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 UNITED STATES DEPARTMENT OF LABOR

 + + + + +

 ADVISORY BOARD ON TOXIC SUBSTANCES

 AND WORKER HEALTH

 + + + + +

 MEETING

 + + + + +

 THURSDAY,

 APRIL 20, 2017

 + + + + +

 The Advisory Board met at 8:00 a.m.

Pacific Time, at the Red Lion Hanford House, 802

George Washington Way, Richland, Washington,

Steven Markowitz, Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

JOHN M. DEMENT

MARK GRIFFON*

KENNETH Z. SILVER

GEORGE FRIEDMAN-JIMENEZ

LESLIE I. BODEN

MEDICAL COMMUNITY:

STEVEN MARKOWITZ, Chair

LAURA S. WELCH

CARRIE A. REDLICH

VICTORIA A. CASSANO

ROSEMARY K. SOKAS** 
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CLAIMANT COMMUNITY:

DURONDA M. POPE

KIRK D. DOMINA

GARRY M. WHITLEY

JAMES H. TURNER

FAYE VLIEGER

DESIGNATED FEDERAL OFFICIAL:

DOUG FITZGERALD

*Participating via telephone

** Not Participating 
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 C O N T E N T S 

 Page

Welcome/Introductions/Logistics

 Douglas Fitzgerald, DFO. . . . . . . . . . . 4

 Steven Markowitz, Board Chair. . . . . . . . 7

COPD Presumption Discussion continued . . . . .10

Part B Lung Conditions

 Carrie Redlich, Chair. . . . . . . . . . . .77

Break. . . . . . . . . . . . . . . . . . . . . . .79

Additional Board Topics

 Steven Markowitz, Board Chair. . . . . . . 111

Board Administrative Issues

 Steven Markowitz, Board Chair. . . . . . . 139

Close of Meeting

 Douglas Fitzgerald, DFO. . . . . . . . . . 148

 Steven Markowitz, Board Chair. . . . . . . 143
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1 P R O C E E D I N G S

2 8:05 a.m.

3 CHAIR MARKOWITZ: On the phone do we

4 have Mr. Griffon? But we do not have Dr. Sokas,

5 correct? Okay. She's --

6 MEMBER GRIFFON: Yes, Steve, I'm here.

7 CHAIR MARKOWITZ: Okay. Great. Okay. 

8 MR. FITZGERALD: Good morning

9 everyone. My name is Doug Fitzgerald. And I'd

10 like to welcome you to this meeting of the

11 Department of Labor's Advisory Board on Toxic

12 Substances and Worker Health.

13 I'm the Board's Designated Officer or

14 the DFO. I want to, on behalf of the Department,

15 thank the Board and the Chairman for all their

16 hard work yesterday. And for their forthcoming

17 deliberations.

18 As the DFO, I serve as the liaison

19 between the Board and the Department. I'm also

20 responsible for ensuring all provisions of the

21 Federal Advisory Committee Act are met regarding

22 the operations of the Board.
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1 I work closely with the Board's Chair,

2 Dr. Markowitz. And I'm responsible for approving

3 the meeting agenda and for opening and adjourning

4 these meetings.

5 I also work with the appropriate

6 agency officials to ensure that all relevant --

7 or excuse me, to ensure that all ethics

8 regulations are satisfied.

9 You will note that the agenda times

10 are approximate. So we'll try as hard as we can

11 to stay with the agenda.

12 But, because we had some leftover

13 business from yesterday, we'll be jumping around

14 a little bit, I think, in addition to that. But

15 we'll be mindful of the break times as well.

16 Copies of all meeting materials are or

17 will be available on the Board's website under

18 the heading meetings. The Board's website can be

19 found at dol.gov/owcp/energy/regs/compliance/

20 advisoryboard.htm. 

21 Or you can simply Google Advisory

22 Board on Topic Substances and Worker Health, and
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1 it will likely be the first url that comes up. 

2 If you haven't already visited the Board's

3 website, I strongly encourage you to do so.

4 After clicking on today's meeting

5 date, you'll see a page dedicated entirely to the

6 week's meeting. That page contains all material

7 submitted to us in advance of the meeting.

8 If you're joining by WebEx, please

9 note that this session is for viewing only, and

10 will not be interactive.

11 And I just wanted to point out, in

12 case there's an emergency, there are two exits at

13 the back, on the left and the right. So, if

14 there is an emergency of some kind, hopefully

15 that won't occur, just exit through those doors.

16 If you need to use the restrooms, they

17 are immediately to the right on the way out.

18 I also want to note that the FACA

19 requires that the minutes for this meeting be

20 prepared to include a description of all matters

21 discussed over the course of the meeting. And 

22 any conclusions reached by the Board.
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1 As DFO I prepare the meeting minutes

2 and ensure that they're certified by the Board's

3 Chair. The minutes of today's meeting will be

4 available on the Board's website no later than 90

5 calendar days from today per FACA regulations. 

6 But if available sooner, we'll have them

7 published before the 90th day.

8 Also, although formal minutes will be

9 prepared, because they're required by the FACA

10 regulations, we'll also be publishing verbatim

11 transcripts. And those will be available by May

12 20.

13 And with that Mr. Chairman, I convene

14 the meeting, and turn this over to you.

15 CHAIR MARKOWITZ: Thank you. I echo

16 Mr. Fitzgerald's welcome to the public for

17 participating, those of you who are on the phone

18 and those of you who are present as well. And I

19 welcome back the Board members.

20 Let's redo the introductions today in

21 the event that we have some new public

22 participants.
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1 I'm Steven Markowitz. I'm an

2 occupational medicine physician and

3 epidemiologist at the City University of New

4 York. Ms. Pope?

5 MEMBER POPE: Duronda Pope, United

6 Steel Workers Emergency Response Team. I was a

7 former worker at Rocky Flats 25 years.

8 MEMBER CASSANO: Tori Cassano,

9 occupational medicine physician, retired

10 military. And Department of Veterans Affairs.

11 MEMBER WELCH: Laurie Welch. I'm also

12 an occupational medicine physician. I work for

13 the Center for Construction Research and

14 Training.

15 MEMBER WHITLEY: Gary Whitley, former

16 worker developer of National Security Complex. 

17 And work with the Worker Health Protection

18 Program.

19 MEMBER DOMINA: I'm Kirk Domina. I'm

20 here representing the Hanford Atomic Metal Trades

21 Council here in Richland, Washington. I am a

22 current worker. I've been onsite for 34 years.
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1 MEMBER DEMENT: John Dement,

2 industrial hygienist and epidemiologist at Duke

3 University in Durham, North Carolina.

4 MEMBER FRIEDMAN-JIMENEZ: I'm George

5 Friedman-Jimenez. I'm an occupational medicine

6 physician and epidemiologist at New York

7 University School of Medicine and Bellevue

8 Hospital, New York City.

9 MEMBER SILVER: Ken Silver. I'm an

10 Associate Professor of environmental health in

11 the College of Public Health at East Tennessee

12 State University.

13 MEMBER REDLICH: Carrie Redlich, I'm

14 a Professor of Medicine at Yale and Director of

15 the Yale Occupational Environmental Medicine

16 program. And I'm also an epidemiologist.

17 MEMBER VLIEGER: Good morning. Faye

18 Vlieger, former Hanford worker, injured Hanford

19 worker from a chemical exposure in 2002. And

20 advocate for the injured workers.

21 MEMBER TURNER: James Turner. I

22 worked at Rocky Flats plant for like probably 26
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1 years. Was diagnosed with chronic beryllium

2 disease in 1990.

3 MEMBER BODEN: Hi, I'm Les Boden. I'm

4 a Professor of occupational environmental health

5 at Boston University School of Public Health.

6 CHAIR MARKOWITZ: Mr. Griffon?

7 MEMBER GRIFFON: And I'm Mark Griffon,

8 a health physics and occupational and safety and

9 health consultant.

10 CHAIR MARKOWITZ: And yesterday we all

11 had the Board member, Dr. Rosemary Sokas, who's

12 an occupational medicine physician. And she

13 couldn't be with us today as scheduled actually.

14 So, we're going to change the agenda

15 a little bit. We're going to finish some of our

16 business from yesterday. And then move onto the

17 Part B lung conditions subcommittee report.

18 And the -- we're going to first

19 address an issue that was left over from a

20 discussion around chronic obstructive pulmonary

21 disease, COPD. I'm going to turn it over to Dr.

22 Welch to lead this discussion.
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1 MEMBER WELCH: As you all remember, we

2 had tabled the question of work outside DOE. I

3 had originally included it as part of the

4 exposure criteria.

5 I talked some to the Department of

6 Labor representatives. And we had some

7 discussion among our SEM subcommittee.

8 I looked up the legislative language

9 and we figured that it's too -- it's -- would be

10 like giving the legislative history of the

11 program, which has focused solely on DOE work

12 that it's really not appropriate for us to change

13 it.

14 I mean, it's kind of like the -- it's

15 not specifically written that way in the

16 legislation. But, you can see how the intent

17 would be that. That's always been the focus of

18 the program.

19 And so my amendment, although we did

20 vote on the slide for the criteria, absent

21 consideration of outside exposures. So, what I'm

22 proposing as the final COPD presumption would be
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1 everything we had, but no mention of outside

2 exposures in the presumption.

3 So, it would be five years exposure in

4 the specific job titles. Or exposure -- yes,

5 this is the legislative language, but I decided I

6 wasn't even going to renew them and they need to

7 cover it.

8 For reported history to vapors, gas,

9 dust, and fumes on the occupational history

10 questionnaire as revised. And that that's the

11 exposure assumption for COPD without direct

12 discussion or required consideration of outside

13 work.

14 So that's the proposal. So, in some

15 ways -- we've already voted on it. Except we

16 voted on it understanding that we would revisit

17 the outside work.

18 So, if we -- I'd leave it up to you

19 whether we want to bring up that slide again and

20 vote on it.

21 CHAIR MARKOWITZ: Well, why don't we

22 bring up the -- what we voted on yesterday.
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1 MEMBER WELCH: Okay.

2 CHAIR MARKOWITZ: If we could.

3 MEMBER WELCH: So Kevin, could you

4 open the COPD one? Yes. There we go. So, go

5 down another slide. There. This is it.

6 So, what we -- we voted on this, but

7 we -- in speaking of it, we're excluding when we

8 voted the parenthetical. So that including non9 DOE work. With the idea we'd come back to it.

10 CHAIR MARKOWITZ: Right.

11 MEMBER WELCH: So what I'm suggesting

12 as an amendment now, is we would delete the

13 including non-DOE work. And have it otherwise

14 stay as the same.

15 CHAIR MARKOWITZ: But, that's what we

16 voted on yesterday. In other words, we voted on

17 this recommendation, removing the two phrases

18 where -- in parenthesis where it said, including

19 non-DOE work.

20 MEMBER WELCH: That's correct.

21 CHAIR MARKOWITZ: Okay. So, we -- I

22 think we can just let it -- yesterday's
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1 recommendation stand. And the live issue for

2 today was whether we wanted to come add non-DOE

3 work.

4 And I think you're saying, let's not

5 add non-DOE work.

6 MEMBER WELCH: Right. That's my

7 recommendation. Let's not add it. But I think

8 we should in some ways get at least an informal

9 consensus of the board on that question, because

10 we did say we were going to come back and revisit

11 it.

12 Yes, could you -- Kevin, could you

13 take out the parenthetical that says, including

14 non-DOE work in the -- those two bullets?

15 CHAIR MARKOWITZ: So, while he's doing

16 that, is it open for discussion now?

17 MEMBER WELCH: Yes.

18 CHAIR MARKOWITZ: Dr. Friedman19 Jimenez?

20 MEMBER FRIEDMAN-JIMENEZ: I agree that

21 for perceptual reasons it's probably better to

22 take out non-DOE work. However, the five years
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1 seemed reasonable, including non-DOE work.

2 So my question, and I'd like Dr.

3 Redlich to comment on this also. My question is,

4 what does the science say about how much exposure

5 you need to get COPD from the exposures involved?

6 Could we reduce the five years to say

7 three years or two years? What is the suspicion

8 amount of exposure if we're not including DOE

9 work in the formal definition?

10 We should probably shorten the DOE

11 time. Because on average, most people will have

12 additional exposures that contribute in the way -

13 - in an additive way at least.

14 MEMBER WELCH: The -- let me just

15 comment on that. That there isn't a lot of

16 population-based studies that look at the overall

17 metric, not specific exposures, don't have --

18 they're looking at long term populations

19 generally. So the only study I could find that

20 looked at VGDF overall that was -- well, it

21 wasn't even in the publication.

22 But John was able to look at it in our
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1 construction workers. And it looked like five

2 years was the -- five years cumulative exposure

3 was where you start to see an increase in COPD.

4 You're correct that we could decide to

5 go four or three with the understanding that it's

6 most probable that people had other exposures. 

7 Or we could go with five and then the people who

8 have four or three can come in with an individual

9 evaluation.

10 And that -- so their treating

11 physician or the industrial hygienist could, in

12 an individual evaluation, look at their total

13 exposure without it being written in our

14 presumption.

15 And that's a -- I was kind of

16 approaching it that way in my mind. But I would

17 still continue to -- for individual people, look

18 at their total exposures.

19 But to recommend it as a specific

20 presumption seems out of keeping with a

21 legislative history.

22 CHAIR MARKOWITZ: Dr. Redlich?
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1 MEMBER REDLICH: I agree with Dr.

2 Welch. I think the reason it gets a little more

3 complicated is just that there's so much overlap

4 between asthma and COPD.

5 And you know, shorter term exposures

6 can cause asthma. The Germans actually lump as -

7 - when they look at work-related obstructive lung

8 disease, they actually treat asthma and COPD as

9 one entity that they term OLD. You know,

10 occupational obstructive lung disease.

11 And so I think that's where one could

12 potentially argue for a shorter time period. 

13 It's not a, you know, a crazy thought.

14 But I think given the literature and

15 these circumstances, it's reasonable to use the

16 five years.

17 CHAIR MARKOWITZ: Dr. Boden, did you

18 want to say something? No.

19 You know, I think it's hard to make a

20 decision based on an assumption that a person

21 otherwise had some years of exposure to VGDF

22 outside of non-DOE work. We're saying that we
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1 can't really justify looking -- in this program,

2 in looking at non-DOE work.

3 And then the suggestion is well, we

4 can assume that blue collar workers generally do

5 blue collar work in their careers. And therefore

6 it's likely that they have outside.

7 But that's an assumption. And it's

8 hard -- I think it's hard to build a compensation

9 program on that kind of assumption. Even though

10 there's some scientific validity to it.

11 So, I guess I would favor the five --

12 staying with the five years. And then in the

13 non-presumption at root, then on an individual

14 basis, it goes through the normal process of

15 looking at the exposures and judging whether

16 there's a contribution from two or three or four

17 years of exposure to the disease.

18 Mr. Domina?

19 MEMBER DOMINA: I just want to make

20 sure, because I don't have 16-02 in front of me

21 that we're not excluding AWE. Because say a guy

22 worked at an AWE site for a couple of years and
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1 then he went to work for DOE, that that's

2 included in the five-year total.

3 CHAIR MARKOWITZ: Yes. You know, Ms.

4 Leiton, could you address that issue? Because

5 that's a coverage issue.

6 MS. LEITON: Okay. So if it's covered

7 employment, and it's an AWE or DOE facility,

8 whatever, actually, I'm sorry, AWEs are only

9 covered for cancer.

10 So the cancer conditions would be the

11 only ones that would be included in that. 

12 Because we don't cover anything other. And Part

13 E is not covered. So never mind.

14 We don't do AWEs because they're not

15 covered under Part E. So, it wouldn't -- the

16 other part, it would only be Part B coverage.

17 So, let me just be clear about that

18 again. AWE coverage does not extend to Part E. 

19 Since this is a Part E presumption, it would not

20 cover for AWE employees.

21 CHAIR MARKOWITZ: Further discussion? 

22 Dr. Redlich? Dr. Silver?
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1 MEMBER SILVER: A rationale statement

2 will accompany this recommended set of

3 presumptions. Maybe that's the place to

4 elaborate on non-DOE exposures around that last

5 point of the presumption.

6 Non-binding guidance, but at least put

7 it on the record for the program to remember when

8 they evaluate individual claims.

9 CHAIR MARKOWITZ: That's a good point. 

10 Other comments?

11 (No audible response.)

12 CHAIR MARKOWITZ: So Dr. Welch, is

13 there a -- do you think there's a need at all for

14 something to vote on? Or are we okay? Okay.

15 Okay, so if we could move to my

16 slides. We're going to discuss occupational

17 asthma.

18 MEMBER GRIFFON: Hey Steve, this is

19 Mark Griffon.

20 CHAIR MARKOWITZ: Yes. Yes?

21 MEMBER GRIFFON: Just before you leave

22 the issue, just one thing. I mean, this might be
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1 a little tricky, my mind was just on it.

2 But, the way it's written right now,

3 it's a five-year aggregate as reported on the

4 OHQ. I think it supposed to be five year

5 aggregate as verified by the Department of Labor,

6 right? At any code facility?

7 I'm not sure if that's not important. 

8 I mean, I think we've got the nature of the

9 recommendation across. But, --

10 MEMBER WELCH: You know, I kind of

11 think that it's kind of assumed that --

12 MEMBER GRIFFON: Okay.

13 MEMBER WELCH: But, I mean, I wish we

14 could just use the OHQ. But I know that the

15 process doesn't work that way.

16 MEMBER GRIFFON: Yes.

17 MEMBER WELCH: So we could say five

18 years cumulative covered employment. If you

19 think that's important.

20 MEMBER GRIFFON: Right. I don't know

21 that we have to revote or anything. I'm just --

22 CHAIR MARKOWITZ: No, but looking at
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1 the language, the only place where OHQ is

2 mentioned is with reference to vapors, gas, dust

3 and fumes. And that's the only place where it's

4 asked.

5 In other words, the OHQ is -- if it's

6 changed, that's going to be the only location

7 where that specific question is asked and

8 documented.

9 MEMBER WELCH: But for example, let's

10 say women in -- yes, we see this in construction. 

11 They say they worked for, you know, seven years

12 at Savannah River.

13 But what can be considered covered

14 employment is like a three-month period in the

15 middle of that. And two years, and you know,

16 it's broken down and maybe not all of it is

17 verified. And so not all of it is covered.

18 So they report something that would

19 get them in under the presumption. But then the

20 amount of years that are accepted by the

21 Department of Labor as covered employees -- or

22 covered employment would put them under the five
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1 years.

2 And that's likely to happen. But I

3 assume that that is going to happen. Because

4 that's, you know, exposures -- if there's no

5 covered -- if the employment isn't verified as

6 covered employment, then it's just not considered

7 under the way the regulation works.

8 So, I was assuming we didn't have to

9 put that in there. In this presumption.

10 CHAIR MARKOWITZ: Okay. Ms. Leiton?

11 MS. LEITON: I just would say, I look

12 at this like my lawyers are going to look at it

13 when they see it. And if they see with reported

14 exposure to VGDF on the OHQ, that's what that

15 says.

16 I mean, it doesn't say verified or

17 anything like that. So, you know, and other

18 people will think well, if I just put it on the

19 OHQ, I'm good.

20 And that might be a problem for us

21 when we're trying to administer. I'm just

22 putting that out there.
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1 And when I know that other people

2 looking at these recommendations might say to me

3 -- well, you know, I don't know for sure, I just

4 want to put that out there.

5 I think it's a good point. Because it

6 does say reported exposure on the OHQ. We verify

7 these in other ways. We get this information

8 from DAR records. We might get it from other

9 sources.

10 It might not be on the O -- you know,

11 there's just a lot of different variations of

12 saying, on the OHQ. So it's, you know, I'm not

13 trying to tell you either way to do it, but

14 that's just probably what they're going to look

15 at and say to me.

16 MEMBER WELCH: And so what we were

17 talking about was something slightly different.

18 MS. LEITON: Okay.

19 MEMBER WELCH: Whether or not

20 verification of the exposure itself, but should

21 we say covered employment? Because this is

22 implying if they were --
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1 MS. LEITON: It does. I mean that

2 would help.

3 MEMBER WELCH: Would help to put that

4 in there? Okay.

5 MS. LEITON: It would probably help.

6 MEMBER WELCH: Okay.

7 CHAIR MARKOWITZ: Dr. Boden?

8 MEMBER BODEN: So, I thought that our

9 discussion yesterday actually kind of

10 contradicted what you just said. That is, our

11 discussion yesterday was a suggestion that the

12 revised occupational health questionnaire, with

13 what detailed information from the worker, could

14 actually be used without external verification.

