Development of a medical examination program for former workers at a Department of Energy national laboratory

The implementation of medical monitoring programs following potentially hazardous exposures: a medico-legal perspective

CONTEXT

Clinical toxicologists may be called upon to determine the appropriateness of medical monitoring following documented or purported exposures to toxicants in the occupational, environmental, and medical settings.

METHODS

We searched the MEDLINE database using the Ovid^® search engine for the following terms cross-referenced to the MeSH database: ("occupational exposures" OR "environmental exposures") AND ("physiologic monitoring" OR "population surveillance"). The titles and abstracts of the resulted articles were reviewed for relevance. We expanded our search to include non-peer-reviewed publications and gray literature and resources using the same terms as utilized in the MEDLINE search. There were a total of 48 relevant peer-reviewed and non-peer-reviewed publications. Publications excluded contained no information relevant to medical monitoring following potentially harmful toxicologic exposures, discussed only worker screening/surveillance and/or population biomonitoring, contained redundant information, or were superseded by more recent information. Approaches to medical monitoring: A consensus exists in the peer-reviewed medical literature, legal literature, and government publications that for medical monitoring to be a beneficial public health activity, careful consideration must be given to potential benefits and harms of the program. Characteristics of the exposure, the adverse human health effect, the screening test, and the natural history of the disease are important in determining whether an exposed population will reap a net benefit or harm from a proposed monitoring program. Broader interpretations of medical monitoring: Some have argued that medical monitoring programs should not be limited to exposure-related outcomes but should duplicate general preventive medicine efforts to improve public health outcomes although an overall reduction of morbidity, mortality and disability by modifying correctable risk factors and disease conditions. This broader approach is inconsistent with the targeted approach advocated by the Agency for Toxic Substances and Disease Registry and the United States Preventive Services Task Force and the bulk of the peer-reviewed medical literature. Medical monitoring in legal contexts: Numerous medical monitoring actions have been litigated. Legal rationales for allowing medical monitoring claims often incorporate some of the scientific criteria for the appropriateness of monitoring programs. In the majority of cases in which plaintiffs were awarded medical monitoring relief, plaintiffs were required to demonstrate both that the condition for which medical monitoring was sought could be detected early, and that early detection and treatment will improve morbidity and mortality. However, the treatment of medical monitoring claims varies significantly depending upon jurisdiction. Examples of large-scale, comprehensive medical monitoring programs: Large-scale, comprehensive medical monitoring programs have been implemented, such as the Fernald Medical Monitoring Program and the World Trade Center Health Program, both of which exceeded the scope of medical monitoring typically recommended in the peer-reviewed medical literature and the courts. The Fernald program sought to prevent death and disability due to non-exposure-related conditions in a manner similar to general preventive medicine. The World Trade Center Health Program provides comprehensive medical care for World Trade Center responders and may be viewed as a large-scale, federally--funded research effort, which distinguishes it from medical monitoring in a medico-legal context. Synthesis of public health approaches to medical monitoring: Medical monitoring may be indicated following a hazardous exposure in limited circumstances. General causation for a specific adverse health effect must be either established by scientific consensus through a formal causal analysis using a framework such as the Bradford-Hill criteria. The exposure must be characterized and must be of sufficient severity that the exposed population has a significantly elevated risk of an adverse health effect. Monitoring must result in earlier detection of the condition than would otherwise occur and must confer a benefit in the form of primary, secondary or tertiary prevention. Outcome tables may be of use in describing the potential benefits and harms of a proposed monitoring program.

CONCLUSIONS

In the context of litigation, plaintiffs may seek medical monitoring programs after documented or putative exposures. The role of the clinical toxicologist, in this setting, is to evaluate the scientific justifications and medical risks and assist the courts in determining whether monitoring would be expected to result in a net public health benefit.

Integrated approach to health screening of former department of energy workers detects both occupational and non-occupational illness

BACKGROUND

The National Supplemental Screening Program (NSSP) uses a Total Worker Health(TM) approach to address U.S. Department of Energy (DOE) former worker health. This article provides the design of the integrated occupational health screening and promotion program.

METHODS

The NSSP implemented a web-based relational health records system to process demographic, exposure, and clinical data. We present medical findings for 12,000 DOE former workers that completed an initial NSSP medical screening between October 1, 2005 and October 4, 2013. We discuss the DOE former worker participant population and the exposure-based and non-occupational medical screening tests used.

RESULTS

The NSSP identified potential occupationally related health conditions in 40.5% of those screened. Notably, we identified 85.8% of participants with addressable non-occupational health conditions, many of which were previously undiagnosed.

CONCLUSION

The NSSP demonstrates that the identification of potential occupational health issues in conjunction with addressable non-occupational health conditions provides former workers with information to more effectively manage health.

Summary of historical beryllium uses and airborne concentration levels at Los Alamos National Laboratory

Beryllium operations and accompanying medical surveillance of workers at Los Alamos National Laboratory began in the 1940s. In 1999 a Former Workers Medical Surveillance Program that includes screening for chronic beryllium disease was initiated. As part of this program, historical beryllium exposure conditions were reconstructed from archived paper and electronic industrial hygiene data sources to improve understanding of past beryllium uses and airborne concentration levels. Archived industrial hygiene sampling reports indicated beryllium was principally used in technical areas-01 and -03, primarily being machined. Beryllium was also used at 15 other technical areas in activities that ranged from explosives detonation to the manufacture of X-ray windows. A total of 4528 personal breathing zone and area air samples for beryllium, combined for purposes of calculating summary statistics, were identified during the records review phase. The geometric mean airborne beryllium concentration for the period 1949-1989 for all technical areas was 0.04 microg Be/m(3) with 97 percent of all sample below the 2.0 microg Be/m(3) occupational exposure limit (OEL). Average beryllium concentrations per decade were less than 1 microg Be/m(3) and annual geometric mean concentrations in technical area-03, the largest user of beryllium, were generally below 0.1 microg Be/m(3), indicating exposure was generally well-controlled, that is, below the OEL. Typical of many retrospective exposure assessments, not all archived data could be extracted and summarized. Despite this, we report a reasonable summary of potential beryllium uses and airborne concentration levels a worker may have encountered from 1949-1989. These data can be used to more effectively identify former worker populations at potential risk for chronic beryllium disease and to offer these workers screening as part of the Former Worker Medical Surveillance Program, and in the event that a case is diagnosed, help to understand historical exposure conditions.