and Technical Capacity in EEOICP The Board recommends that the DEEOICP enhance its scientific and technical capabilities to support the development of program policies and procedures to enhance decisionmaking on individual claims and to inform its assessment of the merit of the work of i ID: 930702
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Slide1
Recommendation Science and Technical Capacity in EEOICP
The Board recommends that the DEEOICP enhance its scientific and technical capabilities to support the development of program policies and procedures, to enhance decision-making on individual claims, and to inform its assessment of the merit of the work of its consulting physicians and industrial hygienists.
Slide2Rationale
The Institute of Medicine’s Review of the DOL Site Exposure Matrices (SEM) in 2013 made numerous recommendations to improve the SEM. These include 1) making sure that the SEM incorporate readily available supplemental data sources into the SEM to provide a more complete picture of known exposure-disease links, and 2) forming an expert advisory panel to establish explicit causal criteria for use by the EEOICP, design and implement a method for reviewing possible exposure-disease links, and identify and peer review new exposure-disease links for use in the SEM.
Slide3Rationale
The Board notes that the EEOICP has ended its contract with the National Library of Medicine for the continued updating of the
Haz
-Map database that is integral to
the SEM
.
Slide4Rationale
The Board has been asked by EEOICP to provide input into numerous possible exposure-disease links. While the Board will assist in this request to the extent possible, it is noted that the Board members have full-time positions in addition to serving on the Board and has, at present, as a Board, no scientific staff or contracted resources to address this request. Moreover, evaluating exposure-disease links is an ongoing task for which the EEOICP needs permanent capacity to complete.
Slide5Rationale
The
Board has observed that numerous current EEOICP policies involving important diseases and exposure-disease links, including chronic obstructive lung disease, asbestos-related diseases, asthma, and others, are not based fully on state-of-the-art scientific knowledge.
The Board is willing to assist the Department of Labor
in implementing
this recommendation.
Slide6Use of Presumptions in EEOICP
Presumptions: attributes
Presumptions in EEOICPA, 2001
Asbestos-related diseases
Asthma
Steven Markowitz MD, DrPH, April 19, 2017
Slide7Presumptions
Fairness
Consistency
Timeliness
Efficiency
Error threshold
Positive vs. negative presumptions
Slide8EEOICPAExposure presumptions in Act
1. Special exposure cohort:
>
250 days work in GDP before
2/1/92 in a job where dosimetry monitoring was
performed or in comparable job
2. Silica exposure: “was present
>
250 days during mining
of tunnels” at DOE facility in NV or AK
Slide9Presumption elements
Exposure:
Duration
Job title (proxy for intensity, frequency, task)
Calendar years
Latency
Disease: diagnostic criteria
Slide10Exposure Presumptions, Part B in EEOICPA, 2000
Exposure criteria
Cancer
Silica
Comments
Duration
>
250 days
>
250 days
NTS, Amchitka
Job title
If dosimetry was performed or comparable job
“present during mining”
Calender
years
Before 2/92
When mining was active
Latency
-
-
Slide11Asbestos
EEOICP
Procedures Manual,
Chapter 2:
1000
0-700
, Exhibit 3 (added post-Circ. 15-05)
EEOICPA
Bulletin No.
13-02
EEOICPA Circular No. 15-
05
Slide12Asbestos-related diseases (ARD)
A
sbestosis
Asbestos-related pleural disease
Lung cancer
Mesothelioma (chest, abdomen)
Cancer of larynx
Cancer of ovary
COPD
EEOICPA CIRCULAR NO.15- 05
Slide13Asbestos
Exposure:
“
Assessing
asbestosis
claims:
DEEOIC
accepts that
asbestos
was a common toxic substance
that existed throughout
all DOE facilities. While asbestos did exist at DOE facilities, the nature of an employee’s exposure would have varied based on different factors such as the period that the employee worked, the type of work performed, and the location of employment
.”
