ORRHES Meeting Minutes,
August 27, 2002
Table of Contents
August 27, 2002
Call to Order/ Opening Remarks
The Oak Ridge Reservation Health Effects Subcommittee (ORRHES) convened
on August 27, 2002, at the YWCA at 1660 Oak Ridge Turnpike, Oak Ridge,
Tennessee. Chairperson Kowetha Davidson called the meeting to order at
12:15 PM, welcoming all attendees.
Introductions
Kowetha Davidson asked the attendees to introduce themselves. The attendees
present at this time were:
Kowetha Davidson, Chairperson, ORRHES
La Freta Dalton, DFO, ATSDR
Brenda Vowell, Tennessee Department of Health
Chudi Nwangwa, Tennessee Department of Environment and Conservation
Elmer Akin, Environmental Protection Agency (EPA)
David Johnson, ORRHES member
Bob Craig, ORRHES member
Susan Kaplan, ORRHES member
James Lewis, ORRHES member
Don Creasia, ORRHES member
LC Manley, ORRHES member
Karen Galloway, ORRHES member
Jeff Hill, ORRHES member
Barbara Sonnenburg, ORRHES member
Pete Malmquist, ORRHES member
Donna Mosby, ORRHES member
Charles Washington, ORRHES member
Peggy Mustain Adkins, ORRHES member
Tony Malinauskas, ORRHES member
George Gartseff, ORRHES member
Don Box, ORRHES member
Herman Cember, ORRHES member
Jerry Pereira, ATSDR
Burt Cooper, ATSDR
Jack Hanley, ATSDR
Bill Murray, ATSDR
Marilyn Palmer, ATSDR
John Steward, Paper, Allied-Industrial, Chemical, and Energy (PACE ) Workers
Union
John Merkle, Karns resident
Al Brooks, Oak Ridge resident
Bob Peelle, Oak Ridge resident
Tim Joseph, Oak Ridge Office, Department of Energy
The recorders are Ken Ladrach and Amylane Duncan, Auxier & Associates,
Inc.
Agenda Review, Correspondence, and Announcements
Agenda Review
Kowetha Davidson reviewed the agenda dated August 27, 2002, noting the
following:
- Work Group presentation sessions
- Guidelines and Procedures Work Group report on facilitating meetings
- Communications and Outreach Work Group demonstration of ORRHES website
- Health Needs Assessment Work Group report on a community clinic
- Public Health Assessment Work Group presentation on combining I-131
doses
- Public comment periods
- Video presentation on chelation therapy in place of presentation
by Paul Charp
- Work Group recommendation sessions
- Community Concerns Database presentation
- James Lewis presentation
Correspondence
Kowetha Davidson reported a letter received from Dr. Falk regarding the
Subcommittee’s recommendations from the March 26, 2002 Subcommittee
meeting. Letters dated June 5, 2002, and June 14, 2002, were received
from Owen Hoffman; response dated July 18, 2002, was provided by Jerry
Pereira.
Announcements
Kowetha Davidson reported that there were no announcements.
Approval of March
26, 2002 ORRHES Meeting Minutes
Kowetha Davidson referred to the March 26, 2002, meeting minutes distributed
previously to the Subcommittee members. Comments on the draft minutes
have been incorporated and revised minutes distributed to Subcommittee
members.
A motion was received and seconded to approve the March 26, 2002 meeting
minutes. A vote was taken by voice with none opposed. The minutes were
declared approved.
Status of Action items – list
provided
The table listing the status of action items has been distributed to
the Subcommittee members. The table of action items was reviewed.
James Lewis asked whether ATSDR will make a presentation about the budget
and the five-year plan. Kowetha Davidson responded that it would be discussed
during the “Unfinished Business” section of the agenda.
Work Group Sessions
AGENDA WORK GROUP PRESENTATION
Barbara Sonnenburg reported that the Agenda Work Group has no recommendations,
the Work Group has worked with Subcommittee members to produce the agenda
for the meeting. There were no comments on the agenda.
GUIDELINES AND PROCEDURES WORK GROUP
Karen Galloway reported that the Guidelines & Procedures Work Group
decided not to pursue revision of a recommendation to change bylaws regarding
membership, which was brought before the Subcommittee at the March 26,
2002 meeting, and referred back to the Work Group.
The Guidelines and Procedures Work Group has assembled information containing
suggestions for chairs to conduct meetings in a more effective manner.
The first recommendation of the Work Group recommends adoption of this
information to a Work Group chairs in facilitation of more effective meetings.
The second recommendation of the Work Group addresses the job description
for an administrative assistant in the field office. The Work Group recommends
also considering ‘facilitation skills’ of the administrative
assistant candidates. Attached to this recommendation are three documents
that the Work Group recommends the Subcommittee send to ATSDR for their
consideration.