15 MEMBER WELCH: Absolutely.

16 MEMBER BODEN: Is that correct? Yes. 

17 Okay.

18 MEMBER WELCH: That was the -- and I

19 specifically pointed out that the direct disease

20 work process link bulletin says that the workers

21 report can be considered probative.

22 So, I think -- yes, what I'm thinking
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1 is that the -- it's not just reported exposure to

2 VGDF, it includes all the task information. 

3 Which helps to validate the exposure.

4 So it's not the answer to that simple

5 question that allows them to accept the claim. 

6 So, I mean, there's the option of -- and I don't

7 know, Steven, do you want to spend any more time

8 on this?

9 We've got to -- we kind of have to

10 move on.

11 CHAIR MARKOWITZ: No.

12 MS. LEITON: Can I make one more

13 comment on that?

14 MEMBER WELCH: Yes.

15 MS. LEITON: If you're talking about

16 coverage, you do say at the first sentence,

17 covered facility. So, it would have to have been

18 at a covered facility.

19 So if that's the issue, I think you've

20 got that in the language.

21 MEMBER WELCH: Okay. Great. Thanks. 

22 Good.
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1 CHAIR MARKOWITZ: Okay. Good. Great. 

2 We can move on. So, if we can bring up the

3 PowerPoint on occupational asthma. So, it should

4 be after that.

5 What slide is -- are we on? Because

6 we covered this yesterday.

7 MEMBER WELCH: Yes. This is not the

8 right slide.

9 CHAIR MARKOWITZ: Okay. So just go to

10 the end and then go back about six slides.

11 MEMBER WELCH: Oh, it's in this slide

12 presentation?

13 CHAIR MARKOWITZ: It's all in the same

14 presentation. So, I'm going to talk about the

15 current policies on occupational asthma, written

16 policies.

17 And if you go up one slide, let me

18 just -- yes. Yes, that would be great. Okay. 

19 So, just a quick review on the current written

20 policy on asthma.

21 Which is that if there is medical

22 evidence of occupational asthma, there's no need
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1 for an exposure assessment or consultation with

2 the SEM. Because the exposure's assumed to occur

3 if the medical evidence is presented by in

4 general, the treating physician.

5 For occupational asthma claims that

6 are filed after the Department of Energy work

7 ends, so this is for retired workers, it requires

8 a well-supported report by a physician, meaning

9 the treating or evaluating physician. And if

10 that isn't present, then the CE collects exposure

11 information and refers it to the CMC for

12 evaluation.

13 For asthma claims that are not -- that

14 do not have presented with them a well-supported

15 rationale for work-relatedness, the CE develops

16 the claim and just refers it to the CMC. And

17 then there is a retroactive look with the

18 institution of this policy in 2015, to look at

19 previous asthma cases and make sure they complied

20 with this guidance.

21 Now, the draft document that was sent

22 to us a week ago, on exposure and disease
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1 presumptions, significantly changes and tightens

2 up the requirements for occupational asthma. And

3 in particular, it requires objective verification

4 of or -- of the asthma by pulmonary function

5 testing.

6 And so why don't I discuss just a few

7 things in general about asthma, about work8 related asthma, and then get into a

9 recommendation. So, work-related asthma is

10 considered to be quite common. And causing up to

11 25 percent of adult onset asthma.

12 Dr. Friedman-Jimenez wrote a review a

13 year and a half ago on occupational asthma. And

14 cited that there are over four hundred workplace

15 agents that are known to cause asthma.

16 In clinical practice, the basis for

17 diagnosing asthma varies considerably among

18 healthcare providers. Often based on the history

19 and a trial of bronchodilators. Sometimes based

20 on pulmonary function testing.

21 But it's a lot of variation, which

22 some of the physicians here can speak to. And
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1 that work-related asthma is frequently diagnosed

2 without the pulmonary function confirmation in

3 practice.

4 So, I'm going to -- I have a

5 recommendation that involves two or three slides. 

6 And then a little bit of rationale mixed in.

7 So, the recommendation is that DOL

8 should use the generally accepted unifying term,

9 work-related asthma for claims evaluation and

10 decision-making. Work-related asthma includes

11 two forms of asthma.

12 One is occupational asthma, which is

13 new onset asthma that has initiated by an

14 occupational agent. The worker didn't have

15 asthma before. They develop asthma. The

16 physician identifies it in relation to a specific

17 exposure in the workplace.

18 There's also a second type of work19 related asthma, which is work-exacerbated asthma. 

20 Which is established asthma, the person already

21 has asthma, or otherwise developed asthma, and

22 it's worsened by workplace exposures.
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1 The recognition of both forms of work2 related asthma should be communicated to

3 claimants, the physicians, and consulting

4 industrial hygienists and CMCs. And this is

5 important because physicians vary in their

6 thinking about work-related asthma.

7 Some physicians maybe sticking with A,

8 only occupational asthma, whereas it's recognized

9 that work-related asthma encompasses a much

10 broader spectrum, not just occupational asthma,

11 but also work-exacerbated asthma.

12 And the background behind this is that

13 this definition exactly coincides with the

14 recommended usage of the terms by the American

15 Thoracic Society from the 2011 statement, and the

16 American College of Chest Physicians in 2008. 

17 And Dr. Redlich served on both of those

18 committees and is a coauthor on these

19 recommendations that were published.

20 This inclusive and well delineated

21 definition is also very conveniently consistent

22 with the standard of causation in EEOICPA. Which
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1 is to say, at least as likely as not, exposure to

2 toxic substance was a significant factor in

3 aggravating, contributing, or causing.

4 So, both the occupational asthma form

5 and the work-exacerbated form of asthma meet the

6 standard of aggravated, contributed or causing.

7 So the second part of the

8 recommendation that is, met the criteria for the

9 diagnosis of asthma. The diagnosis of asthma by

10 a treating or evaluating physician should be

11 sufficient for the recognition that the claimant

12 has asthma.

13 Bronchodilator reversibility of FEV1,

14 which is a pulmonary function test, and/or a

15 positive methacholine challenge test, which is

16 another form of breathing test, maybe helpful,

17 but should not be required to accept a diagnosis

18 of asthma, which is made by a healthcare

19 provider.

20 And then I think this is the third,

21 the last part of the recommendation. So what I

22 just reviewed was how the diagnosis of asthma
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1 should be looked at in the claim. Now we move

2 onto how the diagnosis of work-related asthma

3 should be looked at.

4 Work-related asthma, whether

5 occupational asthma or work-exacerbated asthma is

6 defined as the presence of medically diagnosed

7 asthma that is associated with the worsening of

8 any of one or more, or is key here. One or more

9 of the following in relation to work: asthma

10 related symptoms, meaning shortness of breath or

11 wheezing, asthma medication usage, which is

12 temporarily related to work, or pulmonary

13 function indices, and then I list the various

14 recognized means, meaning change in FEV1 or the

15 peak expiratory flow rate, bronchial hyper

16 responsiveness or a positive inhalation challenge

17 test.

18 Such a history should be documented by

19 the treating or evaluating healthcare provider,

20 or addressed by a CMC if consulted in a claim

21 evaluation.

22 The same criteria for work-related
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1 asthma should be used in evaluating asthma claims

2 whether the claim is made contemporaneous with

3 the period of DOE employment, or after the end of

4 that period of employment.

5 And a specific triggering event

6 causing the onset of work-related asthma may

7 occur, but is not typical or necessary. Inciting

8 exposures, such as dusts, fumes, heat or cold or

9 others, should be specifically identified when

10 possible, but should not be required for the

11 diagnosis of work-related asthma.

12 And so, -- and then just I just

13 provide the American Thoracic Society criteria

14 for work-related asthma from their 2011

15 statement.

16 This is the work-related -- the work

17 you actually -- this is the work-exacerbated

18 asthma, which is the person -- criteria one, the

19 person has asthma already. And criteria two,

20 which is that there's a clear temporal

21 relationship between symptoms or medication use,

22 or objective indicators, and the asthma symptoms.
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1 So, let's open for discussion. Dr.

2 Welch?

3 MEMBER WELCH: I strongly support the

4 use of, you know, well developed, peer reviewed

5 criteria for the diagnosis. So, I think that's a

6 good improvement.

7 CHAIR MARKOWITZ: Dr. Redlich, you're

8 a Pulmonologist.

9 MEMBER REDLICH: Yes. You know, and

10 I am -- I am actually -- I apologize, the

11 internet wasn't working last night. I had

12 emailed back some minor edits to this.

13 I agree with this approach. I think

14 it's also just important to understand that the

15 evidence-based guidelines that are out there, you

16 know, some of which encourage things like trying,

17 you know, confirming asthma with a

18 bronchodilator, or doing peak flows, were really

19 developed for a pulmonologist who is, you know,

20 evaluating a patient real time with work-related

21 asthma. Or with potential work-related asthma.

22 And also must of the literature that
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1 that is based on is sensitizer agents. And

2 predominantly European and Canadian literature.

3 And so I think it's just important not

4 to extrapolate that to U.S. workers. And the

5 situations where someone is using these

6 guidelines based on medical records that they are

7 reviewing.

8 And as an example, it's very commonly

9 stated in these guidelines, which I tried to

10 actually modify this. That, you know, you should

11 do peak flows at and away from work to confirm

12 the association with asthma.

13 And so that then implies that if you

14 haven't shown that association with peak flows,

15 maybe it is not work-related. That literature is

16 based on the relatively rare cases of work17 related asthma where there is a single

18 sensitizing agent.

19 And also studies from the 1960s,

20 1970s, largely in Europe where a worker would be

21 removed from work for three weeks, during which

22 three weeks away from work, their lung function
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1 would improve enough that their peak flows would

2 be better. Then they would be put back at work

3 for three -- two to three weeks.

4 And so we in the United States don't

5 have the ability to do a diagnostic test that

6 involves removing someone from work for two to

7 three weeks. And then, you know, sending them

8 back to work.

9 So unfortunately some of the pieces of

10 the guidelines get extrapolated in a way that

11 because that documentation is not available. And

12 the other one that is unfortunately used

13 inappropriately is, confirming asthma with a

14 bronchodilator response.

15 The great overwhelming majority of

16 asthmatics in the United States and beyond, have

17 a clinical diagnosis of asthma. But have not had

18 spirometry at all, let alone spirometry that

19 shows a 12 to 15 percent improvement following an

20 inhaled bronchodilator.

21 And there are multiple reasons why

22 even if you had the test done, it can be falsely
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1 negative. So I just mention that, because

2 there's some sort of common misconceptions in

3 some of these guidelines when they get applied to

4 current day workers.

5 CHAIR MARKOWITZ: Ms. Vlieger?

6 MEMBER VLIEGER: Having gone through

7 my asthma claim prior to this type of rationale,

8 I can tell you that this will help the workers to

9 no end. Because it is so difficult for them to

10 know first of all, what's wrong with me?

11 To get into a pulmonologist is

12 difficult. I had it reported to me today by a

13 claimant that he's trying to get into see one of

14 the local Pulmonologists here, and we have a

15 pretty robust community of doctors, and it's two

16 to three months out, you know, to be able to get

17 in to see them.

18 So, in the past, the Department of

19 Labor has really wanted them to see a specialty

20 doctor. So if this can be brought back to an

21 initial diagnosis that's accepted from the family

22 practice or general practice doctor, that would
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1 be very helpful in getting them an initial

2 diagnosis accepted by the Department of Labor.

3 CHAIR MARKOWITZ: Dr. Boden?

4 MEMBER BODEN: So, I was very

5 interested to hear Dr. Redlich's description of

6 the problems with the pulmonary function tests

7 when they're using the bronchodilators. In

8 looking at a few claim files, I did see those

9 tests being used.

10 And it occurs to me that since, as you

11 put it, there can be a lot of false negatives on

12 that test that perhaps there should be guidance

13 to claims evaluators about not putting too much

14 weight on a false -- on a bronchodilator PFT. Is

15 that correct?

16 Am I saying that correctly?

17 MEMBER REDLICH: Yes. I think that's

18 correct. I think the current document needs

19 major revisions.

20 And that would be one of them. I

21 mean, asthma's a clinical diagnosis made by a

22 treating clinician or, you know, physician.
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1 Another way to word that is, we have

2 a very extensive asthma clinic at Yale, and if

3 you actually look through -- well we're -- you

4 can't get in to be seen unless you have asthma. 

5 And the physicians, the asthma specialists

6 believe all those patients have asthma.

7 And the great majority of them do not

8 have a positive bronchodilator. And I could go

9 into various issues with the testing and the

10 like.

11 But, that should not be a requirement

12 for a diagnosis of either asthma or work-related

13 asthma.

14 MEMBER BODEN: I'm sorry. I was just

15 wanting to make the point that also that the

16 existence of a negative test should not deny the 

17 claim.

18 MEMBER REDLICH: Oh, absolutely. I --

19 that's correct. And unfortunately, that is --

20 and in fact, when this has been looked at, the

21 great majority of cases that have been diagnosed

22 with work-related asthma in the United States and
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1 also in Canada, do not have a positive

2 bronchodilator.

3 CHAIR MARKOWITZ: Dr. Cassano?

4 MEMBER CASSANO: Two questions. Could

5 we just go to the second slide with the criteria

6 that you -- that you had -- no. Or yes. Okay.

7 I guess what I'm concern -- I agree

8 with this fully. But from a practical

9 standpoint, most primary care doctors that I

10 know, or that I've worked with, yes, you've got

11 asthma. Here's your bronchodilator, go away.

12 Most people are not going to get

13 diagnosed with work-related asthma unless they go

14 to somebody that understands work-related asthma.

15 And what I'm afraid of, I mean, how will the

16 depart -- how would the agency deal with this?

17 Somebody has a diagnosis of asthma. 

18 They believe it's related to work, but all

19 they've got is their doctor's statement that says

20 you've got asthma.

21 They then have to go to a specialist

22 or get referred to a specialist. Which may or
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1 may not be paid for.

2 So that's -- I'm trying to figure out

3 from this very good established criteria, how

4 practically that's going to get executed. Not

5 that we shouldn't do this.

6 But, you've got to get to the next

7 point.

8 CHAIR MARKOWITZ: Yes. The physician

9 has to confirm that the symptoms are work10 related. And that physician can be the primary

11 care provider. It can be the pulmonary

12 specialist or any treating or evaluating

13 physician.

14 And absent that it would be the CMC. 

15 And I don't really see any alternatives, any

16 other choices.

17 It would be a little challenging for

18 the CMC to do that. Because they don't have

19 direct communication with the patient.

20 And so if it's still an open question,

21 they could involve a second COP or whatever it

22 is, the second, you know, opinion evaluation. 
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1 But, there are only so many choices here.

2 Ms. Vlieger?

3 MEMBER VLIEGER: In saying that it

4 needs to be work-related. In some cases there's

5 actually a traumatic chemical exposure that you

6 can cite.

7 For many of the workers, it's an

8 accumulation of long term, low dose. Or a

9 combination of chemicals that you -- they don't

10 even know what it was.

11 So, when you say work-relatedness,

12 that's really relying on the worker realizing

13 what's happening. And knowing, you know, that it

14 was work-related.

15 So, what I find an issue within the

16 Department is that the veracity of the claimant's

17 report of work-relatedness when they really don't

18 know what they were exposed to comes up quite a

19 bit.

20 CHAIR MARKOWITZ: Well, this

21 recommendation doesn't require identification of

22 any specific trigger or any specific set of
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1 dusts, vapors, gases, or whatever in order for it

2 to be work-related asthma.

3 It's that the symptoms have to be

4 identified. Symptoms or medication usage. Or

5 the objective testing have to be identified as

6 being work-related.

7 MEMBER VLIEGER: So is it more of a

8 temporal relationship to the disease then?

9 CHAIR MARKOWITZ: Correct.

10 MEMBER VLIEGER: Okay.

11 CHAIR MARKOWITZ: And even that can be

12 challenging. I understand. But, there's going

13 to be something.

14 MEMBER VLIEGER: Right.

15 CHAIR MARKOWITZ: All right. Dr.

16 Friedman-Jimenez?

17 MEMBER FRIEDMAN-JIMENEZ: Since the

18 definition relies fairly heavily on symptoms, I

19 think when you mentioned symptoms in the

20 definition, you should include the four classic

21 symptoms that are described for asthma, wheezing,

22 which is not actually really a symptom. It's
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1 often not perceived by the person. It's heard by

2 the doctor in the stethoscope.

3 But I would include it. Cough,

4 shortness of breath, and chest tightness are the

5 four symptoms that are typically associated with

6 asthma.

7 And each person has their different

8 symptoms that they perceive when they have an

9 asthma attack. And I would either include all

10 four, or not include any -- not mention them by

11 specifically.

12 Because if you just limit it to

13 wheezing or shortness of breath, many people

14 don't know that they're wheezing, and their

15 doctor tells them they're wheezing because they

16 hear it in the stethoscope.

17 And many people don't experience

18 shortness of breath even though they have

19 significant bronchial objection. So, I would

20 either take out the specific symptoms, or list

21 all four.

22 CHAIR MARKOWITZ: Well, I would
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1 actually favor taking out the symptoms. Because

2 if it -- if we include cough, which can be a

3 manifestation of asthma, but can also be an

4 irritant, bronchitis without real bronco spasm,

5 then it opens the door.

6 So, I would favor just eliminating

7 wheezing or shortness of breath for the line four

8 here. Dr. Redlich?

9 MEMBER REDLICH: Yes. From reviewing

10 a lot of work-related asthma claims in various

11 settings over many years, physicians

12 unfortunately when you review their notes, rarely

13 got -- their visit is usually focused on the

14 patient's current symptoms. And managing those

15 symptoms.

16 And so in the most clear cut cases,

17 you can -- there can be remarkably little. But I

18 think there are other things that can be.

19 And one doesn't want to accept, you

20 know, asthma is a common condition in every

21 single case. But the type of things, and this is

22 what could be included in guidance is, you know,
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1 in the period of time, was there a much greater

2 frequency of visits for asthma treatment?

3 So if you go to a job with a lot of

4 irritants or agents that could cause or

5 exacerbate asthma, and over that three-year

6 period of time, were you seeing a doctor for

7 asthma weekly? Instead of prior it had been only

8 once every two years. So, things like that.

9 Frequency of the medication usage, the

10 visits to physicians can be very helpful. And

11 relationship of that to the period of time that -

12 - of work time that's in question. And that's

13 something that one can get from medical records.

14 But those are the types of guidelines

15 that could be included. You know, A, B, or C in

16 terms of showing this association with work.

17 CHAIR MARKOWITZ: Dr. Friedman18 Jimenez?

19 MEMBER FRIEDMAN-JIMENEZ: One

20 different issue is the diagnosis of work21 exacerbated asthma. This is a relatively

22 recently described and accepted entity.
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1 And most doctors, I think, are not

2 aware of this, the existence of work-exacerbated

3 asthma. And they think of -- you know, if they

4 know about occupational medicine at all, they'll

5 think of occupational asthma in the classic

6 sensitizer-induced situation.

7 So I think the document should

8 emphasize a little bit more the work-exacerbated

9 asthma. It's actually more common than

10 occupational asthma.

11 And it maybe in many cases, as

12 disabling as occupational asthma. And it's an

13 important disease.

14 And I think that this document should

15 really put it on the map of the CMCs and the

16 treating physicians, anyone that consults the

17 document. And patients aren't likely to think of

18 it either. Because they probably have never

19 heard of it either.

20 So, I think work-exacerbated asthma

21 should be highlighted a little bit more in your

22 recommendations.
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1 CHAIR MARKOWITZ: So, it's, you know, 

2 -- so, you know, I can do that in the rationale. 

3 But I point out in the recommendation the last

4 three lines.

5 Which is that the recognition of both

6 forms of work-related asthma should be

7 communicated to claimants, physicians, and

8 consulting IHs and CMCs.

9 Dr. Boden?

10 MEMBER BODEN: I have a question. 

11 Which just raises, but just slightly off topic. 

12 So, pull me in if I'm --

13 CHAIR MARKOWITZ: I will.

14 MEMBER BODEN: If I'm out of line on

15 this. So, my question is, for cases where a

16 presumption would apply, we already have

17 presumptions in the program, is -- are claimants

18 and physicians provided with a link to the

19 presumption in the process of going -- by this

20 CEs?

21 So in other words I'm saying, is there

22 some way of communicating to people who might
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1 otherwise not know that the physician should have

2 this presumption in mind when writing a letter to

3 the -- to the program?

4 CHAIR MARKOWITZ: Ms. Leiton, do you

5 want to address that?

6 MS. LEITON: Yes. When we have really

7 specific criteria such as this, and I think this

8 recommendation actually specifically says that

9 we'd have to do some education, something --

10 language along those lines.

