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T9IB2W / vhg/T-s / nusceUaocoui / S-3-90,2-28-91 SHELL OIL COMPANY LAW LIBRARY P.O. BOX 2463 HOUSTON, TX 77252 TO FROM COMPANY: NAME:p^^0MANjjj LOCATION: PHONE: NAME ' let CtiftLs LOCATION: 4731 OSP FAX: (713) 241-5362 PHONE: (713) 241-3514 DATE: TIME SENT TOTAL PAGES # FAXED TO Hiv AM PM A- +COVER rtb-ieii * IF ALL PAGES ARE NOT RECEIVED, PLEASE NOTIFY REMARKS: This facsimile may contain CONFIDENTIAL INFORMATION which may be LEGALLY PRIVILEGED and which is intended only for the use of the Addressee(s) named below. If you are not the intended recipient of this facsimile, or the employee or agent responsible for delivering It to the intended recipient, you are hereby notified that any dissemination or copying of this facsimile may be strictly prohibited. If you have received this facsimile in error, please immediately notify us by telephone and return the original facsimile to us at the above address via the United States Postal Service. Thank you. OPMC- df LAM 019164 25 TAC 97.155 TEXAS DEPARTMENT OF HEALTH ftourcc: The provisions of this 97.155 adopted to be effective March 13, 1986, 11 TestReg 1045. 97.156. Denial, Suspension, or Revocation of Stamp (a) The division may deny an application for a stamp or suspend or revoke an existing stamp if the applicant or holder fails to comply with the requirements of these sections. The applicant or holder has the opportunity to request a hearing on any of these actions in accordance with depart ment formal hearing rules, 1.21-1.32 of this title (relating to Formal Hearing Procedures). (b) The department will not suspend or revoke a stamp without a prior hearing, except if the division determines that immediate suspension or revocation is necessary because of imminent threat to public health; the division may suspend or revoke the stamp and offer the holder the opportunity for a post-action hearing. Source: The provisions of this 97.156 adopted to lie effective March 13, 1986, 11 TexReg 1045. ' CHAPTER 99. OCCUPATIONAL DISEASES Section 99.1. General Provisions. 99.1. General Provisions (a) Purpose. This section implements the Texas Occupational Disease Reporting Aci, House Bill 2091, 69th Legislature, 1985, which authorizes the Texas Board of Health to adopt rules concerning the reporting and control of occupational dis eases. (b) Definitions. The following words and terms, when used in these sections, shall have the follow ing meanings unless the context dearly indicates otherwise. (1) Case--A person in whom an occupational disease is diagnosed by a physician based upon clinical evaluation, interpretation of laboratory and/or rocntgcnographic finding;;, and an ap propriate occupational history. (2) Commissioner--The commissioner of health. (3) Department--The Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756. (4) Local health authority--The chief admin istrative officer of a public health district or a local health department, or the physician who is to administer state and local laws relating to public health. (5) Occupational diseases--Those diseases and abnormal health conditions that are caused by or are related to conditions itr-the workplace. (6) Reportable occupational disease--Any oc cupational disease or condition for which an official report is required. See subsection (d) of this section. (7) Report of an occupational disease--The notification to the appropriate authority of the occurrence of a specific occupational disease in a human, including all information required by the procedures established by the Board of Health. (8) Suspected case--A case in which an occu pational disease is suspected, but the final diag nosis is not yet made. (c) Reporting requirements. (1) It is the duty of every physician holding a license to practice in the State of Texas to report promptly to the local health authority each pa tient she or he shall examine and who has or is suspected of having any reportable occupational disease. The local health authority may autho rize a staff member to transmit reports. (2) It is the duty of every person who is in charge of a clinical or hospital laboratory, blood bank, mobile unit, or other facility in which a laboratory examination of any specimen de rived from a human body yields microscopical, cultural, serological, chemical, or other evi dence suggestive of a reportable disease to re port promptly that information to the local health authority. (3) The reporting physician or laboratory di rector shall make the report in writing. A local health authority may authorize one or more employees under his or her supervision to re ceive the report from the physician or labo ratory director by telephone; use of this alterna tive, if authorized, is at the option of the report er. The local health authority shall implement a method for verifying the identity of the tele phone caller when that person is unfamiliar to the employee. f'IqT^C. O'* ,Or,^'*'a' r "AstesTvvs * a^oV# - if MJy * ^(f ~tUx , (4) The local health authority shall collect the reports and transmit the information at weekly intervals to the Bureau of Epidemiology, Texas Department of Health. Transmission may be made by mail, courier, or electronic transfer. (A) If by mail or courier, the reports shall be placed in a sealed envelope addressed to the attention of the Bureau of Epidemiology, Texas Department of Health, and marked "Confidential Medical Records." (B) If by electronic transmission, including facsimile