Document 3Q99OgZgRv1Xkzox4eXo3Okv3

UNION. CARBIDE CORPORATION ocd PIDGCBUBV boao. Dansubv. ct osai 7 Corporal* Hcltn. So'ctv aria Er>virar>m*ru*f Affairs Oepor-tment, Hay 23, 1984 Mr. Thomas P. Hall OSHA Division of Consumer Affairs Docket No. H-033-C, Room N-3662 United States Department of Labor Third Street and Constitution Avenue, N.W. Washington, D.C. 20210 Dear Mr. Hal 1: Re: Informal Rulemaking Hearing on the Proposed Rule on Occupational Exposure to Asbestos, 29CFR, Parts 1910, Federal Register (1984) 49: 14116-14145 Please find enclosed herewith a brief outline of the verbal comments I propose to make at the informal rulemaking hearing which commences on June 19, 1984. I also attach three published articles which 1 have authored or co authored on the subject of medical surveillance of asbestos exposed persons. My curriculum vitae is also attached. These items are in response to the request for submission of testimony and documentary evidence. Yours faithfully. <2Gk. Hass, Hilton C. Lewinsohn, MB. BCh., FCCP, MFOM, DHI Assistant Corporate Medical Director HCL:cms enclosures MEDICAL EXAMINATIONS REQUIRED FOR ASBESTOS WORKERS. HILTCN C. LEWD1SCHN, MB BOl., MPCTL, DDL , FCCP. ASSISTANT CORPORATE MEDICAL DIRECTOR, UNION CARBlrC CORPORATION, DANBUPOf j OCNNECTiarr. THE PRE-PLACEMENT EXAMINATION. DETERMINE THE SUITABILITY OF AN INDIVIDUAL FOR THE JOB AND THE JOB FOR THE INDIVIDUAL ESTABLISH A MEDICAL DATA BASE FOR LONG TERM FOLLOW-UP PROVIDES AN IDEAL OPPORTUNITY FOR THE INDIVIDUAL TO BE TOLD OF THE HAZARDS OF EXPOSURE TO ASBESTOS AND TO BE REASSURED ABOUT MODERN CONDITIONS AND ENGINEERING CONTROLS APPLIED THE PERIODIC EXAMINATION. REEVALUATE THE JOB AND THE INDIVIDUAL'S SUITABILITY TO CONTINUE IN THE SAME JOB COMPARE MEDICAL FINDINGS WITH PREVIOUS RECORDS MEDICAL DATA, INTENDED PRIMARILY FOR PREVENTIVE HEALTH PROGRAM CAN BE USED AT LITTLE EXTRA COST FOR EPIDEMIOLOGY STUDIES. TERMINATION AND RETIREMENT. ONCE AN ASBESTOS WORKER, ALWAYS AN "ASBESTOS WORKER" ! MEDICAL SURVEILLANCE SHOULD CONTINUE FOR LIFE.,.............. RETIREES CAN BE CONTACTED BY QUESTIONNAIRE AND REMINDED PERIODICALLY TO HAVE A CHEST RADIOGRAPH TAKEN NON-RETIREES SHOULD BE GIVEN A CAREFULLY WORDED NOTICE AT THE TIME OF TERMINATION AS A REMINDER TO CONTINUE WITH PERIODIC MEDICAL CHECK-UPS AND X-RAYS. THEY SHOULD BE TOLD ' TO GIVE A COPY OF THE. NOTICE TO THE FAMILY PHYSICIAN WITH THE INFORMATION THAT THE INDIVIDUAL HAS PREVIOUSLY BEEN KEPT UNDER SURVEILLANCE AND THAT MEDICAL RECORDS WERE BEING RETAINED IN ACCORDANCE WITH OSHA REGULATIONS. OSHA STANDARD FOR OCCUPATIONAL EXPOSURE TO ASBESTOS------- JUNE, 1972. MEDICAL EXAMINATIONS REQUIRED FOR: * PREPLACEMENT PURPOSES * ANNUAL PERIODIC EXAMINATION * TERMINATION OF EMPLOYMENT MEDICAL RECORDS TO BE MAINTAINED AND RETAINED BY THE EMPLOYER IN ACCORDANCE WITH THE APPROPRIATE OSHA STANDARD. H IO MINIMUM OSHA REQUIREMENTS FOR MEDICAL EXAMINATIONS OF PERSONS EXPOSED TO ASBESTOS. * POSTERIOR-ANTERIOR CHEST RADIOGRAPH, 14* X 17" * HISTORY TO ELICIT SYMPTOMS OF RESPIRATORY ILLNESS * PULMONARY FUNCTION TESTS j - FEV ( l second ). FVC UII DEFICIENCIES IN OS HA REQUIREMENTS TOR MEDICAL EXAMINATIONS OF PERSONS EXPOSED TO ASBESTOS. * MEDICAL EXAMINATIONS: NO SPECIAL QUALIFICATIONS STIPULATED FOR EXAMINING PHYSICIAN} NO CHECK 08 COMPETENCE, * CHEST RADIOGRAPHY: RADIOGRAPHIC TECHNIQUE NOT SPECIFIED TECHNIQUES FOR READING, INTERPRETING AND RECORDING RESULTS NOT SPECIFIED. * RESPIRATORY SYMPTOMS: FORMAT NOT STIPULATED i * PITMONARY FUNCTION TESTS: PROCEDURES NOT STIPULATED TRAINING REQUIREMENTS FOR TECHNICIANS NOT STIPULATED CALIBRATION AND STANDARDIZATION OF INSTRUMENTS NOT STIPULATED. V H I3 TOE BOLE OF TOE PHYSICIAN IS TO INSURE THAT THE INDUSTRY EMPLOYS PEOPLE WHO ARE SUITED TO TOE TASKS REQUIRED CF THEM AND THAT THEY DO NOT SUFFER INJURY OR ILLNESS AS A RESULT CF THE WOfiR'THETY ARE CALLED UPCN TO DO. J] I 3 PHYSICIANS MIST HE ACTIVELY INVOLVED WITH WORKERS AND MANAGEMENT, MUST BE COMPLETELY FAMILIAR WITH THE PROPERTIES CF ASBESTOS IN USE, MUST UNDERSTAND THE MANUFACTURING PROCESS IN THE PLANT WJST HAVE A CLEAR CONCEPT OF THE PLANT DESIGN AND LAYOUT, MUST HAVE A THOROUGH WORKING KNOWLEDGE OF THE ETIOLOGY, PATHOGENESIS, EPIDEMIOLOGY AND THERAPY OF WORK-RELACTED DISEASES, AND MJST ACQUIRE A WORKING KNOWLEDGE AND APPRECIATION CF THE THEORY AND PRACTICE CF INDUSTRIAL HYGIENE, INCLUDING UNDERSTANDING CF SAM?LINO AND MONITORING PRCCEDUTES. jj a i pED ICAL SURVEILLANCE OF PERSONS EXPOSED TO ASEESTOSs PRE ny^KT OR PRE-ASSItll^ENT 0 Medical history - Respiratory Symptoms Questionnaire 9 Physical Examination 0 Chest X-Ray (PA View ir x 17") t Pulmonary Function Tests (FEV^ Fvc, FEV^/TVCX) 0 Sputum Cytology if Indicated and Feasible uaa THE PHYSICIAN