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Page 20 3 Health Monitoring This chapter discusses CSDP monitoring of employee health status as it relates to the workplace. A responsible industrial operation involving hazardous substances must have an effective occupational and environmental health program to monitor workers for health effects that might result from unknown exposures to chemical or physical agents during normal operations or from accidental exposures during upset conditions. Based on recent Stockpile Committee reviews of the operational history of the incinerator-based chemical disposal operations at JACADS and TOCDF (NRC, 1999a) and the integrated designs for the liquid-based processing technologies at Newport and Aberdeen (NRC, 2000a), the Army has clearly made significant efforts to design safe systems at both types of facilities. Moreover, it is also apparent from these reviews that the Army has instituted mechanisms and procedures for operating these facilities in ways that minimize worker exposures to harmful substances. In this chapter, the occupational and environmental health programs at JACADS, CAMDS, and TOCDF, and, by extension, those planned for the additional seven sites, are reviewed and evaluated. FUNCTION OF AN OCCUPATIONAL AND ENVIRONMENTAL HEALTH PROGRAM The function of an occupational and environmental health program is to protect and promote the health and safety of employees and to protect the public and the environment from hazards that may arise from industrial activities. The primary focus of occupational and environmental medicine is on the prevention of occupational injuries and illnesses, rather than on treatment, and on the prevention of occupationally related harm to public health and the environment. The goal of employee health monitoring is to ensure that measures to protect the employee from workplace hazards are effective by carrying out medical surveillance programs for the early detection of adverse health effects. The types of chemical or physical hazards encountered determine the nature of the medical surveillance or health monitoring programs. Monitoring employee health is one part of the exposure assessment in the risk assessment paradigm. The second part is workplace monitoring, the subject of Chapter 2 of this report. The practice of occupational and environmental medicine relies on the profession of industrial hygiene to assess the effectiveness of procedures, including work practices, engineering controls, and personal protective equipment, for protecting employee health. The degree and type of worker protection required during operations involving chemicals are based on available toxicity information for the substances involved. Generally, this information is obtained from studies on laboratory animals. However, human data may also be available, especially for chemicals that have been in use for some time; in the case of chemical warfare agents, for example, there is a fairly extensive animal and human exposure database that is regularly reviewed and assessed (NRC, 1997b, 1999c). Physical hazards, such as noise, heat, vibration, radiation of vari-
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Page 21 ous types, and repetitive motion, must also be considered in protecting employee health. To ensure that employee health is being protected, physicians and others engaged in occupational and environmental medicine conduct medical surveillance programs that address the types of hazards involved in the work situation. Occupational physicians may also use epidemiological studies to assess the effectiveness of employee health protection programs. Physicians practicing occupational medicine require appropriate training, not only in this field, but also in clinical practice and related fields, such as industrial hygiene, toxicology, and epidemiology; they also work closely with industrial hygienists, engineers, and health physicists. Physicians in occupational and environmental medicine must also be aware of applicable laws and regulations. A Generic Program In 1992, the American College of Occupational and Environmental Medicine (ACOEM) issued a statement on the scope of occupational and environmental health programs and practice (ACOEM, 1992). The essential components of this detailed statement are summarized below. Health Evaluation ofEmployees Health evaluations of employees fall into three general categories: Preassignment. The health status of new or current employees should be determined before recommending work assignments to ensure that workers are capable of performing the job safely and without harming others. Periodic medical surveillance. The health status of employees should be reviewed periodically to ensure that no work-related illnesses have developed. Reviews may be limited to appropriate organ(s) or organ system(s). The frequency of reviews is related to the potential hazard(s). Post-illness or post-injury review. The health status of an employee should be reviewed after a