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      Trends in Pneumoconiosis Deaths — United States, 1999–2018

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      , MPH 1 , 2 , , , MD, PhD 2
      Morbidity and Mortality Weekly Report
      Centers for Disease Control and Prevention

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          Pneumoconioses are preventable occupational lung diseases caused by inhaling dust particles such as coal dust or different types of mineral dusts ( 1 ). To assess recent trends in deaths associated with pneumoconiosis, CDC analyzed multiple cause-of-death data* , † for decedents aged ≥15 years for the years 1999–2018, and industry and occupation data collected from 26 states § for the years 1999, 2003, 2004, and 2007–2013. During 1999–2018, pneumoconiosis deaths decreased by 40.4%, with the exception of pneumoconiosis attributed to other inorganic dusts (e.g., aluminum, bauxite, beryllium, iron, and tin oxide), which increased significantly (p-value for time trend <0.05). The largest observed decreases in pneumoconiosis deaths were for those associated with coal workers’ pneumoconiosis (69.6%) and silicosis (53.0%). Asbestosis was the most frequently reported pneumoconiosis and was associated with working in the construction industry. The ongoing occurrence of deaths associated with pneumoconiosis underscores the importance of occupational dust exposure reduction, early case detection, and continued surveillance to monitor trends. The CDC National Vital Statistics System’s multiple cause-of-death data for 1999–2018 were analyzed for decedents aged ≥15 years. For this analysis, decedents were identified using death certificates listing pneumoconiosis as the underlying ¶ or contributing cause of death and included deaths with the following International Classification of Diseases, Tenth Revision (ICD-10) codes: J60 (coal workers’ pneumoconiosis), J61 (pneumoconiosis due to asbestos and other mineral fibers, [asbestosis]), J62 (pneumoconiosis due to dust containing silica, [silicosis]), J63 (pneumoconiosis due to other inorganic dust [applies to berylliosis, a disease caused by exposure to beryllium; pulmonary siderosis, a disease most common in workers exposed to metal fumes during welding; and other diseases]), J64 (unspecified pneumoconiosis), J65 (pneumoconiosis associated with tuberculosis), and J66 (airway disease due to specific organic dust [applies to byssinosis, a disease caused by prolonged inhalation of textile fiber dust]). Death rates per 1 million population were age-adjusted by applying age-specific death rates to the 2000 U.S. Census standard population.** Industry and occupation data were available from 26 states for 1999, 2003, 2004, and 2007–2013 and coded †† in accordance with the U.S. Census 2000 Industry and Occupation Classification System. §§ Cause-of-death data from the 26 states were compiled using CDC’s National Occupational Respiratory Mortality Surveillance system. ¶¶ Data were processed using SAS software (version 9.4; SAS Institute), and Joinpoint regression software (version 4.8.0.1; National Cancer Institute) was used to analyze time trends in deaths and log transformed death rates. During 1999–2018, a total of 43,366 decedents aged ≥15 years had pneumoconiosis listed on their death certificates, including 17,578 (40.5%) for whom pneumoconiosis was the underlying cause of death. Among all pneumoconiosis decedents, 17,797 (41.0%) were aged 75–84 years, and nearly all were male (41,777; 96.3%), white (41,029; 94.6%), and non-Hispanic (42,339; 97.6%). Asbestosis was associated with approximately three fifths of the deaths (26,059; 60.1%), followed by coal workers’ pneumoconiosis (11,203; 25.8%), and unspecified pneumoconiosis (3,409; 7.9%) (Table 1). TABLE 1 Pneumoconiosis mortality time trends among decedents aged ≥15 years, by disease* and year — United States, 1999–2018 Year No. of deaths (rate)† Total Coal workers’ pneumoconiosis Asbestosis Silicosis Pneumoconiosis attributed to other inorganic dusts Unspecified pneumoconiosis Pneumoconiosis associated with tuberculosis Airway disease attributed to specific organic dust 1999 2,738 (12.8) 1,002 (4.7) 1,258 (5.8) 185 (0.9) 12 (—)§ 284 (1.3) 5 (—) 7 (—) 2000 2,859 (13.2) 949 (4.4) 1,486 (6.8) 151 (0.7) 10 (—) 263 (1.2) 7 (—) 10 (—) 2001 2,743 (12.4) 886 (4.0) 1,449 (6.6) 163 (0.7) 10 (—) 233 (1.1) 7 (—) 10 (—) 2002 2,715 (12.2) 858 (3.8) 1,467 (6.6) 146 (0.6) 22 (0.1) 226 (1.0) 6 (—) 9 (—) 2003 2,635 (11.6) 772 (3.4) 1,464 (6.5) 177 (0.8) 12 (—) 210 (0.9) 6 (—) 8 (—) 2004 2,524 (11.0) 703 (3.1) 1,460 (6.4) 165 (0.7) 16 (—) 185 (0.8) 5 (—) 8 (—) 2005 2,425¶ (10.4) 652 (2.8) 1,416 (6.1) 160 (0.7) 19 (—) 189 (0.8) 7 (—) 7 (—) 2006 2,308 (9.7) 654 (2.8) 1,340 (5.7) 126 (0.5) 23 (0.1) 176 (0.7) 0 (—) 7 (—) 2007 2,189 (9.1) 524 (2.2) 1,393 (5.8) 122 (0.5) 9 (—) 144 (0.6) 5 (—) 5 (—) 2008 2,155 (8.8) 470 (1.9) 1,341 (5.5) 146 (0.6) 18 (—) 191 (0.8) 4 (—) 2 (—) 2009 1,993 (8.0) 480 (1.9) 1,255 (5.1) 121 (0.5) 15 (—) 140 (0.5) 2 (—) 1 (—) 2010 2,028 (8.0) 486 (1.9) 1,308 (5.2) 101 (0.4) 12 (—) 131 (0.5) 2 (—) 1 (—) 2011 1,890 (7.2) 409 (1.6) 1,243 (4.8) 88 (0.3) 17 (—) 140 (0.5) 4 (—) 5 (—) 2012 1,850 (6.8) 399 (1.4) 1,208 (4.5) 103 (0.4) 14 (—) 136 (0.5) 1 (—) 2 (—) 2013 1,859 (6.8) 361 (1.3) 1,229 (4.5) 111 (0.4) 22 (0.1) 145 (0.5) 2 (—) 1 (—) 2014 1,790 (6.4) 363 (1.3) 1,218 (4.4) 84 (0.3) 17 (—) 115 (0.4) 0 (—) 2 (—) 2015 1,735 (6.0) 323 (1.1) 1,188 (4.1) 105 (0.4) 25 (0.1) 107 (0.4) 2 (—) 2 (—) 2016 1,662 (5.6) 300 (1.0) 1,142 (3.9) 73 (0.2) 16 (—) 140 (0.4) 2 (—) 3 (—) 2017 1,636 (5.4) 307 (1.0) 1,102 (3.7) 98 (0.3) 17 (—) 118 (0.4) 1 (—) 5 (—) 2018 1,632 (5.3) 305 (1.0) 1,092 (3.5) 87 (0.3) 25 (0.1) 136 (0.4) 2 (—) 2 (—) Total 43,366** (8.6) 11,203 (2.2) 26,059 (5.2) 2,512 (0.5) 331 (0.1) 3,409 (0.7) 70 (0.0) 95 (0.0) Time trends Slope†† 1999–2002 = −19.96 1999–2008 = −58.29§§ 1999–2001 = 102.49§§ 1999–2018 = −5.04§§ 1999–2018 = 0.43§§ 1999–2007 = −15.13§§ 1999–2018 = −0.18§§ 1999–2009 = −0.96§§ 2002–2009 = −102.51§§ 2008–2018 = −20.63§§ 2001–2018 = −23.90§§ 2007–2018 = −3.09§§ 2009–2018 = 0.13 2009–2018 = −45.83§§ APC¶¶ 1999–2001 = −0.88 1999–2018 = −8.56§§ 1999–2002 = 4.02 N/A*** N/A*** N/A*** N/A*** N/A*** 2002–2018 = −5.22§§ 2001–2018 = −3.94§§ Source: CDC WONDER multiple cause-of-death data. https://wonder.cdc.gov/mcd.html. Abbreviations: APC = annual percent change; N/A = not available. * International Classification of Diseases, Tenth Revision codes: J60 (coal workers’ pneumoconiosis), J61 (pneumoconiosis due to asbestos and other mineral fibers, [asbestosis]), J62 (pneumoconiosis due to dust containing silica, [silicosis]), J63 (pneumoconiosis due to other inorganic dusts]), J64 (unspecified pneumoconiosis), J65 (pneumoconiosis associated with tuberculosis), and J66 (airway diseases due to specific organic dust). † Death rates per 1 million population were age-adjusted by applying age-specific death rates to the 2000 U.S. Census standard population. § Dashes indicate unreliable death rates because there were fewer than 20 deaths per year. ¶ Data were compiled using CDC WONDER’s record axis methodology, which differs from Healthy People 2020’s entity axis methodology. Healthy People 2020’s baseline total is 2,430. https://www.healthypeople.gov/node/5046/data_details. ** The sum of decedents is less than sum of disease-associated deaths because some decedents have more than one type of pneumoconiosis listed on their death certificate. †† Calculated using death counts; the slope characterizes the direction of the disease trend (negative slope indicates decrease in deaths over time). §§ p<0.05. ¶¶ Calculated using age-adjusted death rates. *** APCs could not be calculated because of unreliable death rates or insufficient data to determine standard error. During 1999–2018, the overall annual number of pneumoconiosis deaths decreased 40.4%; a significant decline began in 2002 (2,715 deaths) through 2018 (1,632) (p-value for time trend <0.05). Age-adjusted death rates (deaths per 1 million population) decreased from 12.8 in 1999 to 5.3 in 2018 (annual percent change = −0.88% during 1999–2001 and −5.22% during 2002–2018 [p-value for 2002–2018 time trend <0.05]). Deaths decreased for all types of pneumoconiosis during the period studied, with the exception of those attributed to other inorganic dusts, which increased significantly from 12 deaths in 1999 to 25 in 2018 (108.3%; p<0.05). However, none of the distinct disease categories in this group increased significantly. The largest decreases over time were for deaths associated with coal workers’ pneumoconiosis (69.6%), from 1,002 in 1999 to 305 in 2018 (p-value for time trend <0.05), and silicosis (53.0%), from 185 in 1999 to 87 in 2018 (p-value for 2018 time trend <0.05]) (Table 1). Age-adjusted death rates varied across geographic locations for each pneumoconiosis type (Table 2). The highest age-adjusted death rates for the 20-year period were in West Virginia for coal workers’ pneumoconiosis (59.8 per million population), Montana for asbestosis (20.0), Vermont for silicosis (2.3), and West Virginia for unspecified pneumoconiosis (24.1). TABLE 2 Number of coal workers’ pneumoconiosis, asbestosis, silicosis, and unspecified pneumoconiosis-associated deaths* and age-adjusted death rates † among persons aged ≥15 years, by state — United States, 1999–2018 State No. of deaths (rate) † Coal workers’ pneumoconiosis Asbestosis Silicosis Unspecified Alabama 120 (1.5) 818 (10.2) 41 (0.5) 51 (0.7) Alaska —§ 39 (7.2) —§ —§ Arizona 43 (0.4) 337 (3.2) 68 (0.6) 30 (0.3) Arkansas 37 (0.7) 249 (4.8) 20 (0.4) —§ California 155 (0.3) 1,844 (3.4) 105 (0.2) 48 (0.1) Colorado 111 (1.6) 270 (4.1) 119 (1.8) 115 (1.7) Connecticut —§ 327 (4.9) 13 (—)¶ —§ Delaware —§ 218 (14.2) —§ —§ District of Columbia —§ —§ —§ —§ Florida 184 (0.5) 1,667 (4.0) 68 (0.2) 49 (0.1) Georgia 31 (0.3) 308 (2.5) 39 (0.3) 22 (0.2) Hawaii —§ 56 (2.2) —§ —§ Idaho —§ 177 (7.6) 27 (1.1) 11 (—)¶ Illinois 234 (1.1) 435 (2.1) 65 (0.3) 59 (0.3) Indiana 133 (1.3) 216 (2.1) 53 (0.5) 35 (0.3) Iowa 31 (0.5) 153 (2.6) 16 (—)¶ 10 (—)¶ Kansas 12 (—)¶ 134 (2.7) 11 (—)¶ —§ Kentucky 1,596 (22.1) 246 (3.5) 57 (0.8) 350 (4.9) Louisiana 47 (0.7) 515 (7.4) 39 (0.5) —§ Maine —§ 287 (10.8) —§ —§ Maryland 34 (0.4) 728 (8.2) 26 (0.3) 23 (0.3) Massachusetts —§ 641 (5.3) 19 (—)¶ —§ Michigan 79 (0.5) 687 (4.0) 80 (0.5) 35 (0.2) Minnesota 13 (—)¶ 502 (5.6) 59 (0.7) —§ Mississippi 245 (5.3) 666 (14.0) 30 (0.6) —§ Missouri 25 (0.2) 258 (2.5) 41 (0.4) 10 (—)¶ Montana —§ 363 (20.0) 19 (—)¶ —§ Nebraska —§ 102 (3.2) —§ —§ Nevada 16 (—)¶ 132 (3.7) 27 (0.7) 15 (—)¶ New Hampshire —§ 125 (5.6) 10 (—)¶ —§ New Jersey 34 (0.2) 1,318 (8.6) 40 (0.3) 30 (0.2) New Mexico 75 (2.4) 96 (3.0) 51 (1.6) 113 (3.5) New York 52 (0.2) 1,178 (3.5) 119 (0.4) 56 (0.2) North Carolina 112 (0.7) 862 (5.8) 76 (0.5) 35 (0.2) North Dakota —§ 56 (4.3) —§ —§ Ohio 366 (1.8) 1045 (5.1) 204 (1.0) 139 (0.7) Oklahoma 40 (0.7) 206 (3.3) 28 (0.4) 13 (—)¶ Oregon —§ 597 (8.8) 36 (0.5) —§ Pennsylvania 3,258 (12.3) 1,553 (6.0) 268 (1.1) 636 (2.4) Rhode Island —§ 122 (5.9) 14 (—)¶ —§ South Carolina 41 (0.5) 536 (7.2) 39 (0.5) —§ South Dakota —§ 29 (1.8) 15 (—)¶ —§ Tennessee 273 (2.7) 515 (5.1) 52 (0.5) 59 (0.6) Texas 107 (0.3) 2,106 (6.7) 157 (0.4) 52 (0.1) Utah 89 (2.9) 112 (3.8) 45 (1.5) 63 (2.1) Vermont —§ 61 (5.5) 27 (2.3) —§ Virginia 1,300 (10.8) 894 (7.5) 44 (0.4) 326 (2.7) Washington 19 (—)¶ 1,322 (12.8) 36 (0.3) 12 (—)¶ West Virginia 2,191 (59.8) 516 (14.1) 58 (1.5) 887 (24.1) Wisconsin 22 (0.2) 382 (3.8) 116 (1.2) 14 (—)¶ Wyoming 28 (3.3) 45 (5.3) —§ 35 (4.2) Source: CDC WONDER multiple cause-of-death data. https://wonder.cdc.gov/mcd.html. * Pneumoconiosis deaths attributed to other organic dusts or specific organic dust or associated with tuberculosis are not displayed because the numbers of cases were fewer than10 for each state. † Death rates