SHOULD TAKE THE OPPORTUNITY WHICH THE PRE-PIACEMENT EVALUATION ArTCRDS TO aXNSEL AND ADVISE THE JOB APPLICANT REGARDING THE KNOW-5 FACTS ABOUT ASBESTOS-RELATED DISEASES. IT IS SSSTT.'riAL TO EMPHASISE THE SPECIAL RISKS THE PERSON WILL RUN IF HE OR SHE SMOKES CIGARETTES AND EVERY EFFORT SHOULD BE MADE TO DISCOURAGE THE HABIT. I t OTHER CCNTWt-INDICfiTICNS SUGGESTED ARE: 1. NASAL OBSTRUCTIO* N 3ft EEPOlWmf CF SUCH < SEVERITY AS TO SAKE THE WEARING CF A RESPIRATOR IMPOSSIBLE, 2. GROSS PHYSICAL EEFORMITY CF THE CHEST WHICH IMPAIRS LUNG FUNCTION,, 3. CHRCNIC BRCNCHITIS, BRCNCHIECEASIS OR EMPHYSEMA, 4. GROSS HYPERTENSION WITH CARDIAC IMPAIRMENT, 5. fHEUMATOID ARTHRITIS. PERIODIC JCDICAL EVALUATION OBJECTIVE: KEEP EXPOSED WORKERS UNDER OBSERVATION TO DETERMINE - CHANGES IN PHYSICAL STATUS - PHYSIOLOGICAL STATUS " IN CHEST X-RAYS THE WORKPLACE SHOULD BE RE-EVALUATEES WITH THE SAME CARE AND FREQUENCY BY THE PHYSICIAN TO ENABLE A DECISION TO EE MADE WITH REGARD TO THE EMPLOYEE'S SUITABILITY TO CONTINUE DOING THE SAME JCB. MEDICAL SURVEILLANCE OF PERSONS EXPOSED TO ASESTOS: PERIODIC EVALUATION ; ' < 55 YEARS OF AGE OR < 5 YEARS EXPOSURE Medical History - Respiratory Symptoms Questionnaire: anmjai I V Chest X-Ray - (PA View M" x 17") Physical Examination > Every 5 Years Pulmonary Function Tests CFEVj, FVC< FEV]/FVC%) Sputum Cytology - Not Indicated 38A5B MEDICAL SllRVEILUWCE OF PERSONS EXPOSED TO ASEESTOS: PERIODIC EVALUATION : AGES 35~5 YEARS OR 5-10 YEARS EXPOSURE Medical History - Respiratory Symptoms Questionnaire: Annually Physical Examination Chest X-Ray - (PA View W* x 17") "N ( Every 2 Years Pulmonary Function Tests (FEV^. FVC. FEVi/FVC%)j Spittum Cytology - If Indicated by Smoking History or Over age RC Years PFDICAL SURVEILLANCE OF PERSONS EXPOSED TO ASEE5TOS: PERIODIC EVALUATION : >*6 YEARS OF AGE OR >10 YEARS EXPOSURE Medical History - Respiratory Symptoms Questionnaire: Annually c Physical Examination: Annually Chest X-Ray - (PA View 14" x 17"): Aim ially Pulmonary Function Tests CFEVi* FVC, FV]/FVC%): Annually Sputum Cytology - If feasible Annually 38U3B BASIS FOR REMOVAL FROM EXPOSURE: DEFINITE RADIOGRAPHIC EVIDENCE CF DIFFUSE RJI^ENAKY FIBROSIS; WHEN ONLY PLEURAL STIGMATA APE PRESENT CN A CHEST X-RAY, JOB TRANSFER NOT INDICATED BUT COWTINOED MEDICAL SUHVEILIA'CE IS. PLEURAL PLAQUES. PLEURAL CHANGES RELATED TO LENGTH OP EXPOSURE IRRESPECTIVE CF DOSE. PROBABLY AN IMPORTANT - RADIOLOGIC SIGN FOUND IN LOW GRACE EXPOSURE GROUPS WHERE PARENCHYMAL EFFECTS ARE LESS LIKELY TO BE SEEN. E IO INDICATIONS FOR COMPUTED TOMOGRAPHY OF THE THORAX. EARLY PLEURAL PLAGUES CAN HE JOSE RELIABLY DLAGJOSED; PLEURAL PLAQUES AND THICKENING CAN BE DISTINGUISHED FTCK " COMPANION " SHADpKS ADJACENT TO RIBS ; FINE INTERSTITIAL PARENCHYMAL DISEASE CAN BE DETECTED WON NOT VISIBLE OJ CHEST RADIOGRAPHS; USEFUL IN THE DIAGNOSIS CF MESOTHEUCMA. ( Tbe fording cf pleural effusion, rib destruction, pleural plaques or calcifications, intrapuliicfiary r. dules and thickening of pleura, pleur j. fissures and para. mediastinal structures, especially at the bases and posteriorly, should suggest the presence of mesothelioma). EII ASBESTOSISj DIW2CSTIC CRTIERIA, 1. HISTORY CF "ATEOtBOE" EXPOSURE, 2. ELICITING FINE HOINSPIRATCKY CRACKLES AX THE LUNG BASES CN AIBCULXRXIOT, 3. FINGER CLUBBING { MAY BE ABSECT ), 4. PROGRESSIVE CHEST X-RAY CHANGES CF PULMONARY FIBROSIS, 5. RESTRICTIVE PULMCNWaf FUNCTION PATTEOT AND IMPAIK4T.T CF CHS 'EXCHANGE. (AIJWAYS CBSTRUCria: IS NOT USUALLY A FEATURE OF ASBESTCSIS, BUT HAS BEEN REPORTED IN SOME STUDIES.) E IE f'FDICAL SURVEILLANCE QF PERSONS EXPOSED TO jjSffSTQS pnnrtnir. evaluation : termination medical History Physical Examination Chest X-Ray Pulmonary Function Test Spittum Cytology 3843B E IB Plot SURVEILLANCE OF PERSONS E^OSED TQ ASESTOS: PERIODIC EVALUATION : RETIREES Bv Mail Onlv Reminder: Have Regular Medical Checks Health Status Questionnaire - Complete and Return Rely Upon Personal Physician 38AS3B - E IH MEDICAL-SURVEILLANCE OF PERSONS EXPOSED.TO ASBESTOS: PERIODIC EVALUATION : POST-EffllOYPENT - OTO THAN RETIRES Aevisory Letter at Termination: "Cootinue Medical Checks" Consult Personal Physician to Arrange Periodic Follow-Up y . Sec Ill'll | -- Definition Xdwtoos i* a dsllusc iihr*sv , ,1 the putenc tn ma ol the (uni! earned bx exposure str re*pir.ihie uirhoinc avhcviox lihu"' llic tihtOMs i- irreversible and m mihk' pcs'sops processes even alter exposure has jc.i id. < riteria for / /. lh\inr\ (here 'ii.mM be evidence *f snbsianiial occupational exposure i *r substantial pai.t'Occupaiiona! ^4!j*r to .oheMos I thro. I . ( /tnitjl S'/"H\ tjHiJ Si m/U'-trs i'crMvtent basal iiispirutorx crepitation* .)