Occupational Medicine and Industrial Hygiene Water and Food

Occupational Medicine and Industrial Hygiene Water and Food Safety Maj Paine and Col Snyder Updated 20 Jun 2017 by Maj Paine

What is PFOA/PFOS?

What is PFOA/PFOS? • • Perfluorooctanoic Acid (PFOA) Perfluorooctane Sulfonate (PFOS) Found in many products Ingredient in some fire fighting foam

Does your base require ongoing PFOA/PFOS monitoring? Have you heard about this in the news? On your base?

Does your base require ongoing PFOA/PFOS monitoring? • • 105 106 111 143 144 156 188

Does your base require ongoing PFOA/PFOS monitoring? • • 105 106 Disclaimer: The data we presented is based 111 on information is believed to be accurate. 143 However, we recommend you double check 144 the PFOA/PFOS levels at each of your drinking water systems. 156 188

What is the easiest way in Occ Med/Industrial Hygiene subjects to end up in the newspaper?

What is the easiest way in Occ Med/Industrial Hygiene subjects to end up in the newspaper? • Skip your PFOA/PFOS monitoring

Why are we discussing PFOA/PFOS?

Why are we discussing PFOA/PFOS? • Assistant Secretary of the Air Force tasking – For all drinking water sources • Validate levels of PFOA/PFOS • Assure below the health advisory limit

Why are we discussing PFOA/PFOS? • Assistant Secretary of the Air Force tasking – For all drinking water sources • Validate levels of PFOA/PFOS • Assure below the health advisory limit Why was complying with this tasker difficult?

Why are we discussing PFOA/PFOS? • Assistant Secretary of the Air Force tasking – For all drinking water sources • Validate levels of PFOA/PFOS • Assure below the health advisory limit Why was complying with this tasker difficult? We didn’t know how many systems we had

Inventorying Drinking Water Systems • Pulling ANG water systems data – SG’s Defense Occupational and Environmental Health Readiness System (DOEHRS) has no ability to pull a report – Civil Engineer’s Water Enterprise Tracking (WET) – Safe Drinking Water Info System (SDWIS) is an EPA data warehouse – has system info but geared toward violations

Inventorying Drinking Water Systems • Where all the ANG systems? – Started with Civil Engineer inventory – Then had to call and confirm with units • Hundreds of e-mails & phone calls

Inventory • Rhetorical question: How many drinking water systems do Airmen at your installation and GSUs drink from?

Inventory • Rhetorical question: How many drinking water systems do Airmen at your installation and GSUs drink from? • When you have free time, Google “SDWIS” – EPA database of drinking water systems – Safe Drinking Water Information System

Classification

Classification Privatized (ANG doesn’t own any piece of it) Special (non-potable)

Restated: Classification Possibilities • • Privatized (ANG doesn’t own any part of it) Special (non-potable) Non-PWS (small well for a few buildings) PWS – Community – Transient Non-Community – Non-transient Non-Community Note: a PWS may be either regulated or exempt

Re-stated: Classification Possibilities • • Privatized (ANG doesn’t own any part of it) Special (non-potable) Non-PWS (small well for a few buildings) PWS – Community – Transient Non-Community – Non-transient Non-Community Note: a PWS may be either regulated or exempt What is the total number of systems owned by the ANG? How many of each type? (that we know of)

Before we show ANG data… Who wants to describe the inventory and classification of drinking water systems at their base? …and compare it to the best available data that we have?

Classification— 129 total systems • • • Regulated PWS--5 Unregulated/Exempt/Consecutive PWS--110 Non-PWS--13 Special--1 Privatized— 0 (trick question)

Classification • 90 wings have 129 drinking water systems – The ANG produces drinking water at 14 units (18 drinking water systems) – 5 public water systems: 102; 111; 120; 143; Volk Field CRTC – 13 additional small wells serving one building or several buildings: 128; 165; 177; 182; 184; 188; 193; Volk Field CRTCx 2; Alpena CRTCx 3; Gulfport CRTC

Question • What plan, prepared by BEE with support from Civil Engineers, is designed to guide ongoing sampling, and analysis, and monitoring of drinking water?

