All right, ladies and gentlemen, we'll go ahead and get started. Welcome to our session on our Lead Surveillance Program at Joint Base San Antonio. I'm Dr. Steven Hetrick, I'm Medical Director of Occupational Medicine at Joint Base San Antonio. My colleague with me and partner is Dr. Steven Costellar. So we'll begin by saying that we have no relevant relationship, either financial or non-financial, to disclose. And what we talk about today are our views and are not necessarily in line with what the government position or policy may be, and that's U.S. Air Force, DOD, or the U.S. Government. What we would like to do in describing our local program with Lead Surveillance is to put it in very generalizable terms so that you can leave here and think about, in any generic sense, when is a formal occupational medicine surveillance program indicated or triggered? And then once that trigger point has been met, what do you do to set up the program? And perhaps more importantly, what do you do with the results? So here's an old dated photo at our local installation of a pedestrian walkway over a highway, and it advertises that Lackland Air Force Base is the gateway to the Air Force. And what is meant by that is that all enlisted members that are coming into the Air Force have to go through our installation to begin their career with a seven-week basic training course. In fact, there are, as you can see, great numbers, over 35,000 a year, come through our base. In addition, Lackland is the site of a lot of technical training. We have security forces training for the Air Force, but security forces training also occurs there for the Navy and the Marine Corps. There are also a lot of sustainment courses that go through, and we also have to do some particular training involving firearms. If you think about all this training for basic training and security forces training, there's a heck of a lot of firearms training that's necessary. And who does that training? Dr. Costellar will tell us. So the training that's done is performed by combat arms and maintenance technicians, or CADM, combat arms and training maintenance, excuse me, cadre. These individuals are firearms instructors, so they're tasked with teaching DOD personnel how to operate the firearm, how to aim it appropriately, which is harder than you might think. You're thinking machine gun, just spray, it's not quite that simple. And then being able to maintain and do some light repairs. Many of these individuals started out their careers as security forces specialists and then went through an apprentice course specific to become a combat arms cadre. And so these individuals, we'll call them throughout the presentations firearms instructors, but that's who these individuals are. In terms of numbers, we have multiple ranges at Lackland and in some of the surrounding bases that we operate at. So you can see here there's a Navy weapons firing range and several others. The two that I want to call your attention to and that we're going to focus on most today are those instructors that work in the combat arms apprentice course, so training the trainers, and then also those that do the instruction in the machine gun course. Let's talk a little bit about what firearms instructors do. Well their initial duty begins in a classroom because they're describing to students how to appropriately handle the weapon, how to disassemble it, clean it, and fire it. So lots of didactics and academics occur. Then the training moves on to the firing range. Now here we have two different types of ranges. The one on the right is one of our small arms ranges and you can see several soldiers, airmen, are in prone position. The poor fellow that's leaning over there is a firearms instructor who has to be very vigilant about safety and making sure that all the students are handling the weapons correctly and helping them to hopefully improve their technique. In contrast, the very open area to the left is one of our machine gun ranges. You see that that's limited to gun emplacements and because of that, very open area and spread out. Another thing to notice about both of these though is that these are not enclosed ranges. Neither one are inside of buildings. They're both open air ranges. All of the ranges that we have at Lackland are. And so you do get free flow of environmental air. Other duties that are performed by the firearms instructors, they actually don't do any of the cleaning of the firearms. They have the students do that. So they actually get graded on that. But they are in charge of storage of the weapons and the armory, any light repairs that need to be done. They are also in charge of range safety and then the range maintenance and cleanup. You can imagine that at these firing ranges where there's a lot of firearms going off frequently and over decades, that the ranges themselves are not particularly clean in terms of the soil and whatnot. Backing up six years ago, we thought about what would we expect to see in this group of employees. We realized that in 2016, the geometric mean of blood lead level is right around one microgram per deciliter. We also recognize that demographically, our workforce is largely young. Many are in their 20s and their 30s. But importantly, they have young families at home. We know that because of their youth, they would not have expected to have been exposed environmentally to the decades of 50s, 60s, 70s, when we had a lot of tetraethyl lead in the environment from adding it to gasoline. Nor would we expect gross contamination in water distribution systems, as well as the use of lead-based paint. So we're left with the question, what amount of lead are these folks actually being exposed to? And finally, what blood level would we expect to find? Well, clearly, those are two important questions that have to be answered with action. So then you raise the question, well, in this population, is occupational health surveillance indicated? So the ways that you can justify that, and again, we're speaking from our own experience at Lackland, but hopefully the things that we talk about today, you can find application in whatever shop or whatever hazard you're considering at your base or your place of employment. The three that we've generally fallen back on are, first, to be in regulatory compliance. So