11 But, we would be -- even without a

12 letter to the doctor, we would have to say, this

13 is what we consider to be work-related asthma. 

14 You know, please provide us with X, Y, and Z

15 information.

16 So, that would be in the case of a

17 treating physician or a physician that the

18 claimant has already gone to. We would have to

19 tailor it about the letter to include the

20 language that said that.

21 And we do do that in certain

22 circumstances. If it were a CMC obviously we
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1 would have to include that in our CMC training

2 package or whatever, so.

3 CHAIR MARKOWITZ: Okay. Dr. Redlich?

4 MEMBER REDLICH: I agree with the

5 importance of work-exacerbated asthma. I would

6 just say that -- and the great majority of

7 patients that I clinically see are referred to me

8 for work-related asthma. That's the entire bulk

9 of my clinical practice.

10 In the textbooks there's a very clear

11 delineation of new onset occupational asthma,

12 work-exacerbated asthma. In actual practice, it

13 can be very difficult to tell what is

14 exacerbation of pre-existing.

15 So, I think the term work-related

16 asthma is a very good term. Because for this

17 situation, and really for all of the now in the

18 United States compensation systems, the question

19 is, is the asthma either caused or exacerbated by

20 work or work factors contributing?

21 And so this differentiation, because

22 in reality is, did the person have very mild,
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1 minimal pre-existing asthma that then got worse? 

2 Or was this really new asthma?

3 And that is very challenging. And the

4 other factor is, anybody who has asthma, it's a

5 chronic condition, by the time they're seeing a

6 physician, they could already have had symptoms

7 for several years.

8 And whatever the original cause of

9 asthma, even if it was to a very specific agent,

10 becomes more defuse over time. And the triggers

11 become more defuse over time.

12 And so I just mention that. I think

13 in the terminology it would really be better and

14 easier to explain to the, you know, physicians

15 doing this work if one just used the term work16 related asthma. And that included work

17 exacerbation.

18 The other point that I think is

19 important to realize that every published study

20 on work-related asthma in the United States, when

21 you look -- and these are, you know, some of

22 these are publications where pretty extensive
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1 evaluations have been done, you know, by

2 occupational lung specialists.

3 The causative agents that have been

4 found in those, you know, series and studies have

5 almost, you know, over 50 or 80 percent of them

6 are non-specific agents. Not one single

7 substance.

8 So, the literature talks about, you

9 know, a lot of very specific, there are over four

10 hundred different chemicals or things that can

11 cause asthma. In practice, what tends to be

12 identified, you know, is dust irritants, cleaning

13 products, and those sorts of exposures.

14 And then I think the other important

15 sort of factors that do substantially exacerbate

16 asthma and would be relevant at at least of the

17 sites that we've seen are extremes of temperature

18 and extremes of humidity can really seriously

19 exacerbate people's asthma. And limit their

20 ability to work in that environment.

21 I mean, we were told yester -- two

22 days ago that it could either be one hundred
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1 degrees at that site, or you know, below -- you

2 know, very cold.

3 So, I just mention that because I

4 think the discussion should include not just

5 inhalational exposures. But, factors that

6 physical as well.

7 CHAIR MARKOWITZ: Thank you. Yes, I

8 think actually in this room they're trying to

9 recreate some of the experience of working at

10 Hanford.

11 (Laughter.)

12 CHAIR MARKOWITZ: The alternating

13 trips to the Arctic and Aruba, in this room here.

14 (Laughter.)

15 MEMBER REDLICH: No, no. And you

16 know, that is important. And it's also an area

17 where a small modification could keep that person

18 at work too.

19 CHAIR MARKOWITZ: Ms. Vlieger?

20 MEMBER VLIEGER: Slightly off topic. 

21 But I don't know if we're going to address it.

22 But the wording in bulletin 16-01
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1 right now specifically in paragraph 2B that

2 instructs that the position of specific

3 information on the mechanism for causing,

4 contributing, or aggravating the condition, the

5 strongest justification for acceptance in this

6 type of claim is the treating physician can

7 identify the specific asthmatic incidents that

8 occurred while working at a covered work site,

9 and the likely trigger.

10 So --

11 CHAIR MARKOWITZ Right. Well, so let

12 me just point on this reg -- the third part of

13 the recommendation. At the bottom it says a

14 specific triggered event causing work-related

15 asthma may occur but is not typical or necessary.

16 And it also says in citing exposures

17 should be identified when possible, but not

18 required. It tries to address the --

19 MEMBER VLIEGER: So, are we going to

20 recommend that this bulletin be rescinded? Are

21 we moving towards that later in the -- in a later

22 discussion?
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1 CHAIR MARKOWITZ: Well this -- there's

2 a draft document that redoes the whole asthma

3 policy. Where the -- but this recommendation

4 we're trying to --

5 MEMBER CASSANO: Affect.

6 CHAIR MARKOWITZ: Affect. Thank you,

7 affect. Thank you. Right. We're trying to

8 inject some thinking that would affect what the

9 revised draft document would look like -- looks

10 like.

11 MEMBER CASSANO: So, getting back to

12 what they said, I don't think you want to put --

13 I'm sorry. I don't think you want to have a

14 document out there that contradicts what you're

15 trying to do here.

16 So something about modifying 16-02 or

17 16-01 -- 16-01 to include this information or to

18 remove the more stringent information needs to be

19 said. Otherwise you're going to have

20 contradictory documents out there, I think.

21 CHAIR MARKOWITZ: Yes. I don't -- to

22 me if this recommendation is accepted, it
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1 necessarily drastically revises 16-02. And

2 drastically revises the draft presumptions that

3 DOL is looking at.

4 So, to me it would be a formality to

5 say that it should -- that they should rescind

6 that specific guidance. Because if they accept

7 this recommendation, they have to alter very

8 substantially that bulletin.

9 MEMBER VLIEGER: This is Faye. 

10 Rachel, would that normally fall in once -- if we

11 recommend this and they're accepted into that

12 draft procedure manual that we've got?

13 MS. LEITON: Yes. And any changes

14 that we would -- if there are recommendations

15 that change any of the presumptions, anything

16 that's out there that says something else, is

17 going to have to ultimately be changed.

18 I mean, this -- especially right now

19 given that we're going to have a change to the

20 way we do our procedure manual, it will be a lot

21 easier to just make the change in the procedure

22 manual.
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1 Any other documents obviously, like if

2 we were to go forward with the exposure chapter,

3 excepts of which you've received, then we're

4 already -- that says until incorporated into the

5 procedure manual.

6 So that's changing whatever's been out

7 there. We would -- those circulars or bulletins

8 that have that information would no longer be

9 valid. Because we have the most recent guidance

10 out there.

11 CHAIR MARKOWITZ: Okay. Thank you. 

12 So, if we could just stick with comments that

13 aren't necessarily repetitive of previous

14 comments, that would be great.

15 Dr. Silver? Whomever?

16 MEMBER FRIEDMAN-JIMENEZ: Work17 aggravated -- work-related asthma I think is a

18 great example of a disease that illustrates the

19 worsening, contribution to, or cause concept that

20 we're trying to promote with the CMCs.

21 And I think that all this -- in the

22 CMC training it would be worthwhile including the
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1 ATS statements on work-related asthma and work2 exacerbated asthma.

3 And ask them to actually read them. 

4 I think they're quite illustrative of the concept

5 that we're trying to promulgate.

6 CHAIR MARKOWITZ: Dr. Silver?

7 MEMBER SILVER: Asbestos fit neatly in

8 columns and rows yesterday. But here we're

9 talking about hundreds of different agents.

10 And I wonder if those ATS statements

11 maybe say it better. But what I'm hearing is

12 that the CMCs with their old school habits of the

13 mind that we saw on our medical evidence

14 subcommittee need an explicit statement that

15 there's a high degree of inter-individual

16 variability in response to workplace exposures,

17 clinical presentation, time course, response to

18 diagnostic tests, and treatments.

19 They can't use a cookie cutter

20 approach. And the claims examiners need to take

21 that to heart as well.

22 CHAIR MARKOWITZ: Sure. Dr. Redlich? 
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1 Okay. Any other -- Mr. Griffon, do you have any

2 comments?

3 MEMBER GRIFFON: No. Not at this

4 time. I do not.

5 CHAIR MARKOWITZ: Okay. So are we

6 ready for a vote? Or are there other comments?

7 (No response.)

8 CHAIR MARKOWITZ: Should we read this

9 again so we know what we're voting on? Okay.

10 Work-related asthma recommendation

11 one, the Department of labor could use a

12 generally accepted unifying term, work-related

13 asthma, for claims evaluation and decision14 making.

15 Work-related asthma includes A,

16 occupational asthma, or new onset asthma that is

17 initiated by an occupational agent. And B, work18 exacerbated asthma. Which is established asthma

19 that is worsened by workplace exposures.

20 The recognition of both forms of work21 related asthma should be communicated to

22 claimants, their physicians, and consulting
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1 industrial hygienists and CMCs.

2 Two, medical criteria for the

3 diagnosis of asthma. The diagnosis of asthma by

4 a treating or evaluating physician should be

5 sufficient for the recognition that the claimant

6 has asthma.

7 Bronchodilator, reversibility of FEV1,

8 and/or a positive methacholine challenge test

9 maybe helpful, but should not be required to

10 accept the diagnosis of asthma which is made by a

11 healthcare provider.

12 Three, and I will read this, but I

13 will also, in line four there's some language we

14 might want to revise. But let me read it as it

15 is. And then we can get to the revision.

16 Work-related asthma, whether

17 occupational asthma or work-exacerbated asthma is

18 defined as the presence of medically diagnosed

19 asthma that is associated with worsening of any

20 one or more of the following in relation to work. 

21 Asthma related symptoms, wheeze or shortness of

22 breath, asthma medication usage temporally
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1 related to work, or pulmonary function indices

2 change in FEV1 or peak expiratory flow rate,

3 bronchial hyper-responsiveness or a positive

4 inhalation challenge test.

5 Such a history should be documented by

6 a treating or evaluating healthcare provider, or

7 addressed by a CMC if consulted in a claim

8 evaluation.

9 The same criteria for work-related

10 asthma should be used in evaluating asthma claims

11 whether the claim is made contemporaneous with

12 the period of DOE employment, or after the end of

13 that period of employment.

14 A specific triggering event causing

15 onset of work-related asthma may occur, but is

16 not typical or necessary. In citing exposure

17 such as dust, fumes, heat or cold, or others,

18 should be specifically identified when possible,

19 but should not be required for the diagnosis of

20 work-related asthma.

21 So Kevin, if you could bring up the

22 version we can modify. So the question on line
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1 four on this is whether -- and when the symptoms

2 are cited, there are only two symptoms cited,

3 wheezing and shortness of breath.

4 And the idea came, we should have had

5 cough and chest tightness. If you just throw

6 that up. Yes. That's it.

7 So, I think we should just take out

8 wheezing and shortness of breath. Okay. And

9 then on -- so line four, Kevin, in the

10 parenthesis, wheeze or shortness of breath. You

11 can take out the whole thing.

12 And the other issue is what Dr.

13 Redlich raised. Which is healthcare utilization

14 as evidence of asthma.

15 And it says asthma medication usage. 

16 We could amend that to say asthma medication or

17 healthcare-related -- or healthcare utilization

18 temporarily related to work.

19 So, is that -- should we add that? If

20 anybody's following what I'm saying.

21 PARTICIPANT: So it would be more

22 specific in the health evaluation?
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1 CHAIR MARKOWITZ: Or it would be

2 asthma related.

3 MEMBER REDLICH: Well I think the

4 recommendation for the, you know the rationale

5 detail should be added to that.

6 CHAIR MARKOWITZ: Oh right, the other

7 rationale or the guidelines. Okay. Okay. So we

8 could -- you want -- so should we leave it as it

9 is? Asthma medication usage? Or add the asthma

10 related healthcare utilization?

11 MEMBER REDLICH: No. That's fine. 

12 That's fine. I can live with that. That's fine.

13 CHAIR MARKOWITZ: Okay.

14 MEMBER REDLICH: I'm just saying the

15 specifics of that.

16 CHAIR MARKOWITZ: Okay. So before

17 health, if you can put asthma related.

18 MEMBER REDLICH: But I would be

19 interested in getting rid of the change in FEV1

20 peak flow. I think in hundreds of asthma

21 patients where I have tried to document this, I

22 have maybe in 25 years been able to document
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1 physiologic changes, either peak flows or FEV1s

2 in less than five patients in over 25 years.

3 And that's with very intensive trying.

4 CHAIR MARKOWITZ: So you want to take

5 out change in FEV1 and PEFR and leave bronchial

6 hyper-response to this?

7 MEMBER REDLICH: No. Take them all

8 out.

9 CHAIR MARKOWITZ: You want to take out

10 the pulmonary function indices entirely?

11 MEMBER REDLICH: Yes. Those are way

12 too -- in that setting. It is appropriate if one

13 wants to discuss just asthma generally doing

14 spirometry.

15 But in terms of association with work,

16 better at work/away from work, those really

17 should go.

18 CHAIR MARKOWITZ: Okay.

19 MEMBER REDLICH: If you look at the

20 literature, it's just not supported.

21 CHAIR MARKOWITZ: Is anybody disagree

22 with what --
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1 MEMBER CASSANO: I sort of disagree. 

2 Only because if you take that out, if somebody

3 actually has that documentation, then it's not

4 usable.

5 And as being a person that's in a

6 clinic that's, you know, in an industrial

7 setting, I have many times used cross shift of

8 peak flows. And have been able to document it

9 very well.

10 So, if it's here, I think you don't

11 want to lose it.

12 MEMBER REDLICH: No, no. It's a good

13 point. Because it -- including it one wants to

14 encourage doing it. Because it's helpful to

15 encourage.

16 So one wouldn't want to discourage

17 someone from trying to better document. That's

18 correct. It's just -- and that -- I -- if

19 available, that's -- or --

20 CHAIR MARKOWITZ: Well maybe -- yes,

21 Dr. Dement?

22 MEMBER DEMENT: Oh, I was just
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1 pointing out, it's an or. It's not a

2 requirement. And I think this just provides

3 guidance.

4 So, I'm in favor of leaving it in.

5 CHAIR MARKOWITZ: Well --

6 MEMBER REDLICH: I thought as long as

7 people recognize that. Because what tends to

8 morph is once it's there, it tends to be

9 expected.

10 And I don't want to start getting

11 into, it's available, but once you actually have

12 it, well, how much of an improvement is actually

13 needed? Is it 20 percent? Is it 10 percent? Is

14 it -- so it's --

15 MEMBER CASSANO: Maybe you can just

16 modify that a little bit. That it says pulmonary

17 function indices, you know, related to work may

18 be helpful. But are not, you know, are not --

19 MEMBER REDLICH: Yes. And the

20 positive inhalation challenge test that's not

21 done anywhere in the United States. So I think

22 that should be removed.
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1 CHAIR MARKOWITZ: Okay. So let's take

2 out positive inhalation challenge test.

3 MEMBER REDLICH: Yes. That should go.

4 CHAIR MARKOWITZ: And in the rationale

5 --

6 MEMBER REDLICH: Yes.

7 CHAIR MARKOWITZ: In the rationale we

8 can emphasize it.

9 MEMBER REDLICH: And a change in

10 bronchial hyper-responsiveness --

11 MEMBER CASSANO: Yes.

12 MEMBER REDLICH: Should go. Because

13 that means that you're doing --

14 MEMBER CASSANO: A challenge.

15 MEMBER REDLICH: A bronchodilator at

16 work and away from work. And comparing the

17 change in them.

18 CHAIR MARKOWITZ: Okay. So change in

19 FEV1, then take out the or. So --

20 MEMBER CASSANO: No. Keep the PEFR. 

21 Because that's --

22 MEMBER REDLICH: Yes. The peak --
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1 CHAIR MARKOWITZ: No, no. Let me

2 finish. Change the FEV1, PEFR, or bronchial

3 hyper-responsiveness.

4 MEMBER CASSANO: Take out the

5 bronchial hyper-responsiveness

6 MEMBER REDLICH: No, bronchial hyper7 responsiveness.

8 CHAIR MARKOWITZ: Take that out?

9 MEMBER CASSANO: Take that out.

10 MEMBER REDLICH: Yes. Because that --

11 CHAIR MARKOWITZ: Okay. Changing --

12 and I think that you want or PEFR.

13 MEMBER REDLICH: And in fact the

14 current guidelines, the data, it's really for

15 peak flows and not for FEV1. It's not actually -

16 - so it would just be the peak flows is what the

17 -- because to be able to show any change, you

18 have to do repeated tests.

19 And you can do that with a peak flow

20 meter, which is a portable device. You can't do

21 that with spirometry. And also spirometry, you

22 can only do let's say at work if they have it
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1 onsite. And someone might improve the next day

2 in the light, so.

3 CHAIR MARKOWITZ: Okay. That's good.

4 MEMBER REDLICH: The guidelines

5 actually are peak flows.

6 CHAIR MARKOWITZ: Mr. Turner?

7 MEMBER TURNER: I was just wondering

8 about wheezing and shortness of breath. Why

9 would you take that out?

10 CHAIR MARKOWITZ: So, we'll put that

11 in the rationale. But we didn't want it -- the

12 problem is, if we put only two symptoms in, it

13 ignores say, chest tightness.

14 So if we include -- if we list too

15 many symptoms, then it can address conditions

16 that aren't asthma. So, we're going to put that

17 in the rationale.

18 But, the feeling is that we don't need

19 to specify which particular symptoms represent

20 asthma in this recommendation. If that makes

21 sense.

22 MEMBER REDLICH: Just to simplify that
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1 wording. I think the pulmonary function indices,

2 I think if you simply said change in peak flows.

3 CHAIR MARKOWITZ: Okay. So you can

4 take out pulmonary function indices.

5 MEMBER REDLICH: And just leave it as

6 peak flows and get rid of FEV1 also. And that's

7 actually consistent.

8 (Laughter.)

9 MEMBER REDLICH: Yes. Which is only

10 one index. And that's peak flow. 

11 CHAIR MARKOWITZ: Okay.

12 MEMBER REDLICH: Does that make sense?

13 CHAIR MARKOWITZ: That makes sense. 

14 Yes.

15 MEMBER CASSANO: So the change in peak

16 flow only.

17 MEMBER REDLICH: Yes. That's correct. 

18 That's right. That's good. Thank you. Perfect.

19 CHAIR MARKOWITZ: Okay. Again, and

20 once you -- okay. So just to -- if you back up a

21 line, where it says asthma medication usage, or

22 asthma related healthcare utilization.
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1 Okay. So, any other -- any final

2 comments on this? George or Dr. Friedman3 Jimenez?

4 MEMBER FRIEDMAN-JIMENEZ: Yes. I

5 agree with these changes. There -- in the

6 literature several studies have tired -- many

7 studies have tried to do peak flows on

8 asthmatics.

9 And the best case scenarios with

10 people who are continuing to work, have gotten

11 maybe 10 or 20 percent of their group to do the

12 peak flows successfully to two to four weeks.

13 So I think it's as Dr. Redlich was

14 saying, it's doable in some cases, it's the

15 minority of cases. And when it's present, it

16 should be used.

17 But I think there should be a

18 statement in the rationale saying that in the

19 great majority of cases, it's not feasible. And

20 it's not to be expected.

21 CHAIR MARKOWITZ: Right. Okay. 

22 That's fine. So is there a motion to approve
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1 this? This recommendation that I've just read

2 and we've modified?

3 MEMBER BODEN: Can I ask a question?

4 CHAIR MARKOWITZ: Sure, sure.

5 MEMBER BODEN: So, one other thing

6 that I'm hearing, and I'm wondering if it should

7 be explicit in the recommendation, or if I'm

8 hearing it wrong, is that really IH input is

9 irrelevant to the diagnosis.

10 Because we don't really need an

11 exposure. We just need to have somebody have

12 been at work.

13 And I'm wondering if -- I'm wondering

14 a, if that's a misrepresentation. But b, if it

15 isn't, whether it should be explicit in the

16 recommendation?

17 CHAIR MARKOWITZ: Right. So the

18 current policy, it excludes pretty much exposure

19 of the little consultation with the SEM. Because

20 it depends on the diagnosis of occupational

21 asthma.

22 But I can certainly add that to the
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1 rationale. Dr. Cassano?

2 MEMBER CASSANO: The only thing I see

3 missing is, is it possible that somebody could

4 misconstrue this to that one episode of

5 bronchospasm that occurred at work for an unknown

6 reason would be considered -- doesn't it have to

7 be somewhat chronic? Or recurrent episodes?