prolonged illness or injury to ensure that the employee is capable of returning to work safely and that, if necessary, the work assignment can be adjusted until recovery is complete. Termination or postemployment exams. Although not specifically included as an essential component of an occupational health program by ACOEM, termination or postemployment exams establish a record of postemployment health status. The results of every evaluation should be communicated to the employee whether or not abnormalities were detected. When appropriate, follow-up evaluation and/or treatment should be arranged with the employee's own physician. Diagnosis and Treatment Occupational illnesses and injuries should be diagnosed and treated promptly. The occupational physician, who is familiar with workplace hazards, is uniquely qualified to recognize work-related conditions and should be able to arrange for prompt treatment and rehabilitation. Emergency Treatment of Nonoccupational Injuries or Illnesses The occupational medicine program should provide emergency treatment for employees at work. Treatment of nonoccupational conditions may be palliative (i.e., preventing loss of life and limb and keeping the patient comfortable) until more definitive care can be obtained. Education of Employees Employees should be fully informed of the potential hazards associated with their jobs. Regulations, such as the Occupational Safety and Health Administration (OSHA) Hazard Communication Standard, require that hazard information be communicated not only to employees, but also to users of manufactured products (OSHA Standard 29 CFR 1910.1200 Hazard Communication). Information is communicated partly through material safety data sheets and labels. Education and training of employees about health hazards they may encounter on the job, along with appropriate protective measures, should be conducted by a multidisciplinary health team of relevant specialists and trained health educators. Programs for Personal Protective Devices The occupational and environmental health program should ensure that programs are in place for fitting
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Page 22 employees with personal protective equipment and training them in its proper use and maintenance. Programs are required by OSHA standards, such as the standard for respiratory protection (OSHA Standard 29 CFR 1910.134 Respiratory Protection). Personal protection devices may include earplugs, earmuffs, safety glasses, and respirators. Evaluation, Inspection, and Abatement of Workplace Hazards Occupational health personnel should familiarize themselves with the workplace, inspect it regularly, know the jobs and their potential hazards, and make recommendations for mitigating hazardous situations. Toxicological Assessments Occupational health personnel should be familiar with toxicity information on chemicals handled in the workplace. If the information appears to be inadequate, recommendations should be made for obtaining additional information. Biostatistics and Epidemiological Assessments Data on employee work experiences and potential chemical exposures of workers and the public should be gathered and retained, and when appropriate should be used for epidemiological studies to determine whether any exposures have caused illness. Information obtained from these studies can be useful in ensuring that adequate health standards are in place to protect employees and the public. Maintenance of Occupational Medical Records Occupational medical records should record and document occupationally related medical information of all types (e.g., medical examinations, visits to medical facilities [even for nonoccupational reasons], clinical laboratory data, injuries, pulmonary function tests, audiograms, etc.). The period of time that records must be retained is specified by law depending on the type of data and the health-related agent(s) of concern. In most cases, OSHA requires that information be retained for at least 30 years after the termination of employment (OSHA Standard 29 CFR 1910.1020 Access to Employee Exposure and Medical Records). Medical records should be kept in compliance with the OSHA standard, but access to the records should be restricted to health care professionals, the employee and his/her designee, and appropriate certifying/reviewing officials. Release of an individual's medical information must be authorized in writing by that individual. Immunization Against Possible Occupational Infections Protection must be provided to employees against infections for which effective immunizations are available. Development of Government Health and Safety Regulations Occupational health personnel are uniquely qualified to assist in the interpretation and development of regulations as they relate to the workplace and the local community. Periodic Evaluations of the Occupational and Environmental Health Program Regular evaluations of the program are necessary to ensure that it meets its objectives. Disaster