Jeff Hill suggested that the use of a “concerns sheet”, outlined
in recommendation number one may inhibit expression of concerns, and requested
that the use of the “concerns sheet” not be made too rigid.
Karen Galloway responded that the concerns sheet would not be mandatory,
but is intended to ensure that concerns will be addressed, followed up
and tracked. Jeff Hill expressed concern that some dialogue will be lost
and/or not captured. Karen Galloway responded that hopefully the “concerns
sheet” will make the concerned person comfortable that their concern
will be addressed.
James Lewis asked the questions “What constitutes a concern? How
do we formally capture those?” The ‘concerns sheet’
is optional, however, enough specific information about the concern is
needed so that someone can provide a meaningful response to the concern
which makes the ‘concern form’ an important tool for responding
to concerns raised.
Barbara Sonnenburg suggested adding a sentence to the form stating that
a note-taker can fill out the form for the concerned person. Kowetha Davidson
responded that currently ATSDR captures concerns as recorded within minutes
of the meetings.
Donna Mosby commented that much thought went into the ‘concern
sheet’, and it was designed to be sensitive to people raising concerns,
and it is not a requirement that everyone fill out form.
Susan Kaplan commented that the person taking Work Group minutes is usually
not present at the meetings, and takes notes by speakerphone. Therefore
the person designated to fill out the form should be a member of the Work
Group. David Johnson commented that much time and energy went in to developing
the ‘concerns sheet’, and it has not been put into use yet.
It is important to begin using the form to track concerns in order to
determine the timeliness of response to concerns.
James Lewis commented that ATSDR is developing a concerns database and
is currently capturing concerns from meeting minutes, and asked for a
presentation from ATSDR on the concerns database. Kowetha Davidson mentioned
that the presentation for the concerns database is on the agenda for today.
COMMUNICATIONS AND OUTREACH WORK GROUP
James Lewis reported that the Communications and outreach Work Group has
not had a recent meeting. Since the last Work Group meeting the ORRHES
web site is up.
La Freta Dalton began presentation of the ORRHES website and noted that
the website was developed by Eastern Research Group (ERG) and placed on
the ATSDR server in June 2002 (www.atsdr.cdc.gov).
La Freta Dalton demonstrated navigation through the website on screen
for the Subcommittee. Pages accessed included:
- Home Page – Welcome letter from Kowetha Davidson
- Linked pages:
- General Information about the Subcommittee
- Mission Statement, Vision, Goals and Objectives
- History and Activities
- Bylaws
- Compendium of Public Health Activities
- Information about other agencies’ activities
- State of Tennessee activities
- ChemRisk Dose Reconstruction
- Related links
- Other Federal Government Agencies
- Pocket Guide to Chemical Hazards
- Local media, local government organizations
- Membership of the Subcommittee with biographies
- List of Meetings
- Frequently Asked Questions, Acronyms
- Link to e-mail ATSDR staff (Bill Murray and La Freta Dalton)
- Organization charts for ATSDR/roster of ATSDR staff
Herman Cember asked the intended audience of the website. La Freta Dalton
responded that the intended audience is the general public, public officials,
professionals. ATSDR has attempted to make site user friendly for a wide
variety of audiences. Elmer Akin asked how often the site will be updated.
La Freta Dalton responded that the update is once each month.
Jack Hanley pointed out that activities of the Subcommittee, including
workshops handouts, meeting minutes, calendars, and recommendations of
the Subcommittee, are included on the website.
James Lewis commented that the website could be helpful for people to
find/ keep up with issues and asked if it would be possible to list “identified
issues” and have cross-links to particular sets of meeting minutes
(or other documents) that address each issue. Currently it can be difficult
to find issues within the listed agenda. La Freta Dalton responded that
that option is still being examined. Susan Kaplan suggested that a link
entitled “issues addressed” could be added to the links available
for each meeting.
Jeff Hill requested that “The Roane County News” be added
to the list of links on the web site, and asked that future e-mail messages
sent out to Subcommittee members concerning meetings include a hot link
to the ORRHES web site to encourage use of the web site.
Pete Malmquist asked whether the status of recommendations and action
items is accessible on the web site. La Freta Dalton acknowledged that
the recommendations and action items are on the web site because they
are included in Subcommittee meeting minutes on the web site but that
the status chart has not yet been added. James Lewis commented that the
action items from Work Group meetings are not on the web site. La Freta
Dalton clarified that Work Group action items are on the site in the context
of the Work Groups minutes there. Action items are on the web site to
the extent that they were captured in meeting minutes.
Jack Hanley highlighted the Compendium of Public Health Activities on
the site containing information on all the public health activities of
ATSDR, CDC, DOE, and other public health agencies giving comprehensive
information on health study activities in the Oak Ridge area.