transmission by telephone, it shall be in a manner and form authorized by the commissioner or his or her designee in each instance. Any electronic transmission of the reports must provide at least the same degree of protection against unauthorized disclosure as those of mail or courier transmission. The commissioner or his or her designee shall, before authorizing such transmission, establish guidelines for establishing and conduct ing such transmission. (5) When a case of occupational disease is reported to a local health authority, and the person diagnosed as having the disease resides outside his or her area of local health jurisdic tion, the local health authority receiving the report shall notify the appropriate local health authority where the person or persons reside. The department shall assist the local health au thority in providing such notifications if re quested. (d) List of reportable occupational diseases. Oc cupational diseases reportable by name, address, age, sex. race/ethnicity, method of diagnosis, and relevant occupation(s) and employees) of the case, and identity of the reporter, are: SRHB3P silicosis, blood lead levels at or above 40 micri>grams lead/100 milliliters of blood in persons 15 years of age or older, and acute occupational pesticide poisoning. (e) General control measures for reportable oc cupational diseases. The commissioner or his or ' her duly authorized representative shall, as cir cumstances may require, proceed as follows: (1) investigation shall be made for the pur pose of verifying the diagnosis, ascertaining the source of the causative agent, obtaining an oc cupational and employment history and dis covering unreported cases; (2) collection of specimens of the body tis sues, fluids, or discharges and of materials di rectly or indirectly associated with the case, as may be necessary in confirmation of the diagno sis, and their submission to a laboratory for examination; (3) obtaining samples of air or materials from the current or former business or place of employment of a case, as may be necessary to ascertain if a public health hazard exists. If a hazard is found the commissioner or his/her designee shall make appropriate recommenda tions concerning the hazard. (f) Confidential nature of case reporting. (1) All case reports received by the local health authority or the Texas Department of Health are confidential records and not public records. These records will be held in a secure location and accessed only by authorized per sonnel. (2) The department may use information ob tained from repons or health records for statis tical and epidemiological studies which may be public information as iong as an individual is not identifiable. Authority: The provisions of this 99.1 ii&ued under Texas Civil Statutes, Article 5182c, 3. Source; The provisions of this 99.1 adopted to be effective October 11, 1985, )0 TcxReg 3766. CHAPTER 107. [RESERVED] CHAPTER 109. TUBERCULOSIS TUBERCULOSIS CONTROL Section 109.1 through 109.24. [RESERVED] 109.25. Patient Transfers. 109.26. Funeral Service Contracts. 10927. Gifts, Grants, and Donations. 10928. Clothing Needs of Patients. 10929. Marking of Indigent Patients' Graves. Section 109.30. Admission of Quarantine Patients. 109.31. Disposition of Patients' Trust Funds and Miscel laneous Personal Property. Authority-. The provisions of this Chapter 109 issued under Acts 1959, 56th Leg- p. 379, ch. 181, effective August 11. 1959, as amended (Texas Civil Statutes. Article 4477.11); Acts 1965. S9th Leg. p. 124, ch.-51, effective August 30. 1965, as amended (Texas j no 3 PPMC-i LAM 019166 25 TAC 97.155 Texas department of health Source: The provisions of this 97.155 adopted to be effective March 13, 1936, 11 TcxReg 10*5. 97.156. Denial, Suspension, or Revocation of Stamp (a) The division may deny an application for a stamp or suspend or revoke an existing stamp if the applicant or holder fails to comply with the requirements of these sections. The applicant or holder has the opportunity to request a hearing on any of these actions in accordance with depart ment formal hearing rules, 1.21-1.32 of this title (relating to Formal Hearing Procedures). (b) The department will not suspend or revoke a stamp without a prior hearing, except if the division determines that immediate suspension or revocation is necessary because of imminent threat to public health; the division may suspend or revoke the stamp and offer the holder the opportunity for a post-action hearing. Source: Tbc provisions of this 97.156 adopted to 6c effective March 13. 1966, 11 TexAc* 1045. ' CHAPTER 99. OCCUPATIONAL DISEASES Section 99.1. General Provisions. 99.1. General Provisions (a) Purpose. This section implements the Texas Occupational Disease Reporting Act, House Bill 2091. 