Thefirst meeting of the Interim Joint Committee on Labor and Industry was held on Thursday, August 23, 2001, at 1:00 PM, in Room 149 of the Capitol Annex. Senator Katie Stine, Chair, called the meeting to order, and the secretary called the roll.
Members:Senator Katie Stine, Co-Chair; Representative J. R. Gray, Co-Chair; Senators Dick Adams, Walter Blevins, David Boswell, Julie Denton, Ernie Harris, Alice Kerr, Vernie McGaha, Joey Pendleton, and Richard Roeding; Representatives Denver Butler, Charlie Hoffman, Dennis Horlander, Joni Jenkins, Stan Lee, Russ Mobley, Rick Nelson, Stephen Nunn, Jim Stewart, Johnnie Turner, and Brent Yonts.
Guests: Dr. Peter Tuteur, Pulmonary Specialist and Director, Pulmonary Function Laboratory, Washington University School of Medicine, St. Louis, Missouri; Dr. Leon Cander, National Consultant, United States Department of Labor; and Dr. Paul Wheeler (via telephone conference), Radiologist, Johns Hopkins Hospital, Baltimore, Maryland.
LRC Staff: Linda Bussell (CSA), Adanna Hydes, Melvin LeCompte, Betty Davis, and Reni Krey.
Chairman Stine called the meeting to order at 1:10 p.m. and asked the secretary to call the roll. A quorum was present and Senator Stine offered a general overview about future meetings of the Labor and Industry Committee to be held on October 18, and November 15, 2001. She then requested a moment of silence in honor of Mike South, a former president of the National Black Lung Association and a long time advocate of the rights for coal miners, who passed away recently following a lung transplant surgery.
Co-chairman J. R. Gray was recognized for welcoming comments. He said he hoped that a consensus on black lung will be developed to bring about fairness and equity for both the coal employee and the coal employer. He reminded the House committee members about the group discussion meeting scheduled for September 11, 2001, at Kentucky Dam Village, and invited all members of the committee to attend.
Senator Stine briefly reviewed the agenda items and the material contained in the members' meeting folders, and noted that Dr. Wheeler would be joining the committee via telephone conference at 3:00 p.m. Senator Stine said that Drs. Tuteur and Cander would be addressing medical issues including disability and diagnosis of black lung and that Dr. Wheeler, a NIOSH certified “B Reader” would address radiographic diagnosis of black lung and the role of the “B Reader.”
Dr. Peter Tuteur, pulmonologist and nationally recognized expert in occupational lung disease, from Washington University in St. Louis, Missouri was the first speaker on the agenda. Dr. Tuteur provided a handout to the committee which was a paper he prepared on coal workers' pneumoconiosis. He said his presentation would consist of highlights of the concepts in the paper, a ten-minute course on how to be a lung doctor, and a discussion of coal workers' pneumoconiosis from the medical terminology.
In a discussion of coal workers’ pneumoconiosis, Dr. Tutuer said it is important to define the terms. He said the first term, in a medical sense, is coal workers' pneumoconiosis (CWP). He defined CWP as a disease of the lung caused by the inhalation of coal mine dust that produces scar in the lung. He said the scar and other reactions to the coal mine dust is best and most accurately assessed and described by looking at the lung under a microscope where one finds the dust and an adjacent scar or fibrosis. He also pointed out that in association with that observation there is a characteristic change called the coal dust macule which secretes enzymes, similar to a tenderizer, which dissolves small areas in the periphery of the lung. This destruction is called focal emphysema which is different from the emphysema caused by cigarette smoking. This type of emphysema is an anatomical marker but almost never produces enough destruction to cause a loss of lung function. Dr. Tuteur said what he has just described is simple coal workers' pneumoconiosis. It is a disease which produces abnormalities in the structure of the lung, but it does not necessarily produce abnormal lung function. So, one can have the disease, but not be sick from it.
