DECISION NUMBER:

20240005

OBJECTING PARTY:

WORKER

REPRESENTED by:

SELF

RESPONDENT:

EMPLOYER

REPRESENTED by:

SELF (NOT PARTICIPATING)

HEARING:

HEARING IN WRITING – DECEMBER 12, 2023

HEARD by:

C. DA CUNHA, APPEALS RESOLUTION OFFICER

DATED:

DECEMBER 12, 2023

ISSUE

The worker objects to the Occupational Disease & Survivor Benefits Program (ODSBP) Adjudicator’s April 19, 2023, May 10, 2023, and June 13, 2023 decisions.

The worker seeks:

1. Initial entitlement to sarcoidosis arising out of their environmental workplace exposures to chemicals, dust, bacteria, viruses, spores, and mold.

BACKGROUND

Injury History: On July 19, 2012, the worker sought medical attention for shortness of breath, suspicious for pneumonia. A November 16, 2012 computed tomography scan of the thorax subsequently provided a probable diagnosis of sarcoidosis. She had worked with the employer for approximately

13 years, as a Medical Instrument Technician (MIT) at the time.

She stopped working from 2014 to 2018 because of the condition, as well as depression and anxiety, which she attributes to the sarcoidosis. She returned to work in 2018, but stopped working again in 2021.

On January 17, 2023, the worker completed the Worker’s Report of Injury/Disease (Form 6), and the WSIB registered her claim.

The ODSBP Adjudicator’s Decisions: After outlining the employment history, securing the outstanding medical documentation, confirming the sarcoidosis diagnosis with Dr. B.M. McGoveran, WSIB Occupational Medicine Consultant, reviewing the worker’s submissions, and considering the

July 28, 2022 Occupational Policy Branch (OPB) scientific review document on sarcoidosis, the ODSBP Adjudicator denied the claim on April 19, 2023. The ODSBP Adjudicator explained that she was not able to conclude that the worker’s occupational exposures significantly contributed to the onset of the sarcoidosis because there is currently a lack of scientific evidence supporting a causal link between occupational exposures and the condition.

The ODSBP Adjudicator reconsidered and upheld the original decision on May 10, 2023 and June 13, 2023, for essentially the same reason.

The Worker’s Position: The worker argues that she has provided a significant amount of evidence showing that environmental exposures to chemicals, molds, spores, viruses, bacteria, dusts, mists, and vapours cause sarcoidosis. In her role as a MIT, she was regularly exposed to all these agents on a prolonged basis.

In cleaning the dirty medical instruments post-surgery, she was exposed to airborne droplet dispersals, which potentially carried viruses and bacteria. She also used chemical agents to clean the instruments, including ethylene oxide, which is linked to respiratory problems, and H-Klenz II, which contains silicon oxide, with silica exposure linked to the onset of sarcoidosis. Finally, she worked in very wet areas, where mold developed. Mold is also linked to the onset of sarcoidosis.

Noting her environmental exposures at work, and their link to sarcoidosis as confirmed by all the evidence she submitted to the case file, one must conclude that those exposures played a significant role in the development of the condition. Therefore, initial entitlement is in order.

The Employer’s Position: The employer is not participating in the worker’s appeal.

AUTHORITY

Sections 2 and 15 and Regulations 3 and 4 of the Workplace Safety and Insurance Act, 1997 (WSIA)

ANALYSIS

Having reviewed and considered the evidence currently available to me within the case record, as well as the relevant legislation, I find that initial entitlement to sarcoidosis is not in order.

Occupational diseases are adjudicated under Section 2(1), Section 15 and Regulations 3 and 4 of the WSIA, 1997. If the disease is not listed in the Schedules of the WSIA and a relevant policy has not been developed, entitlement to WSIB benefits and services is determined based on the real merits and justice of the individual claim. It must be established that it is more probable than not that the circumstances of a worker’s employment and exposure history significantly contributed to the development of the medical condition being claimed.

The test for determining causation in WSIB claims is that of a significant or material contribution. A significant or material contributing factor is one of considerable effect or importance. It need not be the sole contributing factor.

The standard of proof applied is the “balance of probabilities”. A speculative possibility does not meet this standard, which requires a fact or a causal link to be “more probable than not”.

There is no dispute that the worker’s environmental exposures over her career included chemical agents used in cleaning medical instruments, airborne droplet dispersal from the post-surgical instruments while cleaning, and, potentially, mold in the wet areas where she worked. There is also no dispute that she was diagnosed with sarcoidosis on November 16, 2012. The matter to be determined is whether, on a balance of probabilities, the worker’s history of environmental exposures at work significantly contributed to the onset of the disease. This is, in this specific case, a medical and scientific question.

With respect to this specific case, I note the following significant facts and circumstances:

• None of the medical specialists that assessed, followed, and/or treated the worker over the years related the sarcoidosis to occupational exposures. On June 9, 2023, Dr. L. Ghazala, Respirologist, specifically confirmed that “not much is known as to the origin of this disease” and opined that they were not able to confirm whether the worker’s environmental occupational exposures led to the condition;

• All of the studies and articles submitted by the worker to the case file acknowledge that, currently, the cause(s) of sarcoidosis is/are unknown;

• The employer confirmed that no other MIT has claimed work-related sarcoidosis; and,

• While H-Klenz II contains silicon oxide, the worker’s exposure to that agent while carrying out her duties would be insignificant when compared to a worker exposed to silica dust on a regular basis (e.g. Rock Worker, Concrete Worker, and Construction Worker).

