Compensable Occupational Lung Diseases in Living Miners and

Compensable Occupational Lung Diseases in Living Miners and

Compensable Occupational Lung Diseases in Living Miners and Ex-miners in South Africa, 2003-2013 Presenter: Mpume Ndaba- NIOH MMPA Occupational Lung Disease Symposium 21/04/2018 Introduction The Occupational Diseases in Mines and Works Act (ODMWA) 1973 (as amended in 1993) provides for compensation of occupational lung diseases in living and deceased miners and exminers Administered by the Medical Bureau for Occupational Diseases (MBOD) and the office of the Compensation Commissioner for Occupational Diseases (CCOD) in the Department of Healths Chief Directorate: Occupational Health and Compensation Commission for Occupational Diseases

Background ODMWA: compensable cardio-respiratory diseases attributable to risk work Pneumoconiosis (Fibrosis of the lungs due to inhalation of mineral dust e.g. silicosis, asbestosis and coal workers pneumoconiosis) Tuberculosis contracted while the person was performing risk work Pneumoconiosis jointly with tuberculosis

Permanent airway obstruction Any other permanent diseases of the cardio respiratory organs attributable to performance of risk work Progressive systemic sclerosis Any other disease attributable to risk work as determined by the Minister of Health

Background ODMWA Functions of MBOD: Provision of benefit medical examinations (BMEs) and Certification of compensable occupational diseases through the Certification Committee Annual reports Functions of CCOD: Claim administrative and verification processes Financial procedures up to actual payment of compensation Annual reports Certification

The Certification Committee determines whether or not there is a compensable disease, the type and extent thereof Certification standards for occupational diseases: operational guidelines based on a code of practice guidelines developed within the MBOD and approved by Minister of Health Certification finding: Non Compensable Disease (NCD: disease resulting in less than 10% impairment; presence of disease other than occupational lung disease, previous 2nd D certification) Defer Tuberculosis Only (T current, T can antedate, T reactivated, 1st Degree T and 2nd DT) TB cannot antedate 1st degree Disease (1st D - disease resulting in permanent impairment >10% but < 40%) 2nd degree Disease (permanent impairment of more than 40 percent; simultaneous occurrence

of tuberculosis and another compensable condition, and malignant conditions) Summary ODMWA Compensation process The MBOD database MBOD Mineworkers Compensation (MWC) Database Reconstructed from 2004 Cases submitted before 2004 (1999,2000, 2001 up to 2003) captured as pre-2004 Pre-2004 cases- not a reflection of complete number of cases submitted and certified during those years All new applications submitted to the MBOD, after 2004 are recorded electronically into the database Information recorded- identifiers for each claim, demographic details of the claimant,

submission date, clinical findings, certification date and outcome of certification Originally designed to accommodate information up to claims payment, from the CCOD Certification data Constitute a valuable source of information on occupational lung diseases in the mining industry Occupational lung diseases in deceased miners diagnosed at autopsy are published annually in NIOH Pathology Reports available at www.nioh.ac.za Information on living miners has not been interrogated for over a decade Although the ODMWA compensation system and assessment criteria exist for both deceased and living miners, this study focuses on applicable criteria and system components for the living miners (current and ex-miners) Occupational Lung Diseases-An International Perspective According to the WHO (2016):

OLDs major public health concern globally, one of the most frequently occurring, preventable yet most disabling of all categories of occupational diseases OLDs- one of the occupational health priority area Pneumoconiosis is the most common and most serious occupational lung disease seen in developing countries ILO (2011) prioritized OLDs, particularly pneumoconiosis: definition & development of a classification system of reporting chest radiographs as a means of standardizing classification of these, internationally In the South African context, occupational exposure to mineral dust is mainly encountered in the mining and quarrying industry The South African Mining Industry Largest industry in the primary economic sector (Mineral Accounts for South Africa: 1980-2009)

Chamber of Mines (2012): Platinum and gold sectors- The largest sectors in terms of employment, investment and revenue generation Between 450 000 and 520 000 miners employed in 2004-2012 World Bank (2013) Actual number of ex-miners is unknown, but is estimated 2 million This industry has also contributed significantly to the burden of diseases in the country, mainly occupational lung diseases, and to major epidemics in the South African population (Murray et.al, 2011 and Naidoo, 2013) Burden of Disease in Miners South Africa accounts for a major proportion of the world TB cases

