Silicosis prevention for public health services equally and sustainably
Office of Disease Prevention and Control#9 Nakhon Ratchasima Department of disease control

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
At Sikhio district, Nakhon Ratchasima province, a number of silicosis patients increase every year with the highest number of country (25% of all silicosis cases in Thailand). From the year 2007 to January 27, 2017 there had been 362 silicosis patients and 47 silicosis deaths. The mortality rate was 16 % which showed the severity of silicosis epidemic. Silicosis is caused by inhalation of dusts containing silica into lung. Most of the patients were sandstone-cutting workers (2,089 people or 91.70%). The groups of informal labors who worked as a freelancer were not under the Public Health Services coverage and did not have any occupation health insurance, but they have to do this risky job to earn a living for their families. Not only the mentioned group above, there were also 189 alien labours namely Cambodians and Laos (8.30%) who were required to be triaged and treated in accordance with the standard of public health service system. Previously, Public Health Service units did not provide occupational health service and did not have a channel for the informal labors and aliens allowed to work to have a continual access to public health services. In 2008, the first case of death resulting from Silicosis among the stone cutting workers in the Sikhio district, Nakhon Ratchasima province, was registered. As a result, there was an active campaign in screening and searching for other Silicosis patients in the area and there was a survey on the stone cutting workers in other areas of Sikhio district, too. It was found that there were many other stone cutting workers in the areas who had a high potential of having developed Silicosis. Moreover, in some groups, the symptoms of respiratory diseases were also found. These groups of stone cutting workers seemed to lack clear understanding and awareness of self-protection from dust and never actually received a medical check-up per occupational health risk guideline. In 2009, after having altered the way of sandstone cutting from cold chisel to a modification of lawnmower machine with a cutting disc, a lot of dust had been increased and inhaled more into lung. In this situation, deaths were founded earlier within 2-5 years (10%) in the houses which conduct sandstone cutting and the workers were women and children. This allowed men; heads of families, to get silicosis diseases (85.08%), died from Silicosis (95.74%). Besides, among silicosis patients, 14.64 % of them were women, 4.26% died from Silicosis and 0.28% was children. If the problem remains unsolved, it will lead to an increase of illness, human loss, and lack of earnings. As a result, women will have to take responsibilities for their family allowances, medical treatment expense, and debts. Children will have to leave their schools to help their families work. Additionally, these provide an impact on social problems, air pollution and disrespect from the community leading to economy loss in terms of sandstone product manufacturing of the community and the nation.

B. Strategic Approach

 2. What was the solution?
1. Reduction of dust from the source by preparing / using engineering methods to create devices for dust reduction caused by sandstone cutting and coming up with new criteria in arranging dust-free houses. This helped reduce dust caused by sandstone cutting, resulting in the decrease in risk in developing silicosis among the stone cutting workers in the sandstone cutting areas, or who cut stones at home, or those who live nearby. 2. Improvement of health service for silicosis treatment by providing occupational health services such as implementing proactive patient triage, improving diagnosis by specialists, creating cooperation in diagnosis and providing medical treatment and referral of patients from primary to secondary and tertiary care, and providing a follow-up service by visiting the patients at their houses. This assists in finding people who are at the greater risk for silicosis, suspected cases of silicosis and silicosis patients. They can be brought to diagnosis and medical treatment process in time. Therefore, a disease severity and deaths from silicosis will be decreased. 3. Creating a network where the general public and the concerned authorities can collaborate: by listening to the opinions and responding to the needs of the stone cutting workers and the general public, in terms of the control and prevention of Silicosis. This was achieved by building a technology that controls dust and creating a learning that can be used among communities by themselves continually and sustainably. Per the concerned authorities, many committees were formed to help and improve the Silicosis control and prevention network of Sikhio district in 2014; such as, Public Health Service units, educational institutes, Local Administration units and the general public networks. Together, they analyzed the process, problem conditions and obstacles, and helped set up an MOU (memorandum of understanding) and planned how to work together, resulting in the effective Silicosis Control and Prevention System, a smooth collaboration of work and a continued improvement per PDCA (Deming Cycle).