69th Legislature, 1985, which authorizes the Texas Board of Health to adopt rules concerning the reporting and control of occupational dis eases. (b) Definitions. The following words and terms, when used in these sections, shall have the follow ing meanings unless the context dearly indicates otherwise. (1) Case--A person in whom an occupational disease is diagnosed by a physician based upon clinical evaluation, interpretation of laboratory and/or rocntgcnographic finding::, and an ap propriate occupational history. (2) Commissioner--The commissioner of health. (3) Department--The Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756. (4) Local health authority--The chief admin istrative officer of a public health district or a local health department, or the physician who is to administer state and local lav/s relating to public health. (5) Occupational diseases--'Those diseases and abnormal health conditions that are caused by or are related to conditions kr-fhe workplace. (6) Reportable occupational disease--Any oc cupational disease or condition for which an official report is required. See subsection (d) of this section. (7) Report of an occupational disease--The notification to the appropriate authority of the occurrence of a specific occupational disease in a human, including all information required by the procedures established by the Board of Health. (8) Suspected case--A case in which an occu pational disease is suspected, but the final diag nosis is not yet made. (c) Reporting requirements. (1) It is the duty of every physician holding a license to practice in the State of Texas to report promptly to the local health authority each pa tient she or he shall examine and who has or is suspected of having any reportable occupational disease. The local health authority may autho rize a staff member to transmit reports. (2) It is the duty of every person who is in charge of a clinical or hospital laboratory, blood bank, mobile unit, or other facility in which a laboratory examination of any specimen de rived from a human body yields microscopical, cultural, serological, chemical, or other evi dence suggestive of a reportable disease to re port promptly that information to the local health authority. (3) The reporting physician or laboratory di rector shall make the report in writing. A local health authority may authorize one or more employees under his or her supervision to re ceive the report from the physician or labo ratory director by telephone; use of this alterna tive, if authorized, is at the option of the report er. The local health authority shall implement a method for verifying the identity of the tele phone caller when that person is unfamiliar to the employee. t LAM 019167 DPMC-12790 TUBERCULOSIS (4) The local health authority shall collect the reports and transmit the information at weekly intervals to the Bureau of Epidemiology, Texas Department of Health. Transmission may be made by mail, courier, or electronic transfer. (A) If by mail or courier, the reports shall be placed in a sealed envelope addressed to the attention of the Bureau of Epidemiology, Texas Department of Health, and marked "Confidential Medical Records." (B) If by electronic transmission, including facsimile transmission by telephone, it shall be in a manner and form authorized by the commissioner or his or her designee in each instance. Any electronic transmission of the reports must provide at least the same degree of protection against unauthorized disclosure, as those of mail or courier transmission. The commissioner or his or her designee shall, before authorizing such transmission, estab lish guidelines for establishing and conduct ing such transmission. (5) When a case of occupational disease is reported to a local health authority, and the person diagnosed as having the disease resides outside his or her area of local health jurisdic tion, the local health authority receiving the report shall notify the appropriate local health authority where the person or persons reside. The department shall assist the local health au thority in providing such notifications if re quested. (d) List of reportable occupational diseases. Oc cupational diseases reportable by name, address, age, sex, race/ethnicity, method of diagnosis, and relevant occupation(s) and employees) of the case, and identity of the reporter, are: asbestoses,/ silicosis, blood lead levels at or above 40 micrograms lead/100 milliliters of blood in persons 15 years of age or older, and acute occupational pesticide poisoning. (e) General control measures for reportable oc cupational diseases. The commissioner or his or ' her duly authorized representative shall, as cir cumstances may require, proceed as follows: (1) investigation shall be made for the pur pose of verifying the diagnosis, ascertaining the source of the causative agent, obtaining an oc cupational and employment history and dis covering unreported cases; (2) collection of specimens of the body tis sues, fluids, or discharges and of materials di rectly or indirectly associated with the case, as may be necessary in confirmation of the diagno sis, and their submission to a laboratory for examination; (3) obtaining samples of air or materials from the current or former business or place of employment of a case, as may be necessary to ascertain if a public health hazard exists. If a hazard is found the commissioner or his/her designee shall make appropriate recommenda tions concerning the hazard. (f) Confidential nature of case reporting. (1) Ail case reports received by the local health authority or the Texas Department of Health are confidential records and not public records. These records will be held in a secure location and accessed only by authorized per sonnel. (2) The department may use information ob tained from reports or health records for statis tical and epidemiological studies which may be public information as long as an individual is not identifiable. Authority: The provUiors cf this 99.1 issued under Texas Civil Statutes, Article 5J82c. 3. Source: The provisions of this 99.1 adopted to be effective October 11, 1985, ]0 TcxReg 3766. fP * ^ , "0r"'V* .