In 2012, the prevalence of TB in South Africa was 458 000 cases, incidence was 530 000 and incidence rate of 948/ 100 000 (World Bank, 2013; WHO,2013) In South Africa, mine workers have a significant contribution into the national burden of disease with an incidence rate of 2500-3000/100 000 in 2013, higher than the general population incidence rate and being the working population with the highest TB incidence in the world (World Bank, 2013) Undocumented burden of occupational respiratory diseases, including asbestos related diseases ( Braun & Kisting, 2006)

Reliable data are generated from PATHAUT The Burden of Disease in Miners Autopsy reports High prevalence of occupational lung diseases (OLDs) among miners and exminers in South Africa & up to 25% of these are only diagnosed at autopsy (Murray, et. al, 2001) High rates of OLDs in 1998. Autopsy reports- currently employed and exminers: PTB 18%; silicosis 16% and emphysema 20% (Murray, et. al, 2001)

Prevalence of silicosis within different mining commodities (in 2004) 22.1% (gold), 7.3% (coal) and 4,4% (platinum) (Stanton, et. al; 2006) OLDs in South African miners are a major public health concern, especially in gold miners (Murray, et. al; 2011) Most commonly diagnosed diseases at autopsy (2011)- silicosis in gold miners, tuberculosis from all mining sectors and chronic obstructive pulmonary disease (COPD) (Ndlovu, et. al; 2012)

The Burden of disease in living miners Cross sectional studies ex- miners Pneumoconiosis prevalence of 26.6% in Botswana former miners (Steen et al. 1997) Pneumoconiosis prevalence of 22% to 36% among ex-miners in the Eastern Cape province, South Africa (Trapido, et al. 1998) In a 2008 study on Basotho former gold miners, 50% of the miners examined had at least one potentially occupational respiratory condition and a high prevalence of silicosis (24.6%), tuberculosis (26% past and 6.2% current) and COPD (17.7%) (Girdler-Brown, et al. 2008)

Challenge- inability to assess the incidence and prevalence of mining related occupational respiratory diseases in living current and ex-miners (Leger, 1992) Summary of literature review There is a high burden of occupational lung diseases arising from the mining industry; however disease rates and trends have been estimated from autopsy studies and cross sectional surveys mainly The last published MBOD annual report was in 2000. Data on mining related OLD in living current and miners- scarce A number of other issues are worth reviewing from then, to update the body of knowledge on the amount and extent of diseases in current and ex-miners. Problem statement and Justification

In the South African context : The extent of occupational lung disease in gold miners, following introduction of antiretroviral treatment in 2002, intensified TB management programmes and other socioeconomic conditions, has not been assessed The amount, extent and trends of pneumoconiosis in living current and former miners have not been updated since the last published MBOD report in 2000 Study Aim and Objectives Aim: This study looked at the burden (and trends) of occupational lung diseases using compensation disease certification data (2004-2012) Objective(s) 1. To describe the extent and type of compensable occupational lung diseases in South African mining, 2004-2012, by commodity

1.1 To describe the type and number of compensable occupational lung diseases certified by year from 2004 to 2012 1.2 To describe the certified compensable occupational lung diseases by age, sex, race and commodity Methods and Materials Study Design : Descriptive study Secondary data analysis of certification data recorded in the MBOD certification database and service records of the claims that underwent certification Study Population All miners and ex-miners who were alive during claim submission and were certified from 2004 to 2012 financial years, excluding post mortem claims Sources of Information The Mineworkers Compensation (MWC) database Service records dataset

Data Management and Analysis Data were extracted from databases exported to Stata software version 12 Analysis- Statistical software (Stata version 12) Personal identifiers were removed from the datasets, except for unique identifiers namely Bureau number, claim number and Claim ID Methods and Materials Determination of the final sample used for analysis The mineworkers database was used to extract MBOD certification data of cases certified from 2004 to 2012 Due to incompleteness of data for the other years before and up to 2003, and 2013 financial year, these were excluded from analysis

Deferred cases, all NCD categories, cases dead at the time of claim submission and unknown worker status were excluded from further analysis, as depicted in the below (methodical process flow on how the final the sample for analysis was derived) Data cleaning and regrouping of variables: identifiers; claim status (alive or dead); claim status (current; ex-miner); finding/certification date; finding year; claim age; Mine max service; Mine type-commodity and finding type Descriptive statistical analysis: counts Ethical and Legal Considerations

