Coal Mine Dust Lung Disease –An International Perspective. National Coalition of Black Lung and Respiratory Disease Clinics, Inc. September 26-28, Chicago, Illinois
Robert Cohen, MD, FCCPProfessor of Medicine
Northwestern University Feinberg School of Medicine
Clinical Professor - EOHS, University of Illinois
School of Public HealthChicago, Illinois
Disclosure of Funding Support Funded by the Alpha Foundation for the Improvement
of Mine Safety and Health Funded by HHS/HRSA/ORHP/BLCP & BLCE Employee of NIOSH/RHD Funded by USDOL/OWCP & MSHA Funded by Queensland, Australia DNRME Provide IME’s for Occupational Lung Disease
Pneumoconiosis – China, India, and Australia China
Largest Coal Producer and Consumer Highest rate of pneumoconiosis in the world Accounts for 85% of all reported occupational diseases.
No national surveillance system
India Second largest producer
No national surveillance system
Australia Myth that Black Lung was eliminated
State by state system of surveillance, dust control and monitoring No national surveillance system
World Coal Reserves in BTUs
Source: U.S. Energy Information Administration, International Energy Statistics.Note: Latest data available for the U.S. are 2009, international data are 2008
Coal Production in China – Metric Tons
China’s Coal Mines
China has about 10,760 coal mines (US had 1,885 in 2009) Plan to close 5,600 with production less than 90,000
tons/yr 90% are small mines (<300,000 tons) and make up only
36% of production Safety record worse than that of large mines. Death rates > than large mines –75% of fatalities
Chinese Coal Miners
China has 3,742,176 coal miners in 2010US 50,000 in 2017Chinese state owned mines – better dataChina has small private or
Township/Village Enterprises – less data, less regulated mines
The majority of miners are migrant peasants from rural areasMost vulnerable population
Chinese Miners
China 0.42 tons/miner hour – includes productivity of small mines
Australia – NSW – 4.76 tons/miner hourUS is 6.05 tons/miner hour
Chu C, Jain R, Muradian N, Zhang G. Statistical analysis of coal mining safety in China with reference to the impact of technology. Journal of the Southern African Institute of Mining and Metallurgy. 2016;116(1).
China’s Coal Mines
Regulation and Inspection carried out by State Administration of Worker Safety Combination of MSHA and NIOSH FunctionsOperates Hospitals, Institutes of Occ HealthResponsible for Inspections, EnforcementResponsible for Accident Investigations
National Center for International Exchange & Cooperation in Work Safety (SAWS)Works with MSHA
China – Pneumoconiosis Cases
Difficult to determine current national ratesLast national survey was 1992 then it was stopped
Prevalence of CWP was 6.49% at that timeNow only by company, mine, local or regional studies.
24,206 cases of pneumoconiosis in 2012China National Health and Family Planning
Commission Report: 2009-2013 – There were 105,000 cases of CWP
China – Pneumoconiosis Cases
Diagnosed by 3 radiologists using Chinese Diagnostic Criteria of Pneumoconiosis
Similar to ILO Standard Images88% of reported occupational disease is
pneumoconiosis48% of total reported cases of pneumoconiosis
are CWPReports from some newspapers state there are
70,000 new cases of Black Lung per year
CWP in China – Metanalysis of 11 Carefully Chosen Studies
173,646 dust exposed coal minersFrom 11 provinces in China
10,821 of them had CWPTotal prevalence 6.02%
Study from Hubei Province
Data from 2008-2013
Used annual reports of cases of CWP
3665 cases of pneumoconiosis 97% of these were silicosis and CWP
33% of cases occurred in miners with < 10 years of tenure
42% of cases from small and medium size enterprises
Xia Y, Liu J, Shi T, Xiang H, Bi Y. Prevalence of Pneumoconiosis in Hubei, China from 2008 to 2013. International Journal of Environmental Research and Public Health. 2014;11(9):8612-8621.
317 newly hired coal miners
132 conrols
Pre-employment then 15 follow up health surveys.
