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Response to: Correspondence on ‘Demographic, exposure and clinical characteristics in a multinational registry of engineered stone workers with silicosis’ by Hoy et al
  1. Jeremy Tang Hua1,2,
  2. Lauren Zell-Baran1,
  3. Leonard H T Go3,
  4. Mordechai R Kramer4,
  5. Johanna B Van Bree4,
  6. Daniel Chambers5,
  7. Katrina Newbigin6,
  8. David Deller7,
  9. Michael Matula8,
  10. Elizabeth Fireman9,
  11. Mor Dahbash10,
  12. Cristina Martinez-Gonzalez11,
  13. Antonio León-Jimenez12,
  14. Coralynn Sack13,
  15. Jaume Ferrer Sancho14,
  16. Ana Villar15,
  17. Kirsten S Almberg3,
  18. Robert A Cohen16,17,
  19. Cecile S Rose1,2
  1. 1 Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, Colorado, USA
  2. 2 Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
  3. 3 School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
  4. 4 Pulmonary Institute, Rabin Medical Center, Petah Tikva, Israel
  5. 5 School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia
  6. 6 Department of Radiology, Wesley Hospital, Brisbane, Queensland, Australia
  7. 7 Gold Coast Respiratory and Sleep Clinic, Pindara Private Hospital, Gold Coast, Queensland, Australia
  8. 8 Griffith University School of Allied Health Sciences, Gold Coast, Queensland, Australia
  9. 9 Institute of Pulmonary and Allergic Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  10. 10 Occupational Environmental Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  11. 11 Pneumology Service, Central University Hospital of Asturias, Oviedo, Spain
  12. 12 Pulmonology, Allergy and Thoracic Surgery Department, Puerta del Mar University Hospital, Cádiz, Spain
  13. 13 Departments of Medicine and Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
  14. 14 Pulmonology, Hospital Vall d'Hebron, Barcelona, Spain
  15. 15 Respiratory Medicine Department, Hospital Vall d'Hebron, Barcelona, Spain
  16. 16 Environmental and Occupational Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
  17. 17 Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  1. Correspondence to Dr Jeremy Tang Hua, Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, Colorado 80206, USA; huaj{at}

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We thank Dr Hoy and Dr Sim for their comments on our recent study.1 We wish to respond to three key points raised in their letter to the editor.2

First, we agree that the number of workers enrolled in the Engineered Stone Silicosis Investigators (ESSI) Global Silicosis Registry is indeed a small subset of those with engineered stone (ES) silicosis. We welcome the inclusion of many more Australian workers with silicosis in the registry to better define the demographic, exposure and clinical features that vary widely among patients from different countries, due in part to differences in case ascertainment. We have been particularly eager to involve our colleagues from China, the largest exporter of ES products worldwide, in this work. Efforts to build cooperation with China and other countries (eg, Turkey, India and Russia) producing much of the world’s ES have been stymied by international political challenges that limit, and in some cases preclude, scientific collaboration. Scientists and advocates in these countries along with external support from international policy leaders may help promote such partnerships.

Second, we applaud the Queensland Government in Australia for creating an industry-based screening programme for stone masons exposed to crystalline silica. While such programmes importantly focus on the health of individual at-risk workers, they are generally not designed or funded to provide the aggregate data required to determine risk factors for disease and disease progression at a population level. This is where efforts such as the ESSI registry play a valuable role. Our hope is that, through international collaborations facilitated by the ESSI registry, investigators will share lessons learnt and approaches to early disease recognition, treatment, exposure control and prevention of the multiorgan system effects of crystalline silica. In the USA, the Occupational Safety and Health Administration (OSHA) only recently updated its Respirable Crystalline Silica Standards, and the Mine Safety and Health Administration (MSHA) still has to respond to the resurgence of severe progressive massive fibrosis linked to silica exposure in US coal miners.3 4 Both OSHA and MSHA are understaffed and underfunded, and when exposure monitoring and enforcement do occur, weak monetary and criminal penalties do little to encourage employer-led improvements in hazardous practices.5 It is clear that much remains to be done.

Third, we believe that cases of ES silicosis will continue to emerge and that increasing clinical recognition will further underscore the burgeoning epidemic of new and previously unrecognised cases in countries where ES products are produced and installed. We owe particular gratitude to colleagues in Spain, Israel and Italy who first reported sentinel cases of silicosis in ES workers a decade ago and who continue to develop methods for case ascertainment as well as longitudinal follow-up of affected workers.6–8 We hope that the ESSI registry will help create a foundation for sharing successful strategies for early disease detection, learning from regulatory and implementation failures, and exploring evidence-based practices for treatment and prevention. We invite Dr Sim and Dr Hoy and other interested international collaborators to join in this coordinated effort on behalf of ES workers worldwide.

Ethics statements

Patient consent for publication

Ethics approval

The original study we are responding about involves human participants and was approved by an institutional review board (HS-3483 at the National Jewish Health) under exempt status, and all data were fully de-identified for entry into the registry.



  • RAC and CSR are joint senior authors.

  • Contributors JTH and CSR drafted the response. All authors reviewed and edited the final response. RAC and CSR are guarantors of the research described in this publication.

  • Funding Work conducted at the National Jewish Health was partially supported by the Reuben M Cherniack fellowship award. Work conducted in Israel was partially supported by the Committee for Research and Prevention in Occupational Safety and Health (56/13). The funders had no role in the conduct or interpretation of these research findings.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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