Permission was granted by the Compensation Commissioner to access data from the MBOD and CCOD datasets for analysis for this research project Research approval was granted by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand: Clearance was given for research involving secondary analysis of a database (Ethics clearance number: M130931). Results: Certification Outcome 2004-2012 FY Results: All Compensable Lung Diseases 2004-2012

RESULTS: Age Group RESULTS: Commodity Other = other commodity and missing RESULTS RESULTS Discussion Large burden of compensable occupational lung disease in South African current and ex-miners in South Africa from 2004-2012

OLDs that contributed significantly to the total number of compensable diseases during the period under study were tuberculosis (61%), silicosis (15%) asbestos pleural disease and interstitial asbestosis (12%) These findings are in line with what is already known with regards to the burden of tuberculosis in the mining sector (Naidoo, 2013; White, 2001 ; Nelson,2013; Murray et.al, 2011) Of the active living miners who were employed in SA between 2004 and 2012, 49 179 were diagnosed with occupational lung disease of more than

10% impairment. Discussion Mining status was a major determinant of compensable occupational lung disease in this study: 73% (n=49 179) current miners and almost 25% (n=16 805)in former miners. Possible contributing factors to the lower number of ex- miners vs. current miners: challenges of accessing the system for ex-miners; a higher number of ex-workers who died following leaving work for many reasons (ill health; occupational lung diseases, poor access to health care, return to labour sending areas)

Age group, sex and population group: compensable OLDs predominantly in the 4049 years group, male active mine workers and from the black population group. Demographics similar to what was defined in studies from both current miners (teWaterNaude, et.al, 2006) mainly and the ex-miners studies (Trapido, et.al; 1998). Discussion Silicosis certifications- 15% (n=9894) to the total certifications of compensable OLD Attributable to high silica dust levels in the past Latent period of exposure and manifestation of abnormality is at least 5years for silicosis and typically >= 15years for PMF, the findings of a high proportion of

silicosis can be explained by exposure levels that had not changed in the 1990s as per findings of the Leon Commission (Leon Commission; Steen, et.al; 1998) The OEL for silica dust had not been lowered from the 0.1 mg/m3 (White,2001) Even if the OEL had been lowered, the suggested 0.05mg/m3might have not been sufficiently protective to avert disease (Steen, et.al; 1998). Reduction might have had an impact on lowering the incidence among recruits that were new at that time Asbestos related diseases contributed 13% (n=8665) to the compensable OLDsconfirms the legacy of asbestos mining has remained with South Africa Limitations

Secondary data analysis, information was collected for compensation . Primarily suited for compensation and requirements thereof Incomplete records on the data base potential underestimation of the true burden of compensable disease attributable to specific exposure in a commodity The number of certifications by year and the apparent trends are likely to be artifacts of the Certification Committee rather than a function of actual disease prevalence. (Efforts made in 2007 and 2008 to reduce the backlog of claims

awaiting adjudication, hence the spike in numbers certified). Misclassification of exposureassignment of maximum service workplace as the workplace to which disease is attributed. Conclusion and Recommendations Huge burden of occupational lung diseases in living South African active and ex-miners, certified between 2004 and 2012

The burden consists mainly of TB from the loss of earnings (T current), but also the whole person impairment resulting from tuberculosis (1st and 2nd T) It is recommended that accurate meaningful exposure history is recorded for accurate attribution of diseases to specific commodities The fewer number of claims and certification of ex-miners should be attended to through better access to BME and improvement in submission from various decentralized centers with assistance of adequately trained personnel

Finally, the amount of compensable disease certified in living miners and exminers in this study could be an indication of efficiency of the certification committee, handling of backlog rather than the true extent of disease in this population in South Africa References Mineral Accounts for South Africa: 1980-2009 [Internet]. [cited 2016 Jul 17]. Available from: http://www.statssa.gov.za/publications/D04052/D040522009.pdf Chamber of Mines: Facts and figures 2012. [Internet]. Chamber of Mines South Africa; [cited 2016 May 30]. Available from: https:// commondatastorage.googleapis.com/comsa/facts-and-figures-2013.pdf World Bank. World-Bank-economic-analysis-on-addressing-TB-in-the-mines-brief.