Analyze longitudinal data
Controlled for age, height, pack years, and dust exposure
Rapid initial loss in FEV1, then plateau and partial recovery
Consistent with other studies of initial losses due to dust exposure
Smokers lost greater amounts of FEV1
Young controls < 20 had continued lung growth
Dust exposed miners had declines in FEV1
Study of Tiefa Mine
CXR every 1 to 5 years depending on job
Used Chinese standard films for diagnosis
16,154 miners – 87% working, 9% retired, 4% deceased
CWP rates (positive at lowest category or greater) 0.37%, 12%, 18% in < 10, 10 to 20, and >20 tenure cohorts respectively
CWP related to duration of exposure and job
Cumulative Incidence of CWP by Job CategoryFig. 2. Cumulative incidence rates of CWP among coal miners with different occupational categories.
**indicate statistically significant difference (p<0.01) as compared with Mining by Log-rank test, ##compared with Helping, p<0.01.
Deaths in Coal Mining
80% of World Coal Mining Deaths are in ChinaDeath rate likely higher due to under-reporting
Avoid fines and mine closuresCorruption of small local mines
Rural areas less responsive to central regulation“Mountains are high and the emperor is out of sight”
Deaths in Chinese Coal Mine Industry Are Decreasing
Increased RegulationImproved LawsIncreased Public AwarenessClosure of small mines
Compensation for Death
Prior to 2004 ($1300 to $6400) Allowed operators to pay off families at slightly higher
rates if they agreed not to report
After 2005 ($25,000) Later instituted a fine of $130,000 to local
government agencies for each death. Resulted in incentive for government to be less
interested in prevention Resulted in incentive to negotiate with families to under-
report
China Safety Science Journal, Volume 14, Issue 8, p. 29; China Labor Bulletin, November 2006, Interview with Relatives of Coal Miners Died in Accidents.
China-Coal Mine Fatality Rates
India Coal Mine Fatality Rates
US Coal Mine Fatality Rates
Chinese Approach to the Treatment of pneumoconiosis
In the 1950s they focused on sanitaria which provided rest and recuperation and breathing exercises.
1960s Chinese medicines 1970s-80s anti-fibrotic medications From the midterm of 80s WLL was explored and was a
major part of treatment programs. Now moving away from WLL
Rehabilitation Center for Pneumoconiosis, State Administration of Coal Mine Safety, Beidaihe Sanatorium of Chinese Coal Miners
Beidaihe Sanatorium Whole Lung Lavage Program
Coal Mine Trust Fund (Created 2003) The China Treatment Foundation is funded at
approximately 115 Million RMBFunds approximately 50% of cases. Officially known as China Treatment
Foundation for Coal Worker’s PneumoconiosisEach contributing mine can select patients for
referral 50% of Cases funded privately
Cost of WLL is 10,000 RMB ($1,500)
Whole-lung lavage Fluid (WLLF)
Beidaihe Sanatorium Whole Lung Lavage Program
Performed 400 Cases in 201073% Stage I22% Stage II5% Stage III
5763 cases performed from 1991 to 2010
5716 cases (99.2%) for CWP Other diseases 47 (0.8%)
CWP in India
550,000 Coal Miners500 Coal minesHuge informal work force unorganized labor. Coal - Permissible exposure limit is 2.0 mg/m3 DGFASLI* – India’s NIOSH
Directorate General Factory Advice Service Labor Institutes
Coal Mining in India Coal Mines Nationalized in 1973 Mines act 1978
Provided for initial medical examination Provided for periodic medical examination every 5 years
Difficulty with diagnosis due to lack of standardized interpretation of radiographs and not widespread use of ILO standards.
1997 Study of Prevalence in Southeastern Indian Coal Fields 10 Areas, 72 mines Prevalence of CWP 1/0 or greater was 3%
Category 1 = 81%, Category 2 – 18%, Category 3 – 1%
Mining in Queensland
34 billion Tons Raw CoalBowen Basin8.7 Billion Tons Coking Coal
4 Billion Open Cut
3.7 – Underground
7000 Underground Coal Miners
25,000 Open Cut Coal Miners
Myth Of No Black Lung
1998 Review of Coal Workers’ Health Scheme concluded that pneumoconiosis was not a problem
Changed surveillance program into fitness for work program
Anyone could take CXRs and no standards for whom or how the images were classified
Images sent to the Department of Natural Resources and Mining – but not reviewed
No central data capture or processing
Data from New South Wales
US Investigators Use Australian Data to Question need for lower PEL
Joy GJ, Colinet JF, Landen DD. Coal workers’ pneumoconiosi prevalence disparity between Australia and the United States. Min Eng. 2012;64(7)
Queensland PEL
3 mg/m3
Ignored Data from Other Australian Sources
Study of pneumoconiosis mortality in Australia found that, of the 1,000 deaths attributed to pneumoconiosis between 1979 - 2002, only 6% were classified as CWP, with the number of fatalities decreasing steadily over time.