Elmer Akin commented that the Subcommittee should use the site as a major
communication tool and asked what time during each month the site would
be updated and whether a notation stating the most recent date of update
would be visible to the viewer. La Freta Dalton responded that the site
includes display of the most recent date of update.
Bill Murray suggested that until Subcommittee members become familiar
with the site, ERG could send an e-mail to Subcommittee members notifying
them when the site has been updated.
Susan Kaplan asked if the community input/concerns form is on the site
to allow people to submit concerns to the site. La Freta Dalton reported
that the form is not part of the site but that the possibility of including
the input form on the site will be explored.
James Lewis, commenting on the option of including the community concerns
form on the site, asked how the concerns raised coming through several
different mechanisms will be managed/controlled so that issues and concerns
are not lost. La Freta Dalton responded that concerns brought forth through
any of the available mechanisms will all be channeled into the ATSDR Community
Concerns Database.
Peggy Adkins asked whether the site could have a link to information
about the potential health effects of toxins/substances that members of
the public may be concerned about. La Freta Dalton reported that a link
to toxicity profiles is available on the ATSDR homepage, but that a direct
link is planned for the ORRHES web site as well.
Kowetha Davidson asked whether the ORRHES site has a link to the Association
of Occupational and Environmental Clinics (AOEC). La Freta Dalton believes
the link is there.
Charles Washington pointed out that one way to address concerns would
be to create on the web site a chart of concerns raised, the name of the
concerned individual, and the subsequent response to the concern following
research into the concern. This method is used by the Oak Ridge Site Specific
Advisory Board (SSAB), giving everyone access to each particular concern.
Charles Washington added that the ATSDR and the Subcommittee are making
an assumption that the best method for communicating is through the Internet.
There may be a need to consider alternatives for communicating information.
Donna Mosby asked whether the format of documents viewed on the site
is consistent and whether the site includes information about sites other
than the Oak Ridge Reservation. La Freta Dalton clarified that the documents
are made available on the site as the exact same electronic files submitted
by those who create them, and that the ORRHES site addresses only the
Oak Ridge Reservation.
Jeff Hill asked if links to web sites for sites other than Oak Ridge
could be included, in order to see the progress other sites have made
in their Public Health Assessment process. La Freta Dalton reported that
the only similar site pertains to the Hanford, Washington site and that
the information on that Subcommittee’s site is 2 to 3 years old
and has not been updated. A link for the Hanford Subcommittee’s
site is in the index of the ATSDR homepage.
La Freta Dalton encouraged everyone to visit and view the site and provide
comments/suggestions for improvements.
HEALTH EDUCATION NEEDS ASSESSMENT WORK GROUP
Donna Mosby reported that:
- George Washington University has completed the solicitations for
focus groups.
- James Lewis will make a presentation on the issue of a clinic in
Oak Ridge.
Discussion of clinical services in Oak Ridge:
James Lewis, Pete Malmquist, and Brenda Vowell made a presentation to
the Subcommittee regarding clinical services for the local community.
The presentation followed a series of handout materials distributed to
each member of the Subcommittee and a portion of the videotape of the
January 18, 2001 ORRHES meeting.
Handout A- Summary of Questions/Concerns Regarding Clinical Programs
Overview of Handout A summarizing:
- Questions raised during December 3-4, 2001 presentation by Dr. Robert
Jackson of the Health Resources and Services Administration (HRSA)
regarding establishing a HRSA clinic locally.
- Questions raised during March 13, 2002 meeting of the Health Needs
Assessment Work Group regarding establishing a clinic to diagnose,
treat, and research illness.
- Questions raised during DOE Former Worker Program presentation March
26, 2002 regarding how DOE provided medical surveillance/care for workers.
Handout B- Glossary of Medical Terms
James Lewis highlighted the definitions of Health Surveillance and Medical
Monitoring.
ATSDR Public Health Assessment Flow Diagram
James Lewis highlighted the steps of the ATSDR Public Health Assessment
(PHA):
- Evaluate Site Information
- Collect Community Health Concerns
- Determine Contaminants of Concern
- Identify and Evaluate Exposure Pathways
- Determine Public Health Implications
- Determine Conclusion and Recommendation/Follow-up Action
Community involvement is tied in with several of the steps shown on the
diagram. These six steps complete the PHA process. If the conclusion is
“no action required” the PHA is submitted for review and comment.
If the conclusion is “action is required” there could be pilot
studies, epidemiological studies or surveillance/registry. The primary
focus is on the community.
Charles Washington asked whether the community was divided into workers
and non-workers. James Lewis responded that the PHA process focuses on
impacts outside the DOE facility boundary.