is there an OSHA standard or a DOD-led standard or other type of standard that mandates surveillance? The second is to evaluate pathophysiologic harm or the potential for harm in workers due to a recognized hazard. And the third is to then evaluate the efficacy of any controls that you put into place. There's no sense in having controls if you don't make sure that they're actually working. So moving into the OSHA General Duty Clause, this is something that we're all very familiar with, but just to highlight again that this can apply to any number of hazards, and in fact does here. So each employer shall furnish to each of his employees employment and a place of employment, including our base, which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees. This is something that, again, you're all familiar with, but it does actually apply in this case as well. So looking specifically at that recognized hazard of lead, what is the OSHA lead standard? Just to refresh our memories, the action level for lead is aerosolized or airborne concentration of lead of 30 micrograms per meter cubed, and that's over an eight-hour time weighted average. The permissible exposure limit is 50 micrograms. And the mandated standard for when you have to implement a surveillance program is when you have employees that are exposed to levels of 30 micrograms or more, which is the action level, for 30 days per year. We also have another standard that we need to adhere to, and that's the DOD-led standard. That's been around since 2018. We have a colleague, apparently, who worked on that early on. Thank you very much for your efforts. What's important to know is that the DOD standard is more stringent than the OSHA-expanded standard for lead. And the table has a side-by-side comparison of removal level and return-to-work level for both the OSHA and DOD, and you can see it's quite a difference, the OSHA standard being much older, from 1970, greater than 60 a single, or three of greater than 50 micrograms per deciliter resulted in removal, compared to the DOD at less than 20. And then not surprising for return-to-work levels, 15 for DOD versus 40 for the OSHA standard. The important point to remember also is none of the other requirements that are articulated by the expanded standard have been changed. They're still all in force with the DOD standard. And a question that sometimes gets asked is, well, does the Air Force have to follow OSHA? And the answer is yes, all of the OSHA standards still have to be followed. So for those within the audience who are in uniform, the standard for lead does come under DOD 6055.05 manual. But the point being that it breaks it down into different levels, so it starts out at less than 5, and then 5 to 9, 10 to 19, and 20 to 29 breaks it up. And it specifies or outlines short-term risks, long-term risks, and required actions. And again, just to refresh, there are multiple hazards or places and organs that are affected by lead in the body. I was speaking with a colleague earlier about effects on kidneys, but it does affect heme synthesis, as you recall, with furculitase and aminolevulinate dehydratase. So then we move to that second point. So we say, okay, have we met the criteria for a surveillance standard? Well, we said it had to be for compliance to a mandate, whether it's an OSHA standard or a DOD standard. We do meet that criteria. The second was to evaluate for potential harm to workers. Well, how do you do that? As occupational medicine physicians, industrial hygienists, we know that you have to start with worksite visits. Go out and be with your people. See what they do. And then talk to them. You can talk to them in person when they come into the clinic. You can administer health or exposure questionnaires, because you're only going to be there. Even in a worksite visit, you're not going to see everything. So it's valuable to then approach the workers and say, what are you seeing? What are you concerned about? And then when they bring up potential exposures, they talk about the dust or the fumes. You need to be able to quantify that, so you need to assess that and measure it. See what the exposure actually is. And then see what kind of impact it's having on your workers. So in this case, looking at blood lead levels. So this picture was provided just to show you what level of dust, particulate, fume can be generated at a single firing event. Remember, this is an outdoor range. This particular day was rather stagnant. But if you look closely, you'll see both evidence of dust from impact, as well as the various gases that are being created at the firing line. And to highlight here this individual with the red hat, this is our CADM instructor, our firearms instructor. So these other students are going to be exposed to this dust and fume for a relatively brief period. But that instructor is going to be sitting there for many hours as multiple students cycle through very different types of exposure. These are M4s. They also fire the M9 and the M18, the new M18, which is pistols. So small arms at these ranges. So this next picture shows, in contrast, a much more open range. And this is the type of range that the machine guns are taught in. But importantly, look at the proximity to the weapon with which the instructor needs to be positioned. So we have talked at this conference in years past about frangible munitions, which has a whole set of other issues with copper exposure. We're going to point out, and the focus of our talk today are those weapon systems that employ lead munitions. And specifically, slide. So these are the M249 is the machine gun on the left and the M240 on the right. It's a light machine gun versus a medium machine gun. Not going to go into too much detail other than to point out they're pretty similar except the one on the right. It's a lot heavier and it shoots a bigger round and generates a lot more fume and dust. When you look at these individuals here, so the firearms instructors, aside from instructing others and teaching them, they themselves also have to qualify. So you've got this individual here who's firing. I want you to highlight this right here. So this is the products of combustion from the chamber. So we're concerned about the fumes that come out of the muzzle, but there's also the gases that are released