Increasing black lung disease: five questions answered

ARCHIVE – In this file photo of November 15, 2016, a mechanized shovel loads coal from an 80-foot-thick vein into a hauling truck at the Cloud Peak Energy Spring Creek mine near Decker, Mont. (AP Photo / Matthew Brown, File) (Credit: AP )

What You Need to Know About Black Lung Disease

Editor's Note: Article published on February 6, 2018 in the Journal of the American Medical Association reported that researchers from the National Institute of Occupational Safety and Health had identified 416 cases of advanced black lung disease among coal miners in central Appalachia. Until recently, new cases of black lung have been rare, but this study suggests that the incidence is increasing. Anna Allen and Carl Werntz, professors of occupational medicine at the University of West Virginia who treat miners with black lungs, explain what causes this disabling disease.

What is black lung disease and what causes it?

Underground mining is one of the most dangerous occupations in the United States. Risks include inhaling toxic gases, such as methane, carbon monoxide and hydrogen sulfide; be crushed by roof drops or mining equipment; drowning when the tunnels fill with water; and injuries in fires and explosions. Even if the miners survive in the workplace, they can suffocate to death years later.

Surface and underground mining is badociated with two pneumoconioses, or lung diseases in the dust. Black lung disease, also known as coal worker pneumoconiosis, comes from the inhalation of coal mine dust. The other disease, silicosis, is caused by the inhalation of silica dust from crushed rocks. Black lung and silicosis often appear together because coal seams are found between rock layers that contain silica.

When miners inhale dust, it is deposited along their airways. Their bodies try to eliminate dust by sending special white blood cells called macrophages to wrap and digest them chemically. But cells can not break down dust, so they die and release enzymes that damage lung tissue. This causes problems that include chronic bronchitis, emphysema and fibrosis (scarring). In progressive mbadive fibrosis, the more severe version of the black lung, scarring causes the lung volume to shrink, further damaging the adjacent lung tissue and making the air exchange even worse.

Miners typically work 10 to 12 hours a day and up to seven days a week. This increases your exposure time and decreases the recovery time your bodies need to heal the damage of silica particles and carbon dust. Traditionally, the black lung was badociated with miners who had been working for at least 20 years, and symptoms often appeared after retirement. The recent trend is that the black lung, including progressive mbadive fibrosis, occurs after a shorter time in mining: just five years underground mining.

Are you surprised by the large group of cases described in the JAMA article?

The "hot spot" described in the JAMA study is found in parts of western Virginia, southern West Virginia, and eastern Kentucky. This area includes three of the federal enforcement districts of the Mining and Mine Safety Administration – areas where the agency inspects coal mines and investigates mining accidents and complaints.

We see patients in Morgantown in north-central West Virginia and Cabin Creek in the south. Central West Virginia. We have noticed a greater severity of the disease in patients in the southern part of the state. During our first year, from June 2016 to May 2017, working in Cabin Creek providing black lung exams authorized by the federal government, the incidence was 16 percent for the black lung and 6 percent for progressive mbadive fibrosis . In contrast, the same tests at our Morgantown clinic found black lung in less than 3 percent of cases, and only a few progressive cases of mbadive fibrosis in four years.

What do you think could be causing more cases of black lung disease?

The increase is probably the result of several factors. Much of the coal in the JAMA study area is called "low carbon," with seams that are only 20 to 36 inches high. This "low carbon" is difficult to extract but profitable because it is metallurgical coal, which has a high value for steel production.

Manufacturers stopped producing shorter machines designed to extract "low carbon" in 1990 due to quality control problems. Now the mines use higher machines designed for seams 32 to 36 inches high. As these machines cut the coal from the grain, they must remove at least 12 to 16 inches of sandstone adjacent to the coal.

Cutting so much sandstone significantly increases the exposure of miners to silica dust from crushed rock. Newer machines also cut coal and rock much faster than older models, generating more dust. Generally, what we call black lung is mainly silicosis in a coal miner, so exposure to silica is important for the development and progression of the disease.

Working on "little coal" also involves more physical effort than mining "high carbon". and bending over while carrying mining equipment and operating equipment requires more physical effort. Miners breathe harder and more frequently, which can increase exposure to dust. And it is difficult to maintain the air flow through these smaller mines, so dust concentrations may be higher at some points.

What does the coal industry do to prevent black lung?

Government Coal Workers Health Surveillance Program, which uses X-rays to detect early changes in the lungs. This information is shared with the miners so that they can decide if they continue to work in coal extraction, but it is kept private from their employers.

The main way to prevent the black lung is to prevent the miners from inhaling the dust. After 20 years of debate, recent changes in federal law decreased the allowed exposure of 2.0 milligrams per cubic meter of air to 1.5 milligrams. A continuous sampling of personal dust has also been implemented so that miners can have real-time data on their exposures. This information is used to determine if a mine requires more frequent inspections.

To decrease exposure to dust, mine operators can spray water to remove dust from the air, increase airflow in the tunnels to remove dust more quickly or require miners to wear respirators.

What resources are available to miners who may have a black lung?

The diagnosis of black lung can be complicated. Some of the most common symptoms include shortness of breath, decreased exercise tolerance, chronic cough, cough with phlegm and inability to breathe lying down. Other diseases can cause similar symptoms, so it is important that miners talk to their primary care doctors.

Some states have workers' compensation programs that offer benefits to workers diagnosed with black lung. The Federal Black Lung Program provides medical coverage for eligible miners with pulmonary diseases related to pneumoconiosis, along with benefits for those who are totally disabled by it, and for families of miners who die of black lung disease.

There is no cure for black lung disease: we can only treat the symptoms. Medications, such as inhaled steroids, can help patients breathe more easily. More severe cases may require oxygen and possibly lung transplants. One step that patients can take is to quit smoking, which also destroys lung tissue. Smoking does not cause a black lung, but it can make the symptoms more severe.

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