Videotape of ORRHES meeting January 18, 2001
A portion of the videotape of the January 18, 2001 ORRHES meeting was
viewed. This portion of the videotape captured public comments/concerns
from members of the community expressing the need for a clinic in the
Oak Ridge area to serve exposed/ill persons, and responses from officials
of HRSA (Dr. Paul Seligman) and ATSDR (Dr. Henry Falk). James Lewis pointed
out the emphasis in the video tape of a desire for a clinic among members
of the community.
Handout C- Presentations and Documents Reviewed
James Lewis gave an overview of presenters brought before the Subcommittee
to address issues about community clinics and medical surveillance programs:
- January 18, 2001 – Dr. Paul Seligman, Dr. Henry Falk, Katherine
Kirkland (AOEC)
- December 4, 2001 – Dr. Robert Jackson (HRSA)
- March 12, 2002 – Presentation on ATSDR/PACE program comparison
- March 26, 2002 – Kathleen Taimi (DOE), Donna Cragle (ORISE),
Lyndon Rose (Queens College)
James Lewis highlighted the response from Donna Shalala (Secretary of
Health & Human Services) that CDC, ATSDR and NIH do not provide direct
primary medical services to communities, and they are working with DOE
to plan appropriate public health follow-up activities to address the
concerns of communities regarding the nuclear weapons complex. In addition,
Dr. Robert Jackson’s historical review of HRSA programs found no
examples of HRSA grant dollars supporting the development of environmental
health clinics.
James Lewis highlighted the document reviewed by the Subcommittee entitled
“Proposed Criteria for Selection of Appropriate Medical Resources
to Perform Surveillance of Employees Engaged in Hazardous Waste Operations
and a list of qualified doctors in Tennessee (available on ORRHES website).
Handouts E1 – E3
Pete Malmquist presented criteria for establishing a HRSA clinic. HRSA
would not establish an environmental clinic. There are three types of
HRSA clinics: Community Health Center, Federally Qualified Health Center,
and Rural Health Clinic. The type of HRSA clinic that the Work Group evaluated
for the Oak Ridge area is a Rural Health Clinic (Handout E3). Rural Health
Clinics are located in the most rural areas, and are established under
the authority of the Rural Health Clinic Services Act (Public Law 95-210).
The HRSA website was consulted for guidelines to determine eligibility
for a clinic in the Oak Ridge area. Eligibility criteria to calculate
the Index of Medical Underservice (IMU) include:
- County population
- Percent below poverty level
- Percent of population over age 65
- Ratio of primary care physicians to population
Calculation of the IMU for this area includes 8 counties: Anderson, Blount,
Loudon, Knox, Meigs, Rhea, Morgan, and Roane. Data for each county are
presented in Handout E1.
Brenda Vowell explained the calculation details for Anderson County in
Handout E3 resulting in an IMU value of 83.2. The eligibility for this
type of clinic is an IMU value not exceeding 62. The only county out of
the eight listed which holds a value of 62 or less is Morgan, which already
has a clinical site.
Pete Malmquist summarized that under the HRSA guidelines this area does
not qualify for a Rural Health Clinic.
Peggy Adkins commented that the situation of exposure in this area is
exceptional and has not been dealt with before, old forms of clinics would
not work in this situation. Environmental factors have been tested, however
people have not been tested. Concern was expressed that a clinic should
be used for testing people, not just treatment of people who have health
problems.
Charles Washington agreed with Peggy Adkins on testing people. In the
past workers were exposed to mixtures of many naturally occurring elements
and other chemicals which have effects on human systems. Data on these
exposures should be considered, but may not be applicable to today’s
conditions. Charles Washington stated that in Oak Ridge there has never
been documentation of a death resulting from exposure to toxins from any
of the facilities in the Oak Ridge area, and it would not be in the economical
interest of a physician to document cause of death as a result of a specific
toxin.
Jeff Hill commented that he is a beryllium worker, radiation worker and
asbestos worker, and he is not eligible for any of the medical screening
programs that DOE offers.
James Lewis pointed out to the Subcommittee that comments about testing
people and establishing clinics are all actions that may follow after
the PHA process is completed.
Handout F- Clinical Program Comparison
James Lewis presented an overview of a comparison of programs and emphasized
that each agency is limited by the Congressional mandates that specifies
what they can do within their programs. The clinical program comparison
highlights target populations, types of assessments, and criteria for
screening /medical evaluation, and follow-up actions/benefits for each
agency. James Lewis emphasized that the Congressional mandate for ATSDR
does not provide for diagnosis or treatment and individuals are directed
to their personal physicians or AOEC clinics for follow-up diagnosis and
treatment.