>, /jelcnsiic >! mtcrstuial pulmiTi.i.x 1ihrsiN m.n be heart.! but uic m*i mv.uiablx present Hieathlesviiev* and linger dubbine t-unr bin .ire not spccihc M;ens in themseh es }2! i n I hese arc !:ue bjsai mspiraimcrepitation* a*uail\ biiaicr.il which iiuiir late m inspiration .mt) persist alter coudnne r hvpcrpnoea. I hex .ire churacten*iica!lx bcaid with each inspiration and mi each "u';tMon prevent vcr\ much the *.inie pattern of sound I hex are not e"esitijl to ilie diagnosis ati> more than ihex are pathognomonic of the disease. However. when not accounted lor h\ .mother cause and u I ten heard n at least two .eu'iaiis a lew monthv apart, yivcm a his(< >r\ o| exp*>surc and radiological evidenceo( dust disease, thex do provide valuable continuation ot the diagnosis. In the presence <>{ ' X I \k< iiM.ic'h. { h.nrm.ui 1 li \k*iiu ih.iki. K bi-'iviie d k 1. it k I'J.iaf*) 1! )oini.it V v. I l >ut re dtolemm 1. XJ ie'.iiic-n .ai.ul.o H < I c`.ojs.)uj d v\, 1 \1.ims<im s t eh.tn1 'ii 1. M ( MiiN * 1 K >. XX H. JXiut 0 s \, ( H.il! .icili i J 1 .uu c 1. VX I skii*".. r 11 k 1. It i) K I iuket iS..utlt \li:.,n K Muir.iv ( mai-n i; Ki i I .n* j> 11 mik:> J V :;nK ms l In:, tu :> h M . * Uiv> .mP V.'i'Hu' ' l| / ' 'i \ vli^c resp.inn1 jel.iiiomhip has been .leun tott Hal tvi\u-i'ii the cwcm (f .join's)'> cVpiMlIv Hie i.nlioloeical pur cm ln?.tUh.nLvv l*.ni,ikhxin.il ehaitee i on elates ill ;:w1k-f,si with .in .i.tu'iH1 elJe<t . *n ihe h MUI-Icntt ptO'inovjs o| .HI unlnnhiu) } I* c v v j . :u the .hscike .'1 nk''Oihc:ioni,i. theic o no ahcme pf oenostic Ni'jpil k .nkc .i"-nu,ilat u tlh pieiit.ii ^ h,in:o link*'*-' the\ .ue unusualh se\eie. / " Since pleui uK bailees m.n nuiii in the ahseme "1 p.n emh\ m.il t thi osis. the use <! the Jcriu ''pleut.il .isheM. >ms'` o wikIcmi .thfe i v OlIkT ^.uim."' o| Milh'l.'-Jk.il vh.iuces niU'i be l n'Mlh evvimlcil pjnu to m.ikiuu the uiiaen .4 .obest.>so J ho is mjpoit.mt m the e.irh M.iecs -n the Jise.oe Hi)*.)) ihe t.nti'vh.mees .n; slight / -4 i>liu> />/. ;/;*//* .* 4 / U/'< '/<' f . i > t'-fumuM />.*,//*. When .< prothntuo c-nich ^ picscnt .isivM.>. uhu viM let t ucuioio Nuhes m the sputum jicc\uIcikc"I :\pt'MJK' to .inIv'J.-s I'ul .ue u< *i < h.icm *'I u >1 ohcstosu . i I've;- 'eU.-m wont ;eb i iliacm-Mu po-ccihuv lu .ohesl>si'. J he L ) kk is >h e\p"syt e utuuhi .ill e.uiv tun e keen i ceoumsCii m the tri**ii*' 1% .uJilmeH in 'Ik* toiceo.ne aiUTi.i. Miopxv o iU'litnd it U n Jhouehl ill.lt .HI .nKMw*e\p`soP [Mtieui nun be -nil .line ) r oin *onu* othei pounn.ilh treat.ihle nine disease \m 'in -jomi about in s.^iulikt .i tmo.uu 'per-i'i.Mi nn ,i pel '< >r kn* m n n li n e keen exposed to asbestos should :v usk.u to .'iM.im a 'peumen "t h.ne tissue s*t hisii'liiL'k.il examination ! ' l .v//e futu \>>u>> nuihhi s. I lie th.n.Kiei nil*. .ihn *rm.ililiev .n e those "I teMlk'live liihu ili-e.i'V 1 ! h ;s jevommeiuievl tli.it 'he l \ ( . I ( \ .uni I I V I \'(' r.iih' he reeortk J i uinik-K m st.nui.int l.nlnon \ v.i|ii|Mi rs<*n >l pernulu luni! luneln*n le^tmi! er , -u; in hv'i -} e.ii' K ; : i, i ie t! i . i < \ . i 11 vj e > .i 11< m e 'fni^nrei In' ;;k- 'k.uii.i i.! i!i i `iu'i" '. .fu.- i ;i .i"v >u v.; !Me .' i;.; ~. .-.il. <u .nke 'iiihi Ik- m.uk !. - j u'll.nn eiluue <hile?etke* .mil .`he ') -nm k m-e lulnls / /.U lulc a (csitcvtin1 p.tHcrn ss >i)>i-Jenl utth iln- huretinsn m .ishesloMN. it n ?h>{ spei.)tn. n> tin'' ilne.ne. Vtvst"M>, nun ife'.eli'p kith little or no Jeicu.iblc tesf.ktne ileleet m Hie e.til\ sf.iees \ pfetloniin.inth ohsjriklne pi.iure n uik ' utunou m i he .ih>en.e .'i j *m, k nn: ho tin \ /Mote sophntie.itei) ii)i',i'i!ivin-;nu in tile ,hH'"HK,tU ol rc*trkine luii'J iliM.ke tee. the tHe.out emeni "I tt.insier f.ietor iml Itme cmip)).mti.) .ire tli.ienosiu.iil> helpiul. hut ,ne nn essetitul to the rowime maik.il Mirveill.tikeol .i e'lmip n| .i\hes!>s-v\p.oeil A> rkeis / '> fiif'i u nlm/ /'.'.r.'/MvM, \V hen there .ire tu.iu.il. kulioloeu.il. >r June Imumm .ihnorm.iliiies m u'heMos vnu keis. the eNclu'ion . >l simulate e tli>e.ne neeess.irv tor the correct nuin.ieenieni -i the iiklnulu.il. Ihu n incrcuMnel) mip'rum .is. k nil unpfj >wne >itwtjp.iinm.il h' etene st.iml.iniv .ohestosis hecomes less c^>inm<m /. " ( ottuni 'll I he .in >\ tii.ieni*sn. .i!\\ .n s .i m.itier ' n neiehme prh.ihilnies .uni iookine .tl the total eutlenee. ilem.imls e\pcrr imleemetk haseil oil the inter* p.eunon oi ihe .iho\e criteria I .uh ot them \ on ,i scale ol seventh ami n ts ptissible to I iml hi eh values m 'oute hm v.ilues m oiJu-rs. or .m\ pe `tuil.ihon or )! \ V 'mhlll.llk 'll I *t v [ lief 1.1 Ul fit*- nicji\ :du.