California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 4 - Construction Safety Orders › Article 4 - Dusts, Fumes, Mists, Vapors, and Gases › Appendix B - to Section 1532.3 Medical Surveillance Guidelines (Non-mandatory)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Introduction
The purpose of this Appendix is to provide medical
						information and recommendations to aid physicians and other licensed health
						care professionals (PLHCPs) regarding compliance with the medical surveillance
						provisions of the respirable crystalline silica standard (Section
						1532.3). Appendix B is for
						informational and guidance purposes only and none of the statements in Appendix
						B should be construed as imposing a mandatory requirement on employers that is
						not otherwise imposed by the standard.
Medical screening and surveillance allow for early
						identification of exposure-related health effects in individual employee and
						groups of employees, so that actions can be taken to both avoid further
						exposure and prevent or address adverse health outcomes. Silica-related
						diseases can be fatal, encompass a variety of target organs, and may have
						public health consequences when considering the increased risk of a latent
						tuberculosis (TB) infection becoming active. Thus, medical surveillance of
						silica-exposed employees requires that PLHCPs have a thorough knowledge of
						silica-related health effects.
This Appendix is divided into seven sections. Section
						1 reviews silica-related diseases,
						medical responses, and public health responses. Section
						2 outlines the components of the
						medical surveillance program for employees exposed to silica. Section
						3 describes the roles and
						responsibilities of the PLHCP implementing the program and of other medical
						specialists and public health professionals. Section
						4 provides a discussion of
						considerations, including confidentiality. Section
						5 provides a list of additional
						resources and Section
						6 lists references. Section
						7 provides sample forms for the
						written medical report for the employee, the written medical opinion for the
						employer and the written authorization.
1. Recognition of Silica-Related
						Diseases
1.1. Overview.
The term "silica" refers
						specifically to the compound silicon dioxide (SiO2). Silica is a major
						component of sand, rock, and mineral ores. Exposure to fine (respirable size)
						particles of crystalline forms of silica is associated with adverse health
						effects, such as silicosis, lung cancer, chronic obstructive pulmonary disease
						(COPD), and activation of latent TB infections. Exposure to respirable
						crystalline silica can occur in industry settings such as foundries, abrasive
						blasting operations, paint manufacturing, glass and concrete product
						manufacturing, brick making, china and pottery manufacturing, manufacturing of
						plumbing fixtures, and many construction activities including highway repair,
						masonry, concrete work, rock drilling, and tuck-pointing. New uses of silica
						continue to emerge. These include countertop manufacturing, finishing, and
						installation (Kramer
et al.
2012; OSHA 2015) and hydraulic
						fracturing in the oil and gas industry (OSHA 2012).
Silicosis is an irreversible, often disabling, and
						sometimes fatal fibrotic lung disease. Progression of silicosis can occur
						despite removal from further exposure. Diagnosis of silicosis requires a
						history of exposure to silica and radiologic findings characteristic of silica
						exposure. Three different presentations of silicosis (chronic, accelerated, and
						acute) have been defined. Accelerated and acute silicosis are much less common
						than chronic silicosis. However, it is critical to recognize all cases of
						accelerated and acute silicosis because these are life-threatening illnesses
						and because they are caused by substantial overexposures to respirable
						crystalline silica. Although any case of silicosis indicates a breakdown in
						prevention, a case of acute or accelerated silicosis implies current high
						exposure and a very marked breakdown in prevention.
In addition to silicosis, employees exposed to respirable
						crystalline silica, especially those with accelerated or acute silicosis, are
						at increased risks of contracting active TB and other infections (ATS 1997;
						Rees and Murray 2007). Exposure to respirable crystalline silica also increases
						an employee's risk of developing lung cancer, and the higher the cumulative
						exposure, the higher the risk (Steenland
et al.
2001;
						Steenland and Ward 2014). Symptoms for these diseases and other respirable
						crystalline silica-related diseases are discussed below.
1.2. Chronic Silicosis.
Chronic
						silicosis is the most common presentation of silicosis and usually occurs after
						at least 10 years of exposure to respirable crystalline silica. The clinical
						presentation of chronic silicosis is:
1.2.1. Symptoms--shortness of breath and cough, although
						employees may not notice any symptoms early in the disease. Constitutional
						symptoms, such as fever, loss of appetite and fatigue, may indicate other
						diseases associated with silica exposure, such as TB infection or lung cancer.
						Employees with these symptoms should immediately receive further evaluation and
						treatment.
1.2.2. Physical Examination--may be normal or disclose
						dry rales or rhonchi on lung auscultation.
1.2.3. Spirometry--may be normal or may show only a mild
						restrictive or obstructive pattern.
1.2.4. Chest X-ray--classic findings are small, rounded
						opacities in the upper lung fields bilaterally. However, small irregular
						opacities and opacities in other lung areas can also occur. Rarely, "eggshell
						calcifications" in the hilar and mediastinal lymph nodes are seen.
1.2.5. Clinical Course--chronic silicosis in most cases
						is a slowly progressive disease. Under the respirable crystalline silica
						standard, the PLHCP is to recommend that employees with a 1/0 category X-ray be
						referred to an American Board Certified Specialist in Pulmonary Disease or
						Occupational Medicine. The PLHCP and/or Specialist should counsel employees
						regarding work practices and personal habits that could affect employees'
						respiratory health.