Handout G- ATSDR/PACE Program Comparison
James Lewis highlighted a comparison of the ATSDR versus PACE union programs
and drew attention to the distinctions between the programs; the ATSDR
program addressing exposure outside the DOE facilities and the PACE union
program addressing workers at the DOE facilities. Each program is charged
with specific tasks, ATSDR’s tasks are controlled by congressional
mandates. The program comparison highlights the types of assessments and
the target populations of each program. The PACE worker program involves
a Needs Assessment to determine if a medical surveillance program is needed
while the ATSDR program involves a PHA to determine the need for follow-up
public health action. James Lewis highlighted the overall similarity of
the two programs regarding their exposure assessment processes, sources
of data used (both programs are using the ChemRisk Oak Ridge dose reconstruction
information), and health outcome identification processes.
James Lewis summarized the conclusion aspects of the Public Health Assessment
program:
- Determine the degree of public health hazard,
- Identify illnesses from exposure to contaminants,
- Identify data gaps,
- Determine what public health actions or studies should be undertaken.
Emphasis was placed on the fact that the congressional mandate for ATSDR
does not provide for diagnosis or treatment and ATSDR must complete its
PHA process before developing public health conclusions or making any
recommendations (refer back to the flow diagram of the ATSDR PHA process).
James Lewis highlighted a draft fact sheet (dated 8/20/02) developed
for distribution to the public presenting information about environmental
& occupational medical resources and medical resources for ORR workers.
Donna Mosby read for the Subcommittee the proposed recommendation that
the Health Needs Assessment Work Group brings to the Subcommittee for
vote today.
Discussion:
Janet Michel commented regarding the proposed Health Needs Assessment
Work Group recommendation, disagreeing very strongly with the recommendation
statement that clinical evaluation and medical monitoring are premature
at this point in the ATSDR process in light of 11 years of residents coming
forward with health concerns. Why should there not be any medical screening
begun by now? Janet Michel also asked for an explanation of the current
status of progress in the ATSDR PHA process.
Kowetha Davidson responded that the ATSDR is in the midst of the PHA
process and that in fact the Subcommittee is an integral part of conducting
the PHA process, which will be followed by ATSDR recommendations. James
Lewis added, with visual reference to the flow diagram of the ATSDR PHA
process, that the Subcommittee and the ATSDR are not in a position to
make any recommendations until completion of the steps of the process
outlined in the flow diagram.
Janet Michel noted for the Subcommittee that among six of her friends
raised locally, 3 of them are on Synthroid medication for thyroid anomalies/cancers
now, and asked why disease registry information is not being gathered.
For example, Dr. Elaine Bunick, a local endocrinologist, has diagnosed
over 1200 thyroid problems in the area and has reported this to the State
of Tennessee and contacted MD Anderson Hospital for assistance.
Janice Stokes reported that pharmacists have said to her that synthroid
medication is distributed from their pharmacies by the truckload each
month.
Barbara Sonnenburg asked for an estimate of when the ATSDR PHA process
will be completed for I-131 and when will it be completed for other substances.
James Lewis recalled that the original schedule called for completion
after six months. Burt Cooper added that the schedule is approximately
one year behind and a detailed plan with schedule will be presented to
the Subcommittee soon. Completion of PHAs for selected contaminants are
to be completed within two years.
Jeff Hill commented regarding the fact sheet (dated 8/20/02 Environmental
& Occupational Medical Resources and Medical Resources for ORR Workers
) that a statement needs to be added to the fact sheet stating that workers
need to report health problems to their employers.
Regarding the PHA Process Flow Diagram, Elmer Akin stated that it is
important to distinguish between determining contaminants of concern historically
versus determining contaminants in the environment currently, and disease
resulting from historical exposures versus current exposures. James Lewis
pointed out that the Subcommittee and ATSDR have determined to address
past exposures (prior to 1990 – dose reconstruction studies) separately
from current exposures (since 1990).
Public Comment
Mike Knapp commented on the history of events leading to the development
of the workers compensation program. In 1992 reviews of historical documents
revealed that in the 1940’s doctors and lawyers took steps to limit
liability from worker exposures in order to continue bomb production.
The Nuclear Workers Compensation Program was enacted in the late 1990’s
to compensate workers for the actions in the 1940’s. In order for
a worker to be compensated under the current workers compensation program
medical records must indicate exposure to certain toxins, and in the past
DOE lost, manipulated, and destroyed health-related documents. Today the
workers compensation program is limited to specific disease types (berylliosis,
asbestosis, silicosis, and radiogenic cancers) and does not address modern
disease types/new illnesses from exposure to unknown toxins. Residents
living in this area must also bear the burden of proof of exposure, which
requires documentation to backup illnesses. The reason a clinic is desired
is because workers have diseases which have not been diagnosed, studied
and treated, and residents face the same problem. ATSDR is looking at
the need for a clinic or public health action while people want to have
a clinic first to study and record disease patterns, actions that follow
the public health assessment in the ATSDR process. Mike Knapp commended
the Subcommittee for recommending to ATSDR that exposures to I-131 from
Oak Ridge be added to exposures to I-131 from the Nevada Test Site. Mike
Knapp also commented that the concept of a clinic is one that can be an
integral part of the PHA process on the front end. The burden of proof
of exposure to workers has already been met. The clinic would benefit
residents and also workers who are not compensable under the workers compensation
program.
