UNITED STATES DEPARTMENT OF LABOR

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ADVISORY BOARD ON TOXIC SUBSTANCES AND WORKER

HEALTH

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COMBINED MEETING OF THE SUBCOMMITTEE ON MEDICAL ADVICE RE: WEIGHING

MEDICAL EVIDENCE (AREA#2) AND THE SUBCOMMITTEE ON IH & CMC AND THEIR

REPORTS (AREA #4)

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SUMMARY MINUTES

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TUESDAY,

JUNE 27, 2017

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The Advisory Board met telephonically at 11:00 a.m. Eastern

Time, Victoria A. Cassano and Rosemary K. Sokas, Co-Chairs,

presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

MARK GRIFFON

KENNETH Z. SILVER

GEORGE FRIEDMAN-JIMENEZ

LESLIE I. BODEN

MEDICAL COMMUNITY:

STEVEN MARKOWITZ

VICTORIA A. CASSANO, Co-Chair

ROSEMARY K. SOKAS, Co-Chair

CLAIMANT COMMUNITY:

DURONDA M. POPE

KIRK D. DOMINA

GARRY M. WHITLEY

FAYE VLIEGER
DESIGNATED FEDERAL OFFICIAL:

CARRIE RHOADS
Call to order and roll call

Ms. Rhoads, the DFO for the committee, called the meeting to order at

11:10 am. The board members introduced themselves.

Update on board recommendations from DOL

Ms. Rhoads gave the update. The status of the recommendations is that

they are being reviewed by the Secretary. The second set of

recommendations is being worked on by DOL staff.

Recommendations from the meeting in Oak Ridge

The first recommendation was to rescind circular 15-06 (the post-1995

occupational toxin exposure guidance) and that recommendation was

achieved by circular 17-04. The second recommendation from October

was to ensure that the disease exposure language from the IOM report

was included in the SEM. The third recommendation was that former DOE

workers be hired to administer the occupational history

questionnaire. The fourth recommendation was to establish a process

to allow the IHs (industrial hygienists) to interview the claimants

directly. The fifth recommendation was to post redacted

teleconference notes online. The sixth recommendation was to explore

the feasibility of having new case files made accessible to the

claimant electronically. The seventh was that the DOL reorganize

occupational physicians into an office comparable in structure to the

office for attorneys to support multiple agencies. The eighth

recommendation was that the program make the entire case file

available so that industrial hygienists and contract medical

consultants (CMCs) can see everything in the file, and support the

claims examiners (CEs) in mapping the files.

Recommendations from the meeting in Richland

The first recommendation was a new set of presumptions for asbestosrelated diseases. The second recommendation was a presumption for

work-related asthma. The third recommendation was presumptions for

chronic asbestos pulmonary disease, such that it replace circular 16-

02 with an alternative. The fourth recommendation was revisions to

the occupational history questionnaire (OHQ): that for each exposure,

that the claimants be asked to describe how they were exposed by

describing their tasks and frequency; that the list of hazards should

include several specific things related to occupational diseases; to

add the BTMed list of tasks to the OHQ; that the specific questions

about vapor, gas, dust and fumes be added to the occupational history

questionnaire as well about exposure frequency and description of

tasks; and that the new occupational history questionnaire be tested.

The fifth recommendation was that the program enhance its scientific

and technical capabilities.
The sixth recommendation was that two borderline beryllium

lymphocytic proliferation tests (BeLPT) be considered equal to one

positive test, for adjudication purposes under Parts B and E. The

seventh recommendation is that DOL provide the board with a quality

assessment of 50 CMC evaluations in claim denials. The DOL is working

on responses and then, once they have responses, the recommendations

will be submitted to the Secretary.