at the chamber. And look at how close he is to those gases. And then his proximity as well. You can imagine, so for the students, they're only going to be doing it for several hundred to a few thousand rounds, but that firearms instructor is going to be there. On this particular day, they fired 44,000 rounds, and that was for one firing event. So the range obviously has a whole list of hazards that are posed at these instructors. And the first of which should be very obvious. If you have that many weapons firing, there's a hazardous noise present. Our engineers, bio and bioengineers are the industrial hygienists that we use in the Air Force, have measured through dosimetry impulse noise levels at 108 dB. We live in... Sir? I'm sorry, are you taking questions periodically or at the end? We're going to, if we could, we want to reserve them until the end. Thank you, sir. We live in South Texas, so there's a lot of thermal stress in the summer months. If they're having to work a session of three to four hours, often in the sun, with their uniforms on, that can be a considerable risk for dehydration. Also, as you saw in the pictures, the instructor needs to be very close to the student and be vigilant about safety, so they'll crouch, they may lay prone with the student. And because of the weapon systems that are employed, they generate dust, particulate, and gases. So we need to be concerned about both the particulate inhalation and particulate ingestion if they're doing things orally at the firing line, and then fume inhalation because of proximity. The last one seems maybe a little trivial, psychological stress. These guys love to shoot. Yes, but they've got students who are very novel, maybe only 17, 18 years old with a lethal weapon. So they can get rather stressed with what can occur at the range. We're going to focus most of our efforts, though, in this talk with the particulate dust inhalation and the fume inhalation. So here I'm going to show you a clip of what it's like to be by that M240 as it fires. The thing I want you to pay attention to today, so on this day, again, 44,000 rounds, you'll see not even 100 rounds, it'll be just a couple of rounds that you'll see. But it was a beautiful day, it was not very hot, and there was a nice crosswind, so you'll see the fume that's generated. But it was a nice day. You can just imagine what's going to be different from what you're going to see if that wind was coming from a different direction and was coming a way downrange towards the instructors. So you'll see how the fumes go, and the dust that's being generated as the bullets pass, so the pressure wave. So we... Is it going right past his breathing zone? So we'll actually get into that, because we do look at that, that's a great question. So we go out and we watch workers and we see what the processes are, but obviously we need to talk to the workers. And one way is anecdotally, directly to individuals, but also we employ questionnaires. Here's an example of a pooled questionnaire response asking, what do you experience after one of the large firing events? And most commonly, it's what you would expect to see in a large particulate inhalation. They tend to have, and exposure, they tend to have irritation of the mucosal surfaces. My eyes itch, they burn, my throat burns, my nose burns, I have a cough. And this typically lasts about one to two hours, and then it clears. In the case of the frangibles that we're not going to concentrate on, we also had more of a headache and kind of a drain feeling that would go along with metal fume fever. So having known that they have symptoms, we now need to establish what exactly are they inhaling. And here's an example of an instructor that's rigged with media at collar height, hooked up to filter pumps. That way we can quantify what exactly is going in this person's breathing zone. And looking at the results of that, so you do need to quantify it. So we saw, we've got two different instructors here, just labeled R and S. And you can see the amount of lead that they were exposed to. This was taken over a four hour time period, and then you've got a TWA that's listed. So you can see that we're above the action level, with 77 and 72 micrograms per meter cubed. We're above that lead action level of 30. We're also above the permissible exposure limit of 50 micrograms per meter cubed. So yes, there's a fair bit of inhalation or potential inhalation of lead here. So then we moved a little bit further and we started looking at, well, what were their blood lead levels? How does their exposure transfer into what's going on inside their body? So I want to give you a brief glimpse of some of the surveillance data, and you'll see more of this a little bit later. But we started taking, keeping track of it. You'll see a bunch of blank spaces. That's because we've got multiple people that get turned out over time. So we've got different lines for various individuals. But here in May of 2016 and February of 2017, those that are highlighted in red were above five. So they're six or more. And you can see we've got a fair number. And so when you look at the overall trends, our mean average, so we asked that question, what were the blood lead levels that we should expect in our firearms instructors? That mean in 2016 of the general population was 1.2. Here we found in our instructors, it's 3.88. So quite a bit higher. We noted frequent levels over six. The highest level that we got was 14. And with that, you might say, well, guys, that's really not that high. Young, healthy individuals, not too crazy. But we're also concerned about the innocent bystander effect. And then keep in mind that there's no safe level, no truly safe level of lead. They do have some effect at each level. But we're concerned about these because, as Dr. Hetrick mentioned, we have a generally very young workforce who either have young children themselves, or we also are concerned about our female instructors who are of childbearing age. So we're concerned about that innocent bystander case. So what can we do about it to mitigate this exposure, now that we've got objective data that they are, in fact, being exposed? Well, the obligate hierarchy of controls, with a twist, we also provided you the proportional value that we got from using this. And as you can