GPs are being urged to be aware of their patients’ work environment, particularly blue-collar workers such as welders and fabricators, as dangers on the job become more apparent.
By Eric Martin
While work-related ill health is not a new phenomenon, concern about the risks facing some professions is gaining momentum.
Australia’s workplace hazards have been under intense focus, with the recent ban imposed on the highly popular engineered stone benchtops due to its links to silicosis causing shockwaves through the construction industry.
Similarly, the recent news that welding, which employs about 60,000-70,000 people nationally, causes black lung has seen welding worker vacancies increase by 80% in Western Australia in 2024.
According to Weld Australia, the number of welding trade workers in Australia dropped by 8% over just five years, and the completion rates of welding apprenticeships, including a Certificate III in Engineering (Fabrication Trade), have fallen by as much as 23% with a predicted shortfall of at least 70,000 welders by 2030.
The welding research, a joint project by Curtin’s School of Population Health and the University of Sydney, found that 76% of participants exposed to welding fume inhaled a high level of toxins, as well as being exposed to other carcinogenic metals – most commonly hexavalent chromium and nickel.
Study lead Dr Renee Carey, who was previously involved in a landmark study outlining the dangers of working with engineered stone, said the study of 634 workers and employers showed that many Australian welders could be at risk of developing serious health problems.
“Welding fume exposure has been associated with various adverse health effects, including cancer, respiratory disease, neurological disorders and reproductive effects,” she noted.
While the findings are alarming, the general estimate is that it will likely take 5-10 years for the findings to impact policy, resulting in the type of workplace inspections conducted in factories and on construction sites by WorkSafe WA. But even then, current inspection figures show that this messaging could take even longer to bring about meaningful change in workplaces.
For example, WorkSafe WA has already carried out 29 investigations under its silica verification project in 2024, resulting in 145 notices being issued across the State.
The project found a “continuing level of non-compliance by a large portion of the engineered stone industry” with ongoing concerns including the uncontrolled use of power tools on engineered stone, workers either not being provided with or fit-tested for respirators, workers refusing to wear respirators, poor housekeeping and the inadequate treatment of recycled process water.
WorkSafe WA even found workers with diagnosed or suspected silicosis continuing to work in the industry against medical advice. And significantly, the silicosis story has only deepened, with cases of autoimmune disease now being reported in engineered stone benchtop workers.
Dr Karen Walker-Bone, Professor of Occupational Rheumatology and Director of the Monash Centre for Occupational and Environmental Health, has been spearheading this research in Australia and explained that occupational exposures to respirable crystalline silica (RCS) have been implicated in systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA) and antinuclear cytoplasmic antibody (ANCA)-associated vasculitis.
“Although having detectable autoantibodies is not diagnostic of an autoimmune disease, their presence in certain rheumatic diseases, such as SLE and RA, has been shown to predate clinical features often by many years,” she said.
“The body is only designed to recognise bacterial and viral pathogens but will still do its best to eliminate any foreign body, be it fungus or even ingested plastic. The particles that we call respirable crystalline silica are so tiny they get to the very bottom of the airways, into the alveoli and on to the bloodstream.
“And they when they get that far, nothing removes them, the body’s incapable of clearing that particle. They are so toxic that they kill the body’s first line of defence, the macrophages, leaving both the dead cells and the original particles behind after that first, failed attempt at removal.
“That causes local inflammation in the lungs, or silicosis, but it seems to be the persistence of a foreign body close to a rich blood supply that is precipitating the development of autoantibodies.
“The body continually tries to repair the resulting local tissue damage, eventually exhausting the repair mechanisms and causing an overwhelming state of inflammation and the beginnings of an immunological cascade. And once that cascade is initiated, it’s very hard to switch off again.”
Professor Walker-Bone said that in a study of 133 people with SLE, 78% already had detectable antinuclear antibodies (ANAs) 3.3 years before the onset of symptoms prompting her exploration of the association between autoantibodies, RCS exposure and silicosis diagnosis by quantifying the prevalence of ANAs, extractable nuclear antigens (ENAs), rheumatoid factor (RF) and other autoantibodies – the fundamental tools in the screening and diagnosis of autoimmune disease.
“The first case reports were written about in the 1950s, which is still recent in medical science terms, when patients were diagnosed with silicosis from coal mining and then developed rheumatoid arthritis,” she said
“Rheumatoid factor was the first ever autoantibody we discovered, and while we knew that there was some overlap in coal miners, it was a very different source of exposure, and not such a huge exposure over such a short time as we’ve had in this industry.”
Professor Walker-Bone said the ability to conduct the latest research in RCS autoimmunity was due to WorkSafe Victoria’s funding of a free screening program for all the workers in Victoria’s stone benchtop industry.
“This is the first time that anyone has had such a large group of patients who’ve all had massive exposure over a relatively short time, and then been able to measure their autoantibodies,” she explained.