1.3. Accelerated Silicosis.
Accelerated
						silicosis generally occurs within 5-10 years of exposure and results from high
						levels of exposure to respirable crystalline silica. The clinical presentation
						of accelerated silicosis is:
1.3.1. Symptoms--shortness of breath, cough, and
						sometimes sputum production. Employees with exposure to respirable crystalline
						silica, and especially those with accelerated silicosis, are at high risk for
						activation of TB infections, atypical mycobacterial infections, and fungal
						superinfections. Constitutional symptoms, such as fever, weight loss,
						hemoptysis (coughing up blood), and fatigue may herald one of these infections
						or the onset of lung cancer.
1.3.2. Physical Examination--rales, rhonchi, or other
						abnormal lung findings in relation to illnesses present. Clubbing of the
						digits, signs of heart failure, and cor pulmonale may be present in severe lung
						disease.
1.3.3. Spirometry--restrictive or mixed
						restrictive/obstructive pattern.
1.3.4. Chest X-ray--small rounded and/or irregular
						opacities bilaterally. Large opacities and lung abscesses may indicate
						infections, lung cancer, or progression to complicated silicosis, also termed
						progressive massive fibrosis.
1.3.5. Clinical Course--accelerated silicosis has a
						rapid, severe course. Under the respirable crystalline silica standard, the
						PLHCP can recommend referral to a Board Certified Specialist in either
						Pulmonary Disease or Occupational Medicine, as deemed appropriate, and referral
						to a Specialist is recommended whenever the diagnosis of accelerated silicosis
						is being considered.
1.4. Acute Silicosis.
Acute silicosis is
						a rare disease caused by inhalation of extremely high levels of respirable
						crystalline silica particles. The pathology is similar to alveolar proteinosis
						with lipoproteinaceous material accumulating in the alveoli. Acute silicosis
						develops rapidly, often, within a few months to less than 2 years of exposure,
						and is almost always fatal. The clinical presentation of acute silicosis is as
						follows:
1.4.1. Symptoms--sudden, progressive, and severe
						shortness of breath. Constitutional symptoms are frequently present and include
						fever, weight loss, fatigue, productive cough, hemoptysis (coughing up blood),
						and pleuritic chest pain.
1.4.2. Physical Examination--dyspnea at rest, cyanosis,
						decreased breath sounds, inspiratory rales, clubbing of the digits, and
						fever.
1.4.3. Spirometry--restrictive or mixed
						restrictive/obstructive pattern.
1.4.4. Chest X-ray--diffuse haziness of the lungs
						bilaterally early in the disease. As the disease progresses, the "ground glass"
						appearance of interstitial fibrosis will appear.
1.4.5. Clinical Course--employees with acute silicosis
						are at especially high risk of TB activation, nontuberculous mycobacterial
						infections, and fungal superinfections. Acute silicosis is immediately
						life-threatening. The employee should be urgently referred to a Board Certified
						Specialist in Pulmonary Disease or Occupational Medicine for evaluation and
						treatment. Although any case of silicosis indicates a breakdown in prevention,
						a case of acute or accelerated silicosis implies a profoundly high level of
						silica exposure and may mean that other employees are currently exposed to
						dangerous levels of silica.
1.5. COPD.
COPD, including chronic
						bronchitis and emphysema, has been documented in silica-exposed employees,
						including those who do not develop silicosis. Periodic spirometry tests are
						performed to evaluate each employee for progressive changes consistent with the
						development of COPD. In addition to evaluating spirometry results of individual
						employees over time, PLHCPs may want to be aware of general trends in
						spirometry results for groups of employees from the same workplace to identify
						possible problems that might exist at that workplace. (
See
Section 2 of this Appendix on Medical
						Surveillance for further discussion.) Heart disease may develop secondary to
						lung diseases such as COPD. A recent study by Liu
et al.
2014
						noted a significant exposure-response trend between cumulative silica exposure
						and heart disease deaths, primarily due to pulmonary heart disease, such as cor
						pulmonale.
1.6. Renal and Immune System.
Silica
						exposure has been associated with several types of kidney disease, including
						glomerulonephritis, nephrotic syndrome, and end stage renal disease requiring
						dialysis. Silica exposure has also been associated with other autoimmune
						conditions, including progressive systemic sclerosis, systemic lupus
						erythematosus, and rheumatoid arthritis. Studies note an association between
						employees with silicosis and serologic markers for autoimmune diseases,
						including antinuclear antibodies, rheumatoid factor, and immune complexes
						(Jalloul and Banks 2007; Shtraichman
et al.
2015).
1.7. TB and Other Infections.
Silica-exposed employees with latent TB are 3 to 30 times more likely to
						develop active pulmonary TB infection (ATS 1997; Rees and Murray 2007).
						Although respirable crystalline silica exposure does not cause TB infection,
						individuals with latent TB infection are at increased risk for activation of
						disease if they have higher levels of respirable crystalline silica exposure,
						greater profusion of radiographic abnormalities, or a diagnosis of silicosis.
						Demographic characteristics, such as immigration from some countries, are
						associated with increased rates of latent TB infection. PLHCPs can review the
						latest Centers for Disease Control and Prevention (CDC) information on TB
						incidence rates and high risk populations online (
See
Section
						5 of this Appendix). Additionally,
						silica-exposed employees are at increased risk for contracting nontuberculous
						mycobacterial infections, including
Mycobacterium
						avium-intracellulare
and
Mycobacterium
						kansaii
.
1.8. Lung Cancer.
The National
						Toxicology Program has listed respirable crystalline silica as a known human
						carcinogen since 2000 (NTP 2014). The International Agency for Research on
						Cancer (2012) has also classified silica as Group 1 (carcinogenic to humans).