James Lewis responded that Dr. Bob Eklund (former member of the Subcommittee)
has stated in the past that a physical facility (clinic) does not need
to be located here in order to conduct clinical intervention. Hopefully
the public health assessment process, if it finds public health impacts
associated with exposure, will provide the community at large with information
to assist in getting appropriate medical care.
John Steward agreed with Mike Knapp’s comments, and further commented
that DOE is not supporting the process, citing a particular case of a
worker (30 years at K-25) who has been denied under the workers compensation
program due to lack of documentation of employment. There are similar
examples. John Steward related his own experience with his personal doctor
who refused to accept/examine his CAT scan (performed under the PACE union
worker program) because he did not want to become involved with the worker
exposure controversies. Workers continue to have to pay for their own
medical testing and treatment. John Steward asked the Subcommittee when
a clinic for workers would be recommended.
BREAK
Work Group Sessions (continued)
PUBLIC HEALTH ASSESSMENT WORK GROUP
Presentation and discussion:
Kowetha made a presentation to the Subcommittee entitled “Should
ATSDR Combine Iodine-131 Doses from the Oak Ridge Releases with Those
from the Nevada Test Site”.
Kowetha Davidson began the presentation with an overview of the thyroid
gland, its location and function in the human body, and the mechanism
of control of thyroid hormone levels. The presentation then addressed
benign thyroid tumors (95% of all thyroid tumors) versus cancerous thyroid
tumors (5% of all thyroid tumors), and detailed the prevalence of types
of cancerous thyroid tumors. The majority of thyroid cancers are the papillary
type. Follicular cell cancers, C-cell or medullary cancers, and anaplastic
thyroid cancers are far less prevalent. The risk factors presented for
thyroid cancer incidence include:
- Radiation exposure (either external exposure to the head/neck or from
intake of radioactive iodine),
- Family history (presence of altered RET gene),
- Female gender (females are at higher risk),
- Age (risk increases with age),
- Race (risk is greater among blacks), and
- Iodine deficiency.
Kowetha Davidson reviewed the evidence for the link between thyroid cancer
and exposure to I-131 based on studies performed after the Chernobyl nuclear
accident. These studies indicate: a four year latency period for thyroid
cancer in children, thyroid cancer incidence in children exposed in
utero, peak incidence in children 8 to 9 years old, and the highest
incidence in the Ukraine, Belarus, and Russia.
The 1997 National Cancer Institute (NCI) study (“Estimated Exposures
and Thyroid Doses Received by the American People from Iodine-131 in Fallout
Following Nevada Atmospheric Nuclear Bomb Tests”) and the 1999 National
Academy of Sciences (NAS) review of that study were discussed during the
presentation. The study developed dose estimation methods and thyroid
dose estimates to individuals from NTS releases but did not estimate risks
of thyroid cancer. The NAS review of the study reported that:
- The study was generally reasonable,
- National collective dose estimates are unlikely to greatly under/over-estimate
actual doses,
- County-specific dose estimates are likely too uncertain to use to
estimate individual doses,
- Direct measurements of fallout are too sparse to make precise county/state
dose estimates for all of the U. S.,
- A minority of the population had significant exposure,
- The highest risk was among young children that drank milk from backyard
cows/goats at the time,
- Cancer risk estimates for individuals are more uncertain than dose
estimates due to the uncertainties in risk at low doses,
- Thyroid cancer risk estimates can only be made with a wide range.
Synopsizing information presented by Owen Hoffman to the Subcommittee
June 11, 2001:
- The range of consequences of various levels of radiation dose to
the thyroid,
- I-131 releases from “other” sources in Oak Ridge will
likely not change dose estimates by more than a factor of 3,
- Dose estimates are adequate for general conclusions regarding dose
in the community but not for probability of causation (PC) calculation,
- The range of dose estimates is slightly greater than a factor of
10,
- The impact of adding doses from NTS I-131 releases to doses from
Oak Ridge I-131 releases varies for different locations in the Oak
Ridge vicinity,
- The primary risk factors for thyroid cancer are age at exposure,
I-131 levels in milk, dietary source of milk, milk consumption rate,
and gender,
- The risk of thyroid cancer from releases is low except for individuals
who consumed goat’s milk.