see with your eyeball, we got the most bang for the buck using administrative controls, rules at the range. So of course, you always want to start at the top and think about what options do you have to eliminate the hazard altogether. Here we're talking about firearms instructors at a military base with the specific purpose of going to war. They did actually look at, could we eliminate the risk altogether? So they have thought about doing simulated rounds, doing a simulation with pneumatic rifles and lasers that has been something that was considered. But you're sending people out to war. And so you want them to be very comfortable with the weapon system. And you don't want the first time for them to feel that pushback and actually fire a bullet to be when they're in the chaos of war. So that wasn't really an option. However, we did find that we could simulate the rounds with the grenade launcher. It's still having the same impact. You don't, it doesn't matter to that individual if they watch an explosion or if they watch a poof of colored smoke. And so we did actually have simulated rounds with the grenade launchers. We talked a little bit about substitution. We were somewhat effective or had some success rather in substitution because we moved away from fully leaded rounds at all of the ranges and started using those frangible rounds that Dr. Hetrick mentioned, which are a zinc and copper alloy that's designed to disintegrate upon impact. So it reduces fragmentation, ricochet, and also lead. However, we can't use these frangible rounds in the machine guns at present. Looking at the physical space, ranges have been in existence for many decades. And unfortunately, they can't be reoriented. The arrow provided shows the prevailing wind. The issue is they are largely going down the berms that separate ranges and therefore any kind of dust or fume and particulate from the firing line are going to be expected to be pushed right into where the instructors are being positioned. So unfortunately, that's something that we can't easily change. If we tried to just change the orientation, we have a population center all around the base that would prohibit that. In fact, that's the very reason why when we used to have the .50 caliber at our base, it had to move because of the safety perimeter and air traffic, et cetera. We'll talk a little bit more about this later, but the crosswinds are important in reducing the risk. We did look at generating artificial crosswinds. And so at the small arms ranges, we do have fans that generate a crosswind. But that's not really possible at the heavy machine gun ranges where they're all out in the open. So moving on with that weather effect, as I said, when there's low or no wind, we did see a correlation with the symptoms the instructors were reporting. So they had higher or worse symptoms on a still day or a low or no wind day. And we also actually had higher levels of lead that were detected. When there was a nice breeze that was blowing through, we had air sampling that showed that with very low levels of lead or even non-detectable. And we noticed there's a seasonality about this based on vegetation. Springtime is wet in South Texas. There's usually lush vegetation. That decreases the amount of dust that's generated at the range. Contrast that to the left in the fall time when things are very dry, you're getting impact that create dust, and it's far worse. So moving through the beef of what we were able to, the main gist of what we were able to see with our successful controls were the administrative controls. We did try to limit class size. There are some limitations on how much you can do that because, as we showed, there's a lot of people that are moving through our ranges every year that need that training. Additionally, we have people that are being deployed, and so they would go, aside from those 35,000 that come through for basic training, you have individuals that are being deployed on short notice or even with notice, but they have to qualify right before they're sent to war. So they are limited. They go to about 42 students per class. We also looked at rotating the duties of the instructors. Since we have classroom components and we have range components, do they always have to be sitting there at the range? We looked at rotations there. That does cause some problems with rosters when you're thinking about who you need to surveil. That can become a challenge. And then we implemented a bunch of policies, which many of you will recognize from the OSHA expanded standard. No eating or drinking except in designated areas, no smoking or chewing tobacco, washing your hands when you're finished firing, showering before leaving work, and then having designated work and home clothes, and then, of course, the big one, which is actually that education piece, just letting people know why it's important to follow the rules and policies. Because at the end, things like this, it's up to the individual whether they follow through. We can move on to the least reliable hierarchy or control level, which is personal protective equipment. And this is very problematic. Yes, we could substantially cut down on the particulate that's going in someone's breathing zone. Many instructors have an issue with this regarding safety. It can drastically cut down the communication between student and instructor using lethal weapons. And then secondly, because of the heat, they also complain that it increases the thermal load. And toward the bottom, we'll also add the fact that because of the hazardous noise, the instructors are also on double hearing protection. They're very good at complying with that. And we have not seen significant amounts of threshold shifts with this group. Students are not placed on the program simply because they're only there for one or two days, whereas the instructors are doing this all days of the week. So we've now hit the first two points of having compliance, OSHA and DOD standard compliance, as well as looking for potential pathophysiologic harm. That third point was to evaluate, are your administrative controls or your implemented controls working? And so that's the big point here at the end. How do you set up an occupational surveillance program once you've decided that you need one? In general, you want