^SERVED] RCULOSIS TUBERCULOSi *C Section 109.1 through 109.24. (RESE * 109.25. Patient Transfers. 10926. Funeral Service Contra it 10927. Gifts, Grants, and Dona 10928. Clothing Needs of Patiei 10929. Marking of Indigent Pan e,-rtf'4 , n*' ll. A* Admission of Quarantine Patients. Disposition of Patients' Trust Funds and Miscel laneous Personal Property. CM .--uorttyt The provisions of this Chapter 109 issued under Acts 1959, 56th Leg., p. 379, oh. 181, effective August 11. 1959, as amended (Texas Civil Statutes, Article 4477.11); Acts 1965. 59th Leg , p. 124, ch.-51. effective August 30. 1965. as amended (Texas 191 LAM 019168 TPDN 1986 Vol. 46, No. 48 Page 3 Texas Preventable Disease Vol. 46, No. 48 November 29, 1986 NEWS Ron | Anderson. M D. Robert Bernstein. M D FACP Chairman Commissioner Texas Board ol Health contents: Occupational Disease Reporting in Texas Procedures for Reporting Occupational Diseases Occupational Disease Reporting Rules Danger - Children and Lighters Monthly Statistical Summary CPSC Alert: Voltron Toy Recall Bureau of Epidemiology, 1100 West 49th Street, Austin, Texas 78756-3180 (512-458-7207) OCCUPATIONAL DISEASE REPORTING IN TEXAS: PROCEDURES FOR REPORTING OCCUPATIONAL DISEASES Occupational diseases that are reportable by law are newly confirmed or suspected cases of asbestosis, silicosis, acute occupational pesticide poisoning, and elevated blood lead levels (blood lead greater than or equal to 40 ug/dl in persons 15 years of age or older). The system for reporting these occupational diseases follows that of current communicable disease reports. Physicians and others with case reports are requested to provide the name, address, age, sex and race of the case and the diagnosis and date of diagnosis to their local health department or regional health director who, in turn, will transmit this information to the Texas Department of Health, Bureau of Epidemiology. Reports also may be made directly to the bureau by calling the toll-free number: 1-800-252-8239. Bureau staff then will contact the initiator of the report to obtain more information about the case. The law for occupational disease reporting provides for the confidential handling of all case reports. Please do not hesitate to contact the Bureau of Epidemiology (512/458-7268) if you have any questions or need further assistance. DPMC-I27gp LAM 019169 TPDN 1986 Vol. 46, No. 48 Page 4 TITLE 25. HEALTH SERVICES Part I. Texas Department of Health Chapter 99. Occupational Diseases Reporting 25 TAC SECTION 99.1* The Texas Department of Health adopts new 99.1, with changes to the proposed text published in the July 26, 1985, issue of the Texas Register (10 Texas Register 2399). The new section implements the requirements of House Bill 2091, Article 19, 3, 69th Legislature, 1985, which authorizes the Texas Board of Health to adopt sections covering the reporting of occupational diseases. The new section covers definitions, reporting requirements, confidentiality of reports, general control measures for reportable occupational diseases, and the list of reportable occupational diseases. In addition to the occupational diseases listed in House Bill 2091, 69th Legislature, 1985, this new section also contains the occupational disease of acute occupational pesticide poisoning. The new section is adopted under Texas Civil Statutes, Article 5182c, 3, which authorizes the Texas Board of Health to adopt rules covering the reporting of occupational diseases. 99.1 General Provisions. (a) Purpose. This section implements the Texas Occupational Disease Reporting Act, House Bill 2091, 69th Legislature, 1985, which authorizes the Texas Board of Health to adopt rules concerning the reporting and control of occupational diseases. (b) Definitions. The following words and terms, when used in these sections, shall have the following meanings unless the context clearly indicates otherwise. (1) Case--A person in whom an occupational disease is diagnosed by a physician based upon clinical evaluation, interpretation of laboratory and/or roentgenographic findings, and an appropriate occupational history. (2) Commissioner--The commissioner of health. (3) Department--The Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756. (4) Local health authority--The chief administrative officer of a public health district or a local health department, or the physician who is to administer state and local laws relating to public health. (5) Occupational diseases--Those diseases and abnormal health conditions that are caused by or are related to conditions in the workplace. (6) Reportable occupational disease--Any occupational disease or condition for which an official report is required. See subsection (d) of this section. (7) Report of an occupational disease--The notification to the appropriate authority of the occurrence of a specific occupational disease in a human, including all information required by the procedures established by the Board of Health. LAM 019170 "Adapted from: Texas Register, September 27, 1985, 10 Tex Reg 3766-7. DPMC-1 TPDN 1986 Vol. 46, No. 48 Page 5 (8) Suspected case--A case in which an occupational disease is suspected, but the final diagnosis is not yet made. (c) Reporting requirements. (1) It is the duty of every physician holding a license to practice in the State of Texas to report promptly to the local health authority each patient she or he shall examine and who has or is suspected of having any reportable occupational disease. The local health authority