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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 …
Response to Mundt and Boffetta
Contributors LG completed additional analyses to respond to letter. LG, RMP and HC contributed comments to written response.
Competing interests None declared.
Patient consent Obtained.
Ethics approval University of Washington Institutional Review Board.
Provenance and peer review Not commissioned; internally peer reviewed.