 3. How did the initiative solve the problem and improve people’s lives?
In the past, the prevention and control of silicosis was to monitor health conditions by searching for those who had a high risk of developing Silicosis. This was done by doing a screening check through a survey together with a Spirometry and an auditory check. The workers were educated on how to prevent Silicosis and were trained how to use the protection equipment; such as, dust protection masks, ear covers, eye protectors etc. and 2) to monitor the environments by measuring the amount of dust in the working environment, but there was not an improvement in diagnosis and treatments, which it could not solve the cause of the underlying trouble which should be a reduction of dust from sandstone cutting at working space and home. Furthermore, the sandstone-cutting workers requested for the methods to decrease dust. The diagnosis and remedy in accordance with symptoms did not allow patients to receive the right treatment for their disease. They were not advised on self-prevention and reduction in dust inhalation. Therefore, they got worse and then pass away. There was a case that a patient starting his sandstone cutting job in 1972 and his sickness was found in 1995. The patient received tuberculosis treatments twice in 2005. After these treatments, the patient had side without receiving silicosis treatment in time and died in 2007. According to a lack of the affirmation process for diagnosis from a certified X-Ray B-reader specialist in accordance with ILO criteria (B reader ILO pneumoconiosis chest x-rays classification), some diseases are diagnosed to a higher level than the actual symptom which can lead to a waste of medical expense especially for tuberculosis. Tuberculosis medication may cause an adverse drug reactions (ADR) such as hepatitis and peripheral neuropathy and affect circulatory, integumentary, and respiratory systems as well as cause toxic to kidney. And the agency network demanded that there be a development in the diagnosis and treatment system according to the risks. As a result of mentioned problems above, the ODPC 9 has applied the concept of Prevention and Control of Silicosis in an effective way. This derived from the World Health Organization (WHO) and the International Labour Organization (ILO)’s summary of learning and their proposed measures for prevention and control of silicosis. that are: (1) Primary Measures: controlling the sources of dust, monitoring the working environment, assessing the risks for health, monitoring the health conditions of the workers to analyze them since an early stage, and (2) Secondary Measures: improving the skills in reading the standard films and developing a system to monitor the health conditions of the workers The ODPC 9,together with the agency network and the general public, initiated the service improvement program for the prevention and control of silicosis further to their previous plan such as a control of dust sources health surveillance of workers for diagnosis at primary state, and skill development of standard X-Ray reading to prevent the disease from the root cause. This induced faster diagnosis for early medical treatment and a reduction of death loss.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The objectives of the service improvement are 1. To reduce dust Use the engineering method in decreasing dust at the sources with wet process combining with ADDIE model (Analysis-Design-Development-Implementation-Evaluation). It consist of a) Decreasing dusts at the sources: implementing a model of dust reduction device, then install at the sandstone cutting tools, and using water in reducing dusts. 5 users conducted an experiment to improve the device, reduce the cost, and magnification of results. b) Decreasing dusts at home: apply the principles of adjusting working atmosphere at home which can be a criteria of dust-free house arrangement, make a public hearing from sandstone-cutting workers, ask for volunteers in organizing 5 dust-free house and then extend results. 2. To search for people who are at the greater risk, diagnose, and cure with medical treatment faster Proactively triage people who are at the greater risk. It will help to triage silicosis patients thoroughly, accelerate time of diagnosis, and adjust the diagnosis process by increasing utilization of result from X-Ray film read by B-reading specialists apart from using the record of dusts contact. This can make the diagnosis more specific and faster.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The ODPC 9 created a participation process in studying and analyzing the problem conditions. Also, it did a public hearing and summarized a learning lesson, and worked with the agency network and the general public to listen to the opinions and the needs in order to solve the problems and set up a guideline for Silicosis control and prevention per below: 1. The problem of having a higher amount of dust than allowed by the standard in the working environments and having no body protection from dust lead to Silicosis. Therefore, an implement was in place per below: 1.1 controlling dust amount in working environments with the dust reduction device 1.2 controlling dust amount in residences and communities by using the in-house dust reduction measure so that the dust amount is at a safe level for the stone cutting workers and the neighbors, together with monitoring working environments by constantly assessing the amount of dust so as to reduce the dust amount at the dust sources effectively and thus reducing the chances of developing Silicosis 2. The fact that providing occupational health services among the group of informal labors and aliens allowed to work was not up to the standard and did not cover those who were prone to Silicosis. This led to severity of the illness and death among the patients. Therefore, to prevent this, a management system for occupational health services was set up, so that the workers can have equal rights to the standard of health services per below: 2.1 Active Finding – to fully cover those with high risks and the patients in the areas 2.2 Diagnosis and Treatment 2.3 Enhancement for a quicker and more timely Referral System 2.4 Rehabilitation -- so that the patients can return to work and so as to mitigate the severity of the illness and reduce the rate of death from Silicosis