(f . .in' elements ! Elk- thct'iuM .Ilk} ull.'ll WIJ )) \. v '! Jiii'.1 {:)!. Sk\u*>n H -- Mesothelioma ( 1 )iMum: null mum mesothelioma of the pleura ,t peiUoueum I'.ii iif ptinui \ tUMU UU Hi ! Ik` ecUC! .ll pt spill,! f!if I U IlCH .HtnbMjhIe h .ishesl* 'V ihe 1.11 Clll pCimd het uecu uncial ,T''hc*'(i " c\p<^u;and >fi'd t 1 lie disease t n 1 isu.ill\ ..n n < -hi '.c.i 1 n ><r l.inpci J ll imisi be emptUM/ed flt.il :iic Jeiitmiw di.muoMN ut 'U> cfjvnn.: ' > C.|s\ III .InI'CnI i *\ U 1 M kd s ll 111.* \ i'C .i NMk l.llCil V\ 11 ll .ishcsh 'n|> ' U< *U*jn I ltv` )eu; 'f lhi.Nix can i'c minimal hi miik' s.i-cn them in ii" vwidcme -! , w .u :i uccn>pN\ McN(hcli"fii.i mas nuiii after telninch bud hm .'jjIchnc .in1\ .i,-s v \p< -Nine U hde pletn.d abm umaltitcs.iu- nm)-n m jslvstus m n kci n. :nete e* n v"tkiiiNiic cmJciuc 1 J1.1 f il ihcm'ch .-n )hcv picdi'p* "i' me -1 nci 1. >111,1 I 'ii '('ic i> 'ii 1 >1 ; )k- pU'Hilu . ! pic in .:i i!K'< '1 Ijci i mu.i it I'v U hen ; ,, ,i d . d ii'W m > u < best p.iin .kin n hi an .iNhcNioN w. 11 kci I he min*um m.i\ . 1 urpieteK cik-inc 'lie him:. Peril, meal mcMHhchonu tn.i v ><vwtip\ .1 l.n;jc amount oi th. ahd<annul i.n 1! .1 ikj produce .iswtiCN unit nt unbuilt .ihi1.Miiiii.il p.tm. \lct.M.iN% s dlhuu-jli i.u. . v.iu .1!feet Mher . i u.uin. Inii lov.il Npte.ut in ihe usual 111. -de >1 pi1 -u nmi l 111 he 11 no treatment has been sik'sesstul. '.he "ukuine hcimj itn .n uhi >. latal ,,V hie.ill'.. ;ite ih.ipih'NiN \wl! he *\iNcd on , .uelnl newopsv in oiik;i p.utkisl.n .ilk-n!i<n /n ^nni i, i'\t)inhnc ihe piNsihiln\ <>| pmn.iiv n..hk.? .it M.me vli-t.uit Mie I uj I he; iiini e. :hc Mum mu Hn.uc -h u Ul K 1 eten cd 1 me ? the eNl.jhlivIkd mcN, uhch< m.i leleierkc pane!' nh * h.ti h 1 ^i. *p.i 11 ii 'U ^ s.:. * 11"killed m die vli.mn>*NiN ,ii du- lunii'in m.r. ji*>e their -'pmum Siuh iviik'I- i*-"a cmnI m m.m\ . < 11111 r. e n .`-i1 U ink l.i'C" iik'< !}!.)'-m., m.n .niN^ ;n ;bc euie;.:; p- p . 1. >h a.: 11 -hvkkiN ^.iiin>.-. ihe *! ;ncNfhc)iiM!u v.incn .jic lei.iieii h> .inIvnImn e\pime. Ihe pi*p<>iimn ol ukt- .n: 1 ihiu.it'le !>' .iNhe^k-N c\p"Nme \ .ine>; it is L'le.noi in tile m*re hi.nhh nuhisu mlived 'iimumnieN.cNpc<i.dl > iinNe wn\ \ .1 l.n NhiphiiiMiM1.' -m ship lep.mmu iiuliMr) In imhisiri.tl popul.itii>ux ^enci.ilh. in*''! meNothclkm.i i.ih'n nuv he .iNenhcd k* inPcnIun. .dlhmiiih .'eii in hc^c v`in- uumiik'N n 1 > el.ih. mdiip with .ishe"l<> \..m he cnU hi idled in .. ;m. .pi m t u mi \ .11 \ in*j fi.mi In hi'. In ,>thei ji"np* uhkh lui\e heen .tden'-iAi'h ^hidietl. the pi < >p< 11 tk in 1 it iiicm )| he iu m,i ^ .i-.cn ,iNNi*ci.iievl with jnIynI* *n e \ niu e in iuuei h\il \ .m.ihie. u .til me^n hcht mi.il.i me vine P'.inI'cnI.is. e.;J eiuletiiiv mcNi -t helkm.i in N*'inc .ire.in nt linkev. in helie\ed !> he due Iu .1 fihiuiis Jmiit /e*'fne S \ Smukinv' h.ihil pl.iVN ill 1 pan in the yeneMN nt me'uiheiiu!:;,i .a t.n .in ..m he de'erinuicd .it tile present lime. .V*. IhtN i> icl.i'neh iniL.-mmun e\en .sinmu a h. > Imk h.ul Nuhst.intt.il .nlVM< a e\pnNine M.iin heheic th.it the ifvk n .ic'.vS'iumr meM- ihehmn.j is jiv.iteNi unit emckiuluc. kw uidi .nnuMle. and app.itefiih. !:w unh ehiAsuiilc. while anllmph\line appe.iiN ne' er in h.i\\ .,ni'ed lie >!iieln-m.i in nn xrn nit\i nova. otsnxt.M'f. '>' qsmstos f'leutn. ** - 30 >' /W IV. 8/2 medical surveillance of asbestos workers H. C. Lewinsoha (#) Thor*? .3 r.c euro for ir- rxjal uaia. the vjtlocrf f :r the patient i;tr* . ,r,5 cancer i 3 very peer ar.-J diffuse ;sa 11 grant jseaethtf Ilona of the pleura :r peritofc* ua is invariably fata; v; thin a short period of tir.e after diagr.csi 3. Ir. view zf this -rlocr.y future far the affected wor/or, ur.at can the phyaiciar. new working ir. industry do to intervene or prevent undue au fferinj :n tre part of currently exposed individuals? (*) MB.. BCh., D.i H,, MFOM.. Corpora Mtdksi Director, Rjiybestos-AtasJMsms, Jnc.. jOO Oafcww Drive, Trumbull, Ct. 06611. U.S.A. not s< at.iaod. This perl -1 ;n -ho ;nr<J!f :f r- .06 >pr 1; .--wit r'vi s`.hi i?* at 'pp jr.i'y cr ` p,#' : 7 r irt* ' l i.'i* i 'n V * -i i ** s'* i verifying In 7tier *7 'O'atiiah the lata case f r f.nllaw-'.p. The J'^rza? :' `:o Kanina". I ;n <nJ rcar 1i#j i-rurnn* auch *Jiit ;t in :`:r tt.untfB m4 r*tri^v.ii -y *ic* rtn; * Jim pnccasng , *.h-3 l` rere srasr.aPIc te <;p t ,`e.r.i j : \ t j, iy ir. i in i: vni a . rv.<? p-rpeae ~!' ".he per;"lie *e ii :! exvamai un ,a ic sr,; `.he ;r. i ;v`. :vi 1 'l;*.y *' '-re .: ir** ,,! - s .r rih.; v: :j; r? -.nr.:* *ni .n -..v r nay r.'t - : r*. !'.: .-* \ tete:ie5 U m -Mr.;.' * i.y* wner. i.V.orv^* , :r, 4'.., .n - 1 ir w 11 :'r :.r J'-r'.r.or expir-re ;!' ;n 1`. Mte i r ~r * v.;: ; :r, ;f "r.'Tip/ '.r, !;:*.(?,a . in te lataet -er.l ly -jea .``:r ep : :v- ; j 1 ^i j. tr. i 3*-i* : 11. j- !r;tlya:j .: j<?' err.;.