Dr. Tuteur said the quickest, least expensive way to determine if a coal worker has pneumoconiosis is by a chest radiograph. The x-ray will almost always be abnormal if a if a miner has pathologic lung changes of significance. An abnormal x-ray indicates the presence of CWP, and the next step is to determine if the miner is sick from it. If the x-ray is normal, it is almost certain that the miner does not have CWP to any significant degree. Dr. Tuteur said it is possible, however, that a miner with sufficient exposure to coal mine dust to produce CWP will have a normal x-ray, but upon subsequent examination by autopsy or lung examination will show evidence of the disease. Almost never would that miner be sick or impaired because of it, but it is a possibility, albeit rare and infrequent.
Dr. Tuteur said CWP may also be detected by taking a history. A history is important in order to review the symptons to determine if they are consistent with CWP, employment history to determine whether there have been other occupational exposures, or other health problems that might be manifested in lung disease. Pulmonary studies and a complete examination are also necessary to determine whether there is presence or impairment from CWP. Dr. Tuteur reiterated that an x-ray will indicate that there is no CWP of significance, or there is an abnormality. If there is an abnormal x-ray, other studies are indicated. Consideration of the totality of the evidence is necessary to determine whether there is impairment, and whether the impairment is due to inhalation of coal mine dust.
Dr. Tuteur said the final term that has to be defined is black lung. He said it means very different things to different people. To some, it means a miner with an abnormal chest x-ray. To some, it is an miner with an abnormal chest x-ray who feels that it is the coal dust that produced his problems. To some, it means a miner with an abnormal chest x-ray and abnormal pulmonary function tests, of any kind, or characteristic abnormalities consistent with black lung. Finally, to some it means a miner with an abnormal chest x-ray, sufficient exposure to produce CWP, and based on the totality of the data has impairment severe enough to cause disability due to inhalation of coal dust.
Dr. Tuteur said the next question that is frequently raised is whether coal mine dust can produce a picture of cigarette smoke obstruction. He said yes it can and referred to three studies cited in the handout that discussed this issue. In summarizing the findings of the studies, he said there is a possibility that inhalation of coal dust can produce a picture of cigarette smoke obstruction, but it is very rare and not sufficiently frequent to change the population statistics. Dr. Tutuer said the conclusions contained in the handout were supported by the literature. He said those conclusions were that inhalation of coal mine dust can produce disabling lung disease. When it does so, it is most often classic, small-lung, fibrotic CWP. Very rarely it can produce the obstructive airways disease. When faced with a miner with obstructive airways disease, however, it is at least 15 times more likely, if the miner is a smoker, that the disease was the result of cigarette smoking rather than inhalation of coal mine dust. Finally, the worst of all possible scenarios is progressive massive fibrosis or complicated CWP. It is not difficult to diagnose, obvious on x-ray, and noncontroversial.
In addition, Dr. Tuteur explained silicosis which is a similar but clearly separate condition that may or may not be a coal mine induced process. Silicosis is caused by exposure to silicon dioxide or sand and will produce upper lung field infiltrates over a much shorter exposure period than exposure to coal mine dust. Silicosis is associated not only with small lungs similar to CWP, but also with airflow obstruction. Therefore, the history of exposure or exposures is necessary to make an assessment of silicosis versus CWP. Again, the x-ray will determine whether something is wrong, but the totality of the evidence is necessary to determine the cause if something is wrong.
Dr. Tuteur also stated that comparing never-smoking coal miners and smoking never-miners reveals that 15 to 25 percent of the smokers who never mined will have chronic obstructive pulmonary disease (COPD) of significance. The never-smoking coal miner has this problem less than one percent of the time. He said the true number representing the less-than-one-percent is not clear from the literature but guessed that it is less than one-third. So, if a miner has smoked cigarettes and has cigarette smoking-induced COPD, one can never say one hundred percent of the time, that the COPD is due to cigarette smoking or coal mine dust. All that can be said is that there is much greater likelihood, at least 15 times more likelihood, possibly 50 times more likelihood, that chronic obstructive pulmonary disease is due to cigarette smoking rather than the inhalation of coal mine dust.
