Document jmMBdV9n4V9K0YvVMOvqQDw5R

1 Urdtzd July 26. 1964 Cbrpcrmticm Mr. F. X. Mascianloaio Vice Fre sident Environmental Affairs Subject: Revised Guidelines For Medical Surveillance Asbestos Exposure For your information, a copy of tbe recently revised "Guidelines For Medical Surveillance, Asbestos Exposure", is attached. William C. Marshall. M. D. Assistant Medical Director WCM:rp Attachment cc: Messrs. W. B. Buhrmaan*-^ C. W. Cooaor.'Zn K N. Diehl C. t. Day D. H. Hoffman A. P. Myer ? Forrest Fisher, M.D. _ __ . USX0000930 ' GUIDELINES FOR MEDICAL SURVEILLANCE ASBESTOS EXPOSURE The following guidelines for aedical surveillance shall be followed in all United States Steel Corporation operations whenever exposure to asbestos oeeurs. 9 1. A comprehensive medieal examination shall be provided (or made available) to all employees prior to initial employ ment in an occupation with exposure to airborne concentrations of asbestos fibers. These medical examinations will be required for any 7 to hour time weighted average concentration of 0.1 flbers/ec, or for a greater concentration. (The OSRA Asbestos Standard permits this examination to occur within 30 calendar days of the first exposure.) Annually thereafter, and within 30 calendar days before or after termination of employment Involving exposure to airborne concentration of asbestos fibers, a physical examination, as designated above, shall be provided (or made available) to these employees. Whenever pleural thickening is found on any routine chest x-ray of an Individual who has had any airborne asbestos exposure, this individual shall be kept under yearly medical surveillance. * The minimum components of the examination shall be: (a) A medical history. Including a respiratory question naire to elicit symptomatology of respiratory disease. (b) A 14" x 17" chest x-ray, posterior-anterior view* Whenever there is evidence of pleural response, right and left oblique views and an expiratory posterior-anterior view should be taken to confirm or rule out pleural findings. *. *. . ****** (c) . Pulmonary function testing to include forced vital capacity (rvc) and forced expiratory volume at one second (FEV^). 2. Upon Initial aasignment to an occupation where exposure to airborne concentrations of asbestos fibers may exist, a complete work history shall be taken. This is particu larly Important if changes in the chest x-ray begin to appear. The work history shall include all work experi ences in United States Steel, as well as non-United States Steel work experiences, to determine*the effect of exposure to asbestos. This history should include mili tary exposures, ship and shipyard duties, hobbles, exposures from family SMmbers (father, brothers, grand- USXO000931( ' J. . fathers* mother* sisters* ate.)-who may have -worked end brought asbestos fibers boas on their clothing, residen tial locations for proximity to asbestos mining or manufacturing plants* and even recreational areas in relation to discarded wastes from asbestos factories. 3. All chest x-rays should be read by a certified radiologist who is also a *1* reader. It is permitted to contract with sueh a radiologist to read all x-rays taken at the work location. Where the x-rays are not taken in-plant, arrangements should be made to have the films read by a certified radiologist who is a "B* reader. (A *B* reader is certified following successful completion of Qualifying examination of 125 ehest x-rays by NIOSH and the American College of Radiology.5 4. A clinical evaluation leading to a diagnosis and recom mendations will be made. (a) Correlate all medical findings (history* physical findings* chest x-ray Interpretation, pulmonary function results, and any other medical Information) with the environmental exposure data. (b) Referral to a pulmonary specialist to assist in this evaluation may be done at the option of the plant medical director or other examining-physician. (c) Referral of the chest x-ray to another "B" reader may occasionally be neeessary for the proper interpretation of the x-ray. 5. The clinieal evaluation will usually result in a diag nosis of one of the following in decreasing order of , importance! (a) Asbestosis - typically pulmonary infiltrate of s, t* u type* with or without pulmonary function decrements* and with or without'pleural thickening or plaques (with or without calcification) - record on OSRA-200 log as "Asbestosis*. (b) Pleural thickening with history of asbestos expos ure - bilateral pleural thickening or plaques (with or without calcification) and with or without pulmonary function decrements. Without pulmonary function decrements, there is no need to refer unless requested by the employee. Record on OSHA-200 log as *Pleural thickening with history of asbestos exposure*. USX0000932 I (e) Unilateral plaural thickening or plaques with or without adequate* history of asbestos exposure (with or without calcification) and with or without pulmonary decrements - the most likely explanation for the pleural thickening in this group is one of the following! infection (pleural effusion) or hemorrhage, callous from rib fraeture, radiation fibrosis, seleroderma, ehronle mineral oil aspiration, metastatic disease, lymphoma, myeloma, or a combination of these. BO NOT RECORD ON OSHA-200 LOG. Normal anatomical shadows (pectoral shadow area, extra pleural fat deposits, serratus and external oblique muscle shadows) can usually be ruled out ty the above sectioned (l.(b)) techniques* (d) Normal chest - further follow-up testing fails to substantiate suspicions in original chest x-ray or pulmonary function tests. The role of smoking in any pulmonary function decrement must be carefully evaluated. Diffusing capacity determinations may be helpful in ruling out pulmonary fibrosis and probably should be done. Xn coke plants, the possi bility of coal workers' pneumoconiosis (with or without focal emphysema) must always be ruled out. 6. Recommendations to the physician in discussing findings with the affected employees! (a) Each employee must be Informed of any positive findings discovered as a result of his/her exami nation by the United States Steel physician and/or consultant, and an evaluation of these findings will be diseusssed with the employee. Recorded exposure levels should also be given to the employee. Because of proper handling of asbestos today, thtse environmental levela will likely be low enough to allay any fears of continued exposure to hazardous levels. (b) ' If the employee has a pulmonary Infiltrate due to asbestos exposure, with or without pleural reaction, he/she shall be advised that this response is due probably to exposures of passed years. Depending upon the pulmonary function finding, the risk of continued decrement is probably directly correlated to continued smoking. This is especially true if any continued exposure is properly handled by respiratory protection and is of minimal monitored value. The corporate headquarters' Environmental Health unit shall prescribe the approved manner of handling any continuing exposure. Medical surveil lance should be continued every year and, if pulmonary function levels decrease, then at shorter USX0000933 ^ Intervals if clinically Indicated. Every effort should be Bade to get the individual to STOP smoking if he/she is a smoker. Sy some estimates, the risk of lung cancer in those with parenchymal Infiltrate is up-to sixteen (16) times the risk of a non-smoker with the same exposure and ninety (90) tines that of a worker who is a non-smoker and not exposed to asbestos. (e) An employee with bilateral pleural thickening or plaques due to asbestos exposure (with or without calcification) - should be advised that this response is the result of many years of low level exposure. These changes should not progress if the exposure has been eliminated or properly controlled by proper handling of asbestos or by respiratory protection if exposure continues. Depending upon the pulmonary function findings, the risk of continued decrement is directly correlated with continued smoking. This is especially true if continued exposure is properly handled by respiratory protection and is of minimal monitored value. The corporate headquarters' Environmental Health unit shall prescribe the approved manner of handling any continuing exposure. Medical surveillance should be continued yearly unless there is a decrement in pulmonary function, then at shorter Intervals if clinically indicated. If this occurs, more frequent surveys may be'clinically indicated. Every effort should be made to get the individual to STOP SMOKING if he/she is a smoker. (d) Unilateral pleural thickening or plaques (with or without calcification) - continue to follow on a yearly basis. (e) Normal - yearly follow-up. 1 7. Environmental monitoring - will be carried out by the Environmental Health unit (corporate headquarters or plants) according to requirements -of the OSBA Asbestos Standard. * 6/26/84 USX0000934 * t/z. 'i I