Report on MBOD NIOH collaborative workshop on ODMWA post-mortem examinations



REPORT

On Friday 17 May 2019, in a collaborative initiative between the National Department of Health’s Occupational Health Cluster under the auspices of the Medical Bureau for Occupational Diseases (MBOD), and the Pathology Division of the National Institute for Occupational Health (NIOH), a one-day workshop on post-mortem examinations was held with stakeholders at the Sunnyside Park Hotel in Johannesburg.

The Occupational Diseases in Mines and Works Act (ODMWA) of 1973 provides for benefit medical examinations (BMEs) during all phases of a mine worker’s mining life cycle, i.e. from exposure until death. Section 33(1) of the ODMWA requires that medical practitioners submit cases to the MBOD Director on consideration or suspicion of a ‘compensatable disease’ (occupational lung disease) for any person who has worked at a mine or works, as follows:

“Whenever a medical practitioner in the Republic considers or suspects that any person medically examined or treated by him or her, who has to his knowledge worked at a mine or works, or who he or she believes on reasonable grounds to have so worked, is suffering from a compensatable disease, such ­practitioner shall forthwith communicate to the director his findings at the examination…”

The theme of the workshop was Kitso ke Tshiamiso, translated as ‘Knowledge applied, justice served’, in cognisance of the growing awareness of the state of health of mine workers, with emphasis on former mine workers. This was also in recognition of the Tshiamiso Trust that was established to provide benefits to the claimants of the historic tuberculosis (TB) and silicosis class action settlement agreement of May 2018. The settlement makes provision for compensation for mine workers (or their dependants) who contracted silicosis or pulmonary TB during or after employment, dating back to 1965. Importantly, this settlement makes provision for the compensation of these diseases based on in-life and post-mortem findings.*

Chapters III and IV of the ODMWA legislate post-mortem benefits in sections 34, 35 and 45. These sections require that, in the event of the death of an exposed mineworker, a post-mortem examination of the cardiorespiratory organs is conducted. 

Section 34(1) is explicit about the duties of medical practitioners with regard to post-mortem examinations or services:

“The director may authorise or in writing direct any medical practitioner in the Republic to perform a post-mortem examination or other post-mortem service under this Act of a nature determined by the director, and a medical practitioner so authorised or directed who has performed a post-mortem examination or other post-mortem service in accordance with such authorisation or direction, shall forthwith submit to the director a detailed report on the result of the examination or service performed by him or her.”

Section 35, regarding arrangements for post-mortem examinations and services, states that:

“The Minister may with the concurrence of the Minister of Finance enter into such agreement or make such other arrangements with any institution, hospital or organisation as the Minister may consider necessary for the performance of any post-mortem examinations or post-mortem services required under this Act.”

It should be noted that, while the cardiorespiratory organs may and should be removed anywhere in South Africa, the NIOH is the centre designated by the Minister for pathological examinations, in terms of Section 35. In addition, if a post-mortem of the cardiorespiratory organs is conducted for medico-legal purposes, these organs should be sent to the NIOH.

Section 43 of the ODMWA requires that “standards [are] to be applied in the certification of compensatable diseases”. These guidance standards are described in the “Code of Practice on Medical Examinations and Standards applicable in the Certification of Compensable Diseases” of 1999, and support the adjudication process.

The ultimate interpretation and application of the updated standards contribute to fair and consistent adjudication of submitted cases of occupational lung diseases by Certification Committee members appointed under the ODMWA section 39(2)(a). Thus, it is critical for all medical practitioners to familiarise themselves with the ODMWA and its Code of Practice, to ensure good quality BMEs and submissions thereof to the MBOD. Additionally, medical practitioners, and occupational medical practitioners (OMPs) in particular, need to have a keen understanding of the MBOD and the NIOH services provided under the ODMWA, including pathology assessments of the cardio-respiratory organs.

The overall aim of the workshop was to support the MBOD’s ongoing scientific journey to review and develop certification standards that are evidence-based and objective, and to engage with its stakeholders. The target audience for the workshop was medical practitioners and ODMWA Certification Committee members. The workshop participants were accredited with seven continuing professional development (CPD) points.