						Several studies have indicated that the risk of lung cancer from exposure to
						respirable crystalline silica and smoking is greater than additive (Brown 2009;
						Liu
et al.
2013). Employees should be counseled on smoking
						cessation.
2. Medical
						Surveillance
PLHCPs who manage silica medical surveillance programs
						should have a thorough understanding of the many silica-related diseases and
						health effects outlined in Section
						1 of this Appendix. At each
						clinical encounter, the PLHCP should consider silica-related health outcomes,
						with particular vigilance for acute and accelerated silicosis. In this Section,
						the required components of medical surveillance under the respirable
						crystalline silica standard are reviewed, along with additional guidance and
						recommendations for PLHCPs performing medical surveillance examinations for
						silica-exposed employees.
2.1. History
2.1.1. The respirable crystalline silica standard
						requires the following: A medical and work history, with emphasis on: Past,
						present, and anticipated exposure to respirable crystalline silica, dust, and
						other agents affecting the respiratory system; any history of respiratory
						system dysfunction, including signs and symptoms of respiratory disease
						(
e.g.
, shortness of breath, cough, wheezing); history of TB;
						and smoking status and history.
2.1.2. Further, the employer must provide the PLHCP with
						the following information:
2.1.2.1. A description of the employee's former, current,
						and anticipated duties as they relate to the employee's occupational exposure
						to respirable crystalline silica;
2.1.2.2. The employee's former, current, and anticipated
						levels of occupational exposure to respirable crystalline silica;
2.1.2.3. A description of any personal protective
						equipment used or to be used by the employee, including when and for how long
						the employee has used or will use that equipment; and
2.1.2.4. Information from records of employment-related
						medical examinations previously provided to the employee and currently within
						the control of the employer.
2.1.3. Additional guidance and recommendations: A history
						is particularly important both in the initial evaluation and in periodic
						examinations. Information on past and current medical conditions (particularly
						a history of kidney disease, cardiac disease, connective tissue disease, and
						other immune diseases), medications, hospitalizations and surgeries may uncover
						health risks, such as immune suppression, that could put an employee at
						increased health risk from exposure to silica. This information is important
						when counseling the employee on risks and safe work practices related to silica
						exposure.
2.2. Physical Examination
2.2.1. The respirable crystalline silica standard
						requires the following: A physical examination, with special emphasis on the
						respiratory system. The physical examination must be performed at the initial
						examination and every three years thereafter.
2.2.2. Additional guidance and recommendations: Elements
						of the physical examination that can assist the PHLCP include: An examination
						of the cardiac system, an extremity examination (for clubbing, cyanosis, edema,
						or joint abnormalities), and an examination of other pertinent organ systems
						identified during the history.
2.3. TB Testing
2.3.1. The respirable crystalline silica standard
						requires the following: Baseline testing for TB on initial examination.
2.3.2. Additional guidance and recommendations:
2.3.2.1. Current CDC guidelines (
See
Section 5 of this Appendix) should be
						followed for the application and interpretation of Tuberculin skin tests (TST).
						The interpretation and documentation of TST reactions should be performed
						within 48 to 72 hours of administration by trained PLHCPs.
2.3.2.2. PLHCPs may use alternative TB tests, such as
						interferon-
y
release assays (IGRAs), if sensitivity and
						specificity are comparable to TST (Mazurek
et al.
2010; Slater
et al.
2013). PLHCPs can consult the current CDC guidelines
						for acceptable tests for latent TB infection.
2.3.2.3. The silica standard allows the PLHCP to order
						additional tests or test at a greater frequency than required by the standard,
						if deemed appropriate. Therefore, PLHCPs might perform periodic
						(
e.g.
, annual) TB testing as appropriate, based on employees'
						risk factors. For example, according to the American Thoracic Society (ATS),
						the diagnosis of silicosis or exposure to silica for 25 years or more are
						indications for annual TB testing (ATS 1997). PLHCPs should consult the current
						CDC guidance on risk factors for TB (
See
Section
						5 of this Appendix).
2.3.2.4. Employees with positive TB tests and those with
						indeterminate test results should be referred to the appropriate agency or
						specialist, depending on the test results and clinical picture. Agencies, such
						as local public health departments, or specialists, such as a pulmonary or
						infectious disease specialist, may be the appropriate referral. Active TB is a
						nationally notifiable disease. PLHCPs should be aware of the reporting
						requirements for their region. All States have TB Control Offices that can be
						contacted for further information. (
See
Section
						5 of this Appendix for links to
						CDC's TB resources and State TB Control Offices.)
2.3.2.5. The following public health principles are key
						to TB control in the U.S. (ATS-CDC-IDSA 2005):
(
1
) Prompt detection and reporting of
						persons who have contracted active TB;
(
2
) Prevention of TB spread to close
						contacts of active TB cases;
(
3
) Prevention of active TB in people
						with latent TB through targeted testing and treatment; and
(
4
) Identification of settings at high
						risk for TB transmission so that appropriate infection-control measures can be
						implemented.
2.4. Pulmonary Function Testing
2.4.1. The respirable crystalline silica standard
						requires the following: Pulmonary function testing must be performed on the
						initial examination and every three years thereafter. The required pulmonary
						function test is spirometry and must include forced vital capacity (FVC),
						forced expiratory volume in one second (FEV 1), and FEV
						1/FVC ratio. Testing must be administered by a
						spirometry technician with a current certificate from a National Institute for
						Occupational Health and Safety (NIOSH)-approved spirometry course.
