Challenges

The prevention and control of silicosis in India face significant challenges, including worker-related, disease-related, and systemic challenges (Table 2). One major programmatic challenge is the absence of a comprehensive national health program dedicated to silicosis control, resulting in a lack of coordination among stakeholders and limited surveillance mechanisms.

Table 2 Challenges in the prevention and control of silicosis in India Worker-related challengesJob-related issues

People working in the silica-dust industries are mostly contract laborers, making it difficult for them to obtain new employment due to a lack of job opportunities [18, 41, 42, 45,46,47,48,49]. Workers fear that if they are diagnosed with any silica dust-related illnesses, they may be asked to quit, thereby exposing them to unemployment [45, 46]. They do not seek healthcare on time and instead return to dusty work conditions out of fear of getting laid off [42, 44, 46]. Due to the low socioeconomic conditions, vocational rehabilitation of people working in silica dust-related occupations into different occupations is challenging [20]. Moreover, employers do not allow them to take time off to visit the hospital, and workers prefer to consult unqualified doctors in the event of any health-related complaints to avoid wage loss [45, 50].

Lack of awareness

Due to a lack of awareness, patients do not suspect a major health problem and believe that silicosis cannot affect them [18, 42, 51,52,53,54,55]. Due to a lack of awareness, coupled with lower education levels that contribute to it, workers in these occupations not only fail to seek appropriate healthcare guidance,[37, 42] but also exhibit a limited inclination towards using personal protective equipment [49, 51,52,53,54, 56].

Disease-related challenges

Silicosis is frequently misdiagnosed as TB [6, 28, 42, 44, 45]. Because the symptoms of tuberculosis (TB) and silicosis are similar, factory workers too believe that they have recurrent TB [18]. As silicosis is incurable, patients’ symptoms continue even after the completion of TB treatment. Upon symptomatic relief, workers return to dusty work settings, increasing their exposure to silica dust even more. The vicious cycle continues, and they experience the progression of silicosis and relapses of TB [40].

Silica dust clogs the alveoli of the lungs,[57] leading to the potentially fatal complication pneumothorax among patients with chronic silicosis [58]. Dormant TB bacilli are occasionally triggered in individuals with silicosis due to macrophage dysfunction and immunological dysregulation, resulting in TB relapses [59, 60]. Because fibrosis of the lung tissue reduces blood flow, TB medications are unable to permeate the tissue and hence reach lower concentrations [59, 61, 62]. Although non-pathogenic, patients with silicosis often demonstrate the presence of non-tuberculous mycobacteria along with the TB bacilli [63,64,65]. Non-tuberculous mycobacteria are resistant to several of the medications included in the national TB treatment regimen [66].

Systemic challenges

Control measures aimed at mitigating exposure have generally been implemented and enhanced over time in developed countries like North America and Europe [67]. However, the situation contrasts in developing nations such as China and India, where high levels of exposure persist, leading to a higher prevalence of silicosis [67]. Notable progress has been made in addressing the issue of silicosis in specific occupational settings, such as sandblasting of jeans, with countries like the United States and Germany implementing positive measures like independent factory inspections in response to documented studies [68]. However, it is worth noting that the extent of similar actions being taken in India appears to be limited, highlighting the need for further attention and initiatives in this regard.

The majority of silicosis cases are anticipated to be reported in smaller units and cottage industries [28, 41]. Small enterprises may also be exempt from the statutory norms outlined in the Factories Act, 1948, and the Mines Act, 1952 [20, 28, 41, 44]. As a result, accountability must be assigned among the statutory bodies to execute the provisions of the Factories Act, 1948, the Mines Act, 1952, and the Building and Other Construction Workers (BOCW) Act, 1996, at the smaller units [40]. According to Sect. 112 of the Factories Act, 1948, the Chief Inspector of Factories in each respective state possesses the authority to designate any hazardous unit, regardless of the number of workers employed, as subject to the legal provisions and regulations stated in the Act [69]. As of now, only a limited number of states, such as Gujarat, have taken the initiative to pass resolutions affirming the application of these provisions within their jurisdictions.