[Internet]. [cited 2016 Jun 7]. Available from: http://pubdocs.worldbank.org/en/770861483124917730/World-Bank-economicanalysis-on-addressing-TB-in-the-mines-brief.pdf Naidoo RN. Mining: South Africas legacy and burden in the context of occupational respiratory diseases. Glob Health Action [Internet]. 2013 Feb 21 [cited 2016 Jul 12];6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579952/ World Health Organisation. WHO_workers_health_web.pdf [Internet]. [cited 2016 Jul 5]. Available from: http://

www.who.int/occupational_health/who_workers_health_web.pdf Braun L and Kisting S. Asbestos-related disease in South Africa: the social production of an invisible epidemic. Am J Public Health. 2006 Aug;96(8):138696. References Murray J, Davies T, Rees D. Occupational lung disease in the South African mining industry: Research and policy implementation. J Public Health Policy. 2011 Jun;32(S1):S6579. David W Stanton, Bharath K Belle, Kobus JJ Dekker and Jan JL Du Plessis. South African Mining Industry Best Practice on the Prevention of Silicosis [Internet]. Mine Health and Safety Council; 2006. Available from:

http://www.ilo.org/wcmsp5/groups/public/@ed_protect/@protrav/@ safework/documents/publication/wcms_118101.pdf Ndlovu N, Milne S, Davies T, Nelson G, Murray J. Pathology Division Report: Demographic Data and Disease Rates for January to December 2011. [Internet]. National Institute f Occupational Health, National Health Laboratory Service, South Africa.; Report No.: NIOH Report 1/2012. Available from: ISSN 1812-7681. Steen TW, Gyi KM, White NW, Gabosianelwe T, Ludick S, Mazonde GN, et al. Prevalence of occupational lung disease among Botswana men formerly employed in the South African mining industry. Occup Environ Med. 1997;54(1):1926

Microsoft Word - LeonreportVol1.doc - LeonCommissionV1.pdf [Internet]. [cited 2016 Jul 11]. Available from: http://www.cwbpi.com/AIDS/reports/LeonCommissionV1.pdf References

Neil White. Occupational Lung Disease. In: SIMRAC Handbook of Occupational Health Practice in the South African Mining Industry. The Safety in Mines Research Advisory Committee (SIMRAC); 2001. teWaterNaude JM, Ehrlich RI, Churchyard GJ, Pemba L, Dekker K, Vermeis M, et al. Tuberculosis and silica exposure in South African gold miners. Occup Environ Med. 2006 Mar;63(3):18792. Trapido AS, Mqoqi NP, Williams BG, White NW, Solomon A, Goode RH, et al. Prevalence of occupational lung disease in a random sample of former mineworkers, Libode District, Eastern Cape Province, South Africa. Am J Ind Med. 1998;34(4):305 313. Nelson G. Occupational respiratory diseases in the South African mining industry. Glob Health Action [Internet]. 2013 Jan 24 [cited 2016 May 18];6(0). Available from: http:// www.globalhealthaction.net/index.php/gha/article/view/19520 Girdler-Brown BV, White NW, Ehrlich RI, Churchyard GJ. The burden of silicosis,

pulmonary tuberculosis and COPD among former Basotho goldminers. Am J Ind Med. 2008 Sep 1;51(9):6407. Leger JP. Occupational diseases in South African mines--a neglected epidemic? S Afr Med J. 1992 Feb 15;81(4):197201. Acknowledgements Professor David Rees (supervisor) and Dr Spo Kgalamono (co-supervisor) Dr Barry Kistnasamy, the Compensation Commissioner, for permision to use and access data from databases in the MBOD and CCOD, of the Department of Health.

Mr Cornelius Nattey- statistical and database expertise support Nontobeko Mtembu and Thando Mabeqa- NIOH, Information Services To the MBOD and CCOD staff members: who helped me understand the processes and content databases : Ms Danesh Naidoo, Ms Rachel Meredith, and Ms Doreen Lesejane, Mr Simon Masilela, Mr Monty Lesotho, Ms Thembi Khakha, Ms Aveetha Naidoo and Mr Sam Mulaudzi. Thank you Dr Mpume Ndaba

Occupational Medicine Section National Institute for Occupational Health National Health Laboratory Services Tel +27 (0)11 712 6430| Fax +(0)86 [email protected]

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