2.4.2. Additional guidance and recommendations:
						Spirometry provides information about individual respiratory status and can be
						used to track an employee's respiratory status over time or as a surveillance
						tool to follow individual and group respiratory function. For quality results,
						the ATS and the American College of Occupational and Environmental Medicine
						(ACOEM) recommend use of the third National Health and Nutrition Examination
						Survey (NHANES III) values, and ATS publishes recommendations for spirometry
						equipment (Miller
et al.
2005; Townsend 2011; Redlich
et al.
2014). OSHA's publication,
Spirometry Testing
						in Occupational Health Programs: Best Practices for Healthcare
						Professionals,
provides helpful guidance (See Section
						5 of this Appendix). Abnormal
						spirometry results may warrant further clinical evaluation and possible
						recommendations for limitations on the employee's exposure to respirable
						crystalline silica.
2.5. Chest X-ray
2.5.1. The respirable crystalline silica standard
						requires the following: A single posteroanterior (PA) radiographic projection
						or radiograph of the chest at full inspiration recorded on either film (no less
						than 14 x 17 inches and no more than 16 x 17 inches) or digital radiography
						systems. A chest X-ray must be performed on the initial examination and every
						three years thereafter. The chest X-ray must be interpreted and classified
						according to the International Labour Office (ILO) International Classification
						of Radiographs of Pneumoconioses by a NIOSH-certified B Reader.
Chest radiography is necessary to diagnose silicosis,
						monitor the progression of silicosis, and identify associated conditions such
						as TB. If the B reading indicates small opacities in a profusion of 1/0 or
						higher, the employee is to receive a recommendation for referral to a Board
						Certified Specialist in Pulmonary Disease or Occupational Medicine.
2.5.2. Additional guidance and recommendations: Medical
						imaging has largely transitioned from conventional film-based radiography to
						digital radiography systems. The ILO Guidelines for the Classification of
						Pneumoconioses has historically provided film-based chest radiography as a
						referent standard for comparison to individual exams. However, in 2011, the ILO
						revised the guidelines to include a digital set of referent standards that were
						derived from the prior film-based standards. To assist in assuring that
						digitally-acquired radiographs are at least as safe and effective as film
						radiographs, NIOSH has prepared guidelines, based upon accepted contemporary
						professional recommendations (
See
Section
						5 of this Appendix). Current
						research from Laney
et al.
2011 and Halldin
et
						al.
2014 validate the use of the ILO digital referent images. Both
						studies conclude that the results of pneumoconiosis classification using
						digital references are comparable to film-based ILO classifications. Current
						ILO guidance on radiography for pneumoconioses and B-reading should be reviewed
						by the PLHCP periodically, as needed, on the ILO or NIOSH Web sites
						(
See
Section
						5 of this Appendix).
2.6. Other Testing.
Under the respirable
						crystalline silica standards, the PLHCP has the option of ordering additional
						testing he or she deems appropriate. Additional tests can be ordered on a
						case-by-case basis depending on individual signs or symptoms and clinical
						judgment. For example, if an employee reports a history of abnormal kidney
						function tests, the PLHCP may want to order a baseline renal function tests
						(
e.g.
, serum creatinine and urinalysis). As indicated above,
						the PLHCP may order annual TB testing for silica-exposed employees who are at
						high risk of developing active TB infections. Additional tests that PLHCPs may
						order based on findings of medical examinations include, but is not limited to,
						chest computerized tomography (CT) scan for lung cancer or COPD, testing for
						immunologic diseases, and cardiac testing for pulmonary-related heart disease,
						such as cor pulmonale.
3. Roles and
						Responsibilities
3.1. PLHCP.
The PLHCP designation refers
						to "an individual whose legally permitted scope of practice
						(
i.e.
, license, registration, or certification) allows him or
						her to independently provide or be delegated the responsibility to provide some
						or all of the particular health care services required" by the respirable
						crystalline silica standard. The legally permitted scope of practice for the
						PLHCP is determined by each State. PLHCPs who perform clinical services for a
						silica medical surveillance program should have a thorough knowledge of
						respirable crystalline silica-related diseases and symptoms. Suspected cases of
						silicosis, advanced COPD, or other respiratory conditions causing impairment
						should be promptly referred to a Board Certified Specialist in Pulmonary
						Disease or Occupational Medicine.
Once the medical surveillance examination is completed,
						the employer must ensure that the PLHCP explains to the employee the results of
						the medical examination and provides the employee with a written medical report
						within 30 days of the examination. The written medical report must contain a
						statement indicating the results of the medical examination, including any
						medical condition(s) that would place the employee at increased risk of
						material impairment to health from exposure to respirable crystalline silica
						and any medical conditions that require further evaluation or treatment. In
						addition, the PLHCP's written medical report must include any recommended
						limitations on the employee's use of respirators, any recommended limitations
						on the employee's exposure to respirable crystalline silica, and a statement
						that the employee should be examined by a Board Certified Specialist in
						Pulmonary Disease or Occupational medicine if the chest X-ray is classified as
						1/0 or higher by the B Reader, or if referral to a Specialist is otherwise
						deemed appropriate by the PLHCP.
The PLHCP should discuss all findings and test results
						and any recommendations regarding the employee's health, worksite safety and
						health practices, and medical referrals for further evaluation, if indicated.
						In addition, it is suggested that the PLHCP offer to provide the employee with
						a complete copy of their examination and test results, as some employees may
						want this information for their own records or to provide to their personal
						physician or a future PLHCP. Employees are entitled to access their medical
						records.