“We screened about 900 or so initially, but they weren’t all sent to hospital during that first stage – they were screened by occupational health physicians and then referred to the hospital if necessary. But eventually, so many of them needed to come to hospital that we now do all the screening there, and we’ve seen about 1300 in total between June 2019 to August 2023.”
WorkSafe Victoria has committed another two years of funding with a possibility of two more beyond that.
“As such, we’re seeing new workers if they’ve not yet had the opportunity to get tested, as well as bringing back some workers that were seen in the occupational health clinics who were thought to be low risk,” she said.
“With the new data available, we have been recalling them to ensure they really are as low risk as we first thought, as well as following up all people we think have evidence of silicosis and/or autoantibody formation.”
RCS exposure was categorised according to the duration of work in the stone benchtop industry and the highest dry processing exposure reported, though in the end, nearly all workers fell into the ‘medium’ and ‘high’ exposure groups.
Almost half (43.7%) had very high levels of exposure to RCS and nearly one-quarter of workers with diagnostic information (253 workers, 24.3%) were diagnosed with silicosis at assessment.
“The only workers with very low exposure were literally confined to the office. They didn’t go anywhere near the factories or the manufacturing process,” Professor Walker-Bone explained.
“But anybody who went anywhere near the environment – if they were cleaning it after the guys had finished work, or if they were doing any work in there, even if they didn’t do it directly – they had such a high level of bystander exposure that it was as good as if they were doing the work.
“The silica dust is so fine that it just gets everywhere. We’ve got some amazing photographs of workers. It looks like they’ve been playing in the snow – they are covered in the dust and you can’t get away from it. Even when you’ve washed it all down and it dries, there’s still some visible residue.”
In those workers without clinically diagnosed autoimmune disease the prevalence of detectable ANAs was 24.6%, ENAs 4.6% and RF 2.6%, and those with high levels of industrial RCS exposure were more likely to have detectable ANAs. Likewise, detectable autoantibodies were found in significantly higher proportions among those diagnosed with silicosis.
“The prevalence of detectable ANAs in this cohort was also much higher than that expected in the general adult male population. For example, among those aged 40-49 years in the US National Health and Nutrition Examination Survey, the prevalence of ANAs was <6%, whereas in our cohort, the prevalence was 24.6%,” Professor Walker-Bone said.
“One of the most interesting results to emerge from the study was the almost exact correlation between the number of individuals who contracted silicosis and the number who developed an autoimmune disease – almost 25%.
“So, if you have silicosis, you’re more likely to have an autoimmune disease. But the Venn diagram isn’t a precise match. There are people who’ve got one or the other and not both, it’s incredibly strange.”
Despite the insidious nature of airborne hazards, the worst offenders for workplace injuries in WA, and the ones most likely to result in a presentation to a GP, were muscular injuries. Specifically, manual handling accounted for 41% of all work-years lost.
According to the RACGP’s latest Health of the Nation report, musculoskeletal injuries accounted for 37% of GPs’ consultation time.
College guide
The college’s online resources include a detailed article on returning to work after an injury by Dr Peter Fenner, which highlights the importance of documenting any work-related injury properly, noting that the relevant workers’ compensation authority or insurer usually required notification of an injured worker within 48 hours of the injury occurring, using their specific paperwork.
He also stressed that some injuries may initially appear minor while the muscles were still warm.
“However, on cooling down after work, or even the next morning, muscle spasms can greatly restrict movement, causing pain at rest that is aggravated by even the smallest of movements,” Dr Fenner advised.
“It is essential that at the first consultation a detailed history of the mechanism of the injury, as well as any exacerbating or contributing factors, is taken and carefully documented. This should be followed by careful examination of the patient and formulation of a diagnosis based on the history and the physical examination.”
Dr Fenner warned that imaging could be misleading and should not be used to diagnose workplace injuries in general practice, especially imaging of the spine due to the many variants in a ‘normal’ skeleton.
“An exception to this rule is an early MRI for severe unstable knee injuries, which may assist in assessing the need for early orthopaedic intervention. Workers’ compensation funds may pay for MRI in this setting to facilitate faster specialist assessment and treatment, as this speeds recovery and subsequent return to work,” he said.
The RACGP’s guide includes a quick table for GPs to ensure they document all the essential factors correctly during the initial diagnosis, such as the mechanism of injury, previous injuries, the level of pain and any radiation, paraesthesia, other complaints or symptoms, and any current medications or medical problems that may impact recovery – including mental health issues.
Importantly for GPs, according to WorkSafe WA the mental health impact of witnessing a traumatic event resulted in six months lost time from work – outlasting the physiological effects of injuries. This was backed up by current data from the Health of the Nation Report, which revealed that in 2024, 71% of GPs were reporting psychological issues in their top three reasons (and often the most common cause) for patient presentations.
“It is essential that GPs access support and advice from mental health specialists, such as psychiatrists, on the management of patients with mental health issues, and the assessment and treatment of mental illness is informed by a holistic, whole-of-person approach,” the report highlighted.
“Unlike many other public and private health care settings, general practice does not draw a distinction between mind and body systems.”