may authorize a staff member to transmit reports. (2) It is the duty of every person who is in charge of a clinical or hospital laboratory, blood bank, mobile unit, or other facility in which a laboratory examination of any specimen derived from a human body yields microscopical, cultural, serological, chemical, or other evidence suggestive of a reportable disease to report promptly that information to the local health authority. (3) The reporting physician or laboratory director shall make the report in writing. A local health authority may authorize one or more employees under his or her supervision to receive the report from the physician or laboratory director by telephone; use of this alternative, if authorized, is at the option of the reporter. The local health authority shall implement a method for verifying the identity of the telephone caller when that person is unfamiliar to the employee. (4) The local health authority shall collect the reports and transmit the information at weekly intervals to the Bureau of Epidemiology, Texas Department of Health. Transmission may be made by mail, courier, or electronic transfer. (A) If by mail or courier, the reports shall be placed in a sealed envelope addressed to the attention of the Bureau of Epidemiology, Texas Department of Health, and marked "Confidential Medical Records." (B) If by electronic transmission, including facsimile transmission by telephone, it shall be in a manner and form authorized by the commissioner or his or her designee in each instance. Any electronic transmission of the reports must provide at least the same degree of protection against unauthorized disclosure as those of mail or courier transmission. The commissioner or his or her designee shall, before authorizing such transmission, establish guidelines for establishing and conducting such transmission. (5) When a case of occupational disease is reported to a local health authority, and the person diagnosed as having the disease resides outside his or her area of local health jurisdiction, the local health authority receiving the report shall notify the appropriate local health authority where the person or persons reside. The department shall assist the local health authority in providing such notifications if requested. (d) List of reportable occupational diseases. Occupational diseases reportable by name, address, age, sex, race/ethnicity, method of diagnosis, and relevant occupation(s) and employer(s) of the case, and identity of the reporter are: asbestosis, silicosis, blood lead levels at or above 40 micrograms lead/100 milliliters of blood in persons 15 years of age or older, and acute occupational pesticide poisoning. (e) General control measures for reportable occupational diseases. The commissioner or his or her duly authorized representative shall, as circumstances may require, proceed as follows: (1) investigation shall be made for the purpose of verifying the diagnosis, ascertaining the source of the causative agent, obtaining an occupational and employment history and discovering unreported cases; LAM 019171 DPMC-12794 TPDN 1986 Vol. 46, No. 48 Page 6 (2) collection of specimens of the body tissues, fluids, or discharges and of materials directly or indirectly associated with the case, as may be necessary in confirmation of the diagnosis, and their submission to a laboratory for examination; (3) obtaining samples of air or materials from the current or former business or place of employment of a case, as may be necessary to ascertain if a public health hazard exists. If a hazard is found, the commissioner or his/her designee shall make appropriate recommendations concerning the hazard. (f) Confidential nature of case reporting. (1) All case reports received by the local health authority or the Texas Department of Health are confidential records and not public records. These records will be held in a secure location and accessed only by authorized personnel. (2) The department may use information obtained from reports or health records for statistical and epidemiological studies which may be public information as long as an individual is not identifiable. This agency hereby certifies that the rule as adopted has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority. Issued in Austin, Texas, on September 20, 1985. TRD-858690 Robert A. MacLean Deputy Commissioner Professional Services Texas Department of Health ** CPSC ALERT: VOLTRON TOY RECALL The US Consumer Product Safety Commission has announced the recall of 1.5 million "Voltron Lion" toys imported from Taiwan during the past two years due to the presence of a high percentage of lead in the paint used to color the metal parts of the toys. The toys were imported from Taiwan by Matchbox Toys (USA) Ltd of Moonachie, NJ. Two models of the toy are being recalled. The first is the Deluxe Lion version which stands about 11 inches tall and sells for S60 to $90. The second is a minature version about six inches tall which resembles the taller version except that the body parts are not designed to separate. These models are not to be confused with the plastic versions of the same toy or the versions manufactured in Japan. The recalled items carry silver stick-on labels on the back/or bottom of the foot stating they were made in Taiwan; the name Bandai is embossed either on the foot or under the jaw of the larger version. These particular toys were found to contain in excess of 10% lead by weight of the paint. Since young