Under the respirable crystalline silica standard, the
						employer must ensure that the PLHCP provides the employer with a written
						medical opinion within 30 days of the employee examination, and that the
						employee also gets a copy of the written medical opinion for the employer
						within 30 days. The PLHCP may choose to directly provide the employee a copy of
						the written medical opinion. This can be particularly helpful to employees,
						such as construction employees, who may change employers frequently. The
						written medical opinion can be used by the employee as proof of up-to-date
						medical surveillance. The following lists the elements of the written medical
						report for the employee and written medical opinion for the employer. (Sample
						forms for the written medical report for the employee, the written medical
						opinion for the employer, and the written authorization are provided in Section
						7 of this Appendix.)
3.1.1. The written medical report for the employee must
						include the following information:
3.1.1.1. A statement indicating the results of the
						medical examination, including any medical condition(s) that would place the
						employee at increased risk of material impairment to health from exposure to
						respirable crystalline silica and any medical conditions that require further
						evaluation or treatment;
3.1.1.2. Any recommended limitations upon the employee's
						use of a respirator;
3.1.1.3. Any recommended limitations on the employee's
						exposure to respirable crystalline silica; and
3.1.1.4. A statement that the employee should be examined
						by a Board Certified Specialist in Pulmonary Disease or Occupational Medicine,
						where the standard requires or where the PLHCP has determined such a referral
						is necessary. The standard requires referral to a Board Certified Specialist in
						Pulmonary Disease or Occupational Medicine for a chest X-ray B reading
						indicating small opacities in a profusion of 1/0 or higher, or if the PHLCP
						determines that referral to a Specialist is necessary for other silica-related
						findings.
3.1.2. The PLHCP's written medical opinion for the
						employer must include only the following information:
3.1.2.1. The date of the examination;
3.1.2.2. A statement that the examination has met the
						requirements of this section; and
3.1.2.3. Any recommended limitations on the employee's
						use of respirators.
3.1.2.4. If the employee provides the PLHCP with written
						authorization, the written opinion for the employer shall also contain either
						or both of the following:
(1)
Any recommended limitations on the
						employee's exposure to respirable crystalline silica; and
(2)
A statement that the employee should
						be examined by a Board Certified Specialist in Pulmonary Disease or
						Occupational Medicine if the chest X-ray provided in accordance with this
						section is classified as 1/0 or higher by the B Reader, or if referral to a
						Specialist is otherwise deemed appropriate.
3.1.2.5. In addition to the above referral for abnormal
						chest X-ray, the PLHCP may refer an employee to a Board Certified Specialist in
						Pulmonary Disease or Occupational Medicine for other findings of concern during
						the medical surveillance examination if these findings are potentially related
						to silica exposure.
3.1.2.6. Although the respirable crystalline silica
						standard requires the employer to ensure that the PLHCP explains the results of
						the medical examination to the employee, the standard does not mandate how this
						should be done. The written medical opinion for the employer could contain a
						statement that the PLHCP has explained the results of the medical examination
						to the employee.
3.2. Medical Specialists.
The silica
						standard requires that all employees with chest X-ray B readings of 1/0 or
						higher be referred to a Board Certified Specialist in Pulmonary Disease or
						Occupational Medicine. If the employee has given written authorization for the
						employer to be informed, then the employer shall make available a medical
						examination by a Specialist within 30 days after receiving the PLHCP's written
						medical opinion.
3.2.1. The employer must provide the following
						information to the Board Certified Specialist in Pulmonary Disease or
						Occupational Medicine:
3.2.1.1. A description of the employee's former, current,
						and anticipated duties as they relate to the employee's occupational exposure
						to respirable crystalline silica;
3.2.1.2. The employee's former, current, and anticipated
						levels of occupational exposure to respirable crystalline silica;
3.2.1.3. A description of any personal protective
						equipment used or to be used by the employee, including when and for how long
						the employee has used or will use that equipment; and
3.2.1.4. Information from records of employment-related
						medical examinations previously provided to the employee and currently within
						the control of the employer.
3.2.2. The PLHCP should make certain that, with written
						authorization from the employee, the Board Certified Specialist in Pulmonary
						Disease or Occupational Medicine has any other pertinent medical and
						occupational information necessary for the specialist's evaluation of the
						employee's condition.
3.2.3. Once the Board Certified Specialist in Pulmonary
						Disease or Occupational Medicine has evaluated the employee, the employer must
						ensure that the Specialist explains to the employee the results of the medical
						examination and provides the employee with a written medical report within 30
						days of the examination. The employer must also ensure that the Specialist
						provides the employer with a written medical opinion within 30 days of the
						employee examination. (Sample forms for the written medical report for the
						employee, the written medical opinion for the employer and the written
						authorization are provided in Section
						7 of this Appendix.)
3.2.4. The Specialist's written medical report for the
						employee must include the following information:
3.2.4.1. A statement indicating the results of the
						medical examination, including any medical condition(s) that would place the
						employee at increased risk of material impairment to health from exposure to
						respirable crystalline silica and any medical conditions that require further
						evaluation or treatment;
3.2.4.2. Any recommended limitations upon the employee's
						use of a respirator; and
3.2.4.3. Any recommended limitations on the employee's
						exposure to respirable crystalline silica.
3.2.5. The Specialist's written medical opinion for the
						employer must include the following information:
3.2.5.1. The date of the examination; and
3.2.5.2. Any recommended limitations on the employee's
						use of respirators.
3.2.5.3. If the employee provides the Board Certified
						Specialist in Pulmonary Disease or Occupational Medicine with written
						authorization, the written medical opinion for the employer shall also contain
						any recommended limitations on the employee's exposure to respirable
						crystalline silica.