Question • What plan, prepared by BEE with support from Civil Engineers, is designed to guide ongoing sampling, and analysis, and monitoring of drinking water? Answer: The Sampling, Analysis, and Monitoring (SAM) Plan

SAM Plan Contents (Reference AFI 48 -144, paragraph 4. 1) Identification of all sampling sites Annual and long-range sampling schedule Lab support and quality assurance Local procedures to conduct water surveillance • Map of distribution systems • •

My base doesn’t have a regulated PWS, do I still need a SAM plan?

My base doesn’t have a regulated PWS, do I still need a SAM plan? • Yes, unless your base only has a privatized system. Reference AFI 48 -144, Drinking Water Surveillance Program

Drinking Water Summary • Know what drinking water systems serve Airmen under Team Aerospace’s protection • Validate that PFOA/PFOS levels are acceptable – Ask to see the data, if you haven’t already – Conduct PFOA/PFOS monitoring if necessary • Validate Team Aerospace performance – Knowledge of system(s) classification – SAM plan facilitates delivery of safe drinking water

Thoughts/Questions

Part 2: Flight Surgeon Shop Visits Maj Mark Paine NGB/SGPB

Occupational Health Process • “AREC” (Note: this applies to hazards) – Anticipate – Recognize – Evaluate – Control

Occupational Health Process • “AREC” (Note: this applies to hazards) – Anticipate • USAFSAM: https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/pages/index. cfm? id=621 – Recognize • Identified by BEE as “hazards” – Evaluate • Air sampling • Noise measurements – Control • Personal Protective Equipment (PPE) • Training • Medical Surveillance Exams (MSEs)

Occupational Health Process • “AREC” (Note: this applies to hazards) – Anticipate • USAFSAM: https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/pages/index. cfm? id=621 – Recognize • Identified by BEE as “hazards” – Evaluate • Air sampling • Noise measurements Available on an Occupational & Environmental Health Exposure Data sheet (OEHED) produced by BEE – Control • Personal Protective Equipment (PPE) • Training • Medical Surveillance Exams (MSEs) Available on a Clinical Occupational Health Examination & Requirements sheet (COHER) produced by Public Health & Approved by Flight Surgeon

Occupational Health Process • “AREC” (Note: this applies to hazards) – Anticipate • USAFSAM: https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/pages/index. cfm? id=621 – – Available on an Recognize Occupational & Environmental • Identified by BEEHealth as “hazards” The Occupational Process has taken place on your base. Health Exposure Evaluate Data sheet (OEHED) Documented on OEHEDs & COHERs (w/flight surgeon approval). • Air sampling produced by BEE • Noise measurements Visiting shops: Checking that the process is protecting workers. – Control • Personal Protective Equipment (PPE) • Training • Medical Surveillance Exams (MSEs) Available on a Clinical Occupational Health Examination & Requirements sheet (COHER) produced by Public Health & Approved by Flight Surgeon

Risk Assessment Codes (RACs) • Known hazards are identified by RACs – Issued by BEE, Safety, or Fire Department – If significant, a “Notice of Hazard” is posted

Risk Assessment Codes (RACs) • Known hazards are identified by RACs – Issued by BEE, Safety, or Fire Department – If significant, they are posted in the workplace

Requirement 1 (not for ARC) (AFI 48 -149, Flight and Operational Medicine Program (FOMP)) • 3. 2. 2. 2. At bases with stand-alone Occupational Medicine (OM) clinics, FSs will work with OM clinic staff to maintain clinical competency regarding occupational health exams and industrial shop visits. (Not applicable for the ARC)

Requirement 2 (AFI 48 -149, Flight and Operational Medicine Program (FOMP)) • 3. 6. 6. In-Garrison Operations: … “providers should operate at a reduced Full Time Equivalent (FTE) standard with the expectation that the provider team spends up to 50% of their work time outside of the standard clinical setting. The out of office time will be spent interacting with Line personnel, advising the line commander and performing shop visits to better understand support the occupational/operational stressors in these unique work areas. ”

Requirement 3 (AFI 48 -145, Occupational & Environmental Health Program) • 2. 11. 2. “Category 1 workplace require a physician visit annually. A written report for each visit is attached to the OEHWG minutes and a copy sent to the supervisor of the employees in the workplace NLT 60 days following the visit. ”