On July 28, 2022, the WSIB’s OPB reviewed the currently available medical and scientific literature regarding sarcoidosis. After doing so, it explained that sarcoidosis is a multisystem granulomatous disease (a granuloma is a tiny cluster of white blood cells and other tissue that occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate), with nonspecific clinical manifestations, mostly affecting the lungs and other organs, including the eyes, skin, liver, spleen, and lymph nodes. The clinical presentation of sarcoidosis may range from asymptomatic to fatal, depending on the site.

It added that a variety of environmental, occupational, infectious, and genetic risk factors have been suggested since sarcoidosis cases were first documented in Europe over 100 years ago. However, no single exposure has been implicated. Many researchers have hypothesized the role of genetic susceptibility, environmental factors, putative antigens, and autoimmunity in the development of this disease, and most studies to date have investigated sarcoidosis as a reaction to an environmental or occupational exposure and/or genetic predispositions. Despite research efforts, the etiology of sarcoidosis remains unknown, with the most common hypothesis suggesting a combination of genetic predisposition leading to susceptibility to an unidentified environmental trigger.

Although the cause of sarcoidosis is unknown, it has been associated with multiple environmental and occupational exposures. There is increasing evidence that sarcoidosis can occur in workplace settings in which there is exposure to both foreign antigens and inorganic triggers of inflammation that promote a granulomatous immune response.

A 2019 review of the occupational contribution to the burden of major non-malignant respiratory diseases concluded that workplace exposures contributed to the burden of sarcoidosis (occupational burden, 30%). More specifically, the pooled estimated occupational proportion of sarcoidosis ranged from 0% to 54%, with a weighted metaproportion of 30% based on seven studies published from 2003 to 2016.

Therefore, the authors estimated that 30% of overall cases of sarcoidosis are attributable to occupation. For comparison, the occupational contribution to silicosis and asbestosis is essentially 100%.

The OPB review concluded that, at present, a limited body of evidence with adequate methodological quality is available to describe and quantify the risk of sarcoidosis associated with occupational exposures. More specifically, two studies were deemed of acceptable quality. The results from these two studies suggested an increased risk of sarcoidosis among subgroups of workers with medium to high levels of silica dust exposure. These workers included, but were not limited to, concrete workers, rock workers (miners), casters, masons, ceramic and glass manufacturers, and others. However, exposure levels across the two studies were not consistent and references to medium or high levels of exposure were not quantified. In addition, exposure-response relationships based on mean or cumulative exposures were not evident, and non-occupational risk factors were not consistently investigated across the two studies.

Following the OPB’s critical appraisal of available studies, it concluded that the best evidence shows that:

• There is limited evidence for an association between silica exposure and sarcoidosis.

o Results from two higher quality (lower risk of bias) studies provided evidence suggestive of an increased risk of sarcoidosis among silica exposed workers.

o Overall, the present body of scientific evidence is small and inconsistent with methodological limitations that preclude the determination of a causal association including lack of evidence to determine a consistent threshold for duration, intensity, or quantity of exposure.

• There is inadequate evidence for an association between other occupational exposures (i.e. including, but not limited to, manufacturing, welding, and agricultural occupations), in the absence of silica, and sarcoidosis.

o Few studies examined other occupational groups/exposures and their association with sarcoidosis; those that did were of lower quality (higher risk of bias); therefore, causal associations can neither be identified nor ruled out.

Scientific evidence is considered limited if study findings suggest a causal association, but inconsistent results, lack of exposure-response trends, or methodologic weaknesses preclude a definitive conclusion.

Scientific evidence is inadequate to establish a causal association if study findings show no overall association, lack consistency, or are based on few or methodologically weak studies.

In summary, the OPB’s scientific review of the current sarcoidosis literature, which includes all the evidence submitted by the worker, shows that sarcoidosis is a disease without a known probable cause, work-related or otherwise. Furthermore, the evidence shows that the worker was not exposed to silica dust in the workplace and, even if she were, the link would provide limited evidence of an association, which is below the threshold necessary to establish contribution or causation. Additionally, the current literature provides inadequate evidence of a causal association between exposures in non-silica exposure industries (e.g. the healthcare industry) and the development of sarcoidosis.

I am extremely sympathetic to the worker’s current circumstances and acknowledge her strongly-held position that the condition is work-related. However, the currently available evidence, combined with the relevant facts and circumstances of the case file, does not allow me, unfortunately, to establish that the worker’s history of environmental workplace exposures to chemical agents, airborne droplet dispersal, and mold, were, more likely than not, significant contributing factors to the development of the disease. Therefore, I am unable to grant initial entitlement to sarcoidosis under the WSIA.

CONCLUSION

I find that initial entitlement to sarcoidosis is not in order. The worker’s objection is, therefore, denied.

DATED December 12, 2023.

C. da Cunha

Appeals Resolution Officer Appeals Services Division