to, again, identify the potential workforce. You want to identify the processes that they are utilizing, whether that's firing or in any other industrial setting. You want to characterize the hazards that are posed, in this case lead. You want to then use that hierarchy of controls to implement mitigation efforts and then assess the effectiveness. Keep in mind, though, that you don't always have to start out and recreate the wheel. So a lot of these control standards and surveillance programs are actually laid out for you in an expanded standard by OSHA or by the DOD. Our statutory guidance with the DOD lead standard has articulated risks, both short-term, long-term, required actions, and medical management, and ongoing surveillance. We can fly through these, but the important point is to show that it's broken down by observed lead levels. Our initial approach always has to be with a team. We can't be smarter than all of us. We typically will always go out as OCMED docs. Steve and I will go out, but we always rely heavily on our industrial hygiene colleagues. We also go out with public health occupational health specialists. If we have the need, we call safety and they're very responsive and are willing to come out. We also enlist the help of management and the hierarchy of leaders in the organization. So we've looked at the physical environment, the operational environment, we understand what's going on, we've evaluated the blood lead levels, we did air sampling, and then the last thing that we can do is an administrative instrument called a RAC, a Risk Assessment Code. So although it's administrative, it really is helpful. Number one, it increases visibility of the health concern all the way up to the commanding general. It mandates regular reporting, and probably most important, a RAC has a way of empowering getting the money to make repairs to solve the problem. So how do we actually evaluate it on a regular basis? We have an annual occupational medical surveillance exam, and the requirements for this are outlined by the OHOG, or the Occupational Environmental Health Working Group. We are in the military, we love our acronyms. So we do have the OHOG, which Dr. Ettrick and I will chair. And during that exam, we have an occupational exposure questionnaire that we give to them to make sure that we're staying up to speed on what they're using. Have they implemented a new process? Are they using new chemicals? Are they doing something that we're not aware of? And sometimes we find that to be the case, and then we engage our industrial hygienists to find fixes for it. We review with them the exposures that have been measured by our bioenvironmental engineers, which we call the Occupational and Environmental Health Exposure Data, or the OEHED. We review their medical history with them to look for those personal factors that might put them at increased risk. We go over their annual audiograms. We do have them go through a respirator fit test that's done by our industrial hygienists. We'll do a targeted physical exam. We'll review their blood lead levels. And again, speaking about rosters and making sure that you're surveilling the right workforce, because not all of our firearms instructors use leaded rounds, there's a targeted population. But you do have to be very careful when you have, when you start to parse them out, because when they switch around, you wanna make sure that you're not missing anyone. So here's a big picture of that drifting cohort of who exactly is being exposed to lead. We've made it easy for this very busy spreadsheet, color coding anything that shows elevation in lead. And the encouraging issue is, after we really started implementing our interventions, you see that the number of elevations drastically went down as you went right. You're looking at 2016 all the way to current time, 2022. And then more precisely, for that floating cohort of instructors that are teaching the lead-based system, you'll see the average for that floating cohort. Surprise, we made some interventions and noticed that we had a downward curve, and then suddenly we had a spike. So we had to reengage to figure out what's going on. And I believe the reason that we had that spike is that we had new people, new commanders in, and we have to reteach the lessons of the past to make sure everybody's on board. The good news is, when you look at the overall curve, it's definitely going in the right direction. Yeah, the average of 1.24 in March 2022, of course, closely mirrors the 1.2 that was found in the general population in 2016. What's the end? It's changing each, like several month period, but they're overall, there are about 50 that are in this cohort. So what do you do with the results? Of course, we've been tracking them over time. The point is that you need to keep monitoring once you have the results. Hang on to them. If we were just looking at this at one point in time, it would be hard to see what those trends are, as well as it would make it difficult to then determine, is something amiss? Have you had something gone wrong in your processes, or are they still working? You might be able to reduce the frequency of monitoring once you've gotten a recognized hazard under control, but it shouldn't eliminate your monitoring. Workers and supervisors, as we mentioned, will change over time. We actually are currently going to need to re-engage with some of our commanders, once we've talked with workers about some of the challenges they face, and then processes and materials change. So you'll notice this abnormal five right here, that we'll get into right now. So now we had an uh-oh in September of 2021, where we have an unexpected result in our surveillance. He had a level of five micrograms per deciliter, not too terribly high. But what was interesting is when we looked at his past blood lead levels, they were typically lower, at two and three. So we had to ask the question, what exactly has changed that would explain this? So the first thing we had to do is confirm the finding. Maybe this is lab error, maybe this is contamination. Well, the repeat test was done within two weeks, and it was higher now at seven micrograms per deciliter. ZPP was normal at 15 micrograms per deciliter. So what all good OCDOC should do, mean we go out to the shop, figure out what's