Preparedness Planning Occupational health personnel should work with community personnel in preparing for emergencies in the workplace, as well as for accidental releases from the plant that might affect the local community. Preparations are required by Title III of the Superfund Amendments and Reauthorization Act (1986). Rehabilitation of Employees with Alcohol and Drug Dependencies or Emotional Disorders Occupational physicians recognize the importance of trying to rehabilitate employees who have problems with drug and alcohol abuse. This must be done in a confidential manner. Some types of work, such as transportation or military activities, have mandatory drug screening and rehabilitation programs. ACOEM's statement on the scope of occupational and environmental health programs and practice also includes “elective components of occupational and environmental health programs.” These might be thought of as desirable but nonessential components of the pro-
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Page 23 gram. These elective components are described briefly below: palliative treatment of disorders to enable an employee to complete the work shift or for conditions for which an employee may not ordinarily consult a physician repetitive treatment of nonoccupational conditions prescribed and monitored by the employee's personal physician (e.g., physiotherapy, routine injections, etc.), if the employee's personal physician approves controlling illness-related absences from the job assistance in evaluating personal health care immunization against nonoccupational infectious diseases health education and counseling (e.g., mental health, hypertension control, smoking cessation programs, etc.) termination and retirement administration participation in planning, providing, and assessing the quality of employee health benefits participation in systematic research An essential element of any medical program is informed patient consent prior to the performance of any test or procedure. Although informed consent is not specifically mentioned in the ACOEM components of occupational and environmental health programs, it is inherent in the ethical practice of medicine. The ACOEM Code of Ethical Conduct (adopted October 25, 1993) states that physicians should “relate honestly and ethically in all professional relationships.” Also, the Association of Occupational and Environmental Clinics has issued guidance relative to patient consent, confidentiality of medical records, and communication of the results of tests and procedures (AOEC, 1987). CHEMICAL STOCKPILE DISPOSAL PROGRAM OCCUPATIONAL HEALTH PROGRAM Overview Workers in the Army's CSDP face many of the same kinds of workplace health hazards as workers in the chemical industry. The greatest differences are the unique designation of the species being destroyed as chemical warfare agents and the adverse publicity and negative emotions associated with them. The following areas present special challenges: rigid controls required to prevent employee and public exposure to chemical agents rapid response required if an agent is released, especially if exposure of employees or the public has occurred or is anticipated use of multiple contractors (on site and across all sites) to run various aspects of operations utilizing different medical forms and procedures the frequent use of OSHA level A or B ensembles, which can cause heat stress, especially in warm weather public concerns about having chemical agent disposal facilities nearby the high levels of security required around chemical agent storage sites and disposal facilities detailed, frequent communications with the public and local emergency planning officials after a chemical agent release the personnel reliability program (PRP) 1 frequent audits necessitated by the administrative requirements associated with handling chemical agents and munitions Assessment and Evaluation Stockpile Committee members visited both JACADS and TOCDF/CAMDS between June 1999 and October 2000 to review the chemical monitoring and occupational health program at each site and interview site managers and operations personnel. During this same time period, the committee requested and received numerous detailed briefings on the philosophy, implementation, and effectiveness of these programs from senior Program Manager for Chemical Demilitarization (PMCD) personnel responsible for designing and overseeing program-wide monitoring, industrial hygiene, and occupational health programs. Committee members also interviewed Dr. Roger G. McIntosh, vice president and manager, Emergency Medical Training and Preparedness Division, Science Applications International Corporation, the Army's contractor responsible for overseeing the provision of occupational health services for the CSDP. 1 The personnel reliability program (PRP) is a Department of Defense program designed to ensure that each individual whose duties are associated with chemical agents meets the highest standard of personal reliability.