 6. How was the strategy implemented and what resources were mobilized?
1. Inventing the device model in reducing dust- by using a budget and materials from the ODPC 9 and working with professors from Suranaree University of Technology. Sandstone cutting entrepreneurs are advised to invent and develop their own devices to reduce dust. Cost can be reduced from 1,500 baht to not exceed 500 baht. Entrepreneurs use their own budget to invent the devices and utilize all area. But in terms of implementation, there was a conference to inform the entrepreneurs and the stone cutting worker, in groups and in person, to provide instructions and to ask for a cooperation from the entrepreneurs and the stone cutting workers who did not have an employer, to find a dust reduction device, so that every stoner cutters had a dust reduction device. The budget and the materials to make the dust reduction devices were from the entrepreneurs, the stone cutters or partially supported by the Local Administration Organization. 2.Making a prototype of the dust-free house - by using the budget and materials from OPCD 9 together with the house owners. For implementation, a public hearing was conducted among the stone cutting workers who worked at home and the people in the community, to provide instruction and ask for a cooperation from the public health volunteers to make their house a dust-free house, and make sure that every house that cut stones do the same. Local Administration Organization issued a legal code using the dust-free house criteria, to control stone cutting at home. It also held activities to continually promote dust-free house competition. The budget and materials were from the house owners and partially subsidized by the Local Administration Organization. 3. Control and Prevention of Silicosis for children who will become the next generation of stone cutting workers – for the children studying in both non-formal and informal education, to make sure that they know how to protect themselves and their family members, there was a workshop meeting to make a curriculum on Silicosis and its control and prevention. The curriculum consisted of general knowledge of Silicosis, how to use personal protective equipment, how to use the dust reduction devices, and how to make their house dust-free. The teachers who teach Health Education were trained by the local Public Health officials. And the knowledge was incorporated into one of the subjects of the Basic Educational Curriculum. The media master was supported by the OPCD9 and the budget for the workshop meetings was subsidized by the local Public Health Service units. 4. Occupational Health Service System – the OPCD 9, together with the Bureau of Occupational and Environmental Diseases (BOED), provided workshop trainings to improve the capability of the local Public Health Service officials, an improvement and a standard guarantee assessment, and the services of occupational health in the local areas. The occupational health services consist of conducting an active finding for those at high risks once every year, and monitoring the problem conditions or the local needs, using the budget from the Local Administration Organization and the Public Health Service units. For diagnosis, medical treatment and patient transfer, the budget will be from Public Health agencies. In addition, for the skill improvement of certified X-Ray B-readers, the budget will be from Occupational and Environmental Diseases Bureau, Department of Disease Control and hospitals under their supervision. As for patient rehabilitation, the budget will be from the Local Administration Organization and Public Health Service units in the local areas.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1.The Ministry of Public Health has a policy to enhance the improvement of the public health in informal labor. There was a meeting with the agency network of the Public Health Service units, education institutes, the Local Administration Organization and the Pollution Control Department, to create a framework for enhancing the improvement of the public health for informal labor for the stone cutter group. This was proceeded through the committee which consists of the Subcommittee of the Improvement of the public health works, the Provincial Subcommittee of Public Health, the Provincial Subcommittee of Clinics for work-related Diseases and the Provincial Subcommittee of Silicosis, so that there was a collaboration among each unit , thus the same direction and sharing in resources. 2.The Local Administration Organization used legal mechanism in using local ordinances so as to prevent silicosis according to the frame work of managing the budget of the District Health Fund. This benefited the control of occupations and arrangement of the environment conditions in the communities, and also promoted working safely and built the economy in the areas. 3. Cooperation of the stone cutting workers and the choosing of the representatives. This helped control the compliance of the guideline and the local ordinances in terms of Silicosis prevention. 4.The OPCD 9 together, with Suranaree University of Technology, came up with an innovation of the dust reduction devices that are installed onto the portable stone cutters. It took 3 years to develop, so as to have a device that does not require electricity, light in weight, uses less water and low budget. 5.The ODPC 9 is the hub for the film reading system by physicians(B-reader), which there are only 3 of them in the areas. This helped in gathering and forwarding the x-ray films, thus the diagnosis faster and more accurate.

 8. What were the most successful outputs and why was the initiative effective?
1. The dust reduction device can effectively reduce the quantity of dusts in sandstone-cutting factories up to 88% and those in the houses up to 80% (from the evaluation on the effectiveness of dust reduction). The sandstone-cutting workers and the members in the houses are highly satisfied with the dust reduction device (at 93.33% and 92.50%, respectively). 2. The wider groups of people who are susceptible to silicosis have been screened (up to 90.14%). Susceptible persons and patients are faster diagnosed and treated, from longer than 6 months to only within a month. In the primary state of silicosis treatment, the patients are treated the same as tuberculosis patients. Therefore, complete diagnosis would reduce at least 140 tuberculosis patients (41.18%), leading to less consumption of expensive tuberculosis medication during treatment (between THB 2,400 and THB 1,000,000 /person/year) and decreased impact on health from adverse drug reactions (ADR) 3. Collaboration networks were established to prevent and control Silicosis per below: 1 Regional Level (North-Eastern): 1 network 2 Health area level: 4 networks 3 Provincial level: 4 networks 4 District level: 12 networks This leads to the national policy of control and prevention of Silicosis, a push in operations, and a collaboration and an integration of work and resources. It created a wide circle of learning, created 3 common guidelines that are 1) Silicosis diagnosis and treatments 2) follow-up house visits and 3) an active finding. It also leads to the establishment of an Expert Center of Work-related Lung Diseases in a central hospital (Nakhon Ratchasima Maharaja Hospital) at the Tertiary Care level to provide treatments for the patients who have complex work-related diseases.