changed, what don't we know about this worker, and then definitely cone down on this specific worker to see what his practices are. So he's a fairly, an older, relatively older gentleman. Compared to our younger 20s and 30s, for most of our instructors, this is a civilian worker who's come back and continues to work for the Air Force. So he's 68 years old, grew up in Connecticut. He spent his entire career in the military, completed as a senior master sergeant, which is quite high in the enlisted ranks. And then, so he was a firearms instructor for 20 years, over 20 years, and he was always at a particular range. Then he spent the last 10 years working at one range at Lackland. Interestingly enough, this is actually one of our small arms ranges where they're using frangible rounds, so non-lead-based rounds. So you wouldn't expect him to have an elevation at all. Additionally, he's a very clean worker. He, on his own, voluntarily wears gloves whenever he's handling munitions and weapons, and then he wears an N95 filtering face piece. So you have to start looking at, well, what are his potential vocational exposures? He doesn't participate in teaching that employs lead-based rounds, like we talked about. So he doesn't use any weapon systems with lead. He doesn't participate in range cleanup, so you're not concerned about the historical contamination of the soil, and he never eats, drinks, or smokes while at the firing line. So all the easy answers are no. So if there are no clues at the range, hmm, maybe this is explained by something at home, maybe something he's doing. A lot of firearms instructors will end up loading their own munitions, but he doesn't do that. In fact, he says, I never shoot on personal time. I only shoot on the job. The inventory of lead exposures that we tried to go through in maybe hobbies, he denied, no work with car batteries, no radiators, no lead-based paints. Doesn't weld, doesn't solder, he doesn't work on plumbing, and he has not participated in any demolition work. So now we're really scratching our heads, thinking maybe this is a general environmental exposure. Ask about the house, three years old, no apparent sources of lead in the house so far. And then what about water? He's got a well. No, he doesn't. He's on city water, and we have access to the water quality reports, and there are no exceedance of lead standards. So then you start thinking about, well, maybe he's eating it at home. Maybe there's something weird. We are in South Texas. Maybe they're out grubbing around, I don't know. But he denies use of lead crystal, no lead crockery, which, as you are familiar, if you're using leaded glass, it can have leaching of the lead into your alcohol. But he doesn't do that, and he doesn't use Ayurvedic supplements, which are traditional medicines that come from the Far East that are sold by the pound and so often can have contamination with lead or other heavy metals. But he doesn't use any Ayurvedic supplements, and he doesn't use any foreign candy, which has been found to be contaminated with lead. Additionally, we tested his spouse. She agreed that she would be tested for lead to see, hey, was there something there? And her lead came back at 2.3. She's younger. She's in her high 50s. Younger than her husband is what I meant to say. Age is relative. Looking at his reported medical problems, you can see he's nothing terribly surprising here or anything that would raise concern for a source of lead exposure. We did ask about bone trauma. He had had some broken ribs recently, or several years ago, but none recently, excuse me. Review of his medications was pretty non-contributory, with the exception that he did mention that he uses a supplement called Movefree. And there had actually been some reports that Movefree had lead contamination in years past. So this is glucosamine, chondroitin, and this MSM addition. So what we were able to do is get samples of his medication and have the IH folks run it for lead and found there was none in it. Okay. This is very exciting. But it's all very important to ask all of these questions. So is he experiencing a lead exposure? From everything we can tell, the answer to that question is no. We don't have anything from his workplace. We don't have anything in his personal life that would explain why he's had this relative elevation. So then you start asking yourself the question of, well, first off, why is his ZPP normal? Because his levels aren't high enough that you'd see that change. We would also expect the ZPP to lag, the blood lead level. But again, without any obvious exposure, we have to say, okay, well, why is this guy having an elevated lead? He's 68 years old. Maybe he's having some mobilization of bone that was historically containing lead from all of his time living in America with leaded gasoline. Reasonable, right, reasonable? So we thought, okay, does he have osteoporosis? Does he have multiple myeloma? Does he have osteosarcoma? Start looking at his history. Does he have Pott's disease? Is there some sort of tuberculosis in his back that's really causing problems that's gonna suddenly release some lead? Does he have hyperparathyroidism? All potential sources. So to answer these questions, we start with basic chemistry. We do a CMP, and we notice that alkaline phosphatase is normal. Calcium is normal. And we ran a parathyroid hormone, which is also normal. Talked with a buddy from radiology who agreed to do a skeletal survey for us, and he has normal bone density. No lytic lesions. CBC was a bit interesting, where there were large granular lymphocytes on peripheral smear. The pathologist thought this is most likely reactive. However, he cannot rule out a neoplastic process, so recommended further study to include flow cytometry and electrophoresis. Urine, serum, electrophoresis were normal. Flow cytometry showed no abnormal monoclonal B-cell or abnormal T-cell populations. We hope you're all scratching your heads like we were. Because then we sent him to a specialist, contacted the hematologist, said, okay, are we missing something with this individual? And they said, no, no, no serious recommendations, no specific recommendations. Make sure that he's up to date on his age-appropriate cancer screening. So he had had a colonoscopy, and he was no problems there, and he'd