-.c exp-a'jre-rejp jrsse 11:'nsr.; pa sr,l pr:te:t exp:v.-J pera.na. r,*:c pr.ysieurs car. -Llliie ir.e ^r.nul"^e ?a;r,e^ frer. *.:.*? per;.i:c re i i r a 1 exazir.aticr. af *?rapi ayeea *.3 provide tj:lar-* cr.e w..*v~r th- *-; '.ar a^-vher. 1 re^ar :,,:*.*$ '.he p 7 2 3 L11 e * f -x:.3-r =eecras 3f rse'iital fin<in*S3 ah-ai.3 t relatively sizple "3 zair.tuir. )V r 12 4 r OB employed in radiology and pulmonary function testing, and If it is borne in ulnd that the employee's attitude to periodic chec <-up la different from the attitude he or she had towards the preplaeewnt medioal examination. In the sections above, dealing with the medical examination ;rjdten, mention was not made of sputum cytology'. It has. Seen propose! In the United Hates that this should be performed routinely on persons with 10 or more years of exposure to airborne concentrations .f asbestos fibers or who are 15 years of age cr older. (^ } According to til authors of .lection IV :f the ,'nerloan Thoracic Society's Epideal logy Ttandardltatlon Project. "Early data from studies tf smoking men at h gh nlsx of lung cancer :r.di?atc that only :r.e fourth of isymptomatlc lung cancers are detected cv jputum :ytul:uy ir.d tr.c rcmatncer are det *cte d :y cnest radlography , ?CTT PETTPEMENT OR f03? SEVERANCE EXMWH/.TICHS The surveillance of the asbestos worker 3hould ideally not cease when he or she leaves employment, for whatever reason, but every efftrt should be made to continue the process of follow-up for the rest of t.-.e Individual's lifetime. The follow-up of retirees should be administratively aaier "han that of employees whose term of employment is severed prior tw inurement, because the former will probably qualify for retirement pensions ar.d remain :n 78! m I Measurement o:* ar.^le between nail ar.3 cuticie tc locuaent appearance of clubbing of fingers. i Cfclique views, anb occasionally lateral views, nay be required to O' clarify pleuni aDnormalities. REFERENCES 1. SelikofT, l. J., HatHsaond, E. C. "&stmfco; and Slacking" 9 *dAAres i?79; J^;U58 (Editorial) 2. "Epidesuology Standardisation Project'*8' (Benjamin C. Ferris, Principal Investigator). "As. Rev. Respir. 343."" 1973, ll8;55~38. 3. Jaconson. 1. ind Lainh*rt '4. S. TLQ/UC 1971 International ll-saificati of Padicgrapns of the Pneumoconioses", v<f-%d. -aiiCstr. 8, l?"*?, ^3:67. *. r-epartsent of Labor, Occupational Safety and Health Adainlatrati "tccupattonal Expc-jpe to Asbestos, sotice of Propose'! -u:eaKir^ "F* :er 11 iot^r" , 1 '~c ; -iC : uTh^E-^Tbbb . 5, "Epidemiology Standardization Project" Oenjaairr G. Ferris, Principal Investigator), *Aa. Rev. topir. 31a.", 197B; Uc:39~lU /86 Reprinted from Connecticut Medicine September HS2 issue. Vnl. 4ft. No.1) The Medical Surveillance of Persons Exposed to Asbestos \HSTR \t"l* -- This paper w ill briellv review the techniques which allow persons exposed to asbestos to he kept under surveillance. The pre-placement evaluation procedure and its usefulness is discussed. The periodic medical evaluation is described and an outline of the essential requirements is gi*m. The rede of radiological surveillance is brief!' discussed. The point is made (hai both the exposed persons and Ihetr management place reliance upon the ph> sidan in inform them of adverse findings so that the problem of alternative employment and future pro* teetton can in- dealt with in a *"iiini and equitable manner. Medical surveillance should vuriftuuc tor the life time of the individual once exposure has been docu mented and post-retirement or post severance exam inations should be provided whenever practicable. Axbrstns-rrtafed diseases can he prev dieted hv good industrial hygiene practices and engineering con trols. I he phv sician is able to intervene at the interface between worker and work ami hopefully alter flic final outcome to the gw*!. Introduction Exposure to asbestos m various Industrie'* and occupa tions has Keen associated w ith three maj ir lestons oh mg the inirathorucic organs \>N.*stosis. tirst reeoeni/ed HII.IOM t t \X INNOMV M U l-rvwii\ D-evt.-i h.:> ;'ati`na( SjIv'U iml Hc.inn P'. iif.ims I ,fiiM I..1 .v 1 Department i r.pijcmi*->.>:} V .we I ' er*.i v Vii" -i a XK t. :e rimual A'MsTJalC. DepartiiKin.it l .ir. r.l.>r. \leUis .we. I *us it t'unneciKiit Suhi*i*i Mcau;re Reprint requeos to Hc.W(h. Sate.". imJ |-.miri*nmcnial A!!.nrs Dept . 1. nu*n (.`jrhiJc ( "rp Old K.leetnirv KJ . D.inburv ( I I " i Dr l.cwirwnhn i at the beginning ni this *er.!ur- o . :nn inteiMii;w pulmoiur. tihrosis whuJ) has beet: shown t. *v iclafcd * the dlM |.-\ els m (he workplace ami u> fv le; vmlenf ap*r: the duration o< such apoain.' I jiij *.au.