Report from Seattle visit

Co-Chair Cassano said that they had 20 cases to go through in four or

five hours. The optical imaging system used by the office worked very

well and it was easier than thumbing through a big paper file. CoChair Cassano walked through the cases. There needs to be an

independent audit of randomly selected claims of the entire claims

progression. The IH and CMC need access to the entire claim file. The

SEM is not up to date as far as the medical literature goes. The IH

must have info on job tasks and exposures. The CMC must have access

to exposure information and medical reports to determine the causal

aggravation or contributory effects of the exposure. The committees

need to keep discussions around presumptions in the back of their

minds.

Member Silver suggested that the committees take a look at the DOL's

use of the word “significant.” There needs to be a consistent

interpretation of the word “significant.”

Member Vlieger's takeaway from the Seattle visit was that there is no

audit of the CMCs' performance and no confidence that any decisions

are being made in light of current science. One of her concerns is

that chemicals are being looked at in their pure states not their

synergistic effects.

Co-Chair Sokas said that it is critical that the CMC and the IH have

access to the entire file. There needs to be clarification on the

idea of “contribution.” The problem from the beginning has been a

communication failure between the program itself and the IH and CMC

consultants. Co-Chairs Sokas and Cassano will be having a discussion

with the agency's medical director and the agency IH to explore

communication.

Potential merger of working groups

Co-Chair Sokas reminded everyone what the mission of the committees

is. It would be useful to have a working group that had more than one

IH on it. Member Boden said this is a good idea to think about.

Member Markowitz said that a claims examiner examines more than just

the medical evidence. Merging the groups sounded like a fine idea to
Member Markowitz.

Member Vlieger had concerns about the time to review all of the

materials with such a large group. Members might be spread too thin.

Member Silver said that it might be a good idea to take the

presumptions that have been recommended and see how they would have

helped move certain cases forward. Member Markowitz said that this

may not be all that practical and the presumptions require that

different kinds of evidence need to be collected.

Co-Chair Sokas said that the committees need to come up with a

proposal for the full board regarding merging the work groups.

Other items 

Member Markowitz said that there has been little science on

synergistic mixtures and their effects on exposure. The board needs

to explore this issue of synergistic effects more closely. Member

Friedman-Jimenez said that there isn't enough data to separate out

what is happening with multiple chemicals. Maybe the assumption needs

to be an “additive effect or greater” unless there is data to show

that the effect is antagonistic. 

Adjournment

Co-Chair Cassano closed the meeting at 12:25 p.m.

I hereby certify that, to the best of my knowledge, the foregoing

minutes are an accurate summary of the meeting.

Submitted by:

10/12.17

______________________________(date)

Rosemary K. Sokas, MD, MOH, M.Sc

Chair, Subcommittee on IH & CMC and Their Reports

______________________________

Victoria A. Cassano, MD, MPHIL, MPH. FACPM, FACOEM

Chair, Subcommittee on Medical Advice re: Weighing Medical Evidence
Member Markowitz.

Member Vlieger had concerns about the time to review all of the

materials with such a large group. Members might be spread too thin.

Member Silver said that it might be a good idea to take the

presumptions that have been recommended and see how they would have

helped move certain cases forward. Member Markowitz said that this

may not be all that practical and the presumptions require that

different kinds of evidence need to be collected.

Co-Chair Sokas said that the committees need to come up with a

proposal for the full board regarding merging the work groups.

Other items 

Member Markowitz said that there has been little science on

synergistic mixtures and their effects on exposure. The board needs

to explore this issue of synergistic effects more closely. Member

Friedman-Jimenez said that there isn't enough data to separate out

what is happening with multiple chemicals. Maybe the assumption needs

to be an “additive effect or greater” unless there is data to show

that the effect is antagonistic. 

Adjournment

Co-Chair Cassano closed the meeting at 12:25 p.m.

I hereby certify that, to the best of my knowledge, the foregoing

minutes are an accurate summary of the meeting.

Submitted by:

______________________________

Rosemary K. Sokas, MD, MOH, M.Sc

Chair, Subcommittee on IH & CMC and Their Reports

____________________________

Victoria A. Cassano, MD, MPHIL, MPH. FACPM, FACOEM

Chair, Subcommittee on Medical Advice re: Weighing Medical Evidence