children are very susceptible to lead poisoning, parents should remove these toys from use immediately. To receive a free replacement toy consumers may call, toll-free, 1-800-445-8697. The importer will mail a free mailing label for return of the lead-containing toy. If further information is needed, consumers should call CPSC's toll-free number 1-800-638-CPSC or contact Dan Sowards, Bureau of Consumer Health Protection, Texas Department of Health at (512) 458-7519. LAM 019172 GEORGE L DELCLOS. MD, MPH PATRICIA A- BUFFLER, PhD, MPH S. DONALD GREENBERG. MD MARCUS M. KEY, MD, MIH DENNIS M. PERROTTA. PhD CHARLES ALEXANDER, MD, DrPH R KEITH WILSON, MD Asbestos-associated disease: a review ftZLy irSZiL, iLf OJ-ct^lL T {Uosj<^Jr ^ves-f 56) X George L Delclos, MD. MPH. Pulmonary Sec tion. Dept of Medicine. Baylor College of Medi cine. Houston, and The University of Texas School of Public Health. PO Box 20186, Houston. TX 77225; Patricia Buffler, PhD, MPH. and Marcus M. Key. MD. MIH. The University of Texas School of Public Health, Houston; S. Donald Greenberg. MD, Dept of Pathology. Baylor College of Medicine. Houston; Dennis Perrotta. PhD. Division of Epidemiology. Texas Department of Health. Austin; and Charles Alexander. MD. DrPH. Bureau of AIDS and STD Control. Texas De partment of Health, Austin; and R. Keith Wilson. MD. Pulmonary Section. Dept of Medi cine. Baylor College of Medicine. Houston. Send reprint requests to Dr Dclclos. Asbestos and its potential for adversely affecting bestos increased dramatically until the mid-1970s health remain a source of concern to several sec when concern regarding health effects of asbestos tors of society. Since it rarely occurs in the absence and the implementation of strict regulator)' stan of occupational exposure to asbestos, and because dards resulted in a decrease in annual use (from ap it is potentially preventable, asbestosis was re proximately 800,000 metric tons used in the United cently defined as a reportable occupational disease States in 1973 to 210,000 metric tons in 1983). in Texas. An overview of the cardinal characteris Worldwide cumulative production of asbestos prod tics of the asbestos minerals and their associated ucts, however, has continued and it is estimated that health effects is presented. The role of the primary approximately 30 million metric tons of asbestos physician in diagnosis and counseling of indi are still in use in this country (4). viduals with asbestos-associated diseases is Isolated case reports of pulmonary fibrosis in addressed. heavily exposed asbestos factory workers appeared KEY WORDS. ASBESTOS. ASBESTOSIS. OCCUPATIONAL DISEASE REPORTING. as early as 1906 (5) and increased rapidly thereafter (6). Although an association between asbestos ex posure, asbestosis, and lung cancer was suspected as early as 1935 (7), firm epidemiologic evidence in ferring causality was not reported until 1955 (8). In he occupational lung diseases are recognized 1960, a causal association between asbestos ex Tby the National Institute for Occupational posure and mesothelioma, a malignant and invari Safety and Health (NIOSH) as heading the list ably fatal tumor of the pleura and/or peritoneum, of the ten leading occupation-related conditions winas reported (9) and thus further expanded the this country (1). When one considers prevalences, pectrum of asbestos-related diseases. potential disability, premature death, and preven- Asbestosis first became a recognized compensable tabilirv, asbestos as a cause of pulmonary disease disease in 1931, in Great Britain under the Work continues to be a source of concern to industry, men's Compensation Act. In the United States, com labor, government, and the general public. This is pensation was first awarded to an asbestos weaver heightened by different medical, sociopolitical, and in 1927, through the Massachusetts Industrial Acci economic considerations. dent Board (10). The extent to which occupational In 1985, asbestosis, one of the asbestos-related diseases are covered in the United States varies ac diseases, was defined as one of the four reportable cording to each state's workers compensation laws. occupational diseases in Texas (Texas Civil Statutes. This inconsistency has led to numerous cases being Article 5182C) (2). The other three reportable con argued via tort litigation in the courts. ditions are elevated adult blood lead levels, silicosis, Initially, most cases of asbestosis described were and acute occupational pesticide poisoning (3). limited to workers in the mining, milling (11), and This review is one of a series of papers on the re manufacturing (12) sectors. End-product users (eg. portable occupational Qucases in which an over insulators, pipefitters, shipyard workers, etc), were view of the historical, epidemiologic, mineralogical. not regularly reported as being at risk of asbestosis pathological, and clinical features of asbestosis and until the late 1950s and early 1960s (13), although the spectrum of asbestos-related conditions or dis isolated cases in this sector had been described as eases is presented. early as 1934 (6). From a medicolegal standpoint, the asbestos product use sector is of great interest, Modem history since the numbers of exposed workers in these Asbestos is a term that refers to a group of naturally- occupations are now considered to substantially occurring fibrous hydrated silicate minerals, useful outnumber those in the mining, milling, and manu to man because