Compensation data showed that there were 750 new cases of pneumoconiosis (including CWP, asbestosis and silicosis) with 92 deaths in 2003 between 2001 and 2003.
Review of respiratory component of the medical assessment of Qld coal mine workers
Draft scope of the reviewMonash University
Malcolm Sim, Deborah Glass, Mina Roberts, Ryan Hoy
University of Illinois at Chicago
Robert Cohen, Leonard Go, Kirsten Almberg
Coal mine workers’ health scheme
Regular medical assessments Nominated Medical Advisers (NMA)Many organ systems, not just lungs Lung component includes lung conditions,
symptoms, lung function test and chest x-ray X-ray only for those ‘at risk of dust exposure’ Aim is early detection of coal dust lung disease Report on health assessment - NMA
Objectives of the review
Investigate whether the current design and operation of the lung component of the scheme is optimal to effectively detect early CMDLD
If not, recommend changes to improve identified deficiencies and identify what is needed to increase capacity in Qld
Australian Federal Government
Queensland Parliament InvestigationReport Issued May 2017
What has been accomplished since Monash/UIC Report CXR surveillance system comparable to NIOSH
Dual read and adjudication with up to 3 additional reads
Sponsored NIOSH Couse for B-Readers 13 Australian Radiologists Certified
Contract with Australian Provider for CXR surveillance
Training course for NMAs and EMOs Online, Webinars, and in person Workshops
Register for NMAs and EMOs
Spirometry Training Course Developed.
Data on CXR Reads to DateN=20,968
Age Number<30 4184
30-39 597140-49 510550-59 385860-69 141070+ 99
Data on CXR Reads to DateN=20,968
Category NumberNegative 20,417
1/0 1401/1 951/2 21≥2/1 6
A,B,C PMF 4
ILO Classifications by Age and Category
Age Group
Category <30 (n ,%) 30-39 (n ,%) 40-49 (n ,%) 50-59 (n ,%) 60-69 (n ,%) 70+ (n ,%)
Negative 4178 99.9 5945 99.7 5044 98.9 3735 97.1 1344 95.4 89 89.9
Category 1 4 0.0 18 0.3 54 1.0 105 2.7 63 4.5 10 10
≥ Category 2 0 0 1 0.017 0 0 4 0.01 1 0.07 0 0
PMF 0 0 0 0 1 0.0002 2 0.05 0 0 0 0
Total 4182 5964 5099 3846 1408 99
China – Dust Level Regulations
PC-TWA’s Crystalline Silica – 0.3 mg/m3 (US now 0.05 mg/m3 down from 0.1 mg/m3
Ji Y, et. Al. International Journal of Mining Science and Technology. 2016;26(2):199-208.
China and Australia Dust Sampling
Dust Regulations in Australia
Country / Region Concentration mg/m3
US (MSHA) 1.5 as of August 2016China 3.5QLD 3 (shift adjusted)NSW 2.5
BHP Billiton Corporate 2 (shift adjusted)NIOSH recommended 1.0
New South Wales Dust Limits
International Pneumoconiosis – Lessons Learned Medical surveillance is essential to monitor disease trends – especially with
changes in production and industrial processes. Medical surveillance is important to assess efficacy of primary preventive
strategies. Voluntary programs such as those in the US likely underestimate the
problem. Programs that only survey active miners will miss disease in retired/former
workers due to disease latency. Fitness for work programs without quality control and centralized analysis of
data will miss disease. Secondary Prevention may not work unless there are strong protections of
workers rights
U Shaped Curve of Concern in Public Health
New York City TB Rate/100,000 Pop1969-1989
Prevalence (%) of PMF among Appalachian Working Miners >25 years tenure. 1974-2012
From: Cohen, RA et. al. AJRCCM 2016, 194(6):773-775
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