8 CHAIR MARKOWITZ: No. That would be

9 implied in the diagnosis of asthma.

10 MEMBER CASSANO: Okay.

11 CHAIR MARKOWITZ: I mean of -- all

12 right. Yes. So, are we ready to vote? So all

13 those in favor of this recommendation, raise your

14 hand.

15 (Show of hands.)

16 CHAIR MARKOWITZ: Mr. Griffon?

17 MEMBER GRIFFON: Yes.

18 CHAIR MARKOWITZ: Okay. So 14 votes

19 in favor. And there's all 14 of the board

20 members who are participating in this meeting.

21 We're going to revive Dr. Sokas'

22 recommendation that she sent after the discussion
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1 yesterday from the Industrial Hygiene and CMC

2 subcommittee. If you could blow this up.

3 And so we're going to do this. And

4 then we're going to take a break and then we'll

5 move onto the Part B Lung Disease Subcommittee.

6 This is a recommendation that she

7 sent. And I edited the language a little bit. 

8 Because that's what I do.

9 Assessment of quality, objectivity,

10 and consistency of CMC work. We request that the

11 DOL provide the board with resources to conduct a

12 quality assessment of a sample of 50 CMC

13 evaluations that have been associated with claim

14 denials.

15 The quality review will assess the

16 nature of the medication information reviewed by

17 the CMC, the use of standards of causation, the

18 reasoning of the CMC, the scientific basis for

19 the CMC conclusions, among other items.

20 The assessment will likely require

21 contracted services of worker centered

22 occupational physicians who are not associated
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1 with the current CMC contract. The review may

2 lead to recommendations including development of

3 guidance materials.

4 So, it's open for discussion. Dr.

5 Welch?

6 MEMBER WELCH: I think it's great. 

7 Let's vote.

8 (Laughter.)

9 CHAIR MARKOWITZ: All right. Other

10 comments?

11 (No response.)

12 CHAIR MARKOWITZ: Okay. So, is there

13 a motion to accept the -- and there's a second. 

14 Okay. Any final discussion?

15 All those in favor raise your hand.

16 (Show of hands.)

17 CHAIR MARKOWITZ: And Mr. Griffon?

18 MEMBER GRIFFON: Yes.

19 CHAIR MARKOWITZ: So 14 members of the

20 board who are present all vote in favor. Let's

21 start with the Part B Lung Conditions report from

22 Dr. Redlich.
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1 MEMBER REDLICH: Oh, let me get the -- 

2 yes, I'd like to give the -- sorry, I had my

3 PowerPoint program kept crashing last night. 

4 Yes. So let me -- the email's not working.

5 CHAIR MARKOWITZ: Yes. While we're

6 waiting, what we had planned to do if there's

7 time after this report is consider a solvency in

8 hearing loss presumption. And then handle

9 associated items including scheduling the next

10 meeting, so.

11 Anybody experiences any cold induced

12 asthma, there are some pulmonologists in the

13 room.

14 (Laughter.)

15 CHAIR MARKOWITZ: And Ms. Vlieger has

16 an inhaler also.

17 Well, let me say that this is a -- the

18 Joint Outreach Task Group for Energy Employees

19 Occupational Illness Compensation Program is

20 holding two town hall meetings today, one at two

21 p.m. and one at six p.m. at the Red Lion Hotel in

22 Pasco. Is that where we are?
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1 PARTICIPANT: No. We're at Richland.

2 CHAIR MARKOWITZ: Okay. Okay. And

3 these are the JOTG meetings. And representatives

4 from the Department of Labor EEOICPA Program, the

5 ombudsman office of the Department of Labor, the

6 NIOSH of the Health and Human Services, the

7 ombudsman to NIOSH, and the Department of Energy

8 will be in attendance to answer questions and

9 provide information on Part B and Part E parts of

10 EEOICPA.

11 Representatives from the Former Worker

12 Medical Screening Program will provide

13 information on the free medical screening

14 programs.

15 Representatives from the Hanford

16 Resource Center and the Cleveland District Office

17 will also be in attendance to receive new claims

18 and answer claim specific questions. If you have

19 any questions regarding this meeting, you can

20 speak with Mr. Nelson or Mr. Levin in back. Or

21 call their toll free number.

22 But for those of you on the phone
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1 actually, let me give you that toll free number. 

2 It's 877-662-8363. That's 877-662-8363.

3 Attendance at the meeting is strictly

4 voluntary. And registration is not required.

5 So we could take our -- we're due for

6 a break in seven minutes. So if you want, we can

7 take the break now and come back. It's up to

8 you.

9 MEMBER REDLICH: Yes. Maybe we should

10 just take the break.

11 CHAIR MARKOWITZ: Yes. Let's take a

12 break for ten minutes. We'll be back a little

13 bit before 25 of 10:00. Thank you.

14 (Whereupon, the above-entitled matter

15 went off the record at 9:24 a.m. and resumed at

16 9:35 a.m.)

17 CHAIR MARKOWITZ: We're going to get

18 started again. I want to point out the -- it's

19 the professors on the board who don't appear to

20 be back at school -- back in class on time. 

21 SPEAKER: How long do we have to wait

22 for them?
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1 CHAIR MARKOWITZ: Well, I'd say two

2 minutes. Some of the professors have made it

3 back, but, notably, the people who are really the

4 only people absent.

5 MEMBER VLIEGER: The workers are here.

6 CHAIR MARKOWITZ: Exactly. One Board

7 member is arriving on his bicycle. So, that's

8 good. He's a preventative medicine physician. 

9 He has his helmet. His helmet is, however,

10 draped on his bicycle, not on his head.

11 Okay. We're going to -- we're only --

12 Mr. Griffon, are you there? Mark? Okay. Let's

13 get started.

14 MEMBER GRIFFON: Yeah. Sorry, Steve.

15 CHAIR MARKOKWITZ: All right.

16 MEMBER GRIFFON: I am on.

17 CHAIR MARKOWITZ: Okay. So, Dr.

18 Redlich, all yours.

19 MEMBER REDLICH: Okay. And it's --

20 it's 9:30 and just to keep an eye on the time, we

21 need to be finished -- when should I be finished? 

22 I am --
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1 CHAIR MARKOWITZ: Just proceed through

2 your portion.

3 MEMBER REDLICH: Okay. So, I'm going

4 to give an update on the Part B Subcommittee. We

5 actually did do quite a bit since our last

6 meeting.

7 So, I was going to go over -- we

8 reviewed approximately 60 Part B cases. I was

9 going to give a summary of what we learned.

10 Also, the sarcoid presumption,

11 clarification of beryllium exposure, and then I

12 was going to mention a few of the -- responses to

13 a few of the issues and questions that the DOL

14 and also others have raised concerning various

15 parts of Part B. 

16 So, and, actually, I did want to thank

17 the other members of this committee, John Dement,

18 Kirk Domina, James Turner and Laura Welsh. And

19 Faye is -- Vlieger is not an official member, but

20 she has been very helpful. So, thank you.

21 So, the cases that we reviewed

22 included beryllium sensitivity, CBD, sarcoidosis. 
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1 As you can see, chronic silicosis,

2 pneumoconiosis.

3 The numbers, there was a little bit of

4 overlap between some of the cases, so -- as one

5 or two fell under more than one category, but we

6 don't need to worry about that.

7 So, I -- and I should say that the

8 materials that we received, we did not get a

9 thousand pages on each case.

10 We got some of the key documents,

11 accepted facts, the CMC referrals. And as I --

12 since we did not have medical records, there

13 could have been issues that we are unaware of,

14 but this was based on sort of the -- those pieces

15 from the case.

16 And not all of them had all that so

17 that something like IH reports was only on a few

18 of them. The questionnaires was on most, but not

19 all of them as far as the -- as I said, there

20 were different pieces, but what we had very

21 little was the actual medical records. But now

22 that I've heard about all the thousands of pages,
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1 I am glad that we did not get those.

2 So, I think we actually felt like what

3 we saw, we did have a better feel for what was

4 happening with these claims.

5 I would say that there was -- we

6 agreed with a number of the decisions, but areas

7 that we found that there were some problematic

8 decisions predominantly related to sarcoidosis

9 and CBD claims.

10 And most of them actually fell into

11 the group of either a misapplication or a

12 misunderstanding of the sarcoid presumption.

13 I should say that almost all of the

14 claims that we reviewed were ones that had -- in

15 the final decision, had been in the last few

16 years.

17 These were not really ancient,

18 historic claims. So, these were in the last two

19 to three years. So, that was one group.

20 And then there were some where I think

21 the CMC based on the information we had, we felt

22 had made a somewhat narrow interpretation of the
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1 clinical information. There were few of those.

2 A couple -- and we wanted to raise

3 this -- brought up the question of what is a --

4 the definition of a beryllium worker. Because

5 there were, for example, someone who worked for

6 many years at what we thought was a clear

7 beryllium site, but the list then sort of

8 concluded that they had no beryllium exposure. 

9 And that was not -- that was one or two.

10 And then, also, another finding that

11 was evident from several of the cases, was

12 eventually there was a correct decision, but the

13 number of years and the number of re-decisions

14 and -- it was just a lot. And I think, ideally,

15 those could have been diagnosed sooner.

16 And I think that is an issue in terms

17 of all the time, manpower and the stress that

18 someone goes through for many, many years

19 advocating a claim.

20 So, and then the pneumoconiosis and

21 chronic silicosis we did not review as many. A

22 number of them, there were issues which -- that
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1 are beyond us related to the uranium workers,

2 RECA and what -- the different criteria.

3 And the other problem that we

4 identified has already -- has been addressed by

5 the SEM Committee, which was that some of them

6 identified a very limited group of exposures. I

7 think that issue has been addressed by the SEM

8 committee.

9 And then other issues that were -- we

10 noticed, one was that -- so, the ones that we

11 had, half of them had -- 30 of about the 60 had a

12 CMC report in them. Of those, 30, over half of

13 them, were a single CMC.

14 And he was a pulmonary physician with

15 appropriate credentials, but I -- this was not

16 just me. I think there was a clear attitude

17 problem that this person had. 

18 And I think to use one CMC for so many

19 cases -- he was more on the East Coast, also. 

20 Not that there weren't, but there were a lot of

21 West Coast cases, who -- I think that was -- that

22 raises the issue for the CMC Committee or one of
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1 the other committees, but I do think oversight of

2 the people doing this. And this was quite

3 noticeable.

4 So, and then the other issue that came

5 up on a number of cases, and I don't know if this

6 is something that can be addressed, is that

7 sometimes they were asked a quite narrow

8 question.

9 And I can understand doing that, but

10 there -- for example, there might be a worker who

11 was asked a question about silicosis and it was

12 clear bilateral pleural plaques and asbestos

13 disease on the chest x-ray, but the person wasn't

14 asked that question.

15 So, I mentioned this. If the report

16 had a, you know, have you identified another

17 occupation -- or another possible occupational

18 lung disease, at least for the -- if it was a

19 user-friendly system for the workers, that would

20 at least be an opportunity to then, okay, we'll

21 look into the asbestos or the COPD or another

22 disease. 
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1 So, I think that would be something

2 that would be helpful. Then, obviously, people

3 would have to be instructed.

4 So, does anyone have any questions

5 about the review of the cases or anyone else on

6 our group who wanted to comment, Kirk and Laura,

7 everyone else who reviewed them?

8 MEMBER WELCH: Since I haven't seen

9 how you finished the slides, are you going to

10 make a specific recommendation about what you

11 just said adding a -- adding that the CMC asks --

12 I mean, that the claims examiner ask the CMC a

13 broader question about occupational lung disease?

14 MEMBER REDLICH: I hadn't, but I think

15 that is a good suggestion.

16 MEMBER WELCH: Okay.

17 MEMBER REDLICH: And maybe we could --

18 MEMBER BODEN: Just a brief thought of

19 that attitude. In other areas, particularly in

20 areas involving some sort of adjudication, there

21 have been studies that essentially measure

22 attitude. They measure liberalness or
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1 strictness.

2 So, if we're thinking about evaluating

3 CMCs, which we talked about before, then you

4 could actually -- you have to check a little bit

5 on the details of how the CMC cases are

6 allocated, but you could actually look for

7 outliers scientifically.

8 CHAIR MARKOWITZ: Sure. Dr. Cassano.

9 MEMBER CASSANO: What you're asking,

10 obviously, is sort of contingent on some of the

11 other recommendations that we've made.

12 Obviously, if they only ask the

13 question about silicosis and the SOAF didn't

14 mention anything else and they didn't get the

15 medical records which showed the chest x-ray that

16 had the bilateral pleural plaques, there's no way

17 for them to comment on other occupational

18 disease. So, what you're asking has got to be

19 contingent upon them seeing the entire record.

20 And I think we'd want to clarify -- I

21 think that the -- currently, the process -- the

22 procedure is the CMC only asks -- answers
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1 questions that are asked.

2 So, seeing the rest of the medical

3 records and knowing that there's an asbestos4 related disease if this claims examiner hadn't

5 asked about it, the CMC is not supposed to

6 comment on it.

7 So, that's something that would need

8 to be explicitly recommended to change, that the

9 CMC should, you know, doing the medical records,

10 note other potential occupational diseases and

11 send it back.

12 I mean, you know, the claim comes in

13 and the worker may have written down silicosis,

14 when what they had was asbestosis. And it seems

15 to follow that way and nobody stops and says, oh,

16 this is really asbestos-related.

17 And it seems like a simple fix, but I

18 think we have to understand -- and that's kind of

19 your --

20 (Simultaneous speaking.)

21 MEMBER WELCH: Yeah. I think it is

22 the --
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1 MEMBER CASSANO: Yeah. And I think it

2 also applies not just to I get Part 2 cases.

3 MEMBER WELCH: Yes.

4 MEMBER CASSANO: It applies to

5 everything, you know. If somebody -- we see this

6 all the time. Somebody has a particular

7 contingent, it's this disease, this exposure, and

8 it's a different exposure that actually is

9 causing the disease.

10 There needs to be a process by which

11 the CMC can render an opinion on that. And

12 without the entire record and without the

13 guidance to do that, they're not going to be able

14 to.

15 MEMBER REDLICH: Yes. And so, I think

16 that falls under your jurisdiction. Exactly. 

17 So, I will -- I just wanted -- this is sort of

18 what we -- I will also say that because we were

19 limited in what we were given, cases that seemed

20 like a reasonable denial of, let's say, CBD, it's

21 possible that there was evidence of lung disease

22 somewhere in the chart that, you know, we didn't
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1 see.

2 So, this was based on the records we

3 had, but I still think that these -- and as I

4 said, I think that most of these are fixable

5 problems.

6 Okay. So, moving on, the next item

7 was a sarcoid presumption and we had discussed

8 this before.

9 And there is already a presumption of

10 chronic beryllium disease in situations with a

11 diagnosis of sarcoidosis involving the lungs in

12 an individual who meets the definition of a

13 covered beryllium employee.

14 So, I think last time we decided we

15 don't necessarily need to make a recommendation

16 that already exists, but the issue was more the

17 implementation of that recommendation.

18 So, I did bring up -- and in the next

19 few slides I wanted to not spend too much time on

20 this, but I think reviewing the records that we

21 did made it clear what some of the problems with

22 this implementation were and also some of the
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1 problems with the wording.

2 So, I didn't know whether there was a

3 value in us voting again on sarcoid -- not voting

4 again, but voting on this or not. And I'll defer

5 to you.

6 CHAIR MARKOWITZ: All right. So, for

7 the sake of clarity, we did not vote on a

8 recommendation previously.

9 MEMBER REDLICH: Exactly. Yes.

10 CHAIR MARKOWITZ: So, this would be a

11 new recommendation. But what we're looking at,

12 is there additional text with this

13 recommendation, or is it just what we're looking

14 at right now?

15 MEMBER REDLICH: So, since the

16 recommendation is already there, there's not

17 additional text to the recommendation.

18 CHAIR MARKOWITZ: Oh, okay. So, what

19 we're looking at now, those four lines, does this

20 involve -- is this recommending a change in the

21 policy of DOL, or is this just confirming --

22 MEMBER REDLICH: It's not.
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1 CHAIR MARKOWITZ: It's confirming. 

2 So, if it's not a change in their policy, I don't

3 see the need for a recommendation to confirm what

4 they're doing.

5 MEMBER REDLICH: Yes. So, where there

6 could be a potential recommendation, although I

7 did not write it out, was to clarify the wording

8 of the implementation of it.

9 But I think that that needing

10 clarification actually is relevant to a number of

11 parts of the whole Chapter 2 that relates to the

12 B conditions.

13 I was just going to show one or two

14 examples of some of the wording issues.

15 CHAIR MARKOWITZ: Sure.

16 MEMBER REDLICH: So, we're in

17 agreement that because there is a presumption, we

18 don't need to vote on it again. I just -- my

19 memory from the last time was a little -- okay.

20 So, we're already on to the last item

21 here, the responses to some of the questions. 

22 So, we had originally been given a number of
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1 questions and have a more detailed response that

2 I had planned to have it on the website before

3 our meeting, but we'll get to people.

4 I wanted to highlight one or two of

5 the key issues that have come up more than once

6 and what our decision regarding these are.

7 So, not necessarily in the exact

8 order, one of the questions was, what is a

9 chronic respiratory disorder?

10 And so we don't need to read every

11 line of this, but there are currently several

12 definitions in these documents that refer to, you

13 know, define what a chronic respiratory disorder

14 is.

15 So, and this is from the -- what's it

16 called -- the Chapter 2 in the procedure manual. 

17 Thank you. So, this is in Chapter 2 of the

18 procedure manual for a chronic respiratory

19 disorder.

20 This is also in Chapter 2 of the same

21 procedure manual and -- let's see if this pointer

22 -- oh, there it is. Okay.
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1 So, it starts, you know, the last list

2 had specific conditions of a chronic respiratory

3 disorder. Some of them, you know, respiratory

4 infections -- it's a broad list.

5 So, this one had some wording:

6 pulmonary testing performed are not appropriate

7 to document unless interpreted as such by a

8 physician.

9 So, any PFT report does get an

10 interpretation. So, I think it's just an example

11 where the wording, to me, at least, is somewhat

12 confusing as far as what a chronic respiratory

13 disorder is.

14 And then this is from the slides that

15 I believe are used to train; is that correct? 

16 They were under your category, but I found them.

17 (Laughter.)

18 MEMBER REDLICH: So, I spent a lot of

19 time on that website, but -- okay. This then

20 says -- it lists the pre-1993 criteria, which I

21 think all of these, I think -- we were asked for

22 clarification on a number of these criteria,
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1 which we have tried to do.

2 But two things here: One is that at

3 least one of the documents must show that the

4 claimant received treatment for -- received

5 treatment. And previously there's wording that

6 says -- I don't have the exact words, it's in one

7 of these, but it was either treated for or

8 diagnosed.

9 So, treated for or diagnosed is

10 actually different than treated. And it may seem

11 like a minor change, but this is the type of

12 thing that I think creates a lot of confusion and

13 anxiety.

14 Another thing I will just mention,

15 which I think -- is that it says here immunologic

16 tests. And the first test it mentions is a skin

17 patch test.

18 And one of the comments -- I went

19 through all of the comments we've gotten since we

20 started this from various other places to make

21 sure we address the different ones, but one of

22 them mentioned a patient calling around, spending
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1 time trying to find where they can get their skin

2 patch test done.

3 So, this is an easy fix. It should be

4 out, you know, find, delete any mention -- skin

5 patch testing is not indicated. 

6 So, some of the rationale for these

7 points is in our more detailed response, but that

8 -- it would help to remove a reference to skin

9 patch testing throughout.

10 So, I mean, this is just an example of

11 one area where there is confusion in the -- some

12 of the different versions of the wording.

13 And I apologize. My PowerPoint was

14 crashing multiple times last night.

15 I did have a slide that showed what we

16 thought would be reasonable wording for what

17 constituted a chronic respiratory condition,

18 which was basically symptoms with -- chronic

19 symptoms with one other objective piece of

20 evidence for a chronic respiratory condition. 

21 And so, that could be specified.

22 I felt like to start getting into the
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1 -- each one of these points as a recommendation

2 was probably sort of nitpicking.

3 I think the more general

4 recommendation to sort of review the wording for

5 consistency and -- that would make more sense

6 than sort of each specific point.

7 But one of the areas that does need to

8 be addressed for consistency is, what is a

9 chronic respiratory condition.

10 So, then, the area of sarcoidosis

11 presumption where, as I said, that there is a

12 presumption, but the wording seems to vary.

13 Let me see, one of these -- this was

14 the original sarcoidosis presumption in 2008. 

15 And it says: Presumption of chronic in situations

16 with a diagnosis of sarcoid and a history of

17 beryllium exposure. 