Requirement Summary • Perform shop visits – Interact with Line personnel – Advise line commanders – Better understand support the occupational/operational workers

How to Visit a Shop • Ask BEE to let you know when they go to a shop – You won’t be able to go every time…that’s ok • Ask BEE to walk you through certain shops – Maybe all Cat I shops – Prior to an inspection, BEE usually walks through all shops…ask to go with them

Which shops to visit • • • CATM Corrosion Control/Structural Maintenance Cat I shops Cat II shops Any shop you are concerned about

Most common to least common Common Types of FS Visits • BEE Routine IH Survey with FS peel-out – Go with BEE to the routine IH survey – Ask FS questions up front, then leave in order to meet your next scheduled patient • BEE visit tag-along – Ex: Inspection preparation, respiratory protection program review, indoor air quality, customer requested visit • Flight Surgeon requested BEE visit – Ask your BEE to take you to any shop – BEE will coordinate w/ shop supervisor and escort you

Prepare for a Shop Visit In rank order: Most preparation to none • ESOH Service Center Website – https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/ – Google • Ask BEE to print a copy of the Occupational and Environmental Health Data (OEHED) – Is it filled out? Yes – great: No – problem!! • If you don’t have time to prep – Go anyway – Ask the Airmen how they feel about their facilities and working conditions • This is how the IG begins their interviews with workers

What to do in the shop? • Every flight doc has their own style…no single “correct” way to do a shop visit • Ask how the workers feel about their facilities and work environment • Validate the information on the OEHED • Listen to the BEE discussion with the Airmen and interject as appropriate • Ask checklist-style questions (see next slide) • If all else fails, say “please let me see your PPE”…it’s a great conversation starter

Checklist-style Questions Reference: “ABC of Occupational and Environmental Medicine” (Snashall & Patel, 2003)

Notes • It’s rare to observe processes…you are more likely to talk about processes and then look at the equipment • If you don’t see air sampling on an OEHED, but you think air sampling should be done…then ask the BEE to do it

Ear Muffs/Plugs Rules of Thumb • Rating system is NRR – Rule of thumb: 29 and up is good for plugs, 33 is max – Rule of thumb: 28 and up is good for muffs, 30 is max • For double plugs/muffs: take higher NRR and add 3…you don’t add both NRRs together • Common problems – Shops buy cheap muffs that have low NRRs – Shops don’t wear their hearing protection

Noise Surveys • Noise source surveys – Can be done quickly – Measures levels of noise produced – Purpose: to determine effective PPE • Noise dosimetry – Takes days – Measures levels of noise received by workers – Purpose: to determine if audiograms are needed • Rule of thumb: If you have no intention of removing a shop from the hearing conservation program, then noise dosimetry is a lower priority…air sampling may have a bigger payoff

Air Sampling • Likely, you won’t find much evidence of it – Total Force problem – Ask your BEE if you would like to see more • Common limiting factors – BEE doesn’t have the supplies on hand – Shop does the process infrequently – BEE doesn’t know when the shop does the process – Lack of familiarity with air sampling or with DOEHRS air sampling process

Simplify Documentation • BEE Template Shop Letter: States who visited the shop. Why not add the Flight Surgeon if you go?

Simulated Flight Sureon Shop Visit: Corrosion Control/Structural Maintenance Photos and information taken from various documents produced by USAFSAM ESOH Service Center. Check out their website (searchable through a web browser).

Paint Removal: Ideal

Paint Removal: Ideal Note: There are no human exposures

Paint removal: Blast Cabinet

Paint removal: Blast Cabinet Standard questions: 1. When you asked the workers about their concerns, did they mention this equipment/process? 2. Are there “Risk Assessment Codes” (RACs) assigned to this equipment/process? Questions specific to this process/photo: 1. Do you see visible dust outside of the blast cabinet? 2. Is the filtering facepiece device (FFPD) listed as a control? (there is training associated with FFPDs)

Paint removal: Sanding Booth

Paint removal: Sanding Booth Standard questions: 1. When you asked the workers about their concerns, did they mention this equipment/process? 2. Are there “Risk Assessment Codes” (RACs) assigned to this equipment/process? Questions specific to this process/photo: 1. Do you see visible dust outside of the blast cabinet? 2. May I see the housekeeping plan?