Disease: focuses on medical criteria
EEOICP Procedures Manual, Chapter 2
Slide14Asbestos and Ovarian Cancer
Exposure presumption:
250 days of significant asbestos exposure
(worked in a job title in List A)
prior to 1986, and
20 years latency period from initial DOE
exposure to asbestos
Or diagnosis of asbestosis or mesothelioma
EEOICPA
Bulletin No. 13-02
Slide15Significant Asbestos Exposure: Associated Labor Categories and Job Tasks (ATSDR 2014)
Automotive mechanic; Vehicle mechanic; Vehicle maintenance mechanic
Boilermaker
Carpenter;
Dry
waller
; Plasterer
Demolition technician; Laborer
Electrical mechanic; Electrician; Floor covering worker
Furnace & saw operator; Furnace builder; Furnace operator; Furnace puller; Furnace technician; Furnace tender; Furnace unloader
Glazier; Glass installer; Glazer
Grinder operator; Mason (concrete grinding); Tool grinder; Maintenance mechanic (general grinding); Welder (general grinding); Machinist (machine grinding)
Insulation worker; Insulation trade worker; Insulator
Ironworker; Ironworker-rigger
Maintenance mechanic; Electrician; Insulator;
Mason; Brick & tile mason; Concrete and terrazzo worker; Bricklayer,
Tilesetter
Millwright
Heavy equipment operator; Operating Engineer
Painter
Pipefitter, Plumber steamfitter; Plumber/pipefitter; Plumbing & pipefitting mechanic; Plumbing technician, Steamfitter
Roofer
Sheet metal mechanic; Sheet metal fabricator/installer
Welder; Welder burner; Welder mechanic
Slide16Asbestosis
Exposure presumption:
>
250 days of asbestos exposure
10 years latency period from initial DOE
employment
EEOICP Procedures Manual, Chapter 2
0-700, Exhibit 3 (added post-Circ. 15-05)
Slide17Ovarian Cancer and Asbestosis
Claims that do not meet exposure
presumption criteria are reviewed by CE and,
when needed, referred for industrial hygiene
review.
For claims with more limited evidence of asbestos exposure, refer for medical opinion.
EEOICPA Bulletin No.
13-02
EEOICPA Procedure Manual,
Ch
2-0700
Slide18Exposure Presumptions, Asbestos
Exposure criteria
Cancer of the Ovary (2013)
Asbestosis (2015 or 2016)
COPD
(2016)
Duration
250 days
>
250 days
20 years
Job title
List A
Not specified
(?List A)
List A*
Calender
years
Before 1986
-
Prior to 1980
Latency
Min. 20 years
Min. 10 years
*or IH rationale
Slide19EEOICPA CIRCULAR NO.15- 05 (December 17, 2014)
SUBJECT
: Occupational Exposure
Guidance
Relating to
Asbestos
Slide20Asbestos-related diseases (ARD) A
sbestosis
Asbestos-related pleural disease
Lung cancer
Mesothelioma (chest, abdomen)
Cancer of larynx
Cancer of ovary
COPD
EEOICPA CIRCULAR NO.15- 05
Slide21For DOE worker with ARD,
Post-1986 DOE work, assume potential exposure to asbestos but at levels below accepted standards
However, for 19 occupations on List A, who have potential for greater asbestos exposure between 1986 and 1995, it is accepted that they were “potentially exposed” to asbestos but ”likely” at “low levels.”
EEOICPA CIRCULAR NO.15- 05
Slide22Significant Asbestos Exposure: Associated Labor Categories and Job Tasks (ATSDR 2014)
Automotive mechanic; Vehicle mechanic; Vehicle maintenance mechanic
Boilermaker
Carpenter;
Dry
waller
; Plasterer
Demolition technician; Laborer
Electrical mechanic; Electrician; Floor covering worker
Furnace & saw operator; Furnace builder; Furnace operator; Furnace puller; Furnace technician; Furnace tender; Furnace unloader
Glazier; Glass installer; Glazer
Grinder operator; Mason (concrete grinding); Tool grinder; Maintenance mechanic (general grinding); Welder (general grinding); Machinist (machine grinding)
Insulation worker; Insulation trade worker; Insulator
Ironworker; Ironworker-rigger
Maintenance mechanic; Electrician; Insulator;
Mason; Brick & tile mason; Concrete and terrazzo worker; Bricklayer,
Tilesetter
Millwright
Heavy equipment operator; Operating Engineer
Painter
Pipefitter, Plumber steamfitter; Plumber/pipefitter; Plumbing & pipefitting mechanic; Plumbing technician, Steamfitter
Roofer
Sheet metal mechanic; Sheet metal fabricator/installer
Welder; Welder burner; Welder mechanic
Slide23For CE to accept level of exposure above low level, there must be “definitive and compelling evidence” to show that post-1986 DOE work had “consistent, unprotected contact with asbestos or ACM”
Evidence includes: IH monitoring, incident reports, documented abatement breaches, testimony or affidavits, or position descriptions.
EEOICPA CIRCULAR NO.15- 05
Slide24If evidence is suggestive of exposure “above the guidelines,” then CE contacts IH regarding industrial hygiene referral.
EEOICPA CIRCULAR NO.15- 05
Slide25Final Paragraph:“Any findings of exposure, including infrequent, incidental exposure, require review of a physician to opine on the possibility of causation. This is necessary as even minimal exposure to some toxins may have a significant “aggravating or contributing” relationship to the diagnosed illness
.”