had his prostate checked, and his PSA was normal. This was very exciting, as we were getting ready to present here at AECOM. But we did a blood lead level, repeated two months later, and it decreased to 4.5. So why does he have this spike? This is his actual labs, going back to 2016. You can see twos and threes, and then he's got the spike up to seven, and now he's back down to just under four, was the most recent. Well, at this point, we're still dealing with a medical mystery. Intriguing, we really wish we could find an answer. So our evaluation is still ongoing. One more piece of the puzzle. Approximately a week ago, we asked the spouse to repeat her blood lead level. Ooh, 4.1, which is directing our attention back home. I've done multiple interviews of both the spouse and the instructor. Can't come up with anything. No, I haven't. So, that's a good question. I don't actually know what his answer to that was. But he's working at a range, he's working at a range that doesn't use leaded rounds. I'm sorry? The ethnicity of the spouse. She is African-American, and the instructor, you didn't ask, is Native American. I'm sorry? No, neither do. Yeah, we did ask about that. We've asked those questions. And so far, it's been universally negative. The foreign candy was Mexican candy, thinking about that, because those have been contaminated with lead. But he doesn't use any Mexican candy. Yes, sir? Not at that range, no. Because it's not a leaded range. I don't know about that. I asked the spouse about makeup, and she denied. I'm sorry? 68, wife is 59. So, their water comes from the city. We didn't do specific testing at their house. But they do have city water, and it comes, the lead, yeah. They should have this on three years old. Let's go ahead and wrap it up, and then we'll do your questions just at the very end. So, in summary, we've discussed indications for implementing an occupational surveillance program, and we hope that some of these steps are take-homes for you no matter what hazard you're dealing with. We gave examples of how to set up a program, and we discussed what to do with results. That may be surprising. Finally, remember that Murphy's Law is always hard at work. Don't ever ease back on the throttle. Keep looking, because problems arise because processes change, the physical environment may change, and people change. And you won't find a hazard if you're not looking for it. So, you do need to keep looking and pay attention. Because, again, if we just said, hey, look at our surveillance data. We're all ones and twos. Everything's back down to good old normal numbers. We never would have caught a case like this, which is piquing our interest. And we'll open up to questions, discussion. If you guys have ideas of things that we could be doing, we are all ears for that, too. We've got 12 minutes to go. They shouldn't have lead pipes, there'd be... Yeah, it's usually copper, especially in a new construction. So, the standard would be lead pipes. At the DHA, they use five, but as the state programs and all, then we have people, even in the pediatric population, they use 10 pipe as a cut-off for the... Well... Oh, yes, sure. So, my question is, like, you know, you have taken five, the BLL level as five, while I'm from Illinois, and we use 10 for even pediatric population when the initial screening for the pediatric population happens. So, is there any reason? I think probably keeping a lower one is catching more people into your programs and monitoring them. And my second thing is, how often, if you have abnormal lead levels, how often do you do your repeat blood testing for them? Blood testing for them. So, the target that we are aspiring for is as low as achievable. We've got the DOD standard, which defines five, and CDC says upper limit of normal is five micrograms per deciliter. And the lower we get, the better, because of the innocent bystander potential as well in this group. If they are normal, normal, normal, they would get a minimum surveillance of once a year. So, anybody who's above five, how often are you gonna monitor the blood? Just the AID? No, it's at our discretion. And so, when we had all those elevated levels, we were doing it quarterly. Hi, Michael Kostner from Denver. Congratulations on this presentation and your program for tracking it. Thank you. Certainly, the experience of a lot of people has been when you're outdoors, the exposure doesn't tend to be high. But you did document that day of 77, right? So, if these men, as a rule, are generally less than five, we know that that's not their typical exposure, right? Because if people had a typical eight-hour TWA of 77, then they're gonna have blood leads considerably higher, probably above 20, in the high teens to above 20. So, that's an interesting finding. And I need to repeat that. I mean, I think there'd be. Yeah, you might maybe do some more. And we have, sir. And unfortunately, atmospheric conditions really change the results. If there's any element of crosswind, it's non-detectable. Yeah, yeah. We did a study in the Aurora SWAT team, and they all fire AR-15s outdoors, because we were looking for some people with elevated lead levels, slightly elevated. And we had no one above. We took them the day after, or one to two days afterwards, and we had no one above three. So, I think outdoors with good wind, you're not gonna have a problem there. The biggest problem in the DOD, and the thing that really stimulated, I shouldn't say the only big problem, but the thing that really stimulated it were people in chute houses, the special forces who would train in the chute houses for hostage extraction and all that. Now, they're indoors, and they're shooting lots of rain. And the people. We don't, no. So, the people who are in that situation, there's a real concern. And I really applaud the way you went through the ways to control this. I think that the conversion to non-leaded ammunition is great. Are the copper zinc rounds that you're using not containing lead staphinate in the charge? The source of lead exposure is not just the bullet, but it's also the charge. So, one chamber study that was done by the schoolhouse, the US Air Force School of Aerospace Medicine, had a little bit of lead that was detectable, but it was very low. Okay, okay. Because there are potential substitutions