3.2.5.4. Although the respirable crystalline silica
						standard requires the employer to ensure that the Board Certified Specialist in
						Pulmonary Disease or Occupational Medicine explains the results of the medical
						examination to the employee, the standard does not mandate how this should be
						done. The written medical opinion for the employer could contain a statement
						that the Specialist has explained the results of the medical examination to the
						employee.
3.2.6. After evaluating the employee, the Board Certified
						Specialist in Pulmonary Disease or Occupational Medicine should provide
						feedback to the PLHCP as appropriate, depending on the reason for the referral.
						OSHA believes that because the PLHCP has the primary relationship with the
						employer and employee, the Specialist may want to communicate his or her
						findings to the PLHCP and have the PLHCP simply update the original medical
						report for the employee and medical opinion for the employer. This is permitted
						under the standard, so long as all requirements and time deadlines are
						met.
3.3. Public Health Professionals.
PLHCPs
						might refer employees or consult with public health professionals as a result
						of silica medical surveillance. For instance, if individual cases of active TB
						are identified, public health professionals from state or local health
						departments may assist in diagnosis and treatment of individual cases and may
						evaluate other potentially affected persons, including coworkers. Because
						silica-exposed employees are at increased risk of progression from latent to
						active TB, treatment of latent infection is recommended. The diagnosis of
						active TB, acute or accelerated silicosis, or other silica-related diseases and
						infections should serve as sentinel events suggesting high levels of exposure
						to silica and may require consultation with the appropriate public health
						agencies to investigate potentially similarly exposed coworkers to assess for
						disease clusters. These agencies include local or state health departments or
						OSHA. In addition, NIOSH can provide assistance upon request through their
						Health Hazard Evaluation program. (
See
Section
						5 of this Appendix)
4. Confidentiality and Other
						Considerations
The information that is provided from the PLHCP to the
						employee and employer under the medical surveillance section of OSHA's
						respirable crystalline silica standard differs from that of medical
						surveillance requirements in previous OSHA standards. The standard requires two
						separate written communications, a written medical report for the employee and
						a written medical opinion for the employer. The confidentiality requirements
						for the written medical opinion are more stringent than in past standards. For
						example, the information the PLHCP can (and must) include in his or her written
						medical opinion for the employer is limited to: The date of the examination, a
						statement that the examination has met the requirements of this section, and
						any recommended limitations on the employee's use of respirators. If the
						employee provides written authorization for the disclosure of any limitations
						on the employee's exposure to respirable crystalline silica, then the PLHCP can
						(and must) include that information in the written medical opinion for the
						employer as well. Likewise, with the employee's written authorization, the
						PLHCP can (and must) disclose the PLHCP's referral recommendation (if any) as
						part of the written medical opinion for the employer. However, the opinion to
						the employer must not include information regarding recommended limitations on
						the employee's exposure to respirable crystalline silica or any referral
						recommendations without the employee's written authorization.
The standard also places limitations on the information
						that the Board Certified Specialist in Pulmonary Disease or Occupational
						Medicine can provide to the employer without the employee's written
						authorization. The Specialist's written medical opinion for the employer, like
						the PLHCP's opinion, is limited to (and must contain): The date of the
						examination and any recommended limitations on the employee's use of
						respirators. If the employee provides written authorization, the written
						medical opinion can (and must) also contain any limitations on the employee's
						exposure to respirable crystalline silica.
The PLHCP should discuss the implication of signing or
						not signing the authorization with the employee (in a manner and language that
						he or she understands) so that the employee can make an informed decision
						regarding the written authorization and its consequences. The discussion should
						include the risk of ongoing silica exposure, personal risk factors, risk of
						disease progression, and possible health and economic consequences. For
						instance, written authorization is required for a PLHCP to advise an employer
						that an employee should be referred to a Board Certified Specialist in
						Pulmonary Disease or Occupational Medicine for evaluation of an abnormal chest
						X-ray (B-reading 1/0 or greater). If an employee does not sign an
						authorization, then the employer will not know and cannot facilitate the
						referral to a Specialist and is not required to pay for the Specialist's
						examination. In the rare case where an employee is diagnosed with acute or
						accelerated silicosis, co-workers are likely to be at significant risk of
						developing those diseases as a result of inadequate controls in the workplace.
						In this case, the PLHCP and/or Specialist should explain this concern to the
						affected employee and make a determined effort to obtain written authorization
						from the employee so that the PLHCP and/or Specialist can contact the
						employer.
Finally, without written authorization from the employee,
						the PLHCP and/or Board Certified Specialist in Pulmonary Disease or
						Occupational Medicine cannot provide feedback to an employer regarding control
						of workplace silica exposure, at least in relation to an individual employee.
						However, the regulation does not prohibit a PLHCP and/or Specialist from
						providing an employer with general recommendations regarding exposure controls
						and prevention programs in relation to silica exposure and silica-related
						illnesses, based on the information that the PLHCP receives from the employer
						such as employees' duties and exposure levels. Recommendations may include
						increased frequency of medical surveillance examinations, additional medical
						surveillance components, engineering and work practice controls, exposure
						monitoring and personal protective equipment. For instance, more frequent
						medical surveillance examinations may be a recommendation to employers for
						employees who do abrasive blasting with silica because of the high exposures
						associated with that operation.
ACOEM's Code of Ethics and discussion is a good resource
						to guide PLHCPs regarding the issues discussed in this section
						(
See
Section
						5 of this Appendix).