per 1 million population were age-adjusted by applying age-specific death rates to the 2000 U.S. Census standard population. § Suppressed because there were fewer than 10 decedents. ¶ Unreliable death rates because there were fewer than 20 deaths per state. Industry and occupation data were available for 6,223 (96.7%) of 6,436 pneumoconiosis-associated deaths among persons aged ≥15 years from 26 states during 1999, 2003, 2004, and 2007–2013 (Table 3). Whereas the highest number of coal workers’ pneumoconiosis–associated deaths occurred among workers in the coal mining industry (1,331; 74.2%), and among mining machine operators (1,203; 65.0%), the highest number of asbestosis-associated deaths occurred among workers in the construction industry (820; 25.0%) and among pipe layers, plumbers, pipefitters, and steamfitters (264; 8.0%). The highest number of silicosis-associated deaths occurred among workers in the construction industry (63; 18.9%) and among mining machine operators (41; 12.3%). TABLE 3 Top three industries and occupations associated with pneumoconiosis* deaths among persons aged ≥15 years, by diseaseꝉ — 26 states, § 1999, 2003, 2004, and 2007–2013 Disease Characteristic No. (%)¶ of deaths Coal workers’ pneumoconiosis (n = 1,838) Industry Coal mining 1,331 (74.2) Construction 75 (4.1) Nonpaid worker 52 (2.8) Occupation Mining machine operators 1,203 (65.0) Laborers and freight, stock, and material movers 43 (2.3) Homemakers 41 (2.2) Asbestosis (n = 3,284) Industry Construction 820 (25.0) Industrial/Miscellaneous chemicals 162 (5.0) Not specified manufacturing industries 148 (4.5) Occupation Pipe layers, plumbers, pipefitters, and steamfitters 264 (8.0) Electricians 145 (4.4) Carpenters 110 (3.4) Silicosis (n = 333) Industry Construction 63 (18.9) Coal mining 25 (7.5) Foundries 19 (5.7) Occupation Mining machine operators 41 (12.3) Laborers and freight, stock, and material movers 21 (6.3) Construction laborers 14 (4.2) Unspecified pneumoconiosis (n = 792) Industry Coal mining 508 (64.1) Metal ore mining 34 (4.3) Construction 32 (4.0) Occupation Mining machine operators 485 (61.2) Laborers and freight, stock, and material movers 17 (2.1) Electricians 15 (1.9) Source: National Institute for Occupational Safety and Health, CDC. https://webappa.cdc.gov/ords/norms-io2000.html. * Excludes the following International Classification of Diseases, Tenth Revision codes because five or fewer deaths occurred in available industries or occupations: J63 (pneumoconiosis due to other inorganic dusts), J65 (pneumoconiosis associated with tuberculosis), and J66 (airway diseases due to specific organic dust). † International Classification of Diseases, Tenth Revision codes: J60 (coal workers’ pneumoconiosis), J61 (pneumoconiosis due to asbestos and other mineral fibers, [asbestosis]), J62 (pneumoconiosis due to dust containing silica, [silicosis]), J64 (unspecified pneumoconiosis), J65 (pneumoconiosis associated with tuberculosis), and J66 (airway diseases due to specific organic dust [including byssinosis]). § Colorado, Florida, Georgia, Hawaii, Idaho, Indiana, Kansas, Kentucky, Louisiana, Michigan, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, and Wisconsin. States are where the death took place, not necessarily where the decedent had resided. Data were compiled using CDC’s National Occupational Respiratory Mortality Surveillance (NORMS) system. https://wonder.cdc.gov/wonder/help/mcd.html#Location. ¶ Percentage of total deaths associated with specific disease. Discussion CDC previously examined pneumoconiosis mortality for 1968–2000 and reported decreases in death trends in all pneumoconioses with the exception of asbestosis, for which an increase was observed ( 2 ). In this report, the annual number of deaths associated with pneumoconiosis have continued to decline during 1999–2018 for all pneumoconioses with the exception of pneumoconiosis attributed to other inorganic dusts, which increased. In this category, berylliosis and siderosis were the most frequently reported diseases; however, there was no evidence of a change in death rates attributed to these conditions. Each decade, the Healthy People Initiative develops new goals and objectives to improve the health of all Americans. The Healthy People 2020 Occupational Safety and Health Objective 4 set the goal of reducing pneumoconiosis deaths by 10% from the baseline of 2,430 deaths in 2005 to 2,187 deaths in 2020 ( 3 ). Results of this study indicate that the total number of pneumoconiosis deaths in 2018 was 1,632, a 32.8% decline from the baseline. If this trend continues, the goal will likely be surpassed in 2020. The decline in overall pneumoconiosis mortality primarily reflects the decrease in coal workers’ pneumoconiosis and silicosis deaths, which together accounted for nearly one third (31.6%) of all pneumoconiosis-associated deaths reported during 1999–2018. The decline in coal workers’ pneumoconiosis–associated deaths likely reflects the reduction in the coal mining industry workforce (from 108,224 in 1999 to 98,505 in 2015)*** and legislative actions. For example, the 1969 Federal Coal Mine Health and Safety Act ††† required federal inspections of all coal mines, created enforceable safety measures, and added health protections and federal benefits for coal workers’ pneumoconiosis. Several other historical statutes §§§ have been enacted to improve miner safety and decrease disease mortality. Most recently, the 2014 final rule ¶¶¶ of the Mine Safety and Health Administration (MSHA) standard on respirable coal mine dust lowered existing exposure limits from 2.0 mg of dust per cubic meter of air (mg/m3) to 1.5 mg/m3 at underground and surface coal mines, expanded medical monitoring for coal mine dust lung diseases, and made changes in dust monitoring systems to include the use of continuous personal dust monitors. Because of the long latency of coal workers’ pneumoconiosis, this new rule likely did