Paint removal: Vacuum Sanding

Paint removal: Vacuum Sanding Standard questions: 1. When you asked the workers about their concerns, did they mention this equipment/process? 2. Are there “Risk Assessment Codes” (RACs) assigned to this equipment/process? Questions specific to this process/photo: 1. Do you see visible dust outside of the blast cabinet? 2. May I see the housekeeping plan? 3. May I see your hygiene facilities?

Paint removal: Vacuum Sanding Standard questions: 1. When you asked the workers about their concerns, did they mention this equipment/process? 2. Are there “Risk Assessment Codes” (RACs) assigned to this equipment/process? Questions specific to this process/photo: 1. Do you see visible dust outside of the blast cabinet? 2. May I see the housekeeping plan? 3. May I see your hygiene facilities?

Occupational Medicine and Industrial Hygiene Sanitation inspections and the dreaded “Occupants in Bldg XXXX are reporting MOLD!” Show of Hands…how many Docs have faced this in military career?

Part 1: Air Force Mold Policy Maj Mark Paine NGB/SGPB

References • 10 May 2005 memo from HQ USAF/ILE/SGO titled “Interim Policy and Guidance for the Prevention, Surveillance, and Remediation of Water Damage and Associated Mold Contamination in Air Force (AF) Facilities” • AFRL-SA-WP-SR-2014 -0017 titled “Bioenvironmental Engineer’s Guide to Indoor Air Quality Surveys” • Both references are on the AFMS KX and the NGB/SGPB Bioenvironmental Engineering Sharepoint site (Under “Important Documents”)

Key Points • No mold testing (unless physician requests it) • Key players – CE (HVAC and/or Operations) – Facility Manager – Bioenvironmental Engineering • Mold = Moisture AND Moisture = Mold • Limited federal regs…but AF has mold policy • The AF mold policy works…very well

Physician’s Role (Mold Policy, Attach 2, p. 5) 1. Initiate Occupational Illness Investigations “If the medical provider believes the symptoms are related to the building, then they should send an AF Form 190, Occupational Illness/Injury Report, or SF-513, Medical Record - Consultation Sheet through PH. ” 2. Request BEE to sample (rare in the AF). Request must include exactly what type of mold to sample for and how the results will be interpreted. “Mold sampling should only be accomplished as the result of consultation with the physician/health care provider and an occupational medicine physician or allergist in order to provide information that supports a specific clinical diagnosis or aids in medical treatment. ”

BEE Role • Never, ever get involved with a mold issue without CE and/or the facility manager • Conduct a visual inspection – Visible mold – Visible moisture damage • Typical actions/recommendations – Eliminate the source of moisture – Remediate in accordance with mold policy – May issue a risk assessment code (based on AF Mold Policy, not regulations)

Remediation Examples (Mold Policy Attachment 4)

Summary • Visual inspections only • Mold = moisture • Physicians: recommend investigations but do not work in isolation! • BEEs: recommend to follow mold policy and maybe issue a RAC based on mold policy • CE and facility manager: remediate

Questions?

Part 3: When Pilots get hit with Lasers • Follow procedures in the USAFSAM Laser Injury Guidebook • Fill out the incident form online at the ESOH Service Center website

When Pilots get hit with Lasers • Follow steps in Section 2. 0 of AFRL-SA-WP-SR-20120005, USAFSAM Laser Injury Guidebook, available on the ESOH Service Center website: https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/pages/index. cfm? id=717 – 3 pages of instructions – External examination, near visual acuity test, far visual acuity test, Amsler grid test, examine pupils, perform optic vision tester depth perception test if available, color vision exam, and if available a slit lamp evaluation, retinal exam, and look for vitreoretinal hemmorate, chorioretinal lesions, and consider optical coherence tomography

When Pilots get hit with Lasers • Someone in Team Aerospace needs to fill out a form on the ESOH Service Center website: https: //hpws. afrl. af. mil/dhp/OE/ESOHSC/laser injury/ Note: A blank form is on the next slide

Questions?

Flight Doc RSV • • Part 1: Part 2: Part 3: Part 4: Air Force Mold Policy Flight Surgeon Shop Visits When Pilots get Hit with Lasers Safe Drinking Water Last updated: 20 Jun 2017, Maj Paine