18 The purpose, a diagnosis of

19 sarcoidosis is not medically appropriate if there

20 is a documented history of beryllium exposure,

21 period. So, that is a sarcoid presumption.

22 And if that -- you believe in that
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1 presumption, then we don't need many, many pages

2 after that of what to do with this BeLPT or all

3 these other possibilities. So, this presumption

4 was the original presumption.

5 Then there was another circular after

6 this that said that this circular was then,

7 whatever, receded. And now that -- the current

8 version of this is the wording that is in Chapter

9 2.

10 And there were some other pieces of

11 this wording I don't, you know, it goes on to say

12 here: Because a diagnosis of sarcoid for a

13 covered beryllium employee is not medically

14 appropriate, in any instance where this occurs,

15 CBD is to be the presumed diagnosis.

16 And then when we start getting into

17 all the howevers, things get sort of more

18 confusing. And so, I think with a lot of the

19 cases that we reviewed, it's understandable why

20 there was confusion about presumption.

21 And I guess before we go on to Chapter

22 2, I think Dr. Markowitz discussed the basic
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1 principle of a presumption yesterday. And that

2 any presumption, I mean, there are a lot of

3 advantages, as he mentioned, to a presumption. 

4 But when you do have a presumption, there is the

5 potential that one would be either over or

6 undercompensated.

7 So, this is the current wording. And

8 so, it's -- it recognizes that a diagnosis of

9 sarcoidosis especially in cases with a pre10 diagnosis date, could represent a misdiagnosis.

11 Now, I don't know why it would be

12 especially in these cases. It seems that either

13 pre- or post-1993, if you have a presumption --

14 so that is confusing.

15 So, then -- so, and I'm also -- the

16 differentiation between Part E and Part B gets

17 confusing, because -- and I didn't want to go

18 into a whole discussion here of, you know, are

19 they the same disease or are they different? I

20 know that has generated some confusion.

21 I think the point is that

22 pathologically and clinically they can be
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1 indistinguishable. And although certain features

2 may be more common in one than another, such as

3 extrapulmonary involvement, they can exist in

4 both. And I think if there's going to be a

5 presumption, then they should have a presumption.

6 So, and then also it continues with

7 Chapter 2 for Part E claim, the CE can evaluate a

8 claim as CBD. However, a positive is necessary

9 to accept it.

10 So, this is under the discussion of a

11 presumption. So, if it's a presumption, then I

12 don't know why we have to have a, however, you

13 need a positive BeLPT.

14 The other thing is this, too, wording

15 is also like a little bit confusing. This is the

16 actual name of the test that's currently

17 performed, a BeLPT.

18 So, then, without affirmative evidence

19 of a positive, the CE is to proceed with the

20 adjudication of the claim as one for a diagnosis

21 of sarcoidosis. 

22 So, I mean, if you're confused with
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1 the wording here, I'm confused and I'm -- this is

2 my area of expertise. So, I think you've got the

3 idea and we don't need to -- so, there's internal

4 inconsistencies.

5 And then this is all -- this was

6 actually then describing CBD on or after 1993. 

7 And it's relevant to the sarcoid presumption,

8 because, in claims that contain a normal or

9 borderline, and the biopsy confirms the presence

10 of granulomas consistent with CBD, the CE may

11 accept the claim. The lung biopsy is considered

12 the gold standard, period. But then we have the

13 however. So, it's very confusing.

14 And the current document does explain

15 why you can have a negative BeLPT test and still

16 have CBD. For instance if you were on steroids.

17 So, if it is a presumption, then do we

18 need to have exhaustive efforts, you know, to go

19 find every LPT and -- so, if it's, you know, you

20 wouldn't need those exhaustive efforts.

21 Then there's other -- just there's

22 areas that I think create confusion and there was
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1 a case -- one of them I reviewed was denied

2 because of this. I don't know if it was

3 eventually accepted, but this is on the post4 1993.

5 And I should also just clarify when

6 cases were denied, it's important that people

7 recognize that the organ that you biopsy when you

8 diagnose sarcoid, is usually the one that would

9 be least risky to do. So, sometimes skin or

10 nasal. Someone could have pulmonary involvement,

11 but the actual tissue was obtained from the skin.

12 And there were some cases like that

13 denied where -- without an appreciation that

14 there was pulmonary involvement.

15 And if the physician was tuned in

16 enough to actually highlight, yes -- and we

17 mentioned that you can document pulmonary

18 involvement in those situations by chest CT scans

19 showing the findings that would be consistent or

20 pulmonary function testing and that is commonly

21 done.

22 But getting back to -- they discussed
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1 that the mediastinal lymph node biopsy is

2 consistent with CBD, may be used to establish. 

3 So, they say that it's okay to use a mediastinal

4 lymph node biopsy.

5 Then it says that the lymph node

6 biopsy is not the equivalent of a lung biopsy. 

7 So, a mediastinal lymph node is in your chest. 

8 It drains -- these lymph nodes in the chest drain

9 the lung.

10 So, then it says it does not

11 substitute for the assessment of a post-CBD

12 claim. The evidence has to be interpreted as

13 lung pathology. A mediastinal lymph node is not

14 dispositive proof of CBD in the same way as a

15 lung biopsy.

16 So, this is a lot of wording, as a

17 pulmonary specialist, I don't really understand. 

18 I think if you have a -- if you have disease

19 involving, you know, the chest and the lymph

20 nodes in the chest, then that is consistent with

21 CBD.

22 Laura.
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1 MEMBER WELCH: I think some of the

2 what looks like jumping through hoops, is because

3 the legislation defines diagnostic criteria for

4 CBD.

5 So, and it requires -- I don't

6 actually have it up in front of me for Part B

7 cases, requires certain steps that -- and I think

8 it requires some evidence of sensitivity.

9 But you have to kind of compare this

10 to that, because, you know, the first one you put

11 up, however -- it said: However, Part B has

12 specific legislative requirements, so, therefore,

13 blah, blah, blah.

14 So, I think what it is, is it's, you

15 know, the claims examiner can't just say the

16 mediastinal lymph node biopsy is -- shows

17 granulomas and that's good enough. They have to

18 have a physician say that that's part of the

19 lung, because the legislative language may say it

20 has to be a lung biopsy.

21 So, it's sort of like -- I mean, I

22 think we have to -- maybe it makes sense to --
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1 MEMBER REDLICH: No, I do understand

2 that factor, but I think that one could address

3 this problem and also be very scientifically

4 valid and provide guidelines so that each

5 individual person didn't need to know the full

6 literature on these issues.

7 And I think they've done that in some

8 regards, and I think there has been attempts such

9 as explaining why you could have a negative

10 BeLPT, you know, document that the person's on

11 steroids.

12 So, I think there's been an attempt to

13 do that, it's just I think it could be done

14 better and sort of simplified.

15 And I think it is a point that we

16 obviously have to -- okay. So, I won't spend too

17 much more time on this, but the skin patch

18 testing is just -- I mentioned that already. 

19 This is pre- and includes -- and it includes skin

20 patch test and beryllium blood tests. So, that

21 should go.

22 And then there was a question about
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1 the wording -- you know, with -- in a number of

2 places there's wording that is characteristics or

3 consistent with. And I actually didn't fully

4 understand the question that the DOL was asking

5 related to this.

6 I think it's just important to

7 recognize that for CBD and sarcoid and for most

8 pulmonary conditions, there are findings that you

9 do see whether it's the, you know, chest CT scan,

10 the PFTs or the chest x-ray, that are consistent

11 with, but any given one of those is not unique or

12 pathognomonic for the disease.

13 So, I think that that wording is -- I

14 understand that people would like one to be able

15 to say, well, that CT scan finding is it, you

16 know, and is only in CBD and not -- but that

17 actually is not the case.

18 So, if there are other concerns or

19 questions about the wording that I didn't

20 understand. And then just another area where I

21 think wording is creating unnecessary confusion,

22 this is under discussion of characteristics,
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1 chest x-ray findings.

2 Under that, there's a discussion of

3 caseating granulomas. You don't see a caseating

4 granuloma on a chest x-ray, it's histologically

5 what you would see on a biopsy. So, having this

6 discussion under the x-ray findings is somewhat

7 confusing.

8 And then it -- and it says, are

9 sometimes considered characteristic, and then --

10 so, this, again, is an example of confusing

11 wording.

12 And then calcification, there was, I

13 think, one case that was denied because there was

14 some calcification noted somewhere.

15 Now, so you can have calcifications

16 with CBD, and this is documented in the

17 literature. So, this is a wrong statement and

18 just should be removed.

19 And, again, it's an area where -- I

20 mean, this whole discussion is confusing and

21 unnecessary and has nothing to do with a chest x22 ray finding.
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1 Sorry. I hit the wrong -- do you want

2 to get back to just the next slide? Yeah. I'm

3 not used to this little -- I think we're just

4 about --

5 CHAIR MARKOWITZ: I think that was the

6 last slide.

7 MEMBER REDLICH: Okay.

8 CHAIR MARKOWITZ: Granulomas.

9 MEMBER REDLICH: Yes. So, I'll just

10 go back to one earlier here. I think -- yeah,

11 the one topic that I did not have a slide for,

12 but we discussed, was the question of

13 indeterminate BeLPT. And Laura Welch helped with

14 this.

15 It was mentioned -- so, as people

16 know, a BeLPT can be abnormal or normal. 

17 Abnormal being considered positive. And the DOL

18 uses a standard of one positive test.

19 The question has come up of what to do

20 when sometimes you can get what's called an

21 indeterminate -- I'm sorry? Borderline, excuse

22 me. That's my fault. Borderline BeLPT. I will
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1 correct that.

2 And for a borderline BeLPT, it was

3 mentioned yesterday the Department of -- that the

4 state of Washington considers three borderline

5 BeLPTs to be the equivalent of a positive.

6 Given that our DOL standard for

7 sensitivity is one positive BeLPT test, if one

8 looks at the literature of the predictive value

9 of borderline tests, two borderline BeLPT tests

10 is -- gives a similar predictive value as a one

11 positive test.

12 So, we felt that two borderline BeLPTs

13 should be considered the equivalent of one

14 positive or abnormal BeLPT.

15 I did not put that in a formal

16 recommendation, but I think that that is

17 appropriate.

18 And Laura can -- if you want to

19 comment further ---

20 MEMBER WELCH: Well, I do think at

21 some point it has to be a formal recommendation,

22 because the board has to vote on it.
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1 MEMBER REDLICH: Okay.

2 MEMBER WELCH: And we have to vote on

3 specific language, but I leave that up to our

4 chair to decide.

5 CHAIR MARKOWITZ: Sure. Well, you

6 know, we can communicate this discussion to DOL,

7 but -- and at the next meeting, to formulate a

8 specific recommendation and have a complete

9 rationale to go along with it.

10 MEMBER REDLICH: Well, you know, if we

11 want, we can formulate a recommendation now. I

12 wrote the rationale in our response to all the

13 questions as a rationale, but --

14 CHAIR MARKOWITZ: We could also, by

15 the way, have a telephonic -- I think telephonic

16 meeting of the board in the interim between our

17 face-to-face meetings if you want to consider a

18 recommendation.

19 So, we could have one, you know, in

20 six to eight weeks.

21 MEMBER REDLICH: Okay. You know, I

22 didn't know if that fell to the level of needing
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1 a specific recommendation. But if people think

2 that that is --

3 CHAIR MARKOWITZ: Yeah. Well, Dr.

4 Boden.

5 MEMBER BODEN: So, a question. What

6 would a recommendation look like?

7 So, one thought of what a

8 recommendation could look like is recommended

9 rewording of a document, but we could also --

10 that is specific recommended rewording, but we

11 could also simply recommend to DOL that it takes

12 certain things into account when it rewords.

13 So, I'm wondering what people are

14 thinking.

15 MEMBER REDLICH: It is true that this

16 -- some of the other points I made were more, I

17 think, you know, wording that needs to be

18 clarified.

19 The -- currently, there is no -- no

20 sort of decision about how to handle borderline

21 BeLPTs.

22 And what, in practice, happens, is
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1 that people that have borderline lungs, you know,

2 go for more tests and need more testing.

3 MEMBER BODEN: Let me --

4 MEMBER REDLICH: And so, the only --

5 I think the only real -- people have decided that

6 they are -- mean something and the only issue is

7 whether it's three that are a positive or two.

8 And I think given that the standard

9 for -- the DOL uses is one abnormal BeLPT, that

10 the equivalent of that would be two borderline.

11 CHAIR MARKOWITZ: So, is the

12 recommendation simply that two borderline BeLPTs

13 be considered equivalent to a single positive

14 BeLPT?

15 MEMBER REDLICH: Yes.

16 CHAIR MARKOWITZ: If that's the

17 language, then without getting -- if it gets more

18 complicated or, you know --

19 MEMBER REDLICH: No, it's not.

20 CHAIR MARKOWITZ: -- starts other

21 issues, then I think --

22 (Simultaneous speaking.)
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1 CHAIR MARKOWITZ: If that's the

2 specific language, I think we can discuss it and

3 vote on it.

4 So, Kevin, if you wouldn't mind just

5 typing that out?

6 MEMBER REDLICH: Yeah. I --

7 CHAIR MARKOWITZ: Is there any further

8 discussion we need to have on this?

9 MEMBER CASSANO: Given how complicated

10 all of the language is in the procedure manual

11 and the training documents and everything else, I

12 think making one specific change added onto all

13 of this is going to be even more confusing.

14 And I think without the rewrite -- the

15 recommendation to rewrite Chapter 2 completely

16 and including that might just add more confusion

17 to something that's already confusing.

18 CHAIR MARKOWITZ: Ms. Vlieger.

19 MEMBER CASSANO: I don't know. My

20 thoughts.

21 MEMBER VLIEGER: The recommendation to

22 actually be put forward to the Department of
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1 Labor as a bulletin to supplement whatever you

2 guys end up with a draft PM that's on -- the

3 procedure manual that's going on right now, I do

4 think this is significant and it affects a number

5 of workers.

6 So, to wait for the procedure manual

7 rewrite, I think, is going to be too long.

8 CHAIR MARKOWITZ: Other comments?

9 Dr. Silver.

10 MEMBER SILVER: It's disheartening for

11 someone who naively read the statute upon passage

12 to see that what we thought was going to be a

13 simple set of presumptions has been turned into

14 another science project for physicians and claims

15 examiners.

16 In each of our public comment periods,

17 we've heard from one of the advocates, Stephanie

18 Carroll, about the idea of established beryllium

19 disease per the statute.

20 Was that framework at all helpful to

21 you in analyzing where DOL has gone wrong with

22 this part of their procedure manual?
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1 MEMBER WELCH: Well, I actually think

2 that we probably -- I think we should think about

3 -- you've said a lot of things, but I don't think

4 it's specific enough for DOL to know how to

5 change the procedure manual.

6 So, I think those two -- there's two

7 issues. There's the simple, straightforward one

8 that we have that Kevin is typing out right now

9 about handling borderline BeLPTs. So, we could

10 address that.

11 And then the rest of it, I think we

12 have to look at it in terms of legislative

13 language.

14 Part E doesn't have any specific

15 diagnostic criteria, but Part B does. And so,

16 how you can take current knowledge about

17 beryllium disease and sensitization and make it

18 fit -- I think what we've seen is many attempts

19 to kind of make it fit with the legislative

20 language.

21 And it's been tweaked so many times

22 it's -- there's not one instruction about what to
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1 do.

2 So, I actually think it would probably

3 be helpful if we made recommendations, what to

4 change.

5 MEMBER REDLICH: Yeah. So, I didn't

6 mean to overly confuse -- I partly want just an

7 example of some of the language. I mean, I

8 agree.

9 I think that the borderline test is a

10 specific issue that should be fixed and really

11 does not have to do with, like, the confusing

12 wording in the text.

13 So, I would vote that we suggest we

14 vote on that.

15 MEMBER CASSANO: Question: Is this

16 for both beryllium sensitivity and beryllium

17 disease as in both Part B and Part E as we may

18 need to say that, but it's for both sensitivity

19 and disease, as well as under both parts?

20 MEMBER REDLICH: I think throughout --

21 there is consistency throughout the -- all the

22 documents that when they are referring to
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1 sensitization, that it is one positive BeLPT.

2 So, if one says that two borderlines

3 are the equivalent of one positive, that piece is

4 consistent.

5 CHAIR MARKOWITZ: Dr. Friedman6 Jimenez.

7 MEMBER FRIEDMAN-JIMENEZ: I don't know

8 this literature, and I'm wondering if you could

9 maybe give us some references of the test,

10 because I'd like to know what the gold standards

11 were and what the predictive values were.

12 MEMBER REDLICH: Yes. So, Laura Welch

13 can describe, but there are a couple papers that

14 looked at the predictive value of the borderline

15 test.

16 And I don't know if we here want to

17 get into how many positive --

18 MEMBER WELCH: Yeah. I mean, I could

19 send you some of that. There's no -- there's

20 sort of no gold standard, but you can look at the

21 predictive value clinically and use that as the

22 gold standard. And I'll send you those pages.
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1 MEMBER REDLICH: And I think that so

2 much of the convoluted language and the like, the

3 one piece of the Act that if one could go back in

4 time and change, was the -- such an emphasis on

5 the BeLPT test, because the -- post-1993 it's

6 almost -- it's sort of been a bottleneck.

7 And I put it in our longer response

8 and rationale, but there's a number of reasons

9 for why you could be sensitized and have CBD and

10 have a negative BeLPT test that go beyond just

11 being on steroids.

12 And it's shown that when you do, it's

13 not a perfect test. And when you do lavage and

14 peripheral blood, each of those can be falsely

15 negative and falsely positive.

16 And, in fact, when you actually have

17 active disease, the sensitized lymphocytes may go

18 to the lung and cause one disease. And then when

19 you measure peripheral blood, they're not in the

20 peripheral blood, because they're in the lung. 

21 And so, you can have a -- definitely have CBD

22 with a negative BeLPT.
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1 Unfortunately, because of the wording

2 of the Act, a lot of the convoluted wording in

3 the various manual circulars, updated guides, you

4 know, are trying to solve that problem.

5 But I think hopefully moving forward,

6 there would be a way to do this that created less

7 confusion.

8 CHAIR MARKOWITZ: Mr. Whitley.

9 MEMBER WHITLEY: At that last meeting,

10 we had a lady that spoke that had eight

11 uninterpreted --

12 MEMBER WELCH: Eight borderline.

13 MEMBER WHITLEY: No, she had eight

14 uninterpreteds.

15 MEMBER WELCH: Okay. Uninterpreted is

16 a different question.

17 MEMBER WHITLEY: Did we change

18 anything on that?

19 MEMBER WELCH: It's a sort of

20 technical thing. There probably are -- someone

21 shouldn't be just repeatedly retesting if that's

22 uninterpretable. There are ways to try to run
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1 the test differently to get it to the

2 interpretable.

3 Uninterpretable usually means the

4 cells didn't grow or they overgrew or a bunch of

5 things. It's not -- borderline, there's a

6 sensitivity to beryllium, it's just not a high

7 signal.

8 Uninterpretable is a problem with the

9 test. So, I mean, it's -- we do it differently

10 and we can -- sometimes there are people for whom

11 you just can't get a BeLPT. But then at some

12 point, you stop and why keep sending them.

13 If their serum and their cells always

14 come up with an uninterpretable result, you have

15 to accept that's how that person is and deal with

16 it in that context.

17 So, it could be -- there's probably

18 ways to find ways for a claim to be accepted for

19 people who have an uninterpretable BeLPT as well

20 and we can look at that specifically for people

21 who you just can't get a real -- can't get a good

22 result.
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1 MEMBER REDLICH: I think it's also

2 important to understand that the whole beryllium

3 lymphocyte proliferation testing literature and

4 the sort of guidelines were developed in the

5 setting of where you're doing surveillance on

6 healthy workers and you don't want to go crazy,

7 deny someone a job, start doing a ton of invasive

8 procedures when you have a positive test.

9 So, there's been concern about, you

10 know, why do you want to have repeated tests,

11 because you -- and that's doing a test with the

12 purposes of surveillance of healthy workers.

13 The perspective where I see patients

14 with beryllium disease are people who are

15 diagnosed with sarcoidosis or interstitial lung

16 disease and the -- and then what is the

17 predictive value of a test and the utility of

18 doing it in that situation?

19 And so, that is different in someone

20 with, let's say, preexisting disease who has

21 known beryllium exposure.