-r m hc.ivi;. exposed workers in indusmes *Uvh -i' ni'-.i.itum. .o:: siruction. ship-building aiul ,i**v'to' tcvti.es niaiuil.w lure, has beer; adequately do*,umcntc.l or;* 1 related * asbestt s e\p *sure Asbestos ev ;s **v\l pe j *> *n * a lu on* . cigarettes jp|vat to have .1 *' times crt.it.: Juu:,, dune Ironi him: v.mo't than n -ns.4.111.; .>ii .i-iv*-!' - exposed persons I he thud . nd.tnai j with exposure (o asbestos hi: i*t 'in-*-- 510 CONNECTICUT MHOlUNh. M.IMI-.MBIK l`)>: :hmu 4 ;*u ;ji .1 <..? .1.> I nldi` .fdvvin*,* .i)! hint' :;.n .k .v :in' i .ire luMin h.i-* Nvll tu.'ii' tilltk nil !* n ktms } ,] >v,' <w inl j\illu*h'.ju Y.smU'' , , \ .;i * M i".v i.i!!>*nv h.w '\in Pi'ittlVil H\ i.\pMik' .Mki v.lllu"'- nv M \ me liv j.t'ii."iiiK-vini.ii ;i ,u \ .nul * .nk ii v tn > lhi. r `I J Jill' 'tiv l\ .I** HV Ml MU "I ' eilul 4 uMIlv i .UK v'l * M Mu* in UI'IIH'I! p.!' `Hilt .i'>vfHVdk* wlV'lt's I'XpovUfC it v NtiU'jk'vuM :lui Hie *.tM.- Pe^nNkl AiK' .i,fu.ilh '*< ;VtMUk\H . M i J r t` -till! v(iK t 'tkaheil.UK i!k'4`fJk'h'ffU 'l :lu :x'i ili'iu ;un (l :u.i\ (v P11 f :* wff (i' <li'Urcjm'h ,n Mil ..ti.ii't'iiu rjt'ni jviift`np.il ;iv'i`i!k/n*nu Hi-* .H|vv M (\ Iklv.l'lllj ;I`.P A kfeM'Y.kJ HI Mk` s \ n "..ms luliivirt*-' Jinni:; 'hi- p.iM v>i ...js-* .Mine hi* infii . ..-fv !;jj>i-' H b.jv 'Yen .''inuk'l ;,.i( tuih -ii . 4 ;v< 'jhi !).i\ e fv* m * ' p* vd '11 \ .tiu tix a i'. ' :< ..jiimij' ..iii.-fk-' .4 .i-iV'!'" If;*. : * l.fkkj .!) '*..1'^ v ,r,- |)i >| f e.uhU HlHU.H'ii' \' ' 'i.-A., ; ! > >.!*' e ' l' `i.lt I* *'*. Hvi'.nt i -n . m**5 ' -vi' ;v.4 .iii.i : ,i v. Hk : H T.i.i -1 `Ik' Pa'ii-i i : iMik-mu ' !!'. .1 : .it'H UP.. % 'fun .1 'H.'f i T Mr.* iH*i Pkie * !:.* v. * ui :'!.i*: * r.j n Mk kP.t'ii :.l . jr. t- n : *T % -u !;,*:. ui. i 4 '%,:* ;*i .p. r I (. > .1!* :vpi i:_ '.. ,r:t*4 * tv u ; k . IP uuhi. -ul!M:n j iHtu.iti'-nv ' null .*nplt\mail V 'lie u'val: crki* .ilrc.ulv *:.nivii m tlkMlcwl^pmcni * vv'iU.uuo [Mik'i.urv. the Miii.iHhlv -4 piovp* j't\eev i**r ltk` vpe*. ilu i.^k'm i{Uv`vi;>'n u K- .tiui f'.i'C i up'*n v'efiiki/ wfufiufi , rfrtVf.f 'lU'ulit tv .<ppiipf i.ifi'K s'UUfveh J p.mime >t .`(tietuise Inf viiijhuju`fj| m ui) .ivhi'vi.- .ufufn`is ,nij il .jm fevliuJumv nveit l>` 4: 'molk.il eH'UikJv !he\ vhonlittv tiulu ufeil h* rhe .fiui l)k`en;plnet piun u> j'l.uenk'iu .11 Hie ;i*h *k ll.ilii ik'hikM n*ihSHionN .vluvh 'lu 'i.mulii .:U' cm]'!"Miu'in .1 lissmis .*i pu-\n*ii .ninths ;nuuvh\ .vith 4 ieii>CM/,ei{ .Sum h.i/.u *.m) imnuie' f n**ik* ^uarntm:. .111 eM'fuie p h'.fnll\ Jne in pnetinn'i ni 1*'iv >>i li-nr '.mu-.e. :he puvi'ikt "1 `'h'lHklne .iiiu.iNv .h* <tr Aiih*ul vinph* vm.i, uvinm.i ,uu! .'I'j.ittk e.iv t Mho * 1`Uif.iuuhi.iti'i>* i" uni'M'uiii-m 'h 't itish h.iw Ivci' f\.v`fwncrkli\f .ire f i > N.i>. In 4" n ik'tnrrmu 4 'k h .1 ileerce .i\ J*J>ktke Jh I .1 ;i`l rii.ivi. tllJ -4 *' e . - M `k- rev! mi.!: i- '-'i. .1 .VMjJl .} Iht 'kn k v,Jt _* ! . - 1 . 11 . t) i '! " . h!` * l.i v 1' hi 'npM\'Otu i- .1.'" - Mill.1* .uijvmniv 'I .nk! ' M.* >-i \n > r .11 .. |.-i.| il \ -tf >. ..j... .1 ..u.l ;*..`VnS .n .iuv|\ \.;k ''i P*. '' .u . u u 14 ''TV*'' ;*m i**`'i * I * '1 .if'n-lull . mu .!.r . a Ml '!*. ; * :r\l i:l a ,f|. .'fk" pf.-" mi Uk r.nr.t' 1. *! nijk't.ik.i it !!:. i' .aIk.'.; t*f Mr:' i.m. -1H I.f' nf Mk 2 >V* i:\Ilk'll.il . \ s'f.ir-M.u.: v 1 ki'-u.*. ,!u. ik-ii II 'hi' A .i . .1 ;! '*k!!.' . .pnpikii ' 1 ui.i'_v Mu he.uth ;**.[:. A.n* li; ;.MM _ u ! * .11 * \;*i :. it* * ' M-* a . 4 Kpl.i* . Mk pn .it: r.*Vx!' * Miiii ; lit. 4.4ien -.u.ik,i,. m.ha 4 t * Mini--;'* p.itt:*-.* ik ' *p->P tin.-i : . x. *! Mix:.:'-. A..( : .'!.ik .! !'* lik ph-.'iv .u 1 . 4i 1.! a* 4.. : a 4^ is. j l: a :* P^-* .in.! pj4 1.4. Mk Ilk *r- .4ii p: .1* !i* . : .r;.!u-M r. .** l.e .Ji* liufin u, .nP.-; ' ` ui.* ' .m pi u P t 4': ' " n ; p*. s . n It;*. 4 ;.* pk\ ;* :..i. ;> U'.ii. M it iiP..-'-, . t : i j' t. - ' ' 1 *'li: ,vf ;i{ ' IJ.il 'r, v 4 -<ii 1.4* M\ .m'.i! 'l,v 'i4.. 1 \puk-. . U f* 4 ' a: *, : . m: . - . .r. * ,c. I. k . j P'*.|. 1 l'rvriuii'iiu'iH >l PlTMltlN J- l ';slu.Miu tu \s|VN|MS 1 i-.* j'ku * ::.* t'.l 4'*'Pi..n e - .r. .i.il i> 4; . .!*--;.Mti.; ' iv t . J I- .11* Ma ' ...l.ihlittM till' 'U.I.i'MP'. >: Ilk' 4 Mk' * - Up.. ' v'l. 4 M:*' ll.H ;nf* 1.4 Ml*- :I!P1 ;! i., *.4k*rk'P i'.L--n i- wv i ' ,'|i`ivi|tL' 1*. ,).*.:% Mk a*4 pi.lv i' > 4k I Ms- 41' Mitl'l tk' k 1 ;m A || 'k I. l e . t*\ I vji 4, ' * . 111 'V i knle .il'i 'ip .1 pr. ' j v. If..' *mi p`i- *s ev 'Aim inoik ,il -i iff .i II.* pll\'l*;.U: 'll.'Uk! '.U'.- Mk- -pp< 4 1111:11 pi*- pi.* nf . .> ii i ,tf t > 41 vlk'tit' v..nr.*. In' 1*4' .ipph*. Ii;t V _\l7hl, J M.I Mi.-.WI :,.*: ''V I V l.lflki .ll'l .1 e ' || l' < * flip'- ; . ..if r >. . flu- pir 41 -A Ml MM : Ik .4 -f ;*' ' I * m:1 *'. et\ (-!!m! Ik -uki fv nij.'p Jr . VOl.l Ml: 4(i NO `I 1 ,hu .! U*:m minim > 'tjiim mu "' !