Specific objectives of the workshop were to enable delegates to:
• Identify and manage, on suspicion, cases of specific occupational lung diseases such as silica dust diseases (including tuberculosis) and asbestos-related disorders, applying clinical diagnostic guidelines and leading practices;
• Understand and interpret the relevant sections of the ODMWA: Chapters III / IV, sections 34, 35 and 45 on post-mortem examinations;
• Understand the diagnostic criteria for post-mortem examinations and guidelines for first-degree and second-degree awards of compensation at autopsy;
• Understand the NIOH Pathology Division processes and collation of surveillance reports on the Pathology Automation (PATHAUT) database; and,
• Understand how post-mortem examinations contribute to the certification process and compensation for mine workers.
A select group of experienced subject matter experts left an indelible mark on all participants with their enlightening, well-researched lectures, ranging from cultural aspects of providing consent for post-mortem examinations to pathology examinations of deceased mine workers’ cardio-respiratory organs, and culminating in a fascinating walk-through tour of the Pathology Division at the NIOH.

The cutting-edge knowledge shared by our speakers in their engaging presentations was appreciated by all our delegates. What could have been a rather morbid event, was brought to life through many insightful presentations.

Prof. Jill Murray (Consultant Associate Professor, Pathology Division, NIOH) set the scene with an ‘Introduction to the autopsy process’, emphasising the process of autopsy examinations, including removal of the cardiorespiratory organs, receipt of specimens at the NIOH, completion of the pathology report, capture of the information on the PATHAUT database, and submission of the pathology report to the MBOD. She emphasised that post-mortems are performed regardless of the clinical cause of death, i.e. for both natural and unnatural causes of deaths, and for both active and former mine workers. Mine workers can, and do, give consent for post-mortems in life; the onus is on the last attending doctor to arrange for the organs to be removed and sent to the NIOH.

The ODMWA compensatable diseases are listed below and Prof. Murray discussed the important pathological aspects of some of these diseases.

 pneumoconiosis
 pneumoconiosis and tuberculosis
 tuberculosis
 permanent obstruction of the airways
 any other permanent disease of the cardio-respiratory organs
 progressive systemic sclerosis
 any other disease which, in the opinion of the certification committee, is attributable to the performance of risk work at a mine or works.
The members of the Certification Committee at the MBOD, appointed under ODMWA section 39(2)(a), determine whether any of these ‘compensatable’ diseases is indeed compensable. Guided by the standards that are set in the ODMWA Code of Practice, the Certification Committee considers the presence and severity of diseases, together with the intensity of dust exposure, duration of mine work, number of shifts, length of service and degree of pulmonary impairment, before awarding non-compensable disease (NCD), or first or second degree certification of occupational lung disease.

Prof. Murray also journeyed through the ‘Silica dust diseases including TB’, explaining the different sources of exposure, diseases associated with silica exposure, diagnostic criteria, and post-mortem compensation. She emphasised that dust-related diseases frequently manifest in former mine workers long after they have left employment, hence the post-mortem service is as important for former mine workers as it is for current mine workers.

One of the key aims of Prof. Murray’s talk was to stress the continued need for post-mortem-based compensation because potentially compensatable diseases are frequently missed in life. In a study published in 2002,1 Prof. Murray and her co-researchers found that, over a one-year period, 28% of cases had compensatable disease at post-mortem; only  9% had been compensated in life, and the other 19% received a new or upgraded certification as a result of post-mortem examination.  

Mrs Ntombizodwa Ndlovu (Wits School of Public Health) discussed further studies that described how frequently occupational diseases are missed or misdiagnosed in life, especially silicosis,2,3 asbestos-related diseases4 and TB.5-7

It is the responsibility of the medical practitioner to exercise a high index of suspicion during the mine worker’s life cycle, to probe the occupational history, to conduct a good medical examination, to request appropriate investigations, and to follow up former mine workers. Even then, cases might be missed, and the post-mortem examination becomes the last opportunity for the mine worker and his or her family to submit a claim for compensation.

Mrs Ndlovu enlightened delegates on ‘The PATHAUT database: trends and analysis’, illustrating how the database has contributed to research and knowledge in public health surveillance since its launch in 1975. Importantly, she highlighted how the PATHAUT database has contributed to good public health surveillance in the following manner:
• Detecting and tracking the disease burden of occupational lung diseases, demonstrated by the findings of a detailed analysis of trends of autopsy-diagnosed PTB over a 40-year period8
• Identification of groups at risk of developing disease, using the findings from a study on silicosis and PTB in autopsied women in mining9
• Stimulation of research for prevention and control policy
• Monitoring and evaluation of prevention and control programmes
Ms Julian Mthombeni delivered a captivating lecture on ‘Consent for post-mortem examination’. In her study on ‘Exploration of factors influencing the uptake of autopsy compensation for miners in South Africa’,10 she found that the post-mortem rate, as a proportion of all mine workers dying while employed on the mines, varied widely across the industry. She explored a number of factors that influenced this, including trust in service providers, cultural practices, communications approach, and work pressures of service providers on the mines, and compensation payment challenges. She shared a quote from a doctor in her study that sparked dialogue: “I have got other priorities, living patients.”

With regard to cultural factors, gendered power relations were important, with male relatives generally making decisions regarding consent.

Ms Mthombeni’s recommendations, following her study, included that:
• Mine workers should be encouraged to sign a living will;
• The MBOD, as custodians of the ODMWA through the NIOH, should build the capacity of health professionals involved in autopsy provision;
• The MBOD and the CCOD need to improve their administration and communication processes; and
• Community awareness campaigns should be given priority.

Dr Naseema Vorajee (Specialist Histopathologist, Pathology Division, NIOH) shared her knowledge and experience on ’Asbestos Related Diseases’ in the pleura and the lung, emphasising that the pleura and the lung can be involved in different disease processes when exposed to asbestos, as illustrated in Figure 1.


Figure 1. Lung and pleural involvement in asbestos-related diseases
 

Delegates were invited to a practical activity, a ‘Walking tour of the NIOH Pathology Division’, by Dr Vorajee. They were transported back to third-year pathology lectures and got to don some gloves to appreciate the gross features of common pathology such as silicotic nodules, progressive massive fibrosis, emphysema and, even, mesothelioma.

The panel discussion focused on two key questions:
1. How do post-mortem examinations contribute to knowledge application and compensation services for mine workers? 
2. How are employers and OMPs gearing up for medical surveillance post-employment until death?
Dr Jim teWaterNaude (Diagnostic Medicine) and Dr Thuthula Balfour (Head of Health, Minerals Council) responded to these questions. Dr teWaterNaude delivered a talk on ‘Learnings from Kuruman, highlighting the reality that, despite the Kuruman asbestos mines closing by 1998, and asbestos being officially banned in South Arica in 2008, OMPs need to exercise a high index of suspicion in these mine workers and communities that might have been inadvertently exposed to asbestos, either through occupation or the environment. Many ex-mine workers and the greater Kuruman area residents still present with signs of asbestos-related disease. Some may be fortunate to be diagnosed in life, while others are only discovered after death. Hence, the importance of accessing the post-mortem service was once again brought to the fore.

Dr Thuthula Balfour further emphasised the role of OMPs in exercising their statutory obligations and assisting deceased mine workers’ families to access the ODMWA benefits of post-mortem examinations. She noted that it is commendable that the country has a firm system (PATHAUT) of analysing the causes of death among mine workers and that South Africa has historically been a leader in this field. She further noted that the fragmented legislation for prevention and compensation is a barrier to the seamless surveillance of mine workers and, thus, there exists an imperative for OMPs and other doctors to be astutely aware of these benefits. 

To close the workshop, Dr Mpho Rabada, on behalf of the Director: MBOD, provided an overview and summary of the ODMWA, highlighting the role of medical practitioners in ensuring that mine workers (former and current), and families of deceased mine workers, access their benefits to have the best possible chance of compensation. He expressed gratitude to the delegates for attending.

No workshop is successful without its participants and, for that, the organisers were grateful. The sharing of experiences, new knowledge, deep insights, high energy and enthusiasm for difficult aspects of old legislation left all delegates engaging with the content long after the workshop ended.

KEY LEARNINGS
1. Medical practitioners have a legal, professional and ethical role to play in the lifelong medical surveillance of mine workers: from engagement, throughout employment, long after employment ends, well into retirement, upon death, and even beyond.
2. There are many missed opportunities to diagnose occupational lung disease in life; a post-mortem examination is the last opportunity for a deceased mine worker’s family to access the ODMWA compensation system.
3. Medical practitioners value collective learning, and recognise the need for more collaborative workshops; the MBOD and the NIOH should continue to share cutting-edge knowledge on a consistent basis.

ACKNOWLEDGEMENTS
Prof Murray, Dr Vorajee, Dr Mtshali.
The workshop and the article would not have been possible without the strong leadership and mentorship, passion for doing good for mineworkers, and utmost attention to detail by Prof Jill Murray; words are powerless to do justice to your support.
Also to Dr Vorajee, for your time and patience, working through the night in the path lab putting the programme and content together, with such finesse.
Dr Nhlanhla Mtshali Director : MBOD for her support of this initiative when the seed was planted almost a year ago, with the review the ODMWA Code of Practice, and for sponsoring the event.
And last but not least Dr Spo, Prof Rees and team NIOH, Tshepang Mtshemla and the team at Wits health consortium for joining all the dots and making it happen.

**On 26 July 2019, the High Court in Johannesburg approved an historic 5 billion ZAR settlement in the ongoing silicosis case involving thousands of mine workers.**

REFERENCES

1. Murray J, Coetzee L, Back P, Banyini A, Ross M. Analysis of occupational lung disease identified at autopsy and compensated in the South African mining industry. Occup Health Southern Afr. 2002; 8:3-5.

2. Hnizdo E, Murray J, Sluis-Cremer GK, Glyn Thomas R. Correlation between radiological and pathological diagnosis of silicosis: an autopsy population based study. Am J Ind Med.1993; 24:427-445.

3. Ehrlich R, Murray J, Rees D. Subradiological silicosis. Am J Ind Med. 
2018; 61:877-885.

4. Ndlovu N, Rees D, Murray J, Vorajee N, Richards G, teWaterNaude J. Asbestos-related diseases in mineworkers: a clinicopathological study.  ERJ Open Res. 
2017; 3:00022-2017 doi.org/10.1183/23120541.00022-2017.

5. Murray J, Lowe P, Coetzee L. SIMHEALTH 611: Clinico-pathological study to reduce the rate of missed and misdiagnosis of pulmonary tuberculosis in the South African mining industry. Johannesburg, South Africa: Mine Health and Safety Council; 2000.

6. Sonnenberg P, Lim MSC, Dowdeswell R, Field N, Glynn J, Murray J.  Quantifying errors in the estimation of tuberculosis mortality in a population of South African miners. Int J Tuberc Lung Dis. 2012; 16:1449-1454.

7. Field N, Murray J, Wong ML, Dowdeswell R, Dudumayo N, Rametsi L. Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care. BMC Public Health. 2011; 11:127.

8. Ndlovu N, Musenge E, Park SK, Girdler-Brown B, Richards G, Murray J. Four decades of pulmonary tuberculosis in deceased South African miners: trends and determinants. Occup Environ Med. 2018; 75(11):767-775.

9. Ndlovu N, Richards G, Vorajee N, Murray J. Silicosis and pulmonary tuberculosis in female South African miners. Occup Med. 2019; 69(4):272-278.

10. Mthombeni JQ. Factors influencing the autopsy consent process for South African miners [MPH research report]. Johannesburg: University of the Witwatersrand; 2016.

 

Report by:
Dr Vanessa Govender
Programme Director and Organiser
Occupational Medicine Specialist and Public Health Consultant
Chair: Certification Committee, MBOD
e-mail: vanessa@masakhanehealth.co.za
 

NIOH Pathology Division contact details:
Dr Deepna Govind Lakhoo
e-mail: deepnal@nioh.ac.za

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