of their properties of enhanced facturing sectors, in the United States, it has been strength, flexibility, and resistance to physical and estimated that over 27 million persons have been chemical insults. It was used sporadically for pro occupationally exposed to asbestos since 1940 duction of purses and lamp wicks for hundreds of (14). The potential medical, economic, and legal years. Widespread production and use of asbestos implications of these figures are readily apparent. began in the late 19th century with the introduc Implementation of regulator)- measures and safe tion of the steam engine. Unique properties of as workplace practices paralleled scientific knowledge; bestos--flexibility and virtual indestructibility-- the measures taken initially, such as those of the US were unmatched at the time by any other mineral Public Health Service, however, were limited and or man-made fiber and quickly led to its use in the left up to industry to implement and enforce (15). manufacture of a long list of construction materials A major step towards stricter workplace regulation and textiles, including cement, insulation products, took place in 1970 with the passage of the Occupa friction materials, electrical appliances, and protec tional Safety and Health Act and the subsequent tive garments Worldwide production and use of as creation of the Occupational Safety and Health Ad- DPMC-12796 Texas Medtcme LAM 019173 Asbestos-associated disease 56 The most common presenting symptoms of the patient with mesothelioma are unremitting chest pain and increasing dyspnea upon exertion. Chest radiographs may show a moderate or large effusion and pleural thickening encroaching on the inter lobar fissures and infiltration of the mediastinum, as the tumor progressively encases the lung and neigh boring structures. Establishing a pathologic diag nosis prior to death is frequently difficult. Closedneedle biopsy of the pleura and pleural fluid analysis may have a low diagnostic yield; open- or thoracoscopically-guidcd pleural biopsy procedures pro duce better samples. Other tumors such as meta static adenocarcinoma may mimic mesothelioma, and frequently a combination of gross pathology, microscopic study of specimens, and histochemical testing for the presence or absence of certain mucins and enzymes is required for a definitive diagnosis. OTHER MALIGNANCIES Although there is general agreement on the associa tion between asbestos and both lung cancer and mesothelioma, a consensus does not exist as to whether there is an increased risk of other tumors such as gastrointestinal, laryngeal, renal, and ovarian carcinomas in asbestos-exposed populations. Among these tumors, the epidemiologic evidence is most abundant for tumors of the digestive tract, with some studies reporting an increased risk, although not always statistically significant, among those ex posed to asbestos (85,102,103); other studies have not found such an increase (29,104). Exposureresponse relationships have not been documented in studies of asbestos exposure and tumors of nonrespiratory sites, the biological plausibility of an effect has been questioned, and animal experiments have been unable to substantiate the association of gastrointestinal tumors with asbestos exposure (4,105). Doll and Peto (106) suggest that misclassification of cases of peritoneal mesothelioma as gastrointestinal cancer may account for most of the observed excess. Notwithstanding this, OSHA con sidered gastrointestinal cancer as probably asso ciated with asbestos exposure when it recently re vised its exposure limits (16). There arc fewer data on the associations between tumors other than gastrointestinal and lung and as bestos exposure. Although some studies have sug gested an excess number of laryngeal carcinoma cases among asbestos workers, these studies were limited by problems with study design, lack of ade quate reference populations, and lack of adjustment for the confounding effects of smoking and alcohol intake (4,107). Even so, the likelihood of misdiag nosis of laryngeal carcinoma, particularly in casecontrol studies, is low, and an argument is made for the biological plausibility of such an association. This association, therefore, remains unresolved and further study seems warranted (106). Role of the primary physician The primary physician has two important roles with respect to patients with a history of asbestos exposure: the identification and counseling of indi viduals at risk and the accurate diagnosis of asbestosassociated diseases when present. Obtaining a care ful occupational history, which includes a detailed description of onset of exposure and the duration and nature of exposures, cannot be overempha sized. Likewise, an accurate smoking history and careful review of radiographs for evidence of both malignant and nonmalignant pathology are essentiaL When identified, persons at risk should be accu rately informed as to possible complications deriv ing from their exposure and the health significance of any pulmonary changes. Baseline and periodic pulmonary function testing, as well as radiographs, may be helpful in this assessment. When a possible asbestos-associated disease is identified, the patient should be informed, for purposes of compensation, of the existence of a statute of limitations from the date of notification. If a diagnosis of asbestosis is suspected or con firmed, the case should be reported either to the local health authority or directly