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Correspondence
Author response: Extended follow-up of lung cancer and non-malignant respiratory disease mortality among California diatomaceous earth workers
  1. Lisa Gallagher1,
  2. Robert M Park2,
  3. Harvey Checkoway3
  1. 1 Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
  2. 2 National Institute for Occupational Safety and Health, US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
  3. 3 Department of Family & Preventive Medicine, University of California San Diego, San Diego, California, USA
  1. Correspondence to Dr Lisa Gallagher, Department of Environmental and Occupational Health Sciences, University of Washington, Seattle 98195, WA, USA; lgallag{at}u.washington.edu

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We will address the comments offered by Mundt and Boffetta1 on our manuscript describing findings from an update of mortality among California diatomaceous earth (DE) workers.2 We regard the sustained dose–response trends for lung cancer and non-malignant respiratory disease (NMRD) (tables 3 and 4, respectively) as the most important findings regarding risks associated with crystalline silica. The reduction of overall mortality for these outcomes, indicated by reduced standardised mortality ratios (SMR), is more likely to be a ‘depletion of susceptibles’ phenomenon than a ‘balancing out’ effect. We agree that a healthy worker effect is an unlikely explanation for the reduced lung cancer SMR. However, support for the …

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