Dr. Tuteur provided a brief historical overview of the federal CWP legislation. He said public awareness of the disease became heightened following the Farmington, W.Va. mine disaster and media coverage of poor conditions associated with coal mining. Those events plus 100,000 coal mine fatalities over the previous century led to passage of federal black lung legislation. He said compensation was based on presence of pneumoconiosis and disability, and certain presumptions were applicable. Originally, approximately 50% of the miners received benefits. Subsequent amendments were made which further liberalized the eligibility standards which resulted in higher award rates. He noted that additional changes have been made recently in the federal black lung law.
In the final part of his presentation, Dr. Tutuer said it was necessary to understand lung function to understand the goals of the federal laws relating to occupational lung disease. He provided an overview of lung anatomy and examples of various lung disorders. He said that one cannot just look at an x-ray, or the individual, and make an accurate diagnosis, but the totality of the evidence must be considered. He said when a person has obstruction and emphysema, and cigarette smoke-induced disease, lungs get bigger, and when a person has CWP, the lungs get smaller. Valid laboratory studies can differentiate the two. He further explained that the International Labor Organization's (ILO) system for classifying x-rays is an epidemiological tool, a research tool, but it was not designed for the care of patients or for physician to physician communication.
Following Dr. Tuteur's presentation, Chairman Stine opened the floor for questions. She asked Dr. Tuteur for clarification as to whether an x-ray can distinguish between the effects of smoking and exposure to coal mine dust. He responded that an x-ray can determine whether the lung is normal, or if there are changes consistent with CWP. An x-ray cannot determine if a person is sick due to cigarette smoke or coal mine dust exposure, but that statistical analysis can assist in determining the cause of lung obstruction in an individual. He reiterated that it is 15 to 50 times more likely that an obstruction exists because of cigarette smoke rather than from coal mine dust. Senator Stine followed up by inquiring whether the size of the lungs is indicative of either CWP or disease from cigarette smoking. Dr. Tuteur responded that if pulmonary function studies indicate obstruction and an x-ray reveals big lungs, there is an overwhelming likelihood that the individual has a health problem resulting from cigarette smoking.
Dr. Tuteur, in response to questions from Senator Roeding, said federal coal dust standards have caused a decline in the incidence of CWP, and that frequency and severity of CWP have markedly decreased over time due to improved coal mining processes and control of coal dust. Also, Dr. Tuteur said individual susceptibility and biological differences play a very significant factor in an individual's likelihood of developing pulmonary disease such as CWP.
Senator Stine asked if progression of CWP ceased upon cessation of exposure. Dr. Tuteur said scarring associated with CWP would never disappear, but miners who develop a cough from coal mine dust induced industrial bronchitis will probably see regression of coughing after cessation of exposure.
In response to a question from Representative Lee, Dr. Tuteur said there are about 150 other causes that might produce scarring of the lungs similar to that of CWP, including viruses and antibiotics, and upon physical examination, medical, and occupational history of the individual could distinguish between CWP and the other conditions.
Senator Stine asked if a CT scan was better than an x-ray to diagnose CWP. He responded that a CT scan is a definite advantage when physicians disagree as to the presence or absence of radiographic abnormalities, because a high resolution CT scan is infinitely more sensitive than an x-ray in detecting presence of an abnormality. He said that the cost of the CT scan was about 10 times that of an x-ray which would make it prohibitive as a screening tool for detection of CWP.
Representative Steve Nunn complimented Dr. Tuteur on his presentation and said it was one of the most informative he has heard since he has been on the committee. He commented further that many people would disagree with Dr. Tuteur because his comments were destructive to a culture in Kentucky because CWP benefits have been paid to miners for decades, possibly without justification.
In response to a question from Senator Adams, Dr. Tuteur said the committee invited him to appear, and he was being reimbursed for his travel expenses.
Representative Lee asked what percentage of smoking coal miners who have pulmonary problems had the disease because of coal mine dust exposure or cigarette smoking. Dr. Tuteur estimated that the ratio is approximately 15 to 1, that is 15 smoking miners will have pulmonary problems versus one who would have pulmonary impairment from coal dust exposure, and that the ratio could be as much as 50 to 1.
