Severe Silicosis in Engineered Stone Fabrication Workers

California, Colorado, Texas, and Washington, 2017-2019

Cecile Rose, MD; Amy Heinzerling, MD; Ketki Patel, MD, PhD; Coralynn Sack, MD; Jenna Wolff; Lauren Zell-Baran, MPH; David Weissman, MD; Emily Hall, MPH; Robbie Sooriash, MD; Ronda B. McCarthy, MD; Heidi Bojes, PhD; Brian Korotzer, MD; Jennifer Flattery, MPH; Justine Lew Weinberg, MSEHS; Joshua Potocko, MD; Kirk D. Jones, MD; Carolyn K. Reeb-Whitaker, MS; Nicholas K. Reul, MD; Claire R. LaSee, MPH, MSW; Barbara L. Materna, PhD; Ganesh Raghu, MD; Robert Harrison, MD


Morbidity and Mortality Weekly Report. 2019;68(38):813-818. 

In This Article

Investigation and Results

California. In January 2019, the California Department of Public Health identified, through review of hospital discharge data for silicosis diagnoses (International Classification of Diseases, Tenth Revision [ICD-10] code J62.8), a Hispanic man aged 37 years who was hospitalized in 2017 (CA-1) (Table). He worked at a stone countertop fabrication company during 2004–2013, mainly with engineered stone. His work tasks included polishing slabs and dry-cutting and grinding stone edges. Workplace measurements during a California Division of Occupational Safety and Health inspection in 2009 showed respirable crystalline silica levels up to 22 times higher than the permissible exposure limit (PEL) of 0.1 mg/m3 in effect in California at that time. After developing respiratory symptoms in 2012, he had a chest CT scan, which revealed findings of silicosis. Pulmonary function testing showed restrictive defects with reduced diffusion capacity; surgical lung biopsy showed mixed dust pneumoconiosis with polarizable particles consistent with silica. He concurrently received a diagnosis of scleroderma, with positive anti-Scl-70 and antinuclear antibodies. He died from silicosis in 2018 at age 38 years.

Further investigation of patient CA-1's place of employment, in collaboration with the California Division of Occupational Safety and Health, identified two additional silicosis cases among stone fabricators. The first patient (CA-2) was a Hispanic man who worked at the same company during 2003–2016 and died in 2018 at age 36 years. He had a history of rheumatoid arthritis with positive rheumatoid factor and cyclic citrullinated peptide antibodies. He was hospitalized in 2016 with respiratory symptoms and chest CT findings of silicosis but was lost to medical follow-up. After his death, investigators obtained lung tissue from autopsy, which showed silicotic nodules and alveolar proteinosis (indicating accelerated silicosis). The third case occurred in a Hispanic man aged 36 years who had worked at the company for 11 years and received a silicosis diagnosis in 2018 (CA-3). Since initiation of this investigation, three additional employees of the same stone fabrication company, all Hispanic men aged 35–59 years (CA-4, CA-5, and CA-6), have screened positive for silicosis by chest radiograph, with diagnoses subsequently confirmed by chest CT.

Colorado. In January 2019, a Colorado physician specializing in occupational lung disease observed an increasing number of silicosis cases in her practice and undertook a systematic review of electronic medical records for patients she had seen during June 2017–December 2018 with a silicosis diagnosis (ICD-10 code J62.8). Typically, the physician saw two cases of silicosis in a year; however, during June 2017–December 2018, seven cases of silicosis were identified (CO-1–CO-7), all among employees of stone fabrication companies (Table). Two workers were female, and all seven of the workers were Hispanic. They had worked at 12 Colorado companies during 1984–2018, most of which employed <50 workers. Five patients reported cutting, grinding, and polishing mainly engineered stone; two reported only bystander exposure to engineered stone dust during workplace housekeeping duties.

All seven patients had chest CT findings consistent with silicosis. Four had undergone diagnostic lung biopsy before occupational medicine referral. One biopsy was prompted by findings on chest CT, and three patients had received a rheumatoid arthritis diagnosis based on positive autoimmune serology testing and erosive joint disease with lung biopsies showing findings of silicosis. Two patients had latent tuberculosis infection diagnosed by positive interferon-gamma release assays and negative sputum cultures. Pulmonary function was abnormal in five patients; one had severe restrictive lung disease, and four had exertional hypoxemia indicated by arterial blood gas testing. Six patients had two or more chest images for comparison; five showed progressive silicosis evidenced by increased profusion of lung nodules over time. Patients were medically removed from any ongoing silica exposure and counseled on workers' compensation and the need for long-term medical follow-up. The federal Occupational Safety and Health Administration and the Colorado Department of Public Health and Environment were informed of these cases as occupational sentinel health events needing follow-up to protect other potentially exposed workers.

Texas. During March–April 2019, the Texas Department of State Health Services received reports of an apparent cluster of silicosis cases among workers at an engineered stone countertop manufacturing and fabrication facility. Twelve cases were identified as meeting the National Institute for Occupational Safety and Health surveillance case definition for silicosis.§ Four of the 12 workers (TX-1–TX-4) had silicosis diagnoses confirmed by chest CT (Table); the remaining eight workers screened positive by chest radiograph but did not have confirmatory findings on chest CT. All four of the persons with confirmed silicosis were men aged 40–59 years; two were Hispanic, and two were non-Hispanic black. Three worked as fabricators, and one worked in engineered stone slab casting and stripping. Work tasks included cutting, sanding, gluing, and finishing engineered stone countertops. Pulmonary function testing was abnormal in two patients, with findings of moderate to severe restriction.

Washington. In May 2018, Washington's Occupational Respiratory Disease Surveillance Program, through routine surveillance of workers' compensation data, identified a case of biopsy-confirmed silicosis in a Hispanic man aged 38 years who had worked in stone countertop fabrication during 2012–2018 (WA-1) (Table). His work tasks included cutting, polishing, and lamination of both natural and engineered stone. Chest CT demonstrated findings of silicosis, and lung biopsy found conglomerate areas of fibrosis and polarizable particles. Pulmonary function testing showed a severe restrictive defect and reduced diffusion capacity. He received a diagnosis of progressive massive fibrosis (the most advanced form of silicosis) and has had progressive lung function decline, necessitating referral for lung transplantation evaluation. Washington's Division of Occupational Safety and Health was informed of this case and completed a workplace inspection.

A permissible exposure limit (PEL) is the highest permissible level of exposure for a specific substance for an employee, as established under state or federal occupational safety and health regulations. The PEL cited here is for exposure as an 8-hour time-weighted average, which represents an employee's average airborne exposure to a particular substance during an 8-hour work shift.