not contribute to any decreases in mortality; however, adherence to this rule is expected to foster continued disease mortality reduction. The decline in silicosis-associated deaths likely reflects the enactment of national compliance standards for silica dust exposure in 1971, implementation of disease prevention initiatives, and changes in industrial activity ( 4 ). The early standards, however, did not include measures such as medical surveillance requirements or employer and employee training about silica hazards. In 2016, the Occupational Safety and Health Administration (OSHA) published a final rule,**** for crystalline silica, lowering the permissible exposure limit to 50 μg/m3 of air in all industries covered by the rule and included requirements to further protect employees (e.g., including exposure control, respiratory protection, hazard communication, medical surveillance, and recordkeeping). The rule also issued two separate standards, one for general industry and maritime and the other for construction, to tailor requirements to the respective industries’ hazards. Asbestosis continues to be the most frequently reported cause of pneumoconiosis mortality, accounting for 60.1% of all pneumoconiosis deaths during 1999–2018. The number of annual asbestosis-associated deaths began to decline in 2001. This ongoing decrease likely reflects the cessation of asbestos mining, discontinued manufacturing of asbestos-containing products in the United States, †††† adoption of standards intended to control emissions of asbestos into the environment ( 5 ), and adoption of lower permissible exposure limits ( 6 ). In 1971, OSHA established a permissible exposure limit for asbestos at 12.0 fibers per cubic centimeter (f/cc) of air as an 8-hour time-weighted average. This initial permissible exposure limit was subsequently reduced to 5.0 f/cc in 1972, to 2.0 f/cc in 1976, to 0.2 f/cc in 1986, and to 0.1 f/cc in 1994. Despite the decline in mortality and updated regulatory actions addressing occupational exposures to hazardous dusts, pneumoconiosis-associated deaths continue to occur, underscoring the need for maintaining exposure prevention measures and continued surveillance. Recent reports indicate the re-emergence of progressive massive fibrosis (the most severe form of coal workers’ pneumoconiosis) ( 7 ), new tasks and occupations (e.g., quartz countertop installation and hydraulic fracturing) that put workers at an increased risk for silicosis ( 8 ), continued importation of asbestos-containing materials for domestic consumption, and an increase in prevalence of other asbestos-associated diseases (e.g., malignant mesothelioma) ( 9 ). In addition, a 2019 significant new use rule §§§§ for asbestos, promulgated to ensure that any discontinued uses of asbestos cannot re-enter the marketplace without Environmental Protection Agency review, still permits importation of asbestos into the United States; use of asbestos in gaskets, brakes, and chemical manufacturing; and asbestos mining. The findings in this report are subject to at least five limitations. First, death records were not validated by medical records; therefore, results might be subject to misclassification. Second, some silicosis-associated deaths might not be work-related. For example, pneumoconiosis attributable to talc dust (ICD-10 code J62.0) in some decedents has been associated with use of illicit drugs ( 10 ); however, these pneumoconiosis-associated deaths were considered in this study to maintain comparability with previous studies and the Healthy People 2020 methods. Third, the industries and occupations represent the usual ¶¶¶¶ industries and occupations entered on each death certificate, which might not be the industry and occupation in which the decedent’s exposure occurred. Fourth, the age-adjusted mortality rates might not correctly project disease frequency. The rates were calculated using data on the general population that might include those who are not at an occupational risk for developing the disease. Finally, because of small death counts, trends in pneumoconiosis attributable to other inorganic dusts could not be evaluated by distinct disease categories. The decrease in pneumoconiosis-associated deaths during 1999–2018 indicates that prevention strategies are effective. The findings underscore the importance of maintaining primary prevention strategies to reduce exposures to respirable dusts, secondary prevention through early disease detection, and surveillance to monitor trends over time, in particular focusing on pneumoconiosis attributable to other inorganic dusts. Prevention strategies are available at the websites of OSHA (https://www.osha.gov/), MSHA (https://www.msha.gov/ ), and CDC’s National Institute for Occupational Safety and Health (https://www.cdc.gov/niosh/index.htm). Summary What is already known about this topic? Pneumoconioses are a group of occupational lung diseases caused by inhaling organic dust and inorganic mineral dust particles. From 1968 to 2000, death rates for all pneumoconioses decreased with the exception of those for asbestosis. Although preventable, deaths continue to occur. What is added by this report? Pneumoconiosis deaths decreased from 2,738 deaths in 1999 to 1,632 in 2018, and age-adjusted death rates decreased from 12.8 to 5.3 per million population. All pneumoconioses decreased with the exception of pneumoconiosis attributed to other inorganic dusts. What are the implications for public health practice? Pneumoconiosis-associated deaths continue to occur, underscoring the importance of occupational dust exposure reduction, early case detection, and continued surveillance to monitor trends, with an increased focus on pneumoconiosis attributable to other inorganic dusts.

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          Malignant Mesothelioma Mortality — United States, 1999–2015

