Document GzGX0g33eEpJwkkxLpb1v44B7

Liiuir SUBJECT: Vinyl Chloride and Related Topics May 12, 1977 Following a review of the vinyl chloride presentations by Dr. Burdick and Dr. Robinson in a resume' of the Louis ville seminar concerning vinyl chloride, the following discussion is made for your consideration, editing and/or approval. 1. We have recommended that the routine x-ray of the distal phalanges be discontinued in the initial examination for vinyl chloride. ThJs complication of fecraosteolysis developing in the initial workers has not been reported in recent years due to im provement in engineering techniques. We feel that this is a non-productive area in the care of the m-0 Jf**f**P'*<+ r worker. u This is not covered as a ppjsfcion of the mandatory examination. 2. In a previous letter of communication from Dr. Robinson, in which the standard deviation was in creased 10 - 20%, increasing flexibility in the determination of the enzymes standards, permitting a possible decrease in the cases placed on and maintained on restriction. The file figures have not been tabulated. However, we have now removed 4 individuals from restriction during the past 30 days. It must be remembered as mentioned in the resume' from the Louisville seminar that, the EC 2836 Page 2 quality control of the laboratory and/or labora tories doing these enzymes studies must have exact control mechanisms and quality standard controls. 7^ It has been demonstrated in previous reports that as many as 16% of the control groups can have de viation of standards showing abnormalities, pre c!c/" 7 sumably some of these being due to re-agent meoha- The pathologist at Louisville had made recommendations concerning this problem. These can be noted in Dr. Robinson's resume'. 3. IT IS OF SIGNIFICANT NOTE THAT NONE OF THE BIOPSY SPECIMENS, OF WHICH THERE WERE 3, PRESENTED TO THE PATHOLOGIST AT LOUISVILLE (1 related to a brain tumor, not related to vinyl chloride) BRINGING THE u ci TOTAL TO 4 -- THESE -SPECTOENS--FASED- -TO- REVEAL ANY EVIDENCE OF HISTO-PATHOLOGICAL CHANGES COMPATIBLE WITH VINYL CHLORIDE INTOXICATION. It is my under standing that subcapsular necrosis and focal necro sis represent those areas which would be affected and caused by vinyl chloride liver intoxication. 4. We now recommend that the intermediate liver scan be eliminated, and that should an individual show persistently elevated liver enzymes of those relat ed vinyl chloride intoxication, namely LDH-5, alka line phosphatase^live^, SGOT, GGPT, and SGPT, that is to say following a satisfactory period of restric tion that these individuals be r ferred to a gastro enterologist for evaluation at which time the liver EC 2837 Page 3 scan can be done. We feel that this would not place any compromise in diagnostic evaluation of the individual. 5. We have now extended that period of time between enzyme studies from 3 to 6 weeks. We feel that the half life of the enzyme, and that although alcoholism and etc. produce elevated enzymes that, this would present no compromise to the individual's health and that the standards as presented by OSHA do not specifically state a requirement of 3 weeks that a 6-week period is more realistic in awaiting a re turn to normal of these enzyme studies. With the above statments we feel that we can now intro duce the following conclusions: 1.1 All individuals with persistently elevated enzymes should have a work profile, namely, where and how, and what type of vinyl exposure does he have. (A recent in cident involving a Maintenance man which failed to wear a mask because he was outside of the vinyl area, al though he was removing valves which were plugged with vinyl and was occasionally exposed to large concentra tions. This man had not had a personal monitor at any ^v, C,J 1.2 Following initial enzyme studies, thev"*fee' elevatfetty a period of 6 weeks should be allowed to inter vene before the repeat enzyme studies are done. EC 2838 Page 4 1.3 Should the enzymes be elevated on the second study, the individual should be restricted from the vinyl area. 1.4 Following a 6-week period of restriction and a repeat enzyme study, should they be elevated again the individual should then be referred to a gastro- enterologistTfer-instanee(Dr. Louis Hargus) for eval uation. At this time the patientj_s drug profile and alcoholic profile will be it must be remembered that at all times the individual worker is asked not to ingest alcoholic beverages during his period of observation should any of his abnormalities present themselves in the enzyme study. dispositioned 1.5 The individual shall be dispestiened by the recom mendation of the gastroenterologist, and f........................s work-up as to return to work in the vinyl rsr main on restriction or be-removed permanently from the vinyl area. 1.6 The new values will be enclosed in the attached graph showing the standard values resulting from calcu- . lation of standard and mean deviation. In our conversation I also requested a letter of confirms tion regarding disposition of individual who donates kidney to his brother for a kidney-transplant operation. Should this individual be returned to the lead area and what work restrictions should be place on him. Pending evaluation and FO 2839 Page 5 consultation with a nephrologist, it would be my opinion at this time that no restriction should be placed on the indi vidual . The lead check program which you are familiar with and which I discussed, will be revised so that individuals with a& (v - 100 micrograms of lead/urine with less- on 3 occasions cgtf: Ccl'1*** ^ ** will be restored to the lead area should they have been previously restricted. I would appreciate your comments regarding possibility of selective removal of the showering for lead check, either by virtue of 3 previous consecutive values of less that 100 not requiring showering possibility of individual not shower ing on coming to work, although this is difficult at this plant. Perhaps, it should be noted that further engineering controls have lessened the lead in the air, and hopefully this trend will continue so that the lead contact with the individual^ clothing and skin may not^suffficient to warrant further routine showering previous to lead check. Another suggestion would be that the possibility of the odd numbers not require shower, and should the elevations be over 100 tyjj-f then it would be repeated I AM ENCLOSING THE LETTER FROM MR. BRUTON WITH REFERENCE TO THE STATISTICAL FIGURES WHICH YOU REQUESTED. We are unable to uncover any cause related to our activities at this plant which would reduced the reduction in spot urine checks. DICTATED Enel. or u--Dr.~Burd-irok EC 2840