EEOICPA CIRCULAR NO.15- 05
Slide26Summary
1. Elevated exposure =
>
250 days work on List A
prior to 1986
2. Post-1986, assume asbestos exposure was below
accepted standard, except for List A workers
EEOICPA CIRCULAR NO.15- 05
Slide27Summary
3. For List A workers, 1986-1995 work, assume
potential asbestos
exposure
“likely” but at low
levels.
4. To show greater than low level asbestos exposure
in post-1986
DOE work
, need “definitive
and
compelling
evidence” to show that
had
“consistent,
unprotected
contact with asbestos or ACM
”
EEOICPA CIRCULAR NO.15- 05
Slide28Summary
5. If evidence of #4, screening referral to industrial
hygienist
.
6
. Any finding of exposure requires physician
review.
EEOICPA CIRCULAR NO.15- 05
Slide29Issues
1. Pre-1986 presumptions?
2. List A work between 1986 and 1995: “likely
low exposure” is not evidence-based.
3. Designation of 1986-1995 List A work as
involving “likely low” exposure does not
facilitate decision-making.
EEOICPA CIRCULAR NO.15- 05
Slide30Issues
4. CE has to judge whether submitted evidence
meets a vague threshold for IH referral:
“
consistent, unprotected contact
with asbestos or
ACM
”
5. Exposure-based CE decision-making is
contradicted by stated basis for physician
review.
EEOICPA CIRCULAR NO.15- 05
Slide31Possible remedies for claims of ARDs
1
. Expand List A
2. Modify presumption of low exposure post-1986
3. Pick calendar year as cutoff that has a
safety margin.
4
.
Consider including
minimum exposure
duration
and latency
in
presumptions for all ARD’s
.
EEOICPA CIRCULAR NO.15- 05
Slide32Possible remedies for claims of ARDs
5.
For all
claims that do not meet presumption
criteria,
have
IH and/or CMC review
and
decide on significance of exposure.
EEOICPA CIRCULAR NO.15- 05
Slide331. Asbestos-related disease (ARD) is common at DOE.
2. Asbestos-related scarring:
12% of >73,000 DOE workers in FWP
Up to 1/4 to 1/3 of DOE production and construction workers.
3. Asbestos was widely used in DOE complex
4. Maintenance and construction workers have well-
recognized risk of ARDs.
5. Modest amount of asbestos exposure
can cause ARDs
6. General time trend of asbestos use
is known.
Rationale for Recommendations
Slide34Asbestos-related Diseases Recommendation
1. All
DOE workers who worked as a maintenance or construction worker at a DOE site for 250 days or more prior to January 1, 2005 and who are diagnosed 15 years or more after the
initiation
of such work with 1 of 5 asbestos-associated conditions will be presumed to have had sufficient asbestos exposure that it was at least as likely as not that asbestos exposure was a significant factor in aggravating, contributing to, or causing such asbestos-associated conditions. The five asbestos-associated conditions are
asbestosis, asbestos-related pleural disease, lung cancer, and cancer of ovary and larynx.
Slide352. All DOE workers who worked as a maintenance or construction worker at a DOE site for 30 days or more prior to January 1, 2005 and who are diagnosed 15 years or more after the onset of such work with
malignant mesothelioma
of any bodily site will be presumed to have had sufficient asbestos exposure that it was at least as likely as not that asbestos exposure was a significant factor in aggravating, contributing to or causing the malignant mesothelioma.
Asbestos-related Diseases
Recommendation
Slide363. All claims for one of the six asbestos-associated conditions named above that do not meet the exposure criteria described in items #1 and #2 above will be referred to an industrial hygienist for exposure assessment and to a CMC for evaluation of medical documentation and causation. These six conditions are
asbestosis, asbestos-related pleural disease, malignant mesothelioma, lung cancer, and cancer of ovary and larynx
.
Asbestos-related Diseases
Recommendation
Slide374. Chronic obstructive pulmonary disease may
have
a contribution from asbestos exposure.
However
, claims for this disease should be
evaluated
as part of a broader set of
presumptions
for chronic obstructive pulmonary
disease
.