5. Resources
5.1. American College of Occupational and Environmental
						Medicine (ACOEM):
ACOEM Code of Ethics. Accessed at:
http://www.acoem.org/codeofconduct.aspx
Raymond, L.W. and Wintermeyer, S. (2006) ACOEM
						evidenced-based statement on medical surveillance of silica-exposed workers:
						Medical surveillance of workers exposed to crystalline silica.
J Occup
						Environ Med,
48, 95-101.
5.2. Center for Disease Control and Prevention
						(CDC)
Tuberculosis Web page:
http://www.cdc.gov/tb/default.htm
State TB Control Offices Web page:
http://www.cdc.gov/tb/links/tboffices.htm
Tuberculosis Laws and Policies Web page:
http://www.cdc.gov/tb/programs/laws/default.htm
CDC. (2013). Latent Tuberculosis Infection: A Guide for
						Primary Health Care Providers. Accessed at:
http://www.cdc.gov/tb/publications/ltbi/pdf/targetedltbi.pdf
5.3. International Labour Organization
International Labour Office (ILO). (2011) Guidelines for
						the use of the ILO International Classification of Radiographs of
						Pneumoconioses, Revised edition 2011. Occupational Safety and Health Series No.
						22:
http://www.ilo.org/safework/info/publications/WCMS_168260/lang-en/index.htm
5.4. National Institute of Occupational Safety and Health
						(NIOSH)
NIOSH B Reader Program Web page. (Information on
						interpretation of X-rays for silicosis and a list of certified B-readers).
						Accessed at:
http://www.cdc.gov/niosh/topics/chestradiography/breader-info.html
NIOSH Guideline (2011). Application of Digital
						Radiography for the Detection and Classification of Pneumoconiosis. NIOSH
						publication number 2011-198. Accessed at:
http://www.cdc.gov/niosh/docs/2011-198/.
NIOSH Hazard Review (2002), Health Effects of
						Occupational Exposure to Respirable Crystalline Silica. NIOSH publication
						number 2002-129: Accessed at
http://www.cdc.gov/niosh/docs/2002-129/
NIOSH Health Hazard Evaluations Programs. (Information on
						the NIOSH Health Hazard Evaluation (HHE) program, how to request an HHE and how
						to look up an HHE report). Accessed at:
http://www.cdc.gov/niosh/hhe/
5.5. National Industrial Sand Association:
Occupational Health Program for Exposure to Crystalline
						Silica in the Industrial Sand Industry. National Industrial Sand Association,
						2nd ed. 2010. Can be ordered at:
http://www.sand.org/silica-occupational-health-program
5.6. Occupational Safety and Health Administration
						(OSHA)
Contacting OSHA:
http://www.osha.gov/html/Feed_Back.html
OSHA's Clinicians Web
						page. (OSHA resources, regulations and links to help clinicians navigate OSHA's
						Web site and aid clinicians in caring for workers.) Accessed at:
http://www.osha.gov/dts/oom/clinicians/index.html
OSHA's Safety and Health Topics Web page on Silica.
						Accessed at:
http://www.osha.gov/dsg/topics/silicacrystalline/index.html
OSHA (2013). Spirometry Testing in Occupational Health
						Programs: Best Practices for Healthcare Professionals. (OSHA 3637-03 2013).
						Accessed at:
http://www.osha.gov/Publications/OSHA3637.pdf
OSHA/NIOSH (2011). Spirometry: OSHA/NIOSH Spirometry
						InfoSheet (OSHA 3415-1-11). (Provides guidance to employers). Accessed at
http://www.osha.gov/Publications/osha3415.pdf
OSHA/NIOSH (2011) Spirometry: OSHA/NIOSH Spirometry
						Worker Info. (OSHA 3418-3-11). Accessed at
http://www.osha.gov/Publications/osha3418.pdf
5.7. Other
Steenland, K. and Ward E. (2014). Silica: A lung
						carcinogen.
CA Cancer J Clin,
64, 63-69. (This article reviews
						not only silica and lung cancer but also all the known silica-related health
						effects. Further, the authors provide guidance to clinicians on medical
						surveillance of silica-exposed workers and worker counselling on safety
						practices to minimize silica exposure.)
6. References
American Thoracic Society (ATS). Medical Section of the
						American Lung Association (1997). Adverse effects of crystalline silica
						exposure.
Am J Respir Crit Care Med,
155, 761-765.
American Thoracic Society (ATS), Centers for Disease
						Control (CDC), Infectious Diseases Society of America (IDSA) (2005).
						Controlling Tuberculosis in the United States.
Morbidity and Mortality
						Weekly Report (MMWR),
54(RR12), 1-81. Accessed at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm.
Brown, T. (2009). Silica exposure, smoking, silicosis and
						lung cancer-complex interactions.
Occupational Medicine,
59,
						89-95. Halldin, C.N., Petsonk, E.L., and Laney, A.S. (2014). Validation of the
						International Labour Office digitized standard images for recognition and
						classification of radiographs of pneumoconiosis.
Acad Radiol,
21, 305-311.
International Agency for Research on Cancer. (2012).
						Monographs on the evaluation of carcinogenic risks to humans: Arsenic, Metals,
						Fibers, and Dusts Silica Dust, Crystalline, in the Form of Quartz or
						Cristobalite. A Review of Human Carcinogens. Volume 100 C. Geneva, Switzerland:
						World Health Organization.
Jalloul, A.S. and Banks D.E. (2007). Chapter 23. The
						health effects of silica exposure. In: Rom, W.N. and Markowitz, S.B. (Eds).