< `v v. .'*.K U .MM I.UImvs -IJ' ? ,.>.!.* A..f*vfx a. a '* (m * >i > >if.: < n'l'kH ii. I.iih .1 } miily -r i- 'i*.n !<!.. .1 . . ! iv it . ti.v >i 'U-(unv ?nvl.'t\ ^ i,n !uxU'i\ ,1m.' i .i, ! '\-v ..-II * ,<I|W >vv'v I ! 'U . '|S x -,|.t\ : k *{u >i> ! V ||,!1U lit' Vt.HK-iI - \ I.ifl.'ltlx M ixfi | \ XIRl ' X I S Kx {MI .||.*l N Ss ' v :i.il .i4iU'h\'u.n vik>nv i.ji t n v x-**11 .it m-fi - ; ' \ f'"M|-i(' nit., tu i rH r*iyvl'*.jiii * * I. .iv,kv on 1,1. t -u ^ n.'-n . tii 1r**'1- tile *>->uh' + .*xir.n>vtl ,u \|'i,{<(! . il.'jro '> .! {Ml v n 111 'X ! M 'xlk 'Hi l|| . | ,lU'i Muu'.| ll.Ml .it'll . .<1 w V o s .iMU ni i;'[A'ii iiiiv"'. :,;W'iii _ .t !m . * 'M lxi'x' . >* V ,.:mI , . . ,1V .. M il] V ,ily I *1 '- > ' I \ 'V * I Ijilitl ll I, > :.UHv ;*U'l;t.il i I'M. 11 ' l .11 >* M ' It !).|S }'IV'\ Meed ptMMted < Hi! I fl.il ?)li` pe pt.KCtnclIl MVlllx jl c\ .illMIhih IS .m essential tool f T U'V' m the mcvtiw.il super* iMon oi asbestos workers because n establishes the principles upon which future manaecmeut til *v `vised h . e* the pios|Vx live applu ant .n imi-cht wo the 'et/*>!/*m-'s' >) fbc rvohJc.m .uni enables me pm m x ian to iCsonimend 'Uilahiiitv. miurcd 'UJluNniv > i.ji uitsuiUbdnx oi the uwlix aia.ii tor the rob I he opp.mmilv vmji the pie placemen! phvsixul cxamuutnto pio\;des >>i tne mesliy.tl -tall t' vmiiiih-i T.e uuliv nhul ami .'tab ;Vm>hI at *i:e y.ueef >J `he b .ij';1 uat.l ;m\ u,V' \V.S 'V^i .*pjn iinmn\ 'i't :he es*ivfme "! JenhJ.v .it:. .lelail* in*I . y;,; . a,e t lu i.i n Ik i ' * . 'i.ii ii'ii 'lie . i.ii.i i m* .'he Ictnj 'i'll, vv up IVnudic Medical f s .duahmi !V Kw'pt viiuler Micila.n ui . e ill.iik . 1 < a*ie. I > *! pen. ^lu . x.iimnati*nis js Jhm *\ "* vU t. .tt.inees m me phVu.tf yMikhtn't}. phv s!4l*i af >l.jtUs .>i iadi*! *'ju at .ippc.uaiKes >t the exfV'^ed jvfM*ri hut .ijs.f l re evaiuatv the \M'rk|Wue y*iJni>ns .iml tlu autnuluji ' sinf.ihiJitv to vi*mmue vloine lite same .oh Med:. .il : md:ne' v art Iv Kkutdci! on an oneome basis . .ilU>\.v .ompaM'.'ii !i*m me evaimiuhi n u< the next I tie jvti.slu it\ *I Hie ex aJ uation priKess xsrfI dcfvml uj'on .JemunsM.ili.-i! need .*inl ax JijjMe nun l^'xvcr as .veil as reeulamn re^mremtills the OvkUpalmnjI Saletx and MejJth Vditimis(r.i(n<it pu muiealed the \she'ti*s Siandatd'l IK Pi hi Hail in )uh P#"Z Se.tinii Pj*tI|M m tequifes that e'erx em plove" sluil prm ,Je. *r nuke jx.nlahic. at least anmutlx vHinprehensixe tried.*.a) exarimutn'iis t. eaih emploxee cneaecd m an Hk-wUpatioii exposol m .nrfrre .nrkem.a lur)s ol ashesius hhers I he numnmm :eqimemenf is hr 'a v.hesl rvnti'enoeram pusier.*-: `.mn fJ \ 1" lUkhesi. a hisl*rx to eln.il s\mploiii.,:.-i- o| tespiia- !or\ disease, and puhnoha/) tuiiktum tests ti nisJude tofved vital yjpacitx and N*Ked expnatorx \ol umc at I second d ! A t IVrunlik tnemea' exahutren is xle'iened ts dete-.t ttk hioloeical etKMs ! ndulalioit d asheslos is eailx as possible .md J)'|VlIK at a sUvv wtu*n teno\.,j iioin further <*%,eup.itiorr,l ex^.siue to aslvstos m.x ariesi or siemtKantlx del.ix (he ptoercss .'I asivsi*-sis iju OkeuireiKe ol oihe- a'hestos related condif-oirs I pi lemioii\etk CMvIehcCol the value ol thi' phn :dute is n.-; xet axailahle .md the Juncm?: enxitonmeni.d xonditn'iis m I he workplace ihiouehout die as.vstos i:iilus:rx oxer the pasi tiffv veavs onlv senes i,i fconlwse die issue when aitein}>tmu tv' .ishsv (he v.due *'f earfi dMcm-s/s \ \\c {vnoshe ex.ihuhn should injudc a pnx'ic.il ex animation exen ihouch the < 1SH \ sundaid v1 vs not sjv v.d\ d Iheexammei sjnaild voiuenti.it; on tne phs m\ a. Mt'tts assiviatevl vv nil puhnonaix irhiosis stj4). .jN hd.ilei.n end-msptiaii'ix nnc xraxkles a( die une l>.oxs Jmeer vUihhme and t'leaddessness In 'he v .ov- .t ,. n. s iui. empiovees. es^vuaUx lieaxx 'im-veis die ;v ssihiinx lune eaiuei slnuiU alwaxs iv Nme n -min: !-ans*en'. pleural elliJsions ,*vviii n .jsiV't"s .voikeiv I he aim ot ladiolo-jk suix eiii.nu e d .ot\ .s .o-tky'' :s v* yompa'e serial nvnteenoei.nus m - i. `.om a . exposai e pel uni ,t (eeu; it ntv earliest Junees whuit souidix-uh n ,k\..|.n- wuil'.' die *rtdmd<ru! 'h*'ir!<J K .idvoe.i *o i.i.muIi., viepioxTiieih K.uiiv .ipn*. .1 .1.1 I x. -n.>.<..i **. >- - ;'t . ' Ju iee seen lie Mo4,.,i \P i'.au : MU' \sbeslos Inlet iialii 'iial \>'.s - n i o pic i I.s xiiiith.J ( lilai,. :.a :1.x Ih... t..-o . . atid < 'oflsideralj. *n> ui .d.e \'ml- m< . -i 1 .m. i ,i\a a ... Me sotliehoina to \sr'e-f..y| s,;s-..,:e .Wcy:, . . .a a liable ai e.u lx l 's. ( r.x M \f' ......... k i :ii.a ensure .iniipai.P'dilx ) .utioer..j'to "u mub. ,- t n : a. I'll:.,:: .) ..ti il'. *1 ' :.1 . a M' o' pt:r, r.k meiv''- ui u 1 I .. ... -r < e sJlv*uld he 'tiJl as 'oll-.