22 If you look at -- let's say
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1 preexisting granuloma disease in their lung and

2 known beryllium disease, the literature on all of

3 the predictive values and the like have been done

4 -- and the -- sort of the rationale for the whole

5 test and how many repeats you need, was done

6 thinking of what would be best in the

7 surveillance of healthy workers, not -- now, that

8 sort of literature and wording has been taken,

9 you know, sort of more broadly and -- but in the

10 setting of someone who has known granulomatous

11 lung disease and a history of working with

12 beryllium, the overwhelming likelihood, you know,

13 which would be more likely just in terms of

14 probabilistically sarcoid or CBD, sarcoid is a

15 rare disease, you know, whether it's one in

16 10,000 or one in a thousand. Especially sarcoid

17 that involves symptoms and lung disease.

18 So, is one in 10,000 -- how does that

19 compare to the probability of having CBD if

20 you've, you know, had beryllium exposure?

21 And that, you know, whether it's 0.1

22 percent or one percent or five percent, that is a
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1 much higher probability than having sarcoidosis.

2 So, I think part of the confusion

3 about the BeLPT is the setting that you're doing

4 it for.

5 CHAIR MARKOWITZ: So, we have a

6 recommendation and does the -- the recommendation

7 language we look at now need to be modified in

8 any sense? Does it need to be specified, as Dr.

9 Cassano says, under Part B, subpart B and subpart

10 E?

11 MEMBER CASSANO: I would -- I've seen

12 how recommendations can get screwed up when they

13 end up being promulgated. And I think the more

14 explicit we are, the better.

15 CHAIR MARKOWITZ: So, after

16 evaluations, add under subpart B and subpart E of

17 EEOICPA.

18 Any other suggestions on the language?

19 Mr. Whitley.

20 MEMBER WHITLEY: You probably should

21 change should to shall.

22 CHAIR MARKOWITZ: Change the should to
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1 shall?

2 MEMBER WHITLEY: It means it will be.

3 CHAIR MARKOWITZ: Right. Think big or

4 go home? Is that what you just said?

5 (Laughter.)

6 CHAIR MARKOWITZ: Okay. So, if there

7 are any other final comments, we'll take a vote.

8 Mr. Griffon, by the way, do you have

9 any comments you wanted to add?

10 Okay. Ms. Vlieger.

11 MEMBER VLIEGER: I'm not sure

12 evaluations is correct. I think it would be

13 claims adjudication.

14 CHAIR MARKOWITZ: Okay. Change

15 evaluations to adjudication?

16 MEMBER VLIEGER: Yes.

17 CHAIR MARKOWITZ: Okay. Is there a

18 motion to approve this recommendation? A second? 

19 Okay.

20 All those in favor, raise your hand.

21 (Show of hands.)

22 CHAIR MARKOWITZ: Anybody -- oh, Mr.
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1 Griffon?

2 Well, while we're waiting for him, all

3 those opposed? Any abstentions? One. So, of the

4 committee members present, of whom I think we're

5 13, there are 12 in favor, one abstention and no

6 no votes.

7 And, Mr. Griffon? 

8 Well, if he comes back on the line, he

9 can vote. But otherwise -- so, that's done and

10 we're done, Dr. Redlich?

11 MEMBER REDLICH: Yes.

12 CHAIR MARKOWITZ: Okay.

13 MEMBER REDLICH: So, I guess the only

14 thing --

15 MEMBER GRIFFON: You didn't hear me. 

16 I voted yes.

17 CHAIR MARKOWITZ: I'm sorry. I'm

18 sorry. Mark?

19 MEMBER GRIFFON: Yes. You didn't hear

20 me. I voted yes. 

21 CHAIR MARKOWITZ: Okay. Thank you.

22 MEMBER GRIFFON: Okay.
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1 MEMBER REDLICH: So, the only question

2 I would raise is, what are the possibilities or

3 options to revise the manual?

4 CHAIR MARKOWITZ: Well, I guess that's

5 a question for Ms. Leiton.

6 MS. LEITON: So, the -- the

7 recommendations from the Board are going to be

8 considered in one of our procedures that we

9 develop, you know, one way or another.

10 So, a lot of the recommendations

11 you're making today with regard to presumptions

12 if they were to be accepted, we're going to be

13 making changes to the procedure manual.

14 If you have specific wording that you

15 think should be considered in the procedure

16 manual and it's presented to us as a

17 recommendation, obviously it's something we would

18 consider.

19 I'm not sure that answers the

20 question, but --

21 CHAIR MARKOWITZ: That does, actually. 

22 That does. Thank you. Okay.
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1 So, we're not going to be able to

2 fully consider the final recommendation we wanted

3 to look at, but I do think we should present it

4 at least initially, because I would favor

5 actually trying to have a telephone meeting of

6 the Board before our next face-to-face meeting so

7 that we can address this particular presumption

8 and not wait the additional several months.

9 So, if you could bring up the -- which

10 -- it says that there were solvents and hearing

11 loss.

12 MEMBER REDLICH: So, while we're just

13 bringing that up, if I understand if -- I have a

14 version of B that has been edited.

15 Would that be helpful to give that to

16 you?

17 MS. LEITON: When you say a version of

18 --

19 MEMBER REDLICH: I'm sorry. I'm

20 sorry. Of Chapter 2, the 1000.

21 MS. LEITON: I think the one thing to

22 keep in mind is that -- I think a couple of
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1 people have mentioned it, is that the statutory

2 criteria are very specific.

3 So, as long as it's within the

4 framework of what the statute says as pre-CBD,

5 post-CBD, those, you know, within that framework

6 -- obviously you can edit and submit whatever you

7 want to, but that's what we would have to be

8 considering first and foremost, is what is in our

9 statutory language.

10 So, you know, the presumptions on

11 sarcoidosis are really -- we're saying we'll

12 consider sarcoidosis CBD under certain

13 circumstances, and then it reiterates what the

14 CBD criteria are and how they interpret the CBD

15 criteria pre and post.

16 So, any language you would propose for

17 that section, obviously, yeah, we'll consider,

18 you know, what you propose to us.

19 I recognize that one has to --

20 MEMBER REDLICH: Because it's so

21 specific that we don't want to have to go to

22 Congress.
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1 CHAIR MARKOWITZ: Okay. Thank you.

2 Dr. Welch.

3 MEMBER WELCH: Okay. So, we did

4 discuss noise and hearing loss at one of our -- I

5 mean, solvents and hearing loss at one of our

6 previous meetings.

7 And I went through the literature in

8 more detail, found some additional things that

9 were very helpful, and put together something

10 for us to think about for a presumption.

11 As you recall, there currently is a

12 presumption for solvent-related hearing loss. 

13 And this is what I have here.

14 They have to have sensorineural

15 hearing loss in both ears, they're exposed to one

16 of the listed chemical solvents and worked in one

17 of the listed labor categories for required

18 concurrent and unbroken 10-year periods.

19 Now, I'm just trying to remember, and

20 somebody else can help me out, there might have

21 also be in that, a calendar year cutoff.

22 (Off the record comments.)
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1 MEMBER WELCH: Ten years prior to

2 1990.

3 CHAIR MARKOWITZ: Ten consecutive

4 years prior to 1990.

5 MEMBER WELCH: So, I'll be sure to add

6 that back in.

7 And the solvents that were -- are

8 listed -- and so, if these are reported as --

9 from the individual or, you know, their labor

10 category has these exposures in the SEM, they can

11 be considered.

12 And then they have to have that ten

13 continuous years before 1990, but the specific

14 solvents are established as the cause and

15 accepted in the current presumption.

16 Here's the labor categories which you

17 can see that are on the big screen, probably, but

18 it's a, you know, it's a pretty good list of

19 people who would have used organic solvents in

20 their work.

21 As we know from many discussions,

22 there will be people who work as an instrument
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1 mechanic or instrument technician, but their job

2 title may not be instrument mechanic or

3 instrument technician.

4 So, there has been a problem with

5 implementing this particular presumption in that

6 people are doing equivalent work to one of these

7 listed job categories, but there's no way to

8 accept them if they're not in the job category.

9 So, in terms of what the literature

10 shows, recent reviews conclude that both animal

11 and human studies clearly establish effects of

12 solvents on hearing.

13 The animal studies are specific

14 solvents. There are animal studies that are

15 multiple or mixed solvents so that what

16 information we have on mixed solvent exposure

17 comes from human studies.

18 But the solvents that were listed --

19 I have another slide that kind of shows the

20 certainty of it.

21 There are consensus statements

22 available from NIOSH and EPA that solvents cause
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1 hearing loss -- that organic solvents cause

2 hearing loss.

3 Because issues of dose-response or a

4 threshold, meaning -- threshold meaning there's a

5 level below which there's no injurious exposure,

6 you can't really identify those in animal

7 studies.

8 And the human studies are -- because

9 the exposures are complicated and usually mixed,

10 there's not a lot of data that helps us on dose11 response, which is what we need to establish

12 years.

13 So, there was a paper I hadn't read

14 before, which is a systematic review that was

15 done by NIOSH and the Nordic -- the Nordic Expert

16 Group for Criteria Documentation of Health Risks

17 from Chemicals.

18 And they -- and this was published in

19 2010. And there is some data, but not a lot

20 since then. So, I think this is probably a

21 really good evidence-based review to rely upon

22 for this presumption.
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1 So, styrene, toluene, xylene and

2 carbon disulfide cause hearing loss at or below

3 the current OELs. Which would then say

4 immediately that any cutoff date such as 1990

5 where we presume exposures were higher prior to

6 some period of time really can't apply. Because

7 even if the exposures are controlled to the

8 current OEL, there's a risk of solvent-induced

9 hearing loss.

10 So, xylene and ethylbenzene, there's

11 more limited occupational data, but this

12 evidence-based review concluded that animal data

13 shows effects at or below the current OEL. So, I

14 would put those in the same category, styrene,

15 toluene, xylene, carbon disulfide and

16 ethylbenzene.

17 Then TCE and solvent mixtures, there's

18 an effect in human studies. Not really enough

19 data to say whether it's at or above what level

20 below the -- above or below the current OELs.

21 The mixtures that were studied in the

22 human studies most often were MEK, MIBK, xylene
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1 and toluene, which are already on the list of

2 solvents that have been identified and were

3 accepted in the current presumption to cause

4 hearing loss.

5 So, I think that list of solvents is

6 pretty good and those are the ones for which

7 there is evidence. 

8 I think the question for that, and

9 we'll talk about it when we talk about the

10 specific presumption, is how do you establish

11 those exposures.

12 Many people know they worked with

13 solvents, but they may not know they were working

14 with MIBK.

15 And so, then you're relying primarily

16 on the SEM to identify those exposures and then

17 we get back to some of the limitations with the

18 SEM. It may be not a solvable problem, but --

19 so, we're really looking at these particular

20 compounds. Carbon disulfide is not on the

21 previous list and we're going to need to add

22 that.
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1 And then I want to include a

2 recommendation that DOL develop some direct

3 disease work links for the tasks with exposure to

4 those solvents that are in the range of the OEL.

5 And there is -- that's something

6 potentially the Board could help with or

7 industrial hygiene could help with.

8 It would help get around the problem

9 that the labor categories that are listed --

10 can't include all the jobs within the DOE complex

11 that would have performed those tasks.

12 So, if we can identify the tasks and

13 have a direct disease work link, I think that

14 would really, really streamline processing these

15 particular claims. So, that's one

16 recommendation.

17 And then the larger one -- so, I'm

18 recommending we keep the ten-year exposure

19 requirement, but that it be cumulative and --

20 rather than continuous. And that if the -- let

21 me just do the first one.

22 So, ten-year cumulative years in any
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1 of the job titles on the list in the current

2 presumption.

3 No requirement, then, that they had to

4 also report exposure to those specific solvents

5 or that the solvents be present in the SEM.

6 If they did those jobs, we know

7 they're exposed to mixed solvents and many of the

8 solvents on the list.

9 If they weren't in one of those job

10 titles, then we're looking for reported exposure

11 to styrene toluene, xylene, ethylbenzene, TCE or

12 carbon disulfide on the OHQ, or evidence for

13 exposure to those solves in the SEM for at least

14 ten years cumulative.

15 And also, report exposure to solvent

16 mixtures. As I said, that those -- the mixtures

17 most commonly looked at in occupational studies

18 include the specific solvents that are

19 recommended in the paragraph above.

20 Or exposure for ten years cumulative

21 established through work history and a direct

22 disease work link process. 
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1 So, that would be that if someone's

2 got ten years of work in a particular task that's

3 been established to carry these exposures -- and,

4 again, that's not in the SEM yet, but I think

5 this is a good target for the -- for development.

6 So, people would either be in the job

7 list for ten years, they've reported exposures on

8 their occupational history questionnaire and

9 relevant tasks allowing them to -- the evaluation

10 of those for ten years, or solvent mixtures for

11 ten years, or relevant tasks for ten years.

12 And I think -- okay. Yeah. So, the

13 claims examiners should not routinely deny claims

14 if the worker has fewer than ten years of

15 exposure.

16 So, if they don't meet those four

17 bullet points above, claims that did not meet the

18 requirements set forth here, but do have reported

19 exposure to organic solvents for at least five

20 years cumulative should be sent to the IH and/or

21 the CMC for review.

22 Which would, again, as part of a
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1 presumption, the data suggests that you do need

2 at least five years to get solvent-related

3 hearing loss.

4 And if more research comes out to put

5 it at a lower level, this presumption could be

6 adjusted down the road. But currently it's

7 saying if you have ten cumulative years, you're

8 going to get in with one of those ways of

9 documenting what the exposure is.

10 If you have five years, then you need

11 an individual assessment. If you have fewer than

12 five years, you wouldn't be able to file a claim

13 under this presumption. And that's it.

14 CHAIR MARKOWITZ: Okay. So, thank

15 you, Dr. Welch. So, obviously we're not going to

16 discuss this, but I have just a couple questions.

17 One is, could we address -- as opposed

18 to waiting until our next face-to-face meeting,

19 which will probably be in October/November, could

20 we have a telephone meeting of the Board in June

21 or early July specifically to address -- to be

22 able to discuss this and consider it?
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1 You know, claims for hearing loss come

2 in all the time. And if we're going to settle on

3 a recommendation that might significantly change

4 the policy of the DOL, then I feel like we should

5 get to it sooner rather than later.

6 And then the second question is that

7 before that meeting, I think if we had a draft

8 rationale for this, as well as some of the

9 references so we could look at that, that would

10 also be helpful in discussing that.

11 So, how do people feel -- first of

12 all, let me just ask Doug whether it would be

13 possible to have a telephonic meeting of the

14 Board.

15 MR. FITZGERALD: It's theoretically

16 possible.

17 (Laughter.)

18 MR. FITZGERALD: The time frame, I

19 think we're really probably looking at July, not

20 June, only because of the internal clearance

21 process. I think that would be the earliest.

22 Carrie, would you concur with that or
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1 --

2 (Off the record comments.)

3 MR. FITZGERALD: Okay. Well, we just

4 know it took about seven weeks for the last

5 approval process to go through.

6 CHAIR MARKOWITZ: Okay. And it will

7 be a simple agenda.

8 MR. FITZGERALD: Yeah. And the only

9 other issue, and I don't think it's a big one, is

10 just to check our budget for the costs associated

11 with a meeting.

12 CHAIR MARKOWITZ: Okay.

13 MR. FITZGERALD: But since it's

14 telephonic, it shouldn't be that much.

15 CHAIR MARKOWITZ: Okay. And how about

16 the board members? Is that okay to do that?

17 Okay. And, Dr. Welch, in terms of

18 providing a draft rationale and the sources, that

19 would be possible?

20 MEMBER WELCH: Yes. And, you know,

21 this -- our subcommittee -- we've talked about

22 it, but I'll make sure that they get a chance to
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1 look at it first, submit comments, et cetera.

2 CHAIR MARKOWITZ: Right. Okay.

3 MEMBER WELCH: And in addition by the

4 time we all see it again -- I mean we already

5 have the rationale. So I would need to get that

6 out to everybody six weeks before the call, at

7 the time we schedule it. 

8 And since it's going to be a

9 convenience between scheduling the other --

10 CHAIR MARKOWITZ: We wouldn't have

11 time -- I don't think we'd have time for a

12 subcommittee call.

13 MEMBER WELCH: No. No, no.

14 CHAIR MARKOWITZ: Right. Okay.

15 MEMBER WELCH: I'm just saying if --

16 my deadline if we were to have the meeting in the

17 beginning of July -- as long as it's after May -- 

18 CHAIR MARKOWITZ: Well, I don't -- we

19 need -- well, it depends whether we publish the

20 draft -- the recommendation or not, but we'll

21 settle that. We'll settle that.

22 MEMBER WELCH: Yeah.
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1 CHAIR MARKOWITZ: We'll settle that. 

2 MEMBER WELCH: I think that's

3 possible.

4 CHAIR MARKOWITZ: Okay. Okay. Good. 

5 So, just a few miscellaneous items before we

6 close the meeting.

7 The charter for this board is up for

8 renewal in July 2017. And that process has been

9 initiated by Department of Labor.

10 We, as individual members, our

11 individual term expires in February 2018. And

12 the start of that renewal process begins in

13 September of 2017.

14 And we don't know exactly what that

15 renewal process consists of, but I'm sure the

16 Department of Labor will let us know at the

17 appropriate time.

18 You need to -- if you haven't done so,

19 you need to complete your financial disclosure

20 forms prior to next Wednesday. Prior to next

21 Wednesday.

22 Okay. So, if you haven't sent in
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1 those forms, you really need to be so that we can

2 remain in compliance with the regulations.

3 MEMBER BODEN: Can I ask a favor of

4 DOL folks?

5 You just sent around to everybody a

6 request if you haven't completed it.

7 Would you send to the people who have

8 a confirmation, that we have -- I believe I have,

9 but I want to make sure you got it.

10 CHAIR MARKOWITZ: Right. So many

11 financial disclosure forms in so little time.

12 (Laughter.)

13 CHAIR MARKOWITZ: So, in terms of just

14 to remind the subcommittee chairs that if you

15 want to have a call as a subcommittee, you need

16 six weeks advance notice for it to appear in the

17 Federal Register.

18 So, you need to start thinking in the

19 next couple of weeks about scheduling that call

20 and then make the request to the Department of

21 Labor.

22 In particular, I'm thinking that July
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1 and August might be problematic in terms of

2 people's schedules, so that really brings us to

3 the decision of the next couple weeks about that

4 so that you can schedule it during June. You can

5 figure out the timing yourself.

6 In terms of the next board meeting, it

7 will likely be in October. We will -- I think

8 we'll circulate the potential dates and potential

9 sites.

10 I don't really want to have a full

11 discussion of locations now, but I would note

12 it's been extremely useful and helpful to the

13 Board to be in the field, to be at sites where we

14 get a tour of the site, get a better sense of the

15 -- what happens, what occurs within the complex.

16 And we also emphasize sites in which

17 there are large numbers of claimants so that

18 claimants have -- and DOE workers, in general,

19 have access to these meetings. So, we will

20 continue to follow that -- those ideas.

21 The public comments that have come in,

22 Carrie Rhoads will be cataloging and figuring out
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1 some way that we can work with her to keep track

2 of those comments, make sure they're circulated

3 both to the Board as a whole, but also to the

4 relevant subcommittees.

5 We also -- the Board receives letters

6 from individuals, from organizations which are

7 circulated among us. Most of them don't require

8 responses from us, but they will be sent to all

9 the board members and also to the subcommittees.

10 And they raise items -- they're also

11 raised in the public comments as well, but other

12 items as well. So -- but if -- I should say that

13 if you don't -- if members of the public or

14 organization send us letters and you don't

15 receive a response from us, it's because the

16 letter didn't require a response or because we

17 haven't really engaged in that kind of back and

18 forth with that kind of communication.

19 I think that's pretty much -- in terms

20 of -- do members of the board have particular

21 issues, last-minute issues, administrative or

22 otherwise, questions that we should discuss?
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1 MEMBER POPE: I have a question.

2 CHAIR MARKOWITZ: Ms. Pope.

3 MEMBER POPE: I'd just like DOL to

4 keep us informed or keep us updated as to when

5 our recommendations will be implemented.

6 CHAIR MARKOWITZ: Okay. Mr. Griffon.

7 MEMBER GRIFFON: No comments, Steve.

8 CHAIR MARKOWITZ: So, then we've

9 reached the close of this meeting. Let me just

10 thank the members of the Board for all the hard

11 work that we're doing.

12 Also, members of the public for

13 hanging in with us through some interesting and

14 sometimes complicated discussions.

15 We appreciate your attendance. We

16 appreciate your input, really, into the process. 

17 And that includes the members of the public who

18 are here, and also people who are on the phone.

19 I want to thank Department of Labor

20 for helping us have these board meetings,

21 especially Doug and Carrie.