Asbestos-related Diseases
Recommendation
Slide38Exposure criteria
Asbestos-specific
Diseases
Mesothelioma
Asbestos-specific diseases
Asbestosis
,
Asbestos-related pleural disease
Other Asbestos-related
Cancers
Lung cancer,
Cancer of ovary
and larynx
Duration
>
30 days
>
250 days
>
250 days
Job titles
Maintenance
Construction
Maintenance
Construction
Maintenance
Construction
Calendar years
Pre-2005
Pre-2005
Pre-2005
Latency
(minimum)
15 years
15 years
15 years
Slide39EEOICP Procedure Manual
Asthma
Exhibit 1: Matrix for Confirming Sufficient Evidence of Non-Cancerous Covered Illnesses
Slide40EEOICPA BULLETIN NO: 16-01 (Oct 2015)
Asthma
If medical evidence of “occupational
asthma,” no need for exposure assessment
or reference to SEM.
2. OA claims filed after DOE work ends
require well-supported report by MD.
If not, referral to CMC after CE collects
exposure information.
Slide41EEOICPA BULLETIN NO: 16-01 (Oct 2015)
Asthma
3. For asthma claims w/o work-related
rationale, CE develops claim and consults
CMC.
4
.
Adoption of this policy in 2015 required
review of claims previously denied on the
basis of causation.
Slide421. WRA is common, causing up to 25% of adult asthma
(
Tarlo
2008)
2.
Occupational asthma
is known to be caused by > 400 workplace
agents
(Friedman-Jimenez 2015)
3. Basis for asthma diagnosis varies considerably among health
care providers.
4. WRA is frequently diagnosed without PFT confirmation.
Work-Related Asthma
(WRA) Rationale
Slide43Work-Related Asthma - Recommendation
DOL should
use
the generally
accepted unifying term, work-related asthma (
WRA)
for
claims
evaluation and decision-making. Work-related
asthma
includes:
a)
Occupational
asthma (OA), or new onset asthma
that
is initiated by an occupational agent, and
b
)
Work-exacerbated
asthma (WEA), which is
established
asthma that is worsened by workplace
exposures
The
recognition of both forms of work-related asthma should be communicated to claimants, their physicians and consulting IH’s and CMC’s.
Slide44Work-Related Asthma - Rationale
This definition reflects the recommended usage of the terms, according to the American Thoracic Society and the American College of Chest Physicians (
Tarlo
2008;
Henneberger
2011).
This inclusive and well-delineated definition
is consistent with the standard of causation in EEOICPA:
“at
least as likely as not that exposure to a toxic substance at a Department of Energy facility was a significant factor in aggravating, contributing to, or causing the illness
.”
Slide45Work-Related Asthma - Recommendation
2.
Medical criteria for the diagnosis of asthma
The diagnosis of asthma by a treating or evaluating
physician
should be sufficient for the recognition that the
claimant
has asthma. Bronchodilator reversibility of FEV
1
and/or
a positive methacholine challenge test may be
helpful
but should not be required to accept the diagnosis
of
asthma, which is made by a health care provider.
Slide46Work-Related Asthma - Recommendation
3.
Work-related
asthma, whether OA or WEA, is defined as the presence of medically-diagnosed asthma that
is
associated with worsening of any one or more of the following in relation to work: asthma-related symptoms (
wheeze or shortness
of
breath),
asthma medication usage temporally related to work, or pulmonary function indices (change in FEV
1
or PEFR, bronchial hyper-responsiveness, or positive inhalation challenge test
).
Such a history should be documented by a treating or evaluating
health care provider
,
or addressed by a CMC,
if consulted in
a claim
evaluation.
The same criteria for WRA should be used
in evaluating asthma claims whether the claim is made contemporaneous with the period of DOE employment or after the end of that period of employment
.
A
specific triggering event causing onset of WRA may occur but is not typical or necessary. Inciting exposures such as dusts, fumes, heat or cold or others should be specifically identified when possible, but
should not be
required for the diagnosis of WRA.
Slide47Criterion 1: “Pre-existing or concurrent asthma”
Criterion 2: “Asthma–work temporal relationship. It is necessary to
document
that the
exacerbation
of asthma was temporally associated with work, based either on self reports of symptoms or medication use relative to work, or on more objective indicators like work-related patterns of serial PEFR.”
Criterion 3: “Conditions exist at work that can exacerbate asthma.
Criterion 4: “Asthma caused by work (i.e., occupational asthma) is unlikely.”
ATS Criteria for Work-Related Asthma (2011)
Asthma Rationale
Slide48Recommendation Assessment of Quality, Objectivity,
and Consistency
of CMC Work
We request that the DOL provide the Board with
resources to conduct a quality assessment of a sample of 50 CMC evaluations that have been associated with claim denials. The quality review will assess the nature of the medical information reviewed by the CMC, the use of standards of causation, the reasoning of the CMC, the scientific basis for the CMC conclusions, among other items. The assessment will likely required contracted services of worker-centered occupational physicians who are not associated with the current CMC contract. The review may lead to recommendations, including the development of guidance materials.