 9. What were the main obstacles encountered and how were they overcome?
1. Dust reduction device needs a battery and a water pumping machine. This requires the dust reduction device to be charged and recalibrated every time before use. It adds more steps to the process and takes more time in order to operate the device. The stone cutting worker, as a result, came up with a new way that yielded a similar result, in which they used the benefit of water pressure by installing the water tank at a high level instead of using a battery, in order to reduce the cost and the steps of use. Apart from this, the OPCD 9 also gathered a list of venders that sell related materials for the benefits of making and maintaining a dust reduction device. 2. Wastewater from the dust reduction device installed at the sandstone-cutting machine and from cleaning the floor with cutting sandstones: The solution is to advise how to get rid of wastewater with appropriate and hygienic manner by setting up wastewater drainage, disposable water outlet, then reuse the treated water for other purposes in order to prevent impacts on the neighboring areas and the community. 3. High expenses for becoming a dust-free house (averagely THB 2,000 /house): Normally, the house-owners have low income (THB 300 per day on average) and high household expenses. Therefore, they cannot afford certain expensive equipments, such as a fire extinguisher (THB 700-THB 900). The solution is to suggest them the replacements, knowledge on how to prevent, store and get rid of the materials that can cause fire, as well as on basic fire prevention and extinction, while receiving subsidies from the local government.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1. Sandstone-cutting workers, family members, and neighbors receive less dust and thus have less risk from dust-related symptoms and silicosis. 2. Vulnerable persons and initial stage patients are discovered, diagnosed and cured faster through proactive screening which could lessen the severity of the disease and death rate. 3. Public Health Units have effective and up-to-standard service for silicosis patients and has a key tool that helps prevent dust-related diseases and Silicosis, that is the control of dust at the sources; for example, the prototype of dust reduction device to be used with portable stone cutting machines and the prototype set up of dust-free house 4. Local government can continue to promote stone-cutting for making a living to strengthen the economy of the community, while providing sanitation and safety services for the stone-cutting workers and people in the community. 5.After improving the environments per the principles of the working environment at home, it changed the communities to have a better environment and scenery. The amount of dust accumulated in the work places and the nearby areas decreased. The waste water from the dust reduction device and the waste water from cleaning the working places were disposed of correctly per the sanitary guideline. It also helped create a good perception towards the stone products among the communities, resulting in more acceptance among the communities and their less concerns for health effects. 6. Reduction of public expenditure in medical treatment to diagnosed patients up to THB 19,000/person/year.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
1. Pride in the performance: In the past, when learning about the diagnosis result, public health officers had no confidence in informing sandstone-cutting workers and the people about the result and medical treatment. Therefore, 10 public health officers of Sikhio District were trained to develop their skills in giving advices in order to build their confidence in informing the diagnosis result, giving assigned to visit each house to follow-up on a monthly basis (1 officer: 30 patients). As a result, the officers gain up to 70% acceptance from the patients. Only 30% denies or is unsatisfied with this assistance. In addition, it found that there is a 30% increase in the use of masks and dust reduction devices (dust reduction device and dust-free home) to prevent dusts. 2.Creating awareness of people-focused services – the Public Health officials increased specific services for taking care of the patients with high risk occupations and others. As a result, there was a need in improving the diagnosis and consulting team, providing tools and equipment used in the process, and creating a special track (Fast Track) for the workers that come from the high-risk areas, so that they have a chance to be diagnosed with specific equipment and by subject experts and receive faster service. In addition, there were also further assistance for the patients, as well as follow-up house and family visits, using Holistic Care principle, since the early stage to death, by multi-disciplinary professionals of medicine and public health, economy and social, together with education institutes both formal and informal. More over community development team and Public Health Service officials are the main persons to help coordinate with the concerned authorities in solving other issues; such as, having no lands for cultivation, alternative occupations, education for students in the schools etc. 3. Community’s Acceptance: Some groups of people oppose stone-cutting out of their annoyance and troubles from dusts, flowing into their residences. The solutions are to relocate the stone-cutting factories away from the neighborhood and set the wire mesh. The local government issued the law relevant to sandstone-cutting control, bringing about community’s acceptance and no complaints.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The ODPC 9 and the Sikhio Disctrict Health Office conducted assessments of the effectiveness of the dust reduction device and the dust-free house arrangement twice a year, ensuring they were implemented continuously. Public health officers will monthly follow up and visit silicosis patients at home for tracking the treatment’s result and their living conditions as well as the effects on wives, kids, and family members in physical, mental and environmental as well as ensuring that there is no pregnancy while working as a stone cutter. In the case that the head of the family is sick and cannot work, the divisions responsible for occupational development and promotion, and education will come to assist women. In the meantime, the informal education will come to support children leaving schools as well as ensuring there is no child labors. Silicosis has the incubation period around 5-25 years. Although disease patients are increasing up in the initial triage process in order to incorporate the susceptible persons and patients into fast diagnosis and treatment, resulting in the decrease of sickness and death rate. However, the evaluation of the program shall be necessarily continued in the long run.

Contact Information

Institution Name:   Office of Disease Prevention and Control#9 Nakhon Ratchasima Department of disease control
Institution Type:   Government Department  
Contact Person:   Pattareeya Booniaw
Title:   Director of ODPC9  
Telephone/ Fax:   +6644212900
Institution's / Project's Website:  
Address:   Ratchasima-Chokchai Road , Nong Bua Sala
Postal Code:   30000
City:   Muang Nakhon Ratchasima
State/Province:   Nakhon Ratchasima

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