22 And I'd like to thank Ms. Leiton for
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1 attending and being very responsive to the

2 questions we had.

3 And of course we're thankful to the

4 other members of the Department of Labor, Mr.

5 Nelson and colleagues; Department of Energy, who

6 are no longer here, and the like.

7 So, with that, I'd like to close the

8 meeting.

9 MR. FITZGERALD: Okay. Thank you, Mr.

10 Chairman. And I just want to thank you and the

11 board for all your hard work on behalf of the

12 Energy program.

13 I want to thank the public for being

14 here and providing their comments and

15 participating with us.

16 And that brings us to a close and this

17 meeting is officially adjourned.

18 (Whereupon, the above-entitled matter

19 went off the record at 10:55 a.m.)

20

21

22
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irritants 47:4 53:12

issue 10:19 14:1 19:4,5

20:22 26:19 43:15

47:20 63:12 84:16

85:7,22 86:4 91:16

113:6 117:10 141:9

issues 3:15 40:9 81:13

82:13 84:22 85:9

93:14 94:5 106:6

113:21 116:7 133:3

146:21,21

item 91:6 93:20

items 75:19 77:9 143:5

146:10,12

J

James 2:10 9:21 81:18

Jimenez 14:19 47:18

72:3 118:6

job 12:4 47:3 122:7

132:1,7,8 137:1,9

138:6

jobs 136:10 137:6

John 1:15 9:1 15:22

81:17

joining 6:8

Joint 77:18

JOTG 78:3

judging 18:15

July 139:21 140:19

142:17 143:8 144:22

jumping 5:13 105:2

June 139:20 140:20

145:4

jurisdiction 90:16

justification 55:5

justify 18:1

K

K 1:21

keep 54:17 68:20 80:20

121:12 128:22 136:18

146:1 147:4,4

keeping 16:20

Ken 9:9

KENNETH 1:16

kept 77:3

Kevin 13:3 14:12 62:21

63:9 114:4 116:8

key 33:8 82:10 94:5

Kirk 2:8 8:19 81:18 87:6

knowing 43:13 89:3

knowledge 116:16

known 29:15 122:21

123:2,10

L

labor 1:1 11:6 21:5

22:21 38:19 39:2

60:11 78:4,5 115:1

130:17 131:9,16

136:9 143:9,16

144:21 147:19 148:4

Labor's 4:11

lady 120:10

language 11:8 12:5

22:1 26:20 50:10,20

61:13 75:7 105:19

111:3 113:17 114:2

114:10 116:13,20

117:7 119:2 124:7,18

129:9,16

large 145:17

largely 36:20

larger 136:17

last-minute 146:21

Laughter 54:11,14 71:8

76:8 77:14 95:17

125:5 140:17 144:12

Laura 1:20 81:18 87:6

104:22 109:13 110:18

118:12

Laurie 8:11

lavage 119:13

lawyers 23:12

lead 10:22 76:2

learned 81:9

leave 12:18 20:21 64:8

65:5 71:5 111:3

leaving 67:4

left 6:13 10:19

leftover 5:12

legislation 11:16 105:3

legislative 11:8,10 12:5

16:21 105:12,19

116:12,19

Leiton 19:4,6 23:10,11

24:18 25:1,5 26:12,15

50:4,6 57:13 127:5,6

128:17,21 147:22

Les 10:3

LESLIE 1:17

let's 7:20 14:4,7 22:9

35:1 68:1 69:22 76:7

76:20 79:11 80:12

90:20 94:21 122:20

122:22

letter 50:2,12,19 146:16

letters 146:5,14

level 111:22 133:5

134:19 139:5

Levin 78:20

liaison 4:18

liberalness 87:22

light 70:2

likelihood 123:12

limit 45:12 53:19

limitations 135:17
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limited 85:6 90:19

134:11

line 46:7 49:14 61:13

62:22 63:9 71:21

94:11 126:8

lines 49:4 50:10 92:19

link 25:20 49:18 136:13

137:22

links 136:3

Lion 1:11 77:21

list 33:13 45:20 70:14

84:7 95:1,4 131:18

135:1,5,21 137:1,8

138:7

listed 130:16,17 131:8

132:7,18 136:9

lists 95:20

literature 17:14 35:22

36:2,15 53:8 65:20

72:6 106:6 108:17

110:8 118:8 122:3

123:2,8 130:7 132:9

little 5:14 10:15 17:2

21:1 30:6 42:17 46:17

48:8,21 67:16 73:19

75:7 79:12 82:3,21

88:4 93:19 101:15

109:3 144:11

live 14:1 64:12

local 38:14

location 22:6

locations 145:11

long 15:18 43:8 67:6

79:21 115:7 129:3

142:17

longer 58:8 119:7 148:6

look 15:16,22 16:12,17

17:7 23:11,12 24:14

28:17,18 40:3 52:21

56:9 65:19 86:21 88:6

112:6,8 116:12

118:20 121:20 122:22

124:7 128:3 140:9

142:1

looked 11:8 15:20 16:1

33:1,3 40:20 118:14

137:17

looking 15:18 18:1,2,15

21:22 24:2 39:8 57:3

92:11,13,19 135:19

137:10 140:19

looks 56:9 105:2 110:8

lose 66:11

loss 77:8 128:11 130:4

130:5,12,15 133:1,2

134:2,9 135:4 139:3

140:1

lot 15:15 24:11 29:21

39:11 46:10 47:3 53:9

57:20 84:14 85:20

95:18 96:12 99:18

100:2 104:16 116:3

120:2 127:10 133:10

133:19

low 43:8

lower 139:5

LPT 102:19

lump 17:6

lung 3:7 10:17 17:7,10

36:22 53:2 75:5 76:21

86:18 87:13 90:21

102:11 104:6,9,13,15

105:19,20 119:18,20

122:15 123:1,11,17

lungs 91:11 113:1

lymph 104:1,4,5,7,8,13

104:19 105:16

lymphocyte 122:3

lymphocytes 119:17

M

M 1:15 2:7,9

major 39:19

majority 37:15 40:7,21

51:6 72:19

making 60:14 114:12

127:11,13

managing 46:14

manifestation 46:3

manpower 84:17

manual 57:12,20,22

58:5 94:16,18,21

114:10 115:3,6,22

116:5 120:3 127:3,13

127:16

map 48:15

Mark 1:16 10:7 20:19

80:12 126:18

MARKOKWITZ 80:15

material 6:6

materials 5:16 76:3

82:8

matter 79:14 148:18

matters 6:20

mean 11:14 20:22 21:8

21:13 23:16 25:1 26:6

39:21 41:15 53:21

57:18 74:11 87:12

89:12 97:10 100:2

101:22 105:21 108:20

113:6 117:6,7 118:18

121:9 130:5 142:4

meaning 28:8 33:10,14

133:4,4

means 33:14 68:13

121:3 125:2

measure 87:21,22

119:19

mechanic 132:1,2

mechanism 55:3

mediastinal 104:1,3,7

104:13 105:16

medical 1:18 27:21

28:3 36:6 47:13 59:13

61:2 78:12,13 82:12

82:21 88:15 89:2,9

medically 33:6 61:18

98:19 99:13

medication 33:11 34:21

44:4 47:9 61:22 63:15

63:16 64:9 71:21

75:16

medicine 8:2,9,12 9:5,7

9:14,15 10:12 48:4

80:8

meet 32:5 138:16,17

meeting 1:5 3:18 4:10

5:3,16 6:4,6,7,19,21

7:1,3,14 74:20 77:10

78:19 79:3 81:6 94:3

111:7,16 120:9 128:5

128:6 139:18,20

140:7,13 141:11

142:16 143:6 145:6

147:9 148:8,17

meetings 5:4,18 77:20

78:3 111:17 130:6

145:19 147:20

meets 91:12

MEK 134:22

members 1:13 7:19

74:20 76:19 81:17

126:4 141:16 143:10

146:9,13,20 147:10

147:12,17 148:4

memory 93:19

mention 12:1 38:1

45:10 52:12 54:3

81:12 88:14 96:14

97:4

mentioned 22:2 44:19

86:15 96:22 100:3

103:17 106:18 109:15

110:3 129:1

mentions 96:16

met 1:11 4:21 32:8

Metal 8:20

meter 69:20

methacholine 32:15

61:8

metric 15:17

MIBK 134:22 135:14

middle 22:15

mild 51:22

military 8:10

mind 16:16 19:13 21:1

50:2 59:13 114:4

128:22

mindful 5:15

minimal 52:1

minor 35:12 96:11

minority 72:15

minutes 6:19 7:1,3,8

79:6,12 80:2

misapplication 83:11

miscellaneous 143:5

misconceptions 38:2

misconstrue 74:4

misdiagnosis 100:10

misrepresentation

73:14

missing 74:3

misunderstanding

83:12

mixed 30:6 132:15,16

133:9 137:7

mixtures 134:17,21

137:16,16 138:10

modification 54:17

modified 73:2 124:7

modify 36:10 62:22

67:16

modifying 56:16

months 38:16 128:8

morning 4:8 9:17

morph 67:8

motion 72:22 76:13

125:18

move 10:16 20:15

26:10 27:2 33:1 75:5

moving 55:21 91:6

120:5

multiple 37:21 97:14

132:15

N

N 3:1,1 4:1

naively 115:11

name 4:9 101:16

narrow 83:22 86:7

nasal 103:10

National 8:16

nature 21:8 75:16

neatly 59:7

necessarily 57:1 58:13

91:15 94:7

necessary 34:7 55:15

62:16 101:8

need 6:16 12:6 15:5

20:13 27:22 59:14,20

70:18 73:10,11 80:21

82:6 89:7 91:15 93:3
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93:18 94:10 98:7 99:1

101:13 102:3,18,20

106:5 113:2 114:8

117:18 123:5 124:7,8

133:11 135:21 139:1

139:10 142:5,19

143:18,19 144:1,15

144:18

needed 67:13

needing 93:9 111:22

needs 39:18 43:4 56:18

90:10 112:17

negative 38:1 40:16

102:15 106:9 119:10

119:15,22

negatives 39:11

Nelson 78:20 148:5

never 19:13 48:18

new 7:21 8:3 9:6,8

30:13 51:11 52:2

60:16 78:17 92:11

night 35:11 77:3 97:14

NIOSH 78:6,7 132:22

133:15

nitpicking 98:2

node 104:1,4,5,7,13

105:16

nodes 104:8,20

noise 130:4

non- 13:8

Non-binding 20:6

non-DOE 13:13,19 14:2

14:5,14,22 15:1 17:22

18:2 20:4

non-presumption

18:13

non-specific 53:6

Nordic 133:15,15

normal 18:14 102:8

109:16

normally 57:10

North 9:3

notably 80:3

note 5:9 6:9,18 89:10

145:11

noted 108:14

notes 46:12

notice 144:16

noticeable 86:3

noticed 85:10

number 78:21 79:1 83:6

84:13,13,22 86:5

93:10,22 95:22 107:1

115:4 119:8

numbers 82:3 145:17

O

O 3:1 4:1 24:10

objection 45:19

objective 29:3 34:22

44:5 97:19

objectivity 75:9

obstructive 10:20 17:7

17:10

obtained 103:11

obviously 50:22 58:1

87:2 88:10,12 106:16

127:17 129:6,17

139:15

occupation 86:17

occupational 8:2,9,12

9:5,15 10:4,8,12 12:9

17:10 20:16 25:12

27:3,15,22 28:5 29:2

29:13 30:12,14 31:8

31:10 32:4 33:5 48:4

48:5,10,12 51:11 53:2

60:16,17 61:17 73:20

75:22 77:19 86:17

87:13 88:17 89:10

134:11 137:17 138:8

occur 6:15 28:2 34:7

55:15 62:15

occurred 55:8 74:5

occurs 39:10 99:14

145:15

October 145:7

October/November

139:19

OEL 134:8,13 136:4

OELs 134:3,20

office 78:5,16

Officer 4:13

official 2:15 81:19

officially 148:17

officials 5:6

OHQ 21:4,14 22:1,5

23:14,19 24:6,12

137:12

old 17:9 59:12

ombudsman 78:5,7

once 47:8 57:10 67:8

67:11 71:20 94:5

ones 19:11 83:14 85:10

96:21 135:6

onset 29:11 30:13 34:6

51:11 60:16 62:15

onsite 8:22 70:1

open 13:4 14:16 35:1

42:20 76:4

opening 5:3

opens 46:5

operations 4:22

opinion 42:22 90:11

opportunity 86:20

opposed 126:3 139:17

option 26:6

options 127:3

order 44:1 94:8

organ 103:7

organic 131:19 133:1

138:19

organization 146:14

organizations 146:6

original 52:8 98:14 99:4

originally 11:3 93:22

outliers 88:7

Outreach 77:18

outside 11:2,21 12:1,12

12:17 17:22 18:6

overall 15:16,20

overgrew 121:4

overlap 17:3 82:4

overly 117:6

oversight 86:1

overwhelming 37:15

123:12

P

P 4:1

p.m 77:21,21

Pacific 1:11

package 51:2

page 3:2 6:5,6

pages 82:9,22 99:1

118:22

paid 42:1

paper 133:13

papers 118:13

paragraph 55:1 137:19

parenthesis 13:18

63:10

parenthetical 13:8

14:13

part 3:7 10:17 11:3

19:12,15,16,16,18,19

32:7,21 55:12 75:5

76:21 78:9,9 81:4,8

81:15 90:2 100:16,16

101:7 105:6,11,18

115:22 116:14,15

117:17,17 124:2,9

138:22

PARTICIPANT 63:21

78:1

participants 7:22

participating 2:19,20

7:17 74:20 148:15

particular 29:3 70:19

90:6 128:7 132:5

135:19 136:15 138:2

144:22 146:20

particularly 87:19

partly 117:6

parts 78:9 81:15 93:11

117:19

Pasco 77:22

passage 115:11

patch 96:17 97:2,5,9

106:17,20

pathognomonic 107:12

pathologically 100:22

pathology 104:13

patient 35:20 42:19

96:22

patient's 46:14

patients 40:6 48:17

51:7 64:21 65:2

122:13

peak 33:15 35:18 36:11

36:14 37:1 62:2 64:20

65:1 66:8 68:22 69:15

69:16,19 70:5 71:2,6

71:10,15 72:7,12

peer 35:4

PEFR 65:5 68:20 69:2

69:12

people 15:11 16:6,7,17

23:18 24:1 41:12

45:13,17 49:22 67:7

72:10 80:3,4 86:2

87:2 94:3 103:6

107:14 109:15 112:1

112:13 113:1,5

121:10,19,20 122:14

129:1 131:19,22

132:6 135:12 138:6

140:11 144:7 147:18

people's 53:19 145:2

perceive 45:8

perceived 45:1

percent 29:11 37:19

53:5 67:13,13 72:11

123:22,22,22

perceptual 14:21

perfect 71:18 119:13

performed 95:6 101:17

136:11

period 17:12 22:14 34:3

34:4 47:1,6,11 62:12

62:13 98:21 102:12

134:6

periods 115:16 130:18

peripheral 119:14,19

119:20

person 17:20 30:20

34:18,19 45:1,7 51:22

54:17 66:5 85:17

86:13 106:5 121:15

person's 106:10

perspective 122:13

PFT 39:14 95:9
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Neal R. Gross and Co., Inc.

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PFTs 107:10

phone 4:3 7:17 78:22

147:18

phrases 13:17

physical 54:6

physician 8:2,9,12 9:6

10:12 16:11 28:4,8,9

30:16 32:10 39:22

42:8,10,13 50:1,17,17

52:6 55:6 61:4 80:8

85:14 95:8 103:15

105:18

physicians 29:22 31:3

31:5,7,16 40:5 46:11

47:10 48:16 49:7,18

52:14 60:22 75:22

115:14

physics 10:8

physiologic 65:1

piece 97:19 118:3 119:3

pieces 37:9 82:14,20

99:10

place 20:3 22:1,3

places 96:20 107:2

planned 77:6 94:2

plant 9:22

plaques 86:12 88:16

please 6:8 50:14

pleural 86:12 88:16

PM 115:2

pneumoconiosis 82:2

84:20

point 6:11 20:5,9 24:5

40:15 42:7 49:3 52:18

55:12 66:13 79:18

98:6 100:21 106:15

110:21 121:12

pointed 25:19

pointer 94:21

pointing 67:1

points 97:7 98:1 112:16

138:17

policies 27:15,16

policy 27:20 28:18 56:3

73:18 92:21 93:2

140:4

Pope 2:7 8:4,5,5 147:1

147:2,3

population-based

15:16

populations 15:18

portable 69:20

portion 81:2

position 55:2

positive 32:15 33:16

40:8 41:1 61:8 62:3

67:20 68:2 101:8,13

101:19 109:17,18

110:5,7,11,14 113:7

113:13 118:1,3,17

119:15 122:8

possibilities 99:3 127:2

possible 34:10 55:17

62:18 74:3 86:17

90:21 140:13,16

141:19 143:3

post 129:15

post- 103:3

post-1993 100:13 119:5

post-CBD 104:11 129:5

potential 35:21 89:10

93:6 100:5 145:8,8

potentially 17:12 136:6

PowerPoint 27:3 77:3

97:13

practical 41:8

practically 42:4

practice 29:16 30:3

38:22,22 51:9,12

53:11 112:22

pre 129:15

pre- 100:9,13 106:19

pre-1993 95:20

pre-CBD 129:4

pre-existing 51:14 52:1

predictive 110:8,10

118:11,14,21 122:17

123:3

predominantly 36:2

83:8

preexisting 122:20

123:1

prepare 7:1

prepared 6:20 7:9

presence 33:6 61:18

102:9

present 7:18 28:10

72:15 76:20 126:4

128:3 137:5

presentation 27:12,14

59:17

presented 28:3,14

127:16

presiding 1:12

presume 134:5

presumed 99:15

presumption 3:5 11:22

12:2 16:14,20 19:19

20:5 22:19 23:9 49:16

49:19 50:2 77:8 81:10

83:12 91:7,9 93:17

98:11,12,14,15,21

99:1,3,4,20 100:1,2,3

100:4,13 101:5,5,11

101:11 102:7,17

128:7 130:10,12

131:15 132:5 133:22

135:3,10 137:2 139:1

139:5,13

presumptions 20:3

29:1 49:17 57:2,15

115:13 127:11 129:10

pretty 38:15 52:22

73:18 131:18 135:6

146:19

preventative 80:8

previous 28:19 58:13

130:6 135:21

previously 92:8 96:5

primarily 135:15

primary 41:9 42:10

principle 100:1

prior 38:7 47:7 131:1,4

134:5 143:20,20

probabilistically

123:14

probability 123:19

124:1

probable 16:6

probably 9:22 14:21

15:10 24:14 25:5

48:18 98:2 116:2

117:2 120:20 121:17

124:20 131:17 133:20

139:19 140:19

probative 25:21

problem 23:20 70:12

85:3,17 106:3 120:4

121:8 132:4 135:18

136:8

problematic 83:7 145:1

problems 39:6 91:5,21

92:1

procedure 57:12,20,21

58:5 88:22 94:16,18

94:21 114:10 115:3,6

115:22 116:5 127:13

127:15

procedures 122:8

127:8

proceed 81:1 101:19

process 18:14 21:15

25:20 49:19 88:21

90:10 137:22 140:21

141:5 143:8,12,15

147:16

processing 136:14

products 53:13

Professor 9:10,14 10:4

professors 79:19 80:2

program 8:18 9:16

11:11,18 18:1,9 20:7

49:17 50:3 77:3,19

78:4,12 148:12

programs 78:14

project 115:14

proliferation 122:3

promote 58:20

promulgate 59:5

promulgated 124:13

proof 104:14

proposal 12:14

propose 129:16,18

proposing 11:22

Protection 8:17

provide 34:13 50:14

75:11 78:9,12 106:4

provided 49:18

provider 32:19 33:19

42:11 61:11 62:6

providers 29:18

provides 67:2

providing 141:18

148:14

provisions 4:20

public 7:16,21 9:11

10:5 115:16 145:21

146:11,13 147:12,17

148:13

publication 15:21

publications 52:22

publish 142:19

published 7:7 31:19

52:19 133:18

publishing 7:10

pull 49:12

pulmonary 10:20 29:4

29:20 30:2 32:14

33:12 39:6 42:11 62:1

65:10 67:16 71:1,4

85:14 95:6 103:10,14

103:17,20 104:17

107:8

pulmonologist 35:8,19

38:11

pulmonologists 38:14

77:12

purpose 98:18

purposes 122:12

put 20:6 22:22 23:9,18

24:4 25:3 37:2 39:11

48:15 56:12 64:17

70:10,12,16 105:10

110:15 114:22 119:7

130:9 134:14 139:4

putting 23:22 39:13

Q

quality 75:9,12,15

question 11:2 14:9 15:2

15:3 22:7 26:5 42:20

47:12 49:10,15 51:18
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62:22 73:3 84:3 86:8