for that. The other thing that's just worth mentioning, and then I'll pass it on, is that, so, as you mentioned, and I'm really glad you did, DOD adopted, they're the first federal agency to adopt a more stringent medical removal level for blood lead than OSHA. And so, you know, DOD deserves a lot of credit for doing that, okay? And they're a large enterprise, and if they can do it, then it shows that a lot of other places can do it. They haven't yet changed the PEL, the permissible exposure level, but an analysis was done by the DOD, and it was published by Dr. Sweeney, and it's in the peer-reviewed literature, that indicated, using a PBPK model, that in order to keep the 95th percentile, you know, full-time exposed worker having a blood lead less than 10, you would have to have a PEL of three. Which is, you know, dramatically lower than 50. And a similar study was done in California, and their model said 2.1. So, this whole issue of how we're going to deal with the PEL for lead has to be assessed, but bear in mind that there are other metals, currently, where we have very low PELs. The PEL for cadmium is five, the PEL for hexavalent chromium is six, the PEL for beryllium is, I believe, 0.1. So, it's not unprecedented to reduce it. And, you know, in particular, if you're dealing in the military with women of reproductive age or pregnant women, they, in particular, would be concerned. But thank you again for this presentation. It was really informative, and your approach that you took was really educational. Thank you. Thank you. A couple quick comments, and then my question. I'm Curtis Cummings from Philadelphia. For Southerners, that's Philadelphia, PA. There are three others. And I've done some lead research, as well. And the comment about the ZPP not rising, my first ever paper at Mount Sinai in New York addressed that, when they didn't care if blood leads were anything over 20. This was over 40 years ago, and saw all kinds of people with blood leads of 80, 90, 100, 10, 120. And ZPPs wouldn't go up with these blood levels. So, there's one comment. I take care of federal firearms instructors in federal occupational health, and we start to get concerned if blood leads go over five. And some of them will avoid us. I'm gonna ask you about pushback in a moment. If we find that their blood leads are between five and 10, just another comment. And that probably happens elsewhere. I had a full active duty career, and yeah, I saw that there, too. And final comment for the moment is that your work is about perfect. And thank you for that. Thank you. We still get imported consumer goods, most commonly things like toys that are lousy with lead. And you mentioned Mexican candy. I don't know if they still have leaded fuel down there, but not anymore. But for decades, Mexican candy was loaded with lead until proven otherwise. Any thoughts with this couple on going on a treasure hunt through their house to look for not just what they reported, not just imported pottery, but other stuff that could be loaded with lead? That's a logical next step, absolutely. Because we don't have an explanation otherwise. And the spouse has been very forthcoming and very willing to engage. As you saw, she actually had her blood drawn multiple times when she's not required to at all. Any travel history? No. No. Not since COVID, they haven't been moving around. This is Chip Carson. First of all, congratulations on a great presentation. Thank you. And a really exciting case. Your flowchart investigation is perfect here. I work as a toxicologist. I've had a number of cases that look very similar to this. Recently, I had one where I had my residents go through the house with a fine tooth comb and they came up with nothing. We still have not come up with a source of exposure for that person. He was the only one in the family who had the elevated lead, which is another clue. In this case, there could be some alternate sources. There are a lot of health foods and spices that have been shown to be contaminated with lead and other traditional medicines that you can find in San Antonio, like Azarcon and Greta's. Some of his chronic health conditions may have caused someone to maybe provide him with that. The late peak followed by a decline in his blood lead may suggest that he had a short-term exposure to those things. There was a comment earlier regarding pediatric levels of blood lead at 10. I'd like to emphasize that that's way too high for kids. There's a large body of evidence that children experience significant neurological damage at a blood lead of 10, or even as low as five. I think the current CDC action level is still five, is it? No, it's changed to 3.5. 3.5 now. In the CDC? That happened last year. Okay, so yeah, that's a welcome change. Thanks to Dr. Kosnett's comments there. Great presentation, thank you very much. Hi, John Jacobson. Again, great presentation, both of you. My question is, you had several individuals of your academy instructors that had blood lead levels over five. Did you go and investigate any family members looking for these other exposures? Early on, and Dr. Fitz was on board at that time, we would call people in, the instructor, and we would do a host of questions. I don't recall ever actually getting families involved. We may have talked to them over the phone, but we didn't do any in-person of spouses or other families. I can only recall a couple of wives who we interviewed by phone, and offered in-person evaluations, but really having nothing interesting on their interview, elected to just continue to monitor, and all of them declined on their own. Yeah, I don't think anyone took us up on that blood lead test. Excuse me, it's my turn, right? It's just a quick question. I love this kind of presentation, by the way. Where the blood tests were taken, for her and for her husband, just that? They were done at the same laboratory, at our local installation. Our laboratory is Wilford Hall Ambulatory Surgical Center, and all assays that you saw were done at the same institution. Thank you so much. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry.

occupational medicine surveillance program

lead exposure

firearms instructors

regulatory standards

controls

lead ammunition

monitoring

worksite visits

health questionnaires

medical evaluations