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Page 24 At JACADS and TOCDF, committee members met with members of the occupational and environmental health teams, including the clinic medical directors, nurses, and industrial hygienists. Each person described his or her role in the program and answered the committee's questions. The committee observed normal operations of the clinic and reviewed relevant Army and contractor documents, including generic and site-specific forms and regularly used medical and industrial hygiene forms. One anonymous medical file was later reviewed by a committee member. Three Army documents, Generic Medical Support Plan (U.S. Army, 1998a), Generic Medical Implementation Plan (U.S. Army, 1999b), and Generic Medical Continuing Quality Improvement Plan (U.S. Army, 1998b), provide detailed descriptions of the medical support functions at all CSDP sites. They also specify the policies, operational concepts, personnel requirements, and program elements necessary for the provision of medical support. The contractor medical director at each site is expected to use these documents as a guide to the development of site-specific medical implementation plans responsive to local policies and procedures. These documents cover the following areas, which are governed in turn by numerous referenced OSHA and Army standards and regulations, as well as other federal and state regulations: staffing and training medical surveillance, including medical surveillance exams medical surveillance for chemical agent monitoring for heat stress keeping, releasing, and retaining medical records support for the alcohol and drug abuse program support for hazardous waste operations support for the chemical PRP medical response to chemical accidents/incidents hearing conservation program support for the respiratory protection program support for the occupational vision program health education/communication about hazards, including reproductive and carcinogenic hazards treatment of on-the-job illnesses and injuries epidemiological investigations health care administration, including establishment of a quality improvement plan industrial hygiene services protection of patients' rights and responsibilities Emergency treatment of nonoccupational injuries and illnesses is also provided, although it is not specifically referred to in these documents. The Generic Medical Implementation Plan also specifies that the systems contractor's quality assurance unit must conduct regular audits of the systems contractor's occupational health program and that an annual audit of the program must be conducted by PMCD-designated health care professionals. Reports of all audits are forwarded to the clinic medical director and the medical administrator for prompt action. Non-conformance requires a written plan for corrective action. Similar site-specific documents reviewed at JACADS included Occupational Health and Hygiene Plan and Medical Surveillance Program (U.S. Army, 1997c, 2000c). Both documents cover essentially the same areas as the Army's generic plan but include modifications to meet site-specific needs. Site-specific documents for medical procedures were also reviewed at TOCDF. These included Medical Surveillance for Potential Agent Exposure and Cholinesterase Monitoring Program (U.S. Army, 1996b, 1999d). These documents are specific to the medical surveillance program for chemical agents. Several other documents relative to the heat-stress prevention program at JACADS and TOCDF were reviewed, as well as the quality improvement plan (U.S. Army 1998c, 1999b). The Army's CSDP includes all of the essential components recommended by ACOEM for an occupational and environmental health program except for participation in the development of government health and safety regulations. The lack of Army involvement in this area is appropriate because this is an industry regulatory activity. Several of the nonessential program components recommended by ACOEM, such as palliative treatment of disorders to enable a worker to complete a work shift and to obtain health education and counseling, are included in the Army's program. The Army also provides in-depth training for all personnel involved in the occupational and environmental health program. One committee member attended the Toxic Chemical Training Course for Medical Support Personnel given at Edgewood, Maryland, in April 2000. The course lasted one week and covered all aspects of the Army's occupational and environmental health program. An exam was given at the end of the course, which was approved for continuing education credit. The quality of the presentations and the instructional materials was excellent. Based on the committee's review of the Army's
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Page 25 CSDP occupational and environmental health program, the committee believes that the program described in the referenced documents has been fully implemented and that medical records are being maintained as prescribed. The committee noted that medical surveillance for chemical agents and heat-stress prevention programs are carried out rigorously. The committee concluded that the program is comprehensive, professional, and adequate to meet the known occupational health needs of CSDP workers. DEVELOPMENTS IN MEDICAL DIAGNOSTIC TECHNIQUES Advances in biotechnological diagnostic techniques are likely to provide more sensitive methods of detecting very low levels of exposure to some chemicals. As these new techniques become commercially available, the PMCD should consider adding them to the medical surveillance program. For example, recent research has shown that adducts of deoxyribonucleic acid (DNA) and proteins are formed on exposure to a number of chemicals, including aromatic amines, polycyclic aromatic hydrocarbons, and a variety of alkylating agents (Skipper and Groopman, 1991). These adducts, which are often present in blood and urine and thus are easily accessible, are formed even at very low exposure concentrations. Therefore, they sometimes provide a more sensitive measure of exposure than current methods. However, they should not be used as screening tools for predicting adverse health effects in humans until the correlation between exposure and health effects is better known. Preventing exposure is still the key to avoiding adverse health effects. The major chemical warfare agents include vesicants, such as HD, and nerve agents, such as GB and VX. All of the vesicants are alkylating agents and, therefore, will yield adducts with both DNA and proteins, which could serve as the basis for very sensitive assays for exposure (nerve agents are alkylphosphonic esters and are not especially reactive with macromolecules like DNA and proteins). The PMCD should continue to follow and evaluate developments in medical diagnostic techniques and incorporate them into the CSDP medical monitoring program.
Representative terms from entire chapter: