Disclosure I have served as an expert in litigation Tony Mazzocchi - PDF document

Taking t ng the o occupati pational a onal and e envir vironment onmental h l histor ory – y – Center for Surveillance, Epidemiology, and Laboratory Services wh why it y it matter matters Robert Harrison, MD, MPH University of California, San Francisco & California Department of Public Health Disclosure I have served as an expert in litigation Tony Mazzocchi 1926 - 2002

• Take an occupational history • Inform workers • Connect the dots Take an occupational history • 24 y.o. male with 8 months numbness and tingling of extremities, poor concentration, decreased memory. Treated with high dose steroids x 3 months. • PE: decreased vibration, pin, light touch. Broad based gait.

The basic occupational health history 1. What is your job (what kind of work do you do)? 2. Tell me (exactly) what you do at work. 3. Do you work around any chemicals, dusts, or fumes? The advanced occupational health history* 1. Prior work history 2. Names of products, Safety Data Sheets 3. Air monitoring results 4. Duration and intensity of exposure 5. Temporality of symptoms 6. Hierarchy of controls 7. Toxicology and epidemiology research *Probably needs referral to OH provider

No search on Google images shows use of brake cleaner

Peripheral neuropathy due to n-hexane • Cleaned brake linings and wheel wells with n-hexane x 18 months • Nerve conduction: decreased velocity and prolonged distal latencies • Removed from exposure with slow improvement

• N ‐ hexane removed from brake cleaners • No exposure to workers (UCB study) • “Green chemistry” law in California Inform workers

Irma Ortiz • 40 y.o. woman • Mixed dry powder with diacetyl x 5 years • Symptoms of shortness of breath and cough. Treated for asthma. • FEV1 = 0.55 L (18% predicted). HRCT with ground glass opacities. California Department of Health Services http://www.dhs.ca.gov/ohb/flavorings.htm Baltimore Sun - April 23, 2006 Sacramento Bee - July 30, 2006 Nov November 23, 23, 19 1992, Terri Bonar-Stewart received a letter dated November 17, 1992 from the Montgomery County Ohio Coroner's Office regarding investigating the death of Ms. I, a former employee of Fries & Fries.: Ms. I had been on disability leave since 1987, and the coroner requested any reports and health records related to that disability. De December 4. 4. 199 1992: Jim Steinke reported that during a casual conversation with his neighbor, Joseph Thorpe, M.D., Dr. Thorpe expressed a concern that he had been treating one current and one former Tastemaker employee for a condition which he defined as bronchiolitis obliterans. According to Dr. Steinke, Dr. Thorpe noted that bronchiolitis obliterans is an unusual disease, and having two cases of the disease at one site was cause for concern. He noted that the former employee, Ms. JMI was deceased and that he had listed the cause of death as bronchiolitis obliterans. He also identified the other employee as Mr. JW. Mr. W was currently on medical disability leave. Mr. Mike Davis scheduled a meeting for December 8, 1992 to discuss Dr. Thorpe's concern and to establish an action plan.” Egilman 2007 IJOEH; internal company memos

1995: 995: Pulmonary consultant #1: “what we -- what I had was several -- I think five or six, somewhere around that, cases of individuals who had been employed in the company who developed asthma and who had a clinical picture of bronchiolitis obliterans and who had in some cases biopsies, lung biopsies, which substantiated that diagnosis.” 1995: 995: Pulmonary consultant #2 : “diacetyl – this would be added to the butter. It would reach a certain temperature and flash. He subsequently would awaken at night with chest tightness and cough and difficulty breathing… This occurred two to three times per week until the butter operation was transferred to the spray dry area approximately two years prior to this evaluation.” [Diagnosis: bronchiolitis obliterans] Both consultants had signed non ‐ disclosure agreements Source: deposition testimony, various cases NIOSH was not notified and never did an investigation at Givaudan Gilster ‐ Mary Lee Corporation Jasper, MO

NIOSH study at “ sentinel ” • microwave popcorn plant • 4 of 8 workers on lung transplant list • One recent death Abnormal Spirometry by Diacetyl Exposure • Airways obstruction in 40 % affected popcorn workers 35 30 25 20 related to cumulative 15 10 5 0 Lowest quartile Second Third Highest quartile diacetyl exposure levels (dose-response Cumulative diacetyl exposure quartiles relationship) Kreiss K et al. Clinical bronchiolitis obliterans in workers at a microwave popcorn plant. NEJM 347:330 (2002). Petition for emergency standard CalOSHA • AFL/CIO petition for emergency standard granted by Standards Board 1/18/07 • Advisory meetings held 9/28/06, 2/13/07, 3/21/07, and 5/18/07 • Public hearing 11/19/09 • Final standard passed September 16, 2010

Connect the dots January 7, January 7, 2012 2012 Maratho Mar athon Oi n Oil well l well si site te Di Dickinson, ND ND Ph Photo – o – Mike Sorag e Soraghan

Ju July 9, ly 9, 2010 2010 XTO XTO En Energy ergy o oil w l well ll s site te Lambert, MT Lamber MT Photo – Ph o – Mike Sorag e Soraghan

Jul July 9, 9, 201 2010 July 9 ly 9, 2 2010 10 EMS run n EMS ru n notes tes Sidney H dney Health C th Center E nter Emergency ergency Department rtment Sidney Sid ey, MT MT Jul July 9, 9, 201 2010 Sidney ey Health th C Center er E Emerge gency ncy D Department Sidney, MT Sidn , MT

Sep September 9, 9, 20 2013 Sep September 29, 29, 20 2011

Si Silicos licosis is c case se s summa mmary, Ca Californi lifornia (J a (Janua anuary 2 2019 - 19 - Feb ebruary 2 y 2020) 0) N N = = 10 conf 10 confirmed ( (6 ali alive and and 4 4 dea deaths) Data sour Data source Out Outcom ome Comme omments Cas Case #1 #1 Hospital discharge Confirmed, died 2018 Contact tracing of relative “Sentinel” “Se Cas Case #2 #2 Relative of Case #1 Confirmed, died 2018 Lung tissue from coroner Case ses # s #3-6 Worksite case Confirmed Collaboration with investigation CalOSHA Case ses # s #7- Silica medical Possible, pending F/u with company, 12 12 examinations pulmonary evaluation Concentra and pulmonary of sentinel worksite specialist Cas Case #13 #13 Hospital discharge Confirmed, died 2014 Outpatient records, telephone interview with friend Cas Case #14 #14 Kaiser OM department Confirmed Worksite visit Cas Case #15 #15 WC attorney to UCSF Confirmed Information to QME for claim approval Cas Case #16 #16 Hospital discharge Confirmed, died 2017 Interview with family AJPH 1983 AJPH 1983 • Warning signal to improve care and/or prevention • Lead to epidemiologic or IH study • Assist the HCP in diagnosis and treatment

Inher Inherently occupational ntly occupational Asbestosis Byssinosis Chronic beryllium disease Coal Workers Pneumoconiosis Extrinsic Allergic Alveolitis Mesothelioma Scrotal Cancer Silicosis Silicotuberculosis Talcosis Taking t ng the o occupati pational a onal and e envir vironment onmental h l histor ory – y – Center for Surveillance, Epidemiology, and Laboratory Services wh why it y it matter matters

Pedro Alarcon 1969 ‐ 2017 Which of these questions are part of a comprehensive occupational history? A. Prior jobs and exposures B. Use of personal protective equipment C. Names of chemicals or products D. All of the above You diagnose a serious occupational disease among five cases at one company. What is the most effective preventive action to take? A. Sign a non ‐ disclosure agreement as a consultant to the company B. Report the cases to OSHA or the State public health agency C. Continue treatment and not inform anyone D. Check with your malpractice lawyer

A Sentinel Health Event (Occupational) A. Is a disease, disability or death that is legally established as caused by work B. Must be proven by epidemiological or industrial hygiene studies C. Should trigger regulatory or public health investigations that can prevent more disease D. Requires the employer to implement engineering controls or personal protective equipment