to the Epidemi ology Division, Texas Department of Health. Re ports arc accepted by mail or toll-free telephone report (1-800-252-8239). These rules provide for strict confidential handling of case reports. To bet ter serve the purposes of surveillance, a precise case definition for asbestosis has not been established. However, the epidemiologic surveillance criteria for a case is stated as "a person in whom an occupa tional disease is diagnosed by a physician based upon clinical evaluation, interpretation of labora tory and/or roentgenographic findings, and an appropriate occupational history" (108). Pleural ^9 plaques do not require reporting. Mesothelioma, as well as any other cancer, is reportable under the Texas Cancer Control Act. OSHA requires that a preplacement medical ex amination be performed prior to assigning an indi vidual to a job with potential for exposure to air borne asbestos. For active employees, an annual comprehensive medical examination is required. Chest roentgenographs should be offered "at 5 year intervals during the 10 years following any em ployee's first exposure to asbestos. After 10 years from the employee's first exposure, the age category of an employee will determine the frequency of x-ray testing: up until age 35, x-rays will be required at 5 year intervals; between the ages of 35 --45 medical examinations will be required every 2 years; and above age 45, x-ray will be required on an annual basis" ( 16). DPMC-12797 Texas Medicine LAM 019174 c i / j t 80. Cochrane GM, Prieto F, Clark TJH: Intrasubject variability of maximal expiratory flow volume curve. Tho rax 32:171-176, 1977. 81. Lerman Y, Seidman H, Gelb S. ct al: Spiromctric ab normalities among asbestos insulation workers. J Occup Med 30(3):228-233, 1988. 82. McDonald JC, Liddell FD, Gibbs GW, et al: Dust ex posure and mortality in chrysotile mining, 1910--1975. Br J Ind Med 37(1): 11-24, 1980. 83. Hobbs MS, Woodward SD. Murphy B, et ah The in cidence of pneumoconiosis, mesothelioma and other respi ratory cancer in men engaged in mining and milling crocidolite in Western Australia. LARC Sci Publ 30: 615-625, 1980. 84. Newhousc ML, Berry G: Patterns of mortality in as bestos factory workers in London. Ann NY Acad Sci 330:53-60, 1979- 85. SelikofflJ, Hammond EC, Seidman H: Mortality ex perience of insulation workers in the United States and Canada 1943--1976. Ann NY Acad Sci 330:91 -- 116, 1979. 86. Buntoni R. Vercelli M, Merlo F. et al: Mortality among shipyard workers in Genoa Italy. Ann NY Acad Sci 330:353-377, 1979. 87. Browne K: Is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? Br J Ind Med 43(3): 145-149, 1986. 88. Parkes WR: Occupational lung disorders, ed 2. London, Butterworths, 1982. 89. Huang SL Amosite, chrysotile and crocidolite as bestos are mutagenic in Chinese hamster lung cells. Mutat Res 68(3):265-274, 1979. 90. Browne 1C A threshold for asbestos related lung cancer. BrJ Ind Med 43(8):556-558, 1986. 9t. Brown RC, Chamberlain M, Davies R, et al: In vitro biological effects of glass fibers. J Environ Pathol Toxicol 2(6): 1369-1383, 197992. Ives JC, Buffler PA, Greenberg SD: Environmental associations and histopathologic patterns of carcinoma of the lung: the challenge and dilemma in epidemiologic studies (Review article). Am Rev Respir Dis 128( l): 195- 209, 1983. 93- Churg A: Lung cancer cell type and asbestos ex posure. JAMA 253(20): 2984-2985, 1985. 94. Greenberg M, Davies TA: Mesothelioma register 1967-68. BrJ Med 31(2):91-104. 1974. 95. McDonald JC, McDonald AD: Epidemiology of mesothelioma from estimated incidence (Review article). Prev Med 6(3):426-442, 1977. 96. Peterson JT Jr, Greenberg SD. Buffler PA: Nonasbestos-related malignant mesothelioma. A Review (Re view article). Cancer 54(5):95l --960, 1984. 97. Wagner JC, Berry G, Timbrell V: Mesothelioma in rats after inoculation with asbestos and other materials. Br J Cancer 28(2): 173- 185, 1973. 98. Wagner JC, Berry G, Skidmore JW, et al: The effects of the inhalation of asbestos in rats. BrJ Cancer 29(3):252-269, 1974. 99. Weill H, Hughes JM: Asbestos as a public health risk: disease and policy (Review article). Annu Rev Public Health 7:171-192, 1986. 100. Browne K: Asbestos-related mesothelioma: Epi demiological evidence for asbestos as a promoter. Arch Environ Health 38(5):26l --266, 1983- 101. Seidman H, Selikoff IJ. Hammond EC: Short-term asbestos work exposure and long-term observation. Ann NY Acad Sci 330:61-89. 1979. 102. Henderson VL, Enterlinc PE: Asbestos exposure: factors associated with excess cancer and respiratory dis ease mortality. Ann NY Acad Sci 330:117--126, 1979. 103- Finkelstein MM: Mortality among employees of an Ontario asbestos-cement factory. Am Rev Respir Dis 129 (5):754--761, 1984. 104. Hughes J, Weill H: Lung cancer risk associated with manufacture of asbestos-cement products. LARC Sci Publ 30:627-635. 1980. 105. Edelman DA: Exposure to asbestos and the risk of gastrointestinal cancer: a reassessment. BrJ Ind Med 45(2): 75-82, 1988. 106. Doll R, Peto J: Asbestos. Effects on health of ex posure to asbestos. London. HMSO, 1985. 107. Chan CK, Gee JB: Asbestos exposure and laryngeal cancer: an analysis of the epidemiologic evidence (Review article). J Occup Med 30( 1 ):23-27, 1988. 108. Texas Administrative Code. Section 99.1, Art 97, Title 25. For additional resources on this topic, see the MORE ON THE SUBJECTS department in this issue Volume 85 Mm 1989 DPMC- 1273 LAM 019175 rAx /VI K /M V < 11 DPMC-1 LAM 019163