Synopsizing information presented by Charles Miller to the Subcommittee
in September 2001:
- It is possible to combine I-131 thyroid doses contributed from multiple
sources,
- Is important to consider whether I-131 thyroid doses contributed
from multiple sources should be combined,
- If doses are combined it is important to communicate the information
so that people can make informed health decisions,
- Numerical dose estimates are less important than the risk factors:
gender, age at exposure, and consumption of milk from a back yard cow/goat.
Kowetha Davidson summarized the results of a 2001 “Feasibility
Study of the Health Consequences to the American Population of Nuclear
Weapons Tests Conducted by the U. S. and Other Nations”. In summary:
- CDC and NCI were the lead agencies
- The study involved document retrieval, dose estimation, review of
epidemiological literature, risk assessment, and development of health
communication strategies
- The study will be reviewed by the NAS, with formal recommendations
to follow that review
- The study concludes that exposure of the U. S. population by location
and time can be estimated
- Estimates for individuals are imprecise because of variations in
exposure within counties
- The study concludes that cancer risks from fallout can be estimated
for representative exposure scenarios but with large uncertainties
- Accurately determining risk for specific individuals is not possible.
Discussion followed the presentation.
Charles Washington commented that on slide 18 of the presentation the
statement that “…I-131 releases from other sources in Oak
Ridge will likely not change estimates by more than a factor of factor
of three” is statistically significant and asked for an explanation
of the statement that “does estimates range slightly greater than
a factor of ten”. Kowetha Davidson responded that the factor of
three from other Oak Ridge sources would be less than the factor of 10
range in the dose estimates. Charles Washington also asked for explanation
of the statement in slide 17 “Mode of action for thyroid cancer
caused by I-131 is non-threshold linear”. Kowetha Davidson responded
that the non-threshold linear model means that there is no exposure to
I-131 that would not be associated with some risk of cancer. The alternative
model is that there is a threshold dose below which there would be no
risk. Herman Cember commented on the explanation of non-threshold that
it is more correct to say that the model postulates a zero threshold rather
than no threshold.
Susan Kaplan commented that her understanding is that the I-131 releases
from ORNL from the RaLa program range from 3.3 to 6.7 times, assuming
90-95% retention efficiency, where 3.3 refers to 95 percent efficiency
and 6.7 refers to 90 percent efficiency. Kowetha Davidson commented that
this factor of three statement was not in reference to the RaLa program
releases. Susan Kaplan emphasized the importance of correctly clarifying
words from Owen Hoffman’s presentation. Kowetha Davidson replied
that the factor of three statement was not specifically about RaLa releases.
Following the I-131 presentation Kowetha Davidson read the recommendations
of the Public Health Assessment Work Group.
RECOMMENDATION ONE:
ORRHES recommends that CDC/ATSDR present the public health implications
of I-131 thyroid doses (and risks, if feasible) due to releases from
the Department of Energy’s (DOE) Oak Ridge Reservation (ORR),
the Nevada Test Site (NTS), and the combined doses (and risks, if feasible)
from the ORR and NTS in its Public Health Assessment for I-131. ATSDR
should present the doses (and risks, if feasible), their ranges of uncertainty,
and an explanation of the level of uncertainty for public understanding.
Rationale:
Presenters Owen Hoffman and Charles Miller presented background information
on the dose reconstruction for I-131, including the issue of combining
doses of I-131 from Oak Ridge with doses of I-131 from the NTS. Neither
presenter specifically recommended combining the doses. It is technically
possible to combine the doses, but the issue is should the doses be
combined? ATSDR is asked to present the total doses from the Oak Ridge
and NTS and provide separate health implications from those exposures.
ATSDR will determine the feasibility of estimating the risk for developing
thyroid cancer or present their rationale if it is determined that risk
estimation is not feasible.
RECOMMENDATION TWO:
ORRHES recommends that CDC/ATSDR establish an online calculator so
that individuals may obtain estimates of their thyroid doses (and risks,
if feasible) due to releases of I-131 from the Oak Ridge Department
of Energy Reservation and from the Nevada Test Site along with an option
for adding the doses (and risks, if feasible). CDC/ATSDR should provide
information to the public on interpretation, uncertainty, and credibility
of the results from the calculator and any follow-up action the individual
should take as a result of the estimate.
Rationale:
The public has an interest in individuals estimating their I-131 doses.
Dose estimates with health implication information will aid in making
healthcare decisions.
