate and timely health checks, it appears
that not all industries comply with this standard. Some employees, particularly
in the non-mining industries or those who work for small companies, may not
receive the level of health surveillance that their occupational exposure to
toxic dust warrants.
4.32
A further problem highlighted in evidence was the need
for accurate testing as without quality assurance programs for testing, the
results of monitoring, particularly over time, may be questionable and of
little value to the worker and their treating physician. Lung function tests
should also be performed on a regular basis so that deterioration can be
identified as early as possible.
4.33
The Committee considers that adequate medical services are
available for those suffering the effects of toxic dust-related disease.
However, the Committee considers that the particular problems of exposure to toxic
dust are not well understood by medical practitioners and that subsequently not
all workers with dust-related disease will be identified.
Recommendation 3
4.34
That the Australian Safety and Compensation Council, in
conjunction with the Heads of Workplace Safety Authorities, consider mechanisms
to improve health surveillance of employees, particularly those exposed to
toxic dust.
Recommendation 4
4.35
That the Australian Safety and Compensation Council
promote the dissemination of information concerning the health effects of
exposure to toxic dust to the medical profession.
Recommendation 5
4.36
That the Australian Safety and Compensation Council
examine the need for improvements in testing regimes for lung disease
associated with exposure to toxic dust including the training of those conducting
tests and equipment requirements.
Navigation: Previous Page | Contents | Next Page