Silicosis, recognized as a notifiable and compensable disease under the Factories Act, 1948, and the Mines Act, 1952, remains severely underdiagnosed and underreported in India, as evidenced by the recent annual report of the Ministry of Labour and Employment [69,70,71]. The report revealed a mere 441 cases of silicosis reported between 2008 and 2022, underscoring the significant extent of underdiagnosis and underreporting within the country [71]. This discrepancy can be attributed to employers’ inclination to withhold notifications from their factories to avoid legal complications and the subsequent obligation to provide compensation to affected employees [20, 41, 44, 72]. There are also challenges surrounding the intention and integrity of the implementing agencies as far as the unorganized sector is concerned [20, 42, 44]. Additionally, there are concerns regarding the outsourcing of medical examinations of workers to doctors who do not understand occupational health [40].

Employers do not allow time for workers to consult a doctor or visit a health facility if they become unwell [42]. Employers also fail to rehabilitate patients and neglect their relocation to less hazardous environments [41, 42]. Concerns have been raised over the scarcity of water for wet drilling in mines and the subsequent decline in drilling efficiency,[44] highlighting the tendency of employers to prioritize the speed of work completion over worker safety. Implementing dust control measures proves costly for industries [44].

In India, the Factories Act of 1948 and the Mines Act of 1952 stipulate the mandatory periodic measurement of dust and silica concentrations in workplaces [69, 70]. However, employers in the country exhibit a lack of awareness regarding these requirements, and the associated measurement processes are perceived as costly. Consequently, many employers in the industrial sector refrain from conducting such measurements and consequently fail to provide relevant data. Furthermore, those employers who are interested in implementing dust measurements often lack knowledge of suitable methods, equipment, and expertise. Additionally, there is a notable absence of public or private agencies that offer support for conducting dust measurements. To address these challenges, the government can play a pivotal role by acting as a facilitator and providing necessary support to enable the implementation of dust measurements in workplaces.

The current state of awareness and clinical suspicion for silicosis among medical officers and clinicians appears to be inadequate, as they exhibit limited knowledge and understanding of several aspects, even after diagnosing a patient with silicosis [44]. Insufficient attention is given to obtaining the occupational history of patients during medical consultations. Consequently, the misdiagnosis and underreporting of silicosis cases are prevalent. The necessity of enhancing the diagnostic skills of doctors in India, specifically in the interpretation of International Labour Organization (ILO) radiographs for the detection of silicosis is emphasized [44].

In India, a standardized diagnostic algorithm and guidelines for silicosis certification are lacking, as is clarification on who may certify a patient as suffering from silicosis [41, 42, 44]. An exception is the western Indian state of Rajasthan, where there is a policy on the detection, prevention, relief, and rehabilitation of pneumoconiosis [6, 73]. However, there are multiple challenges in its implementation, including unawareness, misdiagnosis, and low reporting rates [44]. In the absence of a surveillance mechanism for silicosis, data is not being captured, and the true burden remains elusive [41]. In the absence of a national health program, there is a lack of coordination among various stakeholders involved in silicosis control [44].

Opportunities

In light of the underreporting of silicosis cases, the actual burden of the disease remains unknown, underscoring the urgent need to enhance diagnostic facilities, provide training to medical officers at primary healthcare centers for accurate diagnosis of silicosis, and establish a robust surveillance mechanism (Table 3). A routine surveillance system would not only generate comprehensive data on the true prevalence of silicosis but also enable monitoring of the disease’s incidence, identification of high-risk areas, and analysis of associated risk factors. By providing timely and reliable information, such a system of surveillance would enable public health authorities to effectively adopt targeted preventive measures and interventions to limit the impact of silicosis.

Table 3 Opportunities for prevention and control of silicosis in India Surveillance

Identifying and mapping locations in India where industries generating silica dust are situated would be the first step toward eliminating the disease [22, 41]. To facilitate effective monitoring, it is essential to define priority districts and sub-district areas/clusters [22, 41]. Considering that a significant portion of these factories operates in the informal sector, tracking efforts would help concentrate control activities specifically on these areas, ensuring targeted implementation of preventive and control measures.

A surveillance system needs to be established for the early detection and tracking of all patients with silicosis [2, 6, 28, 74, 75]. Organizing diagnostic camps in industries where silica dust is generated would also aid in the early detection of silicosis. It is suggested that active case finding, which is currently a part of the national TB program, be expanded to include silicosis [