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106:22 107:4 109:12

109:19 112:5 117:15

120:16 127:1,5,20

135:8 140:6 147:1

questionnaire 12:10

25:12 138:8

questionnaires 82:18

questions 41:4 78:8,18

78:19 81:13 87:4 89:1

93:21 94:1,8 107:19

111:13 139:16 146:22

148:2

quick 27:19

quite 29:10 43:18 59:4

81:5 86:2,7

R

R 4:1

Rachel 57:10

raise 74:13 76:15 84:2

125:20 127:2 146:10

raised 63:13 81:14

146:11

raises 49:11 85:22

range 136:4

rare 36:16 123:15

rarely 46:12

rate 33:15 62:2

rationale 20:1 28:15

30:6 38:7 49:2 64:4,7

68:4,7 70:11,17 72:18

74:1 97:6 111:9,12,13

119:8 123:4 140:8

141:18 142:5

ray 108:22

re-decisions 84:13

reached 6:22 147:9

read 59:3 60:8 61:12,14

73:1 94:10 115:11

133:13

ready 60:6 74:12

real 35:20 46:4 113:5

121:21

reality 51:22

realize 52:19

realizing 43:12

reason 17:2 74:6

reasonable 15:1 17:15

90:20 97:16

reasoning 75:18

reasons 14:21 37:21

119:8

RECA 85:2

recall 130:11

receded 99:7

receive 78:17 146:15

received 58:3 82:8 96:4

96:4

receives 146:5

recognition 31:1 32:11

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recognize 67:7 103:7

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recognizes 100:8

recommend 16:19

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recommendation 13:17

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30:7 32:8,21 43:21

49:3 50:8 55:13 56:3

56:22 57:7 60:10 64:4

70:20 73:1,7,16 74:13

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113:12 114:15,21

124:6,6 125:18

127:17 128:2 136:2

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record 20:7 79:15 88:19

90:12 130:22 141:2

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records 24:8 36:6 47:13

82:12,21 88:15 89:3,9

91:2,20

recreate 54:9

recurrent 74:7

Red 1:11 77:21

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9:13 15:3 16:22 17:1

19:22 31:17 35:7,9

39:17 40:18 46:8,9

51:3,4 54:15 59:22

63:13 64:3,11,14,18

65:7,11,19 66:12 67:6

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68:22 69:6,10,13 70:4

70:22 71:5,9,12,17

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113:4,15,19 114:6

117:5,20 118:12

119:1 122:1 126:10

126:11,13 127:1

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Register 144:17

registration 79:4

regulation 23:7

regulations 5:8 7:5,10

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33:10,12 36:17 41:18

42:10 52:16 60:21

61:21 62:1 63:18 64:2

64:10,17 67:17 71:22

83:8 85:1 89:4 107:5

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remain 144:2

remarkably 46:17

remember 11:1 20:7

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remind 144:14

remove 56:18 97:8

removed 36:21 67:22

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render 90:11

renew 12:6

renewal 143:8,12,15

repeated 69:18 122:10

repeatedly 120:21

repeats 123:5

repetitive 58:13

report 10:17 22:18

25:21 28:8 43:17

76:21 77:7 85:12

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represent 70:19 100:10

representatives 11:6

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requirements 29:2

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requires 6:19 28:7 29:3

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rescinded 55:20

research 8:13 139:4

Resource 78:16

resources 75:11

respiratory 94:9,13,18

95:2,3,12 97:17,20

98:9

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37:14 59:16,17 60:7

76:11 94:1 97:7

111:12 119:7 133:11

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responses 81:12 93:21

146:8

responsible 4:20 5:2

responsive 148:1

responsiveness 33:16

69:7

rest 89:2 116:11

restrooms 6:16

result 121:14,22

resumed 79:15

retesting 120:21

retired 8:9 28:7

retroactive 28:17
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reversibility 32:13 61:7

review 27:19 29:12

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reviewing 36:7 46:9

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revise 61:14 127:3

revised 12:10 25:12

56:9

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revision 61:15

revisions 39:19

revisit 12:16 14:10

revive 74:21

revote 21:21

rewording 112:9,10

rewords 112:12

rewrite 114:14,15 115:7

Rhoads 145:22

Richland 1:12 8:21 78:1

rid 64:19 71:6

risk 134:8

Risks 133:16

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River 22:12

road 139:6

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Rocky 8:7 9:22

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root 18:13

Rosemary 1:21 10:11

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rows 59:8

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S

S 1:20 3:1 4:1

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sake 92:7

sample 75:12

sarcoid 81:10 83:12

91:7 92:3 98:16,21

99:12 102:7 103:8

107:7 123:14,14,16

sarcoidosis 81:22 83:8

91:11 98:10,14,19

100:9 101:21 122:15

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49:21 63:20 64:14

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95:20 96:6,15 98:15

104:5,10 108:8 118:2

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scans 103:18

scenarios 72:9

schedule 142:7 145:4

scheduled 10:13

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scheduling 77:9 142:9

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scientific 1:14 18:10

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106:3

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screening 78:12,13

screwed 124:12

second 30:18 32:7 41:5

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section 129:17

Security 8:16

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116:18 124:11

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85:5,7 131:10 135:16

135:18 137:5,13

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sending 37:7 121:12

sense 70:21 71:12,13

98:5 105:22 124:8

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sensitivity 81:22 105:8

110:7 117:16,18

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sensitization 116:17

118:1

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sensitizer 36:1

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48:6

sensitizing 36:18

sensorineural 130:14

sent 28:21 74:22 75:7

138:20 143:22 144:5

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series 53:4

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serum 121:13

serve 4:18

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services 75:21 78:6

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set 20:2 43:22 115:13

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setting 65:12 66:7

122:5 123:10 124:3

settings 46:11

settle 140:2 142:21,21

143:1

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shift 66:7

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shortness 33:10 45:4

45:13,18 46:7 61:21

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show 69:17 74:15 76:16

93:13 96:3 125:21

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showing 47:16 103:19

shown 36:14 119:12

shows 37:19 105:16

132:10,19 134:13

signal 121:7

significant 32:2 45:19

115:4

significantly 29:1 140:3

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86:11 88:13 89:13

Silver 1:16 9:9,9 19:22

20:1 58:15 59:6,7

115:9,10

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simple 26:4 89:17

115:13 116:7 141:7

simplified 106:14

simplify 70:22

simply 5:21 71:2

112:11 113:12

Simultaneous 89:20

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single 36:17 46:21 53:6

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site 18:22 54:1 55:8

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situation 48:6 51:17

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situations 36:5 91:10

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six 27:10 77:21 111:20

142:6 144:16

skin 96:16 97:1,4,8

103:9,11 106:17,19

slide 11:20 12:19 13:5

27:5,8,11,17 41:5

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Society 31:15 34:13

Sokas 1:21 4:4 10:11

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solely 11:11

solvable 135:18

solve 120:4

solvency 77:7

solvent 132:16 134:17

137:15 138:10

solvent-induced 134:8

solvent-related 130:12

139:2

solvents 128:10 130:5

130:16 131:7,14,19

132:12,14,15,18,22

133:1 135:2,5,13

136:4 137:4,5,7,8,18

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solves 137:13

somebody 41:14,17

66:2 73:11 74:3 90:5

90:6 130:20

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somewhat 74:7 83:22

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77:2 80:14 109:1,21

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88:10 90:17 98:2,4,6

99:17 105:21 106:14

112:20 118:20 119:6

120:19 122:4 123:4,8

123:9

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sources 24:9 141:18

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speak 29:22 78:20

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specialist 41:21,22

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specialists 40:5 53:2

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127:14 129:2,21

131:13 132:13 135:10

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specify 70:19

spectrum 31:10

spend 26:7 91:19

106:16

spending 96:22

spent 95:18

spirometry 37:18,18

65:14 69:21,21

spoke 120:10

stand 14:1

standard 31:22 32:6

102:12 109:18 110:6

113:8 118:20,22

standards 75:17 118:10

standpoint 41:9

start 16:3 67:10 76:21

97:22 99:16 122:7

143:12 144:18

started 79:18 80:13

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state 9:12 110:4

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statute 115:11,19 129:4

statutory 129:1,9

stay 5:11 13:14

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Steel 8:6

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steps 105:7

steroids 102:16 106:11

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stethoscope 45:2,16

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sticking 31:7

stop 121:12

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straightforward 116:7

streamline 136:14

stress 84:17

strictly 79:3

strictness 88:1

stringent 56:18

strongest 55:5

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53:4 72:6,7 87:21

132:11,13,14,17

133:7,8 134:18,22

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subcommittee 10:17

11:7 59:14 75:2,5

81:4 141:21 142:12

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submitted 6:7

subpart 124:9,9,16,16

substance 32:2 53:7

Substances 1:3 4:12

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substitute 104:11

successfully 72:12

sufficient 32:11 61:5

suggest 117:13

suggesting 13:11

suggestion 18:3 25:11

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suggests 139:1

summary 81:9

supplement 115:1

support 35:3

supported 65:20

supposed 21:4 89:5

surveillance 122:5,12

123:7

suspicion 15:7

symptom 44:22

symptoms 33:10 34:21

34:22 42:9 44:3,4,18

44:19,21 45:5,8,20

46:1,14,15 52:6 61:21

63:1,2 70:12,15,19

97:18,19 123:17

system 86:19

systematic 133:14

systems 51:18

T

T 3:1,1

tabled 11:2

tailor 50:19

taken 123:8

takes 112:11

talk 27:14 135:9,9

talked 11:5 88:3 141:21

talking 24:17 26:15

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talks 53:8

target 138:5

task 26:2 77:18 138:2

tasks 136:3,11,12 138:9

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Team 8:6

technical 120:20

technician 132:1,3

telephone 2:19 128:5

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telephonic 111:15,15

140:13 141:14

tell 24:13 38:8 51:13

tells 45:15

temperature 53:17

temporal 34:20 44:8

temporally 61:22

temporarily 33:12

63:18

ten 79:12 131:1,3,12

137:14,20 138:2,7,10

138:11,11,14 139:7

ten-year 136:18,22

tends 53:11 67:7,8

Tennessee 9:11

term 15:18 17:5,9 30:8

43:8 51:15,16 52:15

60:12 143:11

terminology 52:13

terms 31:14 47:16

65:15 84:16 116:12

123:13 132:9 141:17

144:13 145:1,6

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test 32:14,15,16 33:17

37:5,22 39:12 40:16

61:8 62:4 67:20 68:2

96:16,17 97:2 101:16

102:15 106:20 109:18

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121:1,9 122:8,11,17

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69:18 96:16 106:20

110:9,9 113:2 122:10

text 92:12,17 117:12

textbooks 51:10

thank 4:15 7:15 54:7

56:6,7 58:11 71:18

79:13 81:16,20 94:17

126:21 127:22 130:1

139:14 147:10,19,22

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Thanks 26:21

theoretically 140:15

things 29:7 35:16 46:18

46:21 47:8 53:10 96:2

99:17 112:12 116:3

121:5 130:8

third 32:20 55:12

Thoracic 31:15 34:13

thought 17:13 25:8

67:6 84:6 87:18 97:16

112:7 115:12

thoughts 114:20

thousand 82:9 123:16

thousands 82:22

three 15:7 16:5,8 18:16

30:5 36:21,22 37:3,3

37:7 38:16 49:4 61:12

83:19 110:4 113:7

three-month 22:14

three-year 47:5

threshold 133:4,4

throw 63:5

THURSDAY 1:7

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tightness 45:4 63:5

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times 5:9,15 66:7 97:14

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timing 145:5

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tissue 103:11

title 132:2

titles 12:4 137:1,10

today 7:5,20 10:13 14:2

38:12 77:20 127:11

today's 6:4 7:3

told 53:21

toll 78:21 79:1

toluene 134:1,15 135:1

137:11

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topic 5:22 49:11 54:20

109:11

Topics 3:12

Tori 8:8

total 16:12,18 19:2

tour 145:14

town 77:20

toxic 1:3 4:11 32:2

track 146:1

Trades 8:20

train 95:15

training 8:14 51:1 58:22

114:11

transcripts 7:11

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treat 17:8

treated 96:7,9,10

treating 16:10 28:4,9

32:10 33:19 39:22

42:12 48:16 50:17

55:6 61:4 62:6

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treatments 59:18

trial 29:19

tricky 21:1

tried 36:9 64:21 72:7

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trigger 43:22 55:9

triggered 55:14

triggering 34:5 62:14

triggers 52:10

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true 112:15

try 5:10 120:22

trying 23:21 24:13

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56:4,7,15 58:20 59:5

65:3 66:17 97:1 120:4

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Turner 2:10 9:21,21

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tweaked 116:21

two 6:12 13:17 14:14

15:7 18:16 22:15 30:5

30:11 34:19 37:3,6

38:15 41:4 47:8 53:21

61:2 63:2 70:12 72:12

77:20,20 80:1 82:5

83:18 84:9 93:13 94:4

96:2 110:9,12 113:7

113:10,12 116:6,6

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type 30:18 38:7 46:21

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U.S 36:4

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104:17 106:1 107:4

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understanding 12:16

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unfortunately 37:9,12

40:19 46:12 120:1

unifying 30:8 60:12

uninterpretable 120:22

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uninterpreted 120:11

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uninterpreteds 120:14

unique 107:11

United 1:1 8:5 37:4,16

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University 8:3 9:3,7,12

10:5

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108:21

update 81:4

updated 120:3 147:4

uranium 85:1

url 6:1

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usage 31:14 33:11 44:4

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71:21

use 6:16 17:15 21:14

30:8 34:21 35:4 59:19

60:11 75:17 85:18

104:3 118:21

useful 145:12

user-friendly 86:19

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usually 46:13 103:8

121:3 133:9

utility 122:17

utilization 63:13,17

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V

valid 58:9 106:4

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validity 18:10

value 92:3 110:8,10

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values 118:11 123:3

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variability 59:16

variation 29:21

variations 24:11

varies 29:17

various 33:13 40:9

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veracity 43:16

verbatim 7:10

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Veterans 8:10

VGDF 15:20 17:21

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VICTORIA 1:21

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visits 47:2,10

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38:5,6 43:2,3 44:7,10

44:14 54:19,20 55:19

57:9 77:15 80:5 81:19

114:18,21 125:10,11

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voluntary 79:4

vote 11:20 12:20 20:14

60:6 74:12 76:7,20

92:7 93:18 110:22

111:2 114:3 117:13

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W

wait 79:21 115:6 128:8

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wasn't 12:6 15:21 35:11

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94:2 95:19

Wednesday 143:20,21

week 28:22

week's 6:6

weekly 47:7

weeks 36:21,22 37:3,7

72:12 111:20 141:4

142:6 144:16,19

145:3

weight 39:14

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10:22 11:1 13:1,3,11

13:20 14:6,17 15:14

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21:17 22:9 24:16,19

25:3,6,15,18 26:14,21

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105:1 109:13 110:20

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118:18 120:12,15,19

130:2,3 131:1,5

139:15 141:17,20

142:3,13,15,22 143:2

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63:8 70:8

Whitley 2:9 8:15,15

120:8,9,13,17 124:19

124:20 125:2

wish 21:13

women 22:10

wonder 59:10

wondering 70:7 73:6,13

73:13 112:13 118:8

word 40:1

wording 54:22 71:1

92:1 93:7,14 95:5,11

96:5 97:12,16 98:4,12

99:8,11 100:7 101:14

102:1 104:16 107:1,2

107:13,19,21 108:11

112:17 117:12 120:1

120:2 123:8 127:14

words 13:16 22:5 49:21

96:6

work 4:16 5:1,5 8:12,17

11:2,11 12:13,17 13:9

13:13,19 14:3,5,14,22

15:1,9 17:22 18:2,5

19:1 21:15 25:20 28:6

33:9,12 34:16 36:11

36:21,22 37:2,6,8

41:18 47:12,16 51:20

51:20 52:15,16 53:20

54:18 55:8 61:20 62:1

63:18 65:15,16 67:17

68:16,16 69:22 72:10

73:12 74:5 75:10

131:20,22 132:6

136:3,13 137:21,22

138:2 146:1 147:11

148:11

work- 29:7 30:18 31:1

36:16 42:9 47:20

52:15 58:16 59:1

60:17,20

work-exacerbated

30:19 31:11 32:5 33:5

34:17 48:2,8,20 51:5

51:12 61:17

work-related 17:7 29:9

30:1,9,10 31:6,9 33:2

33:4,22 34:6,11,14,16

35:20,21 36:15 40:12

40:22 41:13,14 43:4

43:14 44:2,6 46:10

49:6 50:13 51:8,15

52:20 55:14 58:17

59:1 60:10,12,15

61:16 62:9,15,20

work-relatedness

28:15 43:11,17

work/away 65:16

worked 9:22 18:22

22:11 41:10 84:5

130:16 135:12

worker 1:3 4:12 5:22

8:7,16,17,22 9:18,19

25:13 30:14 36:20

43:12 75:21 78:11

84:4 86:10 89:13

138:14

workers 8:6 9:20 16:1

18:4 25:20 28:7 36:4

38:4,8 43:7 80:5 85:1

86:19 115:5 122:6,12

123:7 145:18

working 35:11 54:9

55:8 77:4 123:11

135:13

workplace 29:14 30:17

30:22 59:16 60:19

works 23:7

worry 82:6

worse 52:1

worsened 30:22 60:19

worsening 33:7 58:19

61:19

worthwhile 58:22

wouldn't 19:15 66:16

102:20 114:4 139:12

142:10

write 93:7

writing 50:2

written 11:15 16:13

21:2 27:15,19 89:13

wrong 38:10 73:8

108:17 109:1 115:21

wrote 29:12 111:12

X

X 50:14

x- 108:21

x-ray 86:13 88:15

107:10 108:1,4,6

xylene 134:1,10,15,22

137:11

Y

Y 50:14

Yale 9:14,15 40:2

year 21:4 29:13 130:21

years 8:7,22 10:1 12:3

14:22 15:6,7,7 16:2,2

17:16,21 18:12,17,22

21:18 22:11,15,20

23:1 46:11 47:8 52:7

64:22 65:2 83:16,19

84:6,13,18 131:1,4,13

133:12 136:22 137:14

137:20 138:2,7,10,11

138:11,14,20 139:2,7

139:10,12

yester 53:21

yesterday 4:16 5:13

10:10,16 12:22 13:16

25:9,11 27:6 59:8

75:1 100:1 110:3

yesterday's 13:22

York 8:4 9:6,8

Z

Z 1:16 50:14

0

0.1 123:21

1

10 3:5 67:13 72:11

10-year 130:18

10,000 123:16,18

10:00 79:13

10:55 148:19

1000 128:20

111 3:13

12 37:19 126:5

13 126:5

139 3:16

14 74:18,19 76:19

143 3:20

148 3:19

15 37:19

16-01 54:22 56:17,17

16-02 18:20 56:16 57:1

1960s 36:19

1970s 36:20

1990 10:2 131:2,4,13

134:4

1993 102:6 103:4

2

2 90:2 93:11 94:16,17

94:20 99:9,22 101:7

114:15 128:20

20 1:8 7:12 67:13 72:11

2002 9:19

2008 31:16 98:14

2010 133:19

2011 31:15 34:14

2015 28:18

2017 1:8 143:8,13

2018 143:11

25 8:7 29:11 64:22 65:2

79:13

26 9:22

2B 55:1

3

30 85:11,12

34 8:22

4

4 3:4

5

50 53:5 75:12

6

60 81:8 85:11

7

7 3:4

77 3:8

79 3:10

8

8:00 1:11

8:05 4:2

80 53:5

802 1:11

877-662-8363 79:2,2

9

9:24 79:15

9:30 80:20

9:35 79:16

90 7:4

90th 7:7
NEAL R. GROSS

COURT REPORTERS AND TRANSCRIBERS 

1323 RHODE ISLAND AVE., N.W. 

(202) 234-4433 WASHINGTON, D.C. 20005-3701 www.nealrgross.com 

C E R T I F I C A T E

This is to certify that the foregoing transcript 

In the matter of: 

Before: 

Date: 

Place: 

was duly recorded and accurately transcribed under 

my direction; further, that said transcript is a 

true and accurate record of the proceedings. 

 

 ----------------------- Court Reporter 

164

Advisory Board on Toxic

Substances and Worker Health

US DOL

04-20-17

Richland, Washington