Public Comment
Bob Peelle stated that at the time the Oak Ridge Health Assessment Steering
Panel (ORHASP) study was performed various experts believed that the contribution
from other sources from X-10 would be approximately 20%, far less than
a factor of three, but the ORHASP committee was aware of the controversy
about the efficiency of filtration of I-131 from the RaLa program. Perhaps
the releases from the RaLa program varied by a factor of three. Bob Peelle
commented regarding the combining of doses from radio-iodine from Oak
Ridge and from the Nevada Test Site, it may be impossible to produce risk
estimates from the doses. Bob Peelle’s opinion is that if risk estimates
cannot be produced, time should not be spent producing the dose estimates
because people do not know how to interpret dose estimates, but risk estimates
are meaningful. Bob Peelle’s recommendation consisted of eliminating
the addition of I-131 doses from Oak Ridge and the Nevada Test Site if
the risks cannot be estimated.
Kowetha Davidson responded that a calculated risk estimate (e.g. 1/1,000,000)
is less meaningful to a physician trying to recommend follow-up public
health actions than defining age at exposure, gender, and whether milk
was consumed from a backyard cow or goat.
Regarding Handout G (ATSDR/PACE Program Comparison), Janet Michel commented
that the PACE union worker program was inadequate and therefore a poor
comparison. Testing was minimal, information was lacking, health physics
dosimetry is not accurate. A Portsmouth, Ohio, health physicist reported
to a Senate Committee that he was instructed to falsify reports, and that
dosimeters were intentionally left on top of sources to test responses.
Janet Michel reported that while working at K-25 with cyanide compounds
personal monitoring and testing were promised, yet never happened. The
medical monitoring programs are far from perfect.
Janet Michel’s health problems consist of an enlarged thyroid and
auto-immune disease. The condition began when handling uranium samples
for school and civic demonstrations. The ATSDR PHA process gives ATSDR
something to do, and makes the public feel as though they have input,
but asked the Subcommittee how many of their recommendations have been
acted upon? While ATSDR is conducting their PHA, waiting a year or more
for information to be complete, sick people are dying.
Kowetha Davidson noted that the Subcommittee is sensitive to comments
from the public, and stated that the Subcommittee is limited to it’s
mandate from Congress.
Barbara Sonnenburg asked how the Subcommittee can change people’s
minds in Congress. Janice Stokes responded that it is possible to change
people’s minds in Congress, by recommendations from panels such
as this ATSDR Subcommittee. A clinic for Oak Ridge is not premature; however
it would have been premature in 1940-1950 when little was known about
exposure to harmful substances. Large doses from releases of iodine have
been acknowledged as having occurred and as being harmful. Effects on
the thyroid resulting from doses of iodine are evident in the community,
as well as thyroid diseases, cancers and other maladies. The Subcommittee
and community members can work together to change people’s minds
in Congress. There is a need to take a step beyond the workers compensation
program for the benefit of people who have lived around the nuclear sites.
As a minimum people should be given the opportunity to be diagnosed, treated
and monitored. In regard to monitoring of emissions from incinerator stacks,
there is not real-time monitoring at the Duratek incinerator or at the
DOE incinerator in Oak Ridge, health physics monitoring data are unreliable.
For example, Bud Aerosmith (Duratek) is quoted as stating that dirty filters
work better than those that are clean, and their stack filters were changed
every six months. People’s lives are at stake on these issues.
Kowetha Davidson invited members of the public to attend and participate
in the Subcommittee’s Work Group meetings, in person or by telephone.
Janet Michel posed the questions “How soon would any of the federal
agencies be able to do something such as helping people monitor their
water wells?” and “Could the Subcommittee request from the
Tennessee Department of Health (TDH) any statistics that they may have
on disease registries?” Janet Michel reported that the TDH has encountered
obstacles to their efforts at collecting such information (e.g. lack of
cooperation from neurologists in the Oak Ridge area in the past). Kowetha
Davidson reported that the Subcommittee will be having a visit from staff
of the TDH to make a presentation on TDH disease registries.
La Freta Dalton commented that, before ATSDR can make any public health
recommendations, it must first document exposure; that is accomplished
through the PHA process. The purpose of the Subcommittee is to provide
input to ATSDR on the PHA. Documenting exposure is the result of evaluation
of available evidence. If necessary, additional data collection to fill
data gaps can be requested. While ATSDR and the Subcommittee hear these
concerns brought forth by members of the public, the Subcommittee and
ATSDR are required to proceed through the PHA process and document exposure
before making public health recommendations.
Janice Stokes replied that this process (PHA) does not work for the people
of the community, and a new approach should be developed by the Subcommittee
to do something different that will work for and benefit the people.
Janet Michel stated that exposure can be documented by examining the
endpoint, the people affected.
Herman Cember offered the comment that dirty filters are more efficient
filters due to the buildup of material on the filter and the filter must
be changed once the buildup has reduced airflow rate to a certain level.
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