-x `!w i..pi * the tit (ti nix .mterroirv ..ed the Jenm ;:b m..o I . revoidine ot .dunce' ai d:o 'adi- .i.ipo o-oai.t ne .leenfilanee xv ith tin,* j| () linei Main nail \i". heat ion > Kadioer.-^is oj ihieui.-H k 'hi. 'C'' 1 Pleurallv-'i1 *ii' ai v` *f \i I fie J'i'! : d.. m "I exposjie to asbestos 1 i.x'x mh. .e. .< iim'1 ditluse . a Its. uh/ed ple.na: Mm *. n e -i . .:n>. t\ ; pleulal platpies '.sith-a a ithoal . ai* ! a(i.-< no., e iinl need n( he as'.-s at. xi a Mi asv.oto -.a.i;. r _ Jjhrosjs | he pleura) ji'ia ti.' ..a: K exteh'ive 'o opsvine 'f:e <mj Ma..:- jmJ a. n . cases. \ud t>" inipatin.eui ol ;,in> ` m. t.ou ll has *'leri .Mown diat 'vhc'e.i `a.: jraphu pal Ifriit y luii-'e a m n.. a i'..[ n. . n1 Mohs experienced nvei d.e .. -ur . a >. :ri..nat. aie refuted Co tefiedh f expo.,a. o. j\-. a (denial yiiaiiccs |-i!' :*iv \ piv - v i:' at u:: :ui a: 1 >j*iv xi en -.xhtyh t- ; .*i .a a - .a.,n.. ihseM.v`d m low eiudc .*.p--siu; ups .iv; pu. yhxmal eMevts aie le" nr.ei*. o x.n 512 conni-ctk'i/t Mi nirisp. si imimki k i ' G / ES A . til ' *> ,tU :' i * s i! . .in i .Ulik.ii .Je 'tUikm-.. h\ the i*h\ *,* ;.ii' .1* h.n* i v v uimm m.ii . ..'N s.'iKxl ilehmte! uUk'`:t.iplV v if'i. ' . \ , n i : x mi *.:11M*J I'.ilient' H li. " In .mi .ivhe'* i .iniu'e ]*ui n x \\t.i .nmiu! lv in nwu Mix' illlll' ulil.ll !*,ji ' m :1k i , \ ''uu :* 1 ,i' .'r"> \\ .IK Iv'.IK' :llx' ;`t. I'.it'iiM % ' I;. 11 Mv 'lukih-n m ..i ; .I ith mile 1 he ,'UMU i :|w ;\i'l x umui.iM w .Ju't . . rue MielK'f rlie ;'ii n\il'i!ifv. f .j'l.'JV' <*i-e 'm-m.,,. *Ai,<k x K f**ui-inim/e :i\ .'e.-iee 1 ? ht-i**-* *1. iw.iu-e ue ->K K*t .!% \ f:! '! 'IX ....iItlhkJ.'t! hIl,.jix* veil .novwi :v. !<'* M!l/x'J III *f !;f.V *n*'i J ,jix..' mint ) J'lAf e . *1 ;ui>\ iklu.u' i th ;n `i I'V.H.SI 'IlKKit! It: *:*; .' v ill.U 'l.lk|Ui ` re .ii^'.ireriitv wile.: x:v.:m I ',i!' i-i'i x \p->wie i,; ! 'v ;iM 1 . 'f 'li. ref v -k .\ t\' ni.'ii , M.xi.' '\ f. I .leJ u., ,i;v U. .1 *\ ! x I,'* */Uf m en *.e.c.i. .-.'V-:*- . VM.-NJI*' .Jk ,i:.l j'kfi.-ihx . t ... a: , *.. . n.n .v r . . ' '<1 . ' ,t. . . ... lb 1 ' 1 he tMe.l'UteMklM '< Mk` -''H : '-'.if -if iMUpi'IK 111**. lUMH'k . \ U.W k .J\k it . i \ < evpn .it .III tk-umu v.ifmne Ht file MtN.' s'ki'fM <f e\.'m ( flu- t.ifii' -'f the^e - ll\ . '* ( *n*`i Mili'il V ti'iii u :u . ('.iff*mu . ..-jjsixtx n Ilk' .Ik' - 'life! i . Mji*'ikr. !e-t re'i ill Ilk' 1. 1 ilii:. 11 _U .:K ' i ,j -ir : Jx -h'x t \ ivheie mmnnmm.il .ilvie VMiere l.ivinlie e\i>i im : u : 'UllilV'' '.niutne ix.IJ'.U if X 1 `.enl:**ii h.i* *Vci m.wle thiiN '..e the '|Mi!un: e\.iimn,ih*m: N>i x\ii*l;.ih\e %!* \ ,m. ft.i- tv ;kil.'ir, :h I*' esp*fcu: a hi* \ ..'Jl ^.>.e i: x 1.1.,' l : t" it'K * . *v . | i., ' -I :v n .1 .-i; .Mill. .Itx n..: u,. m* -u: m : . *. mf- . et -* .e e ..vle.UM 'Jmhj;"'. \>i. a r\,f .ite .!e'. I :..;e 'I :v- iy> i' * :,.iiii:,: a - -`l' kf' - ' 1: - K... 'x . i;. .m *. .a'i v.'.i: . \ i U l M t it. Nt> ' 'i\ ixx ' : . .-..i:..- 'ii * \ ! l> .:l ' * rhs' ;'f!'..ix x '! x ft! .i'll,. ' * .if *Ci Viix.' *, :t\ .iki.iIn ' :fti? .s : . m; *> i/f.if-..:' -* , * . a. .tlx t: 8 .ilV-t miii Sor\ i-iII.nu t IV; !.' .sf"- v. . ' ;*M. .*' ,t:,:. * - it. . kjfu .*! . \;. : ".it ' * '* e - j/ii! | !e II. i. .. '.f.'-:imi ;v ' '' * ' `` 'i ' f ' -r> .'> ; a . >;Jx : ' ai> ' > Mie . . *1 'hv:: -.' Kx ' t,. .ifii - :.. . ,ix , vrt-M. *m* : -!; *`i x .i' x ? . a .*{ n:.,n - -n- ti.eii! . *`I '<> U.u It.t"' ir ,i-.. * ' x ' *i . .fixie., . * s .'tiij'i' .e- tl:, 'ittt.l.t t.J illil.-f "ix.iiv,:! x.J? . x I l. IIK . 1 f.x' l` ii !:k . -uixj tv uMer-.i* >.) mn ne.it: - ! . I.. ti.Miii.. i ni . .i j j n.l x1 `i'i :l e i'. ..III! ? -e.' .1 t'V, ;K i!\| ' ; . akv*:i h) *nrtiT v .srtw *.'r <xnJ tUi'f.ir' >s J*u *> iU-\ mu 'oitoniv: *tU' All !* U'k ,!!<! p*<'i'J i'U` ji.J 5 hi1 ;'u x v`t\tns . *t i.K '!* u'l.ik'ii K ,4p, >f| (, riCHUV-WM-1 U k Hlh 'h 'u*' .J|hj JuM \ `1111 l .k" :*lc *'l :l)t* pj)\ sn jjj> ' 'hi.' 'rv,wnti`,-n o\ ill i*`h pl.k^nkii! irnl nfri'.i .! '!v Uk'H.k^ 'VtWv.M A.'tkwt .ilhl .vhjk Ilk' kkimujuc '! in.klu.jl ^wi\ ^:il.iiu k* :v mu'H'I' mu' n '.lu' Mur! Ahuh v>'m]Mivx the M.il k'l^UitCii '.Jk 'J'l.ihl w ir.pli' vv liv'.iltM I Ik' k!i'<* ***! .,*lVl.ill*`U 'I vmp|.'\.-r ;tk| ^'Itpii'WC U tlk* *llf \ v ll I .'ilk Mi'CUtii .ilK'u* A iv.11 u*\ w* Mx.`!nfu .inf u'Mifh l K-nvlif fii n!h KIHKIMh ^urllll t .:.! <1.j I ` M * '*..* 1 V ' S ' * Vs* * :. ... . \\ \ V V ..... Ml ' ' *1 M. . ..... . I I M. *s|< \ > .1, I V I .I Mi V. M.m VV ll ^ .in ni . -i M " l-i" HW ulv l-i M.v*> M. V. i > . V. r , \vl\ .1 n,l Ms 'U i1- 'in.I i . I ` .1 I /1 III Vx ' I . X II 1 * . s, . . l, >. I Si' v II M ('OSM-C III l I Ml i)U IM V "11 VIII l;