          Malignant mesothelioma is a neoplasm associated with occupational and environmental inhalation exposure to asbestos* fibers and other elongate mineral particles (EMPs) ( 1 – 3 ). Patients have a median survival of approximately 1 year from the time of diagnosis ( 1 ). The latency period from first causative exposure to malignant mesothelioma development typically ranges from 20 to 40 years but can be as long as 71 years ( 2 , 3 ). Hazardous occupational exposures to asbestos fibers and other EMPs have occurred in a variety of industrial operations, including mining and milling, manufacturing, shipbuilding and repair, and construction ( 3 ). Current exposures to commercial asbestos in the United States occur predominantly during maintenance operations and remediation of older buildings containing asbestos ( 3 , 4 ). To update information on malignant mesothelioma mortality ( 5 ), CDC analyzed annual multiple cause-of-death records † for 1999–2015, the most recent years for which complete data are available. During 1999–2015, a total of 45,221 deaths with malignant mesothelioma mentioned on the death certificate as the underlying or contributing cause of death were reported in the United States, increasing from 2,479 deaths in 1999 to 2,597 in 2015 (in the same time period the age-adjusted death rates § decreased from 13.96 per million in 1999 to 10.93 in 2015). Malignant mesothelioma deaths increased for persons aged ≥85 years, both sexes, persons of white, black, and Asian or Pacific Islander race, and all ethnic groups. Despite regulatory actions and the decline in use of asbestos the annual number of malignant mesothelioma deaths remains substantial. The continuing occurrence of malignant mesothelioma deaths underscores the need for maintaining measures to prevent exposure to asbestos fibers and other causative EMPs and for ongoing surveillance to monitor temporal trends. For this report, malignant mesothelioma deaths during 1999–2015 were identified from death certificates and included deaths for which International Classification of Diseases (ICD), 10th Revision codes for malignant mesothelioma ¶ were listed as either the underlying or contributing cause of death in the multiple cause-of-death mortality data. The analysis was restricted to deaths of persons aged ≥25 years, as they were more likely to have been occupationally exposed than were younger decedents. Age-adjusted death rates per 1 million persons aged ≥25 years by demographics, neoplasm anatomical site, and year were calculated using the 2000 U.S. Census standard population estimate. Industry and occupation information was available from death certificates for decedents reported from 23 states for 1999, 2003, 2004, and 2007, and was coded** using the U.S. Census 2000 Industry and Occupation Classification System. Proportionate mortality ratios (PMRs) †† for malignant mesothelioma by industry and occupation were calculated. Confidence intervals (CIs) were calculated assuming Poisson distribution of the data. During 1999–2015, a total of 45,221 deaths with malignant mesothelioma mentioned on the death certificate as the underlying or contributing cause of death among persons aged ≥25 years were reported in the United States; 16,914 (37.4%) occurred among persons aged 75–84 years, 36,093 (79.8%) occurred among males, 42,778 (94.6%) among whites, and 43,316 (95.8%) among non-Hispanics (Table 1). Malignant mesothelioma was classified as mesothelioma of pleura (3,351; 7.4%), peritoneum (1,854; 4.1%), pericardium (74; 0.2%), other anatomic site (5,280; 11.7%), and unspecified anatomic site (35,068; 77.5%). Among 42,470 (93.9%) decedents, malignant mesothelioma was coded as the underlying §§ cause of death. TABLE 1 Malignant mesothelioma deaths and age-adjusted rates* among decedents aged ≥25 years, by selected characteristics — United States, 1999–2015 Characteristics No. of deaths Death rate Total 45,221 13.10 Underlying† cause 42,470 12.30 Age group (yrs)§   25–34 138 0.20   35–44 544 0.75   45–54 1,936 2.69   55–64 6,237 11.22   65–74 12,985 36.31   75–84 16,914 76.28   ≥85 6,467 74.46 Sex   Male 36,093 24.94   Female 9,128 4.65 Race   White 42,778 14.25   Black or African American 1,870 5.84   Asian or Pacific Islander 440 3.52   American Indian or Alaska  Native 133 5.96 Ethnicity Hispanic 1,815 7.38 Non-Hispanic 43,316 13.46 Unknown 90 — Anatomic site¶   Pleura 3,351 0.98   Peritoneum 1,854 0.51   Pericardium 74 0.01   Other 5,280 1.52   Unspecified 35,068 10.14 Year   1999 2,479 13.96   2000 2,529 14.16   2001 2,504 13.77   2002 2,570 13.92   2003 2,621 13.95   2004 2,656 13.94   2005 2,701 13.93   2006 2,586 13.19   2007 2,603 12.98   2008 2,706 13.26   2009 2,752 13.20   2010 2,744 13.10   2011 2,829 13.16   2012 2,873 12.97   2013 2,686 11.80   2014 2,785 11.98   2015 2,597 10.93   P-value** 0.001 <0.001 * Age-adjusted death rates per 1 million persons calculated using the 2000 Standard population. † Underlying cause of death is defined as “the disease or injury which initiated the chain of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury.” § Age-specific death rates per 1 million persons. ¶ The sum of anatomic site totals (45,627) is greater than the total number of deaths (45,221) because some decedents have more than one site listed on their death certificate. ** For 1999–2015, linear time trend was examined using a first-order autoregressive linear regression model to account for the serial correlation. During 1999–2015, the annual number of malignant mesothelioma deaths increased 4.8% overall, from 2,479 in 1999 to 2,579 in 2015 (p-value for linear time trend <0.001). The number of malignant mesothelioma deaths increased among persons aged ≥85 years, both sexes, white, black, and Asian or Pacific Islander race, and all ethnic groups; and patients with mesothelioma of the peritoneum and unspecified anatomic site. Malignant mesothelioma deaths decreased among persons aged 35–44, 45–54, and 55–64 years, and among persons with mesothelioma of the pleura and other anatomic sites. During 1999–2015, the mesothelioma age-adjusted death rate decreased 21.7% from 13.96 per million population (1999) to 10.93 (2015) (p-value for time trend <0.001). This trend in the standardized rate is a weighted average of the trends in the age-specific rates and masks the differences in individual age groups. The age-specific death rate decreased significantly among persons 45–54 (p<0.001), 55–64 (p<0.001), and 65–74 (p<0.001) years and increased significantly among persons aged ≥85 years (p<0.001). During 1999–2015, the annualized state mesothelioma age-adjusted death rate exceeded 20 per million per year in two states: Maine (22.06) and Washington (20.10) (Figure). FIGURE Malignant mesothelioma annualized age-adjusted death rate* per 1 million population, † by state — United States, 1999–2015 * Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S standard population age distribution (https://wonder.cdc.gov/wonder/help/mcd.html#Age-Adjusted Rates). In two states (Maine and Washington), the age-adjusted death rate exceeded 20 per million per year. † Decedents aged ≥25 years for whom the International Classification of Diseases, 10th Revision codes C45.0 (mesothelioma of pleura), C45.1 (mesothelioma of peritoneum), C45.2 (mesothelioma of pericardium), C45.7 (mesothelioma of other sites), or C45.9 (mesothelioma, unspecified) were listed on death certificates were identified using CDC multiple cause-of-death data for 1999–2015. The figure above is a map of the United States showing malignant mesothelioma annualized age-adjusted death rate per 1 million population aged ≥25 years, by state, during 1999–2015. Industry and occupation data were available for 1,830 (96.3%) of 1,900 malignant mesothelioma deaths that occurred in residents of 23 states during 1999, 2003, 2004, and 2007 (Table 2). ¶¶ Among 207 industries and 274 occupations, significantly elevated PMRs for malignant mesothelioma were found for 11 industries and 17 occupations. By industry, the highest PMRs were for ship and boat building and repairing (6.7; 95% CI = 4.3–9.9); petroleum refining (4.1; CI = 2.6–6.0); and industrial and miscellaneous chemicals (3.8; CI = 2.9–5.0). By occupation, the highest PMRs were for insulation workers (26.9; CI = 16.2–42.0); chemical technicians (4.9; CI = 2.1–9.6); and pipelayers, plumbers, pipefitters, and steamfitters (4.8; CI = 3.7–6.1). TABLE 2 Industries and occupations with significantly elevated proportionate mortality ratios, 1,830 malignant mesothelioma decedents aged ≥25 years — 23 states,* 1999, 2003, 2004, and 2007 Characteristic No. of deaths PMR† (95% CI) Industry    Ship and boat building 24 6.7 (4.3–9.9)    Petroleum refining 25 4.1 (2.6–6.0)    Industrial and miscellaneous chemicals 58 3.8 (2.9–5.0)    Labor unions 7 3.7 (1.5–7.6)    Miscellaneous nonmetallic mineral product manufacturing 5 3.6 (1.2–8.4)    Electric and gas and other combinations 7 3.1 (1.3–6.5)    Water transportation 12 2.3 (1.2–3.9)    Electric power generation transmission and distribution 24 2.2 (1.4–3.3)    U.S. Navy 11 2.0 (1.0–3.6)    Architectural, engineering, and related services 23 1.9 (1.2–2.8)    Construction 280 1.6 (1.4–1.8)    Unknown 42 —    All other industries 1,312 — Occupation    Insulation workers 19 26.9 (16.2–42.0)    Chemical technicians 8 4.9 (2.1–9.6)    Pipelayers, plumbers, pipefitters, and steamfitters 67 4.8 (3.7–6.1)    Chemical engineers 12 4.0 (2.1–7.1)    Sheet metal workers 17 3.5 (2.0–5.5)    Sailors and marine oilers 5 3.4 (1.1–8.0)    Structural iron and steel workers 10 3.3 (1.6–6.0)    Millwrights 14 3.1 (1.7–5.2)    Stationary engineers and boiler operators 15 2.9 (1.6–4.8)    Electricians 53 2.8 (2.1–3.7)    Welding, soldering, and brazing workers 30 2.1 (1.4–3.0)    Construction managers 37 2.0 (1.4–2.8)    Engineers, all other 12 2.0 (1.0–3.5)    Mechanical engineers 14 1.9 (1.0–3.2)    First-line supervisors or managers of mechanics, installers, and repairers 27 1.8 (1.2–2.6)    Machinists 39 1.6 (1.1–2.1)    First-line supervisors or managers of production and operating workers 40 1.4 (1.0–2.0)    Unknown 49 —    All other occupations 1,362 — Abbreviations: CI = confidence interval; PMR = proportionate mortality ratio. * Multiple cause-of-death mortality files. https://webappa.cdc.gov/ords/norms-io14.html. † PMR is defined as the observed number of deaths with malignant mesothelioma in a specified industry/occupation, divided by the expected number of deaths with malignant mesothelioma. The expected number of deaths is the total number of deaths in industry or occupation of interest multiplied by a proportion defined as the number of malignant mesothelioma deaths in all industries and/or occupations, divided by the total number of deaths in all industries/occupations. The malignant mesothelioma PMRs were internally adjusted by five-year age groups, gender, and race. CIs were calculated assuming Poisson distribution of the data. Discussion The annual number of malignant mesothelioma deaths is increasing, particularly among persons aged ≥85 years, most likely representing exposure many years ago. However, although malignant mesothelioma deaths decreased in persons aged 35–64 years, the continuing occurrence of mesothelioma deaths among persons aged <55 years suggests ongoing occupational and environmental exposures to asbestos fibers and other causative EMPs, despite regulatory actions by the Occupational Safety and Health Administration (OSHA)*** and the Environmental Protection Agency ††† aimed at limiting asbestos exposure. OSHA established a permissible exposure limit for asbestos of 12 fibers per cubic centimeter (f/cc) of air as an 8-hour time-weighted average in 1971. This initial permissible exposure limit was reduced to 5 f/cc in 1972, 2 f/cc in 1976, 0.2 f/cc in 1986, and 0.1 f/cc in 1994 ( 6 ). Although inspection data during 1979–2003 indicated a general decline in the proportion of samples exceeding designated occupational exposure limits, 20% of air samples collected in the construction industry in 2003 for compliance purposes exceeded the OSHA permissible exposure limit. Moreover, asbestos products remain in use, and new asbestos-containing products continue to be manufactured in or imported §§§ into the United States. Although most deaths from malignant mesothelioma in the United States are the result of exposures to asbestos 20–40 years prior, new cases might result from occupational exposure to asbestos fibers during maintenance activities, demolition and remediation of existing asbestos in structures, installations, and buildings if controls are insufficient to protect workers. The OSHA asbestos standard describes engineering and work practice controls (e.g., use of wet methods, local exhaust ventilation, and vacuum cleaners equipped with high-efficiency particulate air [HEPA] filters) during asbestos handling, mixing, removal, cutting, application, and cleanup and requires the use of respiratory protection if these controls are not sufficient to reduce employee exposure to levels at or below the permissible limit. Moreover, family members of workers engaged in activities placing them at risk for asbestos exposures also have the potential for exposure to asbestos ( 3 ). In addition, ongoing research is focusing on the potential nonoccupational and environmental exposures to asbestos fibers and other EMPs (e.g., erionite, a naturally occurring fibrous mineral that belongs to a group of minerals called zeolites), and nonmineral elongate particles (e.g., carbon nanotubes) to assess exposures and potential health risks ( 7 , 8 ). Among the 96.3% of deaths in 23 states for which industry and occupation were known, shipbuilding and construction industries were major contributors to malignant mesothelioma mortality ( 4 ). The large number of deaths among construction workers is consistent with large number of construction workers with prior direct and indirect exposure to asbestos fibers through most of the 20th century (the construction industry accounted for 70%–80% of asbestos consumption) ( 4 ). For example, direct exposure to asbestos has occurred during installation of asbestos-cement pipes, asbestos-cement sheets, architectural panels, built-up roofing, and removal of roofing felts or asbestos insulation. Workers also might have been exposed to asbestos during spraying of asbestos insulation in multistoried structures during 1958–1972 (asbestos-containing materials were banned for fireproofing/insulating in 1973) ( 4 ). In addition, workers in other occupations (e.g., carpenters, electricians, pipefitters, plumbers, welders) might also have been exposed if they were present on-site during spraying activities. A review of studies projecting the number of deaths from asbestos-related malignant mesothelioma in the United States indicated that the number of deaths during 1985–2009 would range from 620 to 3,270 annually ( 9 ). Based on an estimated 27.5 million workers with some exposure to asbestos during 1940–1972, a 1982 study estimated that the number of malignant mesothelioma deaths would rise to 3,060 annually by 2001–2005 ( 4 ). After 2005, mortality was projected to decrease but would continue for three decades. Based on asbestos consumption and malignant mesothelioma incidence data, it was estimated that the number of mesothelioma cases among males would peak during 2000–2004 (approximately 2,000 cases) and after that period, the number of mesothelioma cases was expected to decline and return to background levels by 2055 ( 10 ). The number of mesothelioma cases among females (approximately 560 in 2003) was projected to increase slightly over time. The results of the current study indicate an increase in the number of malignant mesothelioma deaths during 1999–2015. This discrepancy might be explained, in part, by the methodology of the projection studies, which were based on multiple assumptions including variations in the number of employed workers at risk, exposure levels and timing, and the linear dose–response relationship between asbestos exposure ¶¶¶ and malignant mesothelioma. Moreover, additional persons who might have been exposed to asbestos and be at risk for malignant mesothelioma (e.g., family contacts of asbestos-exposed workers, persons exposed to naturally occurring asbestos, persons exposed to asbestos in surfacing materials or as fireproofing material in buildings) were not considered ( 4 , 10 ). The findings in this report are subject to at least five limitations. First, information on exposure to asbestos or a specific work history was not available to assess the potential source of exposure. The industry and occupation listed on a death certificate might not be the industry and occupation in which the decedent's exposures occurred. Second, the state issuing a death certificate might not be the state or country in which the decedent's exposures occurred. Third, malignant mesothelioma did not have a discrete ICD code until the 10th revision of the ICD; thus, evaluation of mortality trends before 1999 was not possible. Fourth, some mesothelioma cases might not be included in this analysis because of misdiagnosis and the use of incorrect ICD-10 codes ( 1 ). Finally, information on decedents’ industry and occupation was available only for selected states of residence and years, and might not be nationally representative. Despite regulatory actions and the decline in use of asbestos, the annual number of malignant mesothelioma deaths remains substantial. Effective asbestos exposure prevention strategies for employers recommended by OSHA and CDC’s National Institute for Occupational Safety and Health (https://www.cdc.gov/niosh/topics/asbestos/) are available. The continuing occurrence of malignant mesothelioma deaths underscores the need for maintaining asbestos exposure prevention efforts and for ongoing surveillance to monitor temporal trends. Summary What is already known about this topic? Malignant mesothelioma is a neoplasm associated with inhalation exposure to asbestos fibers and other elongate mineral particles (EMPs). The median survival after malignant mesothelioma diagnosis is approximately 1 year. The latency period between the first exposure to asbestos fibers or other EMPs and mesothelioma development ranges from 20 to 71 years. Occupational exposure has occurred in industrial operations including mining and milling, manufacturing, shipbuilding and repair, and construction. Current occupational exposure occurs predominantly during maintenance and remediation of asbestos-containing buildings. The projected number of malignant mesothelioma deaths was expected to increase to 3,060 annually by 2001–2005, and after 2005, mortality was projected to decrease. What is added by this report? During 1999–2015, a total of 45,221 malignant mesothelioma deaths were reported, increasing from 2,479 (1999) to 2,597 (2015). Mesothelioma deaths increased for persons aged ≥85 years, for both sexes, persons of white, black and Asian or Pacific Islander race, and all ethnic groups. Continuing occurrence of malignant mesothelioma deaths in persons aged <55 years suggests ongoing inhalation exposure to asbestos fibers and possibly other causative EMPs. What are the implications for public health practice? Despite regulatory actions and decline in asbestos use, the annual number of malignant mesothelioma deaths remains substantial. Contrary to past projections, the number of malignant mesothelioma deaths has been increasing. The continuing occurrence of mesothelioma deaths, particularly among younger populations, underscores the need for maintaining efforts to prevent exposure and for ongoing surveillance to monitor temporal trends.
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            Resurgence of Progressive Massive Fibrosis in Coal Miners — Eastern Kentucky, 2016

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              Silicosis in a Countertop Fabricator — Texas, 2014

              In May 2014, the Texas Department of State Health Services was notified of a case of silicosis with progressive massive fibrosis in a Hispanic male aged 37 years who worked for an engineered stone countertop company as a polisher, laminator, and fabricator. He was exposed to dust for 10 years from working with conglomerate or quartz surfacing materials containing 70%–90% crystalline silica.* This is the first reported case of silicosis associated with exposure to quartz surfacing materials in North America. In 2010, the patient presented to a primary care provider with a 2-year history of persistent cough and dyspnea on exertion. He had no history of tobacco use or pulmonary disease. On physical examination, he had diminished bibasilar breath sounds and a right-sided inspiratory wheeze. Pulmonary function studies showed a combined obstructive and restrictive defect with no change post bronchodilator and reduced diffusion capacity. An electrocardiogram showed right ventricular hypertrophy, and cardiac catheterization confirmed the presence of pulmonary hypertension. A B Reader† classified the patient’s chest radiograph as large opacity Category “C” with 3/2 profusion, q/r bilateral upper and middle lobe rounded opacities. Computed tomography scan of the chest showed bilateral upper and middle lobe small rounded and large opacities, with hilar and mediastinal adenopathy. The worker was reassigned to a different job to minimize silica dust exposure. He is oxygen-dependent, and his medical condition is being monitored for possible lung transplantation. Clusters of silicosis cases, some requiring lung transplantation, have occurred among fabrication workers exposed to silica dust from quartz surfacing materials in Israel, Italy, and Spain (1–4). In the last year, imports of quartz surfacing materials to the United States have risen 49%,§ and these materials are among the most popular countertop materials. The increased use of this silica-containing material poses a new risk for silica exposure (http://blogs.cdc.gov/niosh-science-blog/2014/03/11/countertops). An investigation by CDC’s National Institute for Occupational Safety and Health of the patient’s work site is ongoing to identify work hazards and assess silica exposures and the health of the other employees. Health care providers need to be aware of quartz surfacing materials as a source of silica exposure, advise reassignment of patients with silicosis to jobs without silica dust exposure, and report cases to their state public health agency; in 2010, silicosis was reportable in 25 states.¶ Employers are responsible for maintaining a safe workplace by measuring silica exposure, limiting access to areas where silica exposures are high, using effective methods to reduce exposure (e.g., wet methods,** local exhaust ventilation, and use of personal protective equipment), providing medical examinations to workers with high exposures, and training workers about silica hazards and how to limit exposures.††
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                12 June 2020
                12 June 2020
                : 69
                : 23
                : 693-698
                Affiliations
                Association of Schools and Programs of Public Health/CDC Public Health Fellowship Program; Respiratory Health Division, National Institute for Occupational Safety and Health, CDC
                Author notes
                Corresponding author: Jessica L. Bell, onm0@ 123456cdc.gov , 304-285-5708.
                Article
                mm6923a1
                10.15585/mmwr.mm6923a1
                7315788
                32525855
                7797a7f3-ec43-4d40-843f-c906be5d4950

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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