						Environmental and Occupational Medicine, 4th edition. Lippincott, Williams and
						Wilkins, Philadelphia, 365-387.
Kramer, M.R., Blanc, P.D., Fireman, E., Amital, A.,
						Guber, A., Rahman, N.A., and Shitrit, D. (2012). Artifical stone silicosis:
						Disease resurgence among artificial stone workers.
Chest,
142,
						419-424.
Laney, A.S., Petsonk, E.L., and Attfield, M.D. (2011).
						Intramodality and intermodality comparisons of storage phosphor computed
						radiography and conventional film-screen radiography in the recognition of
						small pneumonconiotic opacities.
Chest,
140, 1574-1580.
Liu, Y., Steenland, K., Rong, Y., Hnizdo, E., Huang, X.,
						Zhang, H., Shi, T., Sun, Y., Wu, T., and Chen, W. (2013). Exposure-response
						analysis and risk assessment for lung cancer in relationship to silica
						exposure: A 44-year cohort study of 34,018 workers.
Am J Epi,
178, 1424-1433.
Liu, Y., Rong, Y., Steenland, K., Christiani, D.C.,
						Huang, X., Wu, T., and Chen, W. (2014). Long-term exposure to crystalline
						silica and risk of heart disease mortality.
Epidemiology,
25,
						689-696.
Mazurek, G.H., Jereb, J., Vernon, A., LoBue, P.,
						Goldberg, S., Castro, K. (2010). Updated guidelines for using interferon gamma
						release assays to detect Mycobacterium tuberculosis infection-United States.
Morbidity and Mortality Weekly Report (MMWR),
59(RR05),
						1-25.
Miller, M.R., Hankinson, J., Brusasco, V., Burgos, F.,
						Casaburi, R., Coates, A., Crapo, R., Enright, P., van der Grinten, C.P.,
						Gustafsson, P., Jensen, R., Johnson, D.C., MacIntyre, N., McKay, R., Navajas,
						D., Pedersen, O.F., Pellegrino, R., Viegi, G., and Wanger, J. (2005).
American Thoracic Society/European Respiratory Society
						(ATS/ERS) Task Force: Standardisation of Spirometry.
Eur Respir
						J,
26, 319-338.
National Toxicology Program (NTP) (2014). Report on
						Carcinogens, Thirteenth Edition. Silica, Crystalline (respirable Size).
						Research Triangle Park, NC: U.S. Department of Health and Human Services,
						Public Health Service.
http://ntp.niehs.nih.gov/ntp/roc/content/profiles/silica.pdf.
Occupational Safety and Health Administration/National
						Institute for Occupational Safety and Health (OSHA/NIOSH) (2012). Hazard Alert.
						Worker exposure to silica during hydraulic fracturing.
Occupational Safety and Health Administration/National
						Institute for Occupational Safety and Health (OSHA/NIOSH) (2015). Hazard alert.
						Worker exposure to silica during countertop manufacturing, finishing, and
						installation. (OSHA-HA-3768-2015).
Redlich, C.A., Tarlo, S.M., Hankinson, J.L., Townsend,
						M.C, Eschenbacher, W.L., Von Essen, S.G., Sigsgaard, T., Weissman, D.N. (2014).
						Official American Thoracic Society technical standards: Spirometry in the
						occupational setting.
Am J Respir Crit Care Med
; 189,
						984-994.
Rees, D. and Murray, J. (2007). Silica, silicosis and
						tuberculosis.
Int J Tuberc Lung Dis
, 11(5), 474-484.
Shtraichman, O., Blanc, P.D., Ollech, J.E., Fridel, L.,
						Fuks, L., Fireman, E., and Kramer, M.R. (2015). Outbreak of autoimmune disease
						in silicosis linked to artificial stone.
Occup Med,
65,
						444-450.
Slater, M.L., Welland, G., Pai, M., Parsonnet, J., and
						Banaei, N. (2013). Challenges with QuantiFERON-TB gold assay for large-scale,
						routine screening of U.S. healthcare workers.
Am J Respir Crit Care
						Med,
188, 1005-1010.
Steenland, K., Mannetje, A., Boffetta, P., Stayner, L.,
						Attfield, M., Chen, J., Dosemeci, M., DeKlerk, N., Hnizdo, E., Koskela, R., and
						Checkoway, H. (2001). International Agency for Research on Cancer. Pooled
						exposure-response analyses and risk assessment for lung cancer in 10 cohorts of
						silica-exposed workers: An IARC multicentre study.
Cancer Causes
						Control,
12(9):773-84.
Steenland, K. and Ward E. (2014). Silica: A lung
						carcinogen.
CA Cancer J Clin,
64, 63-69.
Townsend, M.C. ACOEM Guidance Statement. (2011).
						Spirometry in the occupational health setting-2011 Update.
J Occup
						Environ Med,
53, 569-584.
7. Sample Forms
Three sample forms are provided. The first is a sample
						written medical report for the employee. The second is a sample written medical
						opinion for the employer. And the third is a sample written authorization form
						that employees sign to clarify what information the employee is authorizing to
						be released to the employer.
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1. New
						Appendix B filed 10-17-2016; operative 10-17-2016 pursuant to Labor Code
						section
						142.3.
						Submitted to OAL for filing and printing only pursuant to Labor Code section
						142.3(a)(3)
						(Register 2016, No. 43).
Note: Authority cited: Sections
						  142.3,
						  9020,
						  9030 and
						  9040, Labor
						  Code. Reference: Sections
						  142.3,
						  9004(d),
						  9009,
						  9020,
						  9031 and
						  9040, Labor
						  Code.