Dr. Leon Cander was the next speaker. Dr. Cander has been a pulmonary consultant for the federal Department of Labor's black lung program, and a former professor and chairman of the Department of Internal Medicine and Physiology at the University of Texas. Dr. Cander informed the committee that his presentation was based on a handout that had been provided to them. The handout consisted of a paper on coal workers' pneumoconiosis prepared by Dr. Cander for a new group of administrative law judges in the federal black lung program.
Dr. Cander said the coal macule associated with CWP may not be visible on x-ray even though there may be serious derangement of lung function. He defined chronic obstructive and restrictive lung disease, and commented that he had never seen a person with CWP that had small lungs. Rather, he said obstructive lung disease causes large lungs because of difficulty in expelling air from the lungs.
Referring to diagrams in the handout, Dr. Cander explained that the lung has defense mechanisms that permit it to get rid of inhaled particulant matter. The first is cilia which line the airways in the lung. When the cilia is overloaded, it has difficulty getting rid of foreign matter, such as coal dust or cigarette smoke. For example, smoking one cigarette paralyzes the cilia in the lung airways for eight hours, and that by smoking three cigarettes a day carcinogenic material stays in the lung which increases the possibility of development of cancer. The second defense mechanism is the presence of scavenger cells, called phagocytes that consume foreign inhaled matter that gets past the cilia. Upon maximum absorption, the phagocyte explodes which causes lung destruction including development of the coal macule as discussed by Dr. Tuteur. Dr. Cander said the CWP disease process begins with the coal macule and evolves into centri-lobular emphysema. He confirmed Dr. Tuteur's comment that regression of CWP does not occur with cessation of exposure.
Dr. Cander commented that functional derangement of the lung is similar despite the type of injury or the cause of obstructive lung disease. He said in order to make a thorough and accurate diagnosis of lung disease, it is necessary to obtain a complete medical history, conduct a complete physical examination, and to identify all possible causes of chronic lung disease. Dr. Cander said breathlessness is the most important sympton of chronic lung disease, but that breathlessness is not quantifiable and cannot be relied upon solely to assess impairment in an individual. Pulmonary function studies, including blood gas studies, should be included in diagnosing the disease. He also reiterated the fact that an x-ray simply shows anatomic changes in the lung, but it will not indicate functional impairment.
Dr. Cander said from a medical standpoint, disability requires some measure of pulmonary impairment, but that disability is a legal issue rather than a medical issue. Referring to a study of coal miners in West Virginia, Dr. Cander said only about four percent of never smokers, or non-smoking coal miners met the disability standards required in the federal black lung program. Among the smoking coal miners, 16 or 17 percent met those standards.
Summarizing his presentation, Dr. Cander said: inhalation of coal mine dust is an independent cause of pulmonary insufficiency separate and distinct from all other causes, including cigarette smoking; pulmonary insufficiency resulting from inhalation of coal mine dust is caused by emphysema; and chest x-rays demonstrate anatomical changes in lung structure, but does not assess functional derangement or pulmonary impairment. Dr. Cander further stated that pulmonary disease resulting from inhalation of coal dust may become disabling, but it is not commonly disabling.
Senator Stine introduced Dr. Paul Wheeler, a radiologist and "B" reader at Johns Hopkins Hospital in Baltimore, Maryland, as the final speaker. She informed the members that Dr. Wheeler is probably the most experienced "B" reader in the country. Dr. Wheeler said he has been a radiologist since 1969, and that he was instrumental in creating NIOSH's "B" reader program in the early seventies. He said the purpose of the "B" reader program was to institute quality control in the evaluation and interpretation of x-rays for purposes of the federal black lung program, and the National Institute of Occupational Safety and Health's (NIOSH) surveillance program to track the prevalence of coal workers' pneumoconiosis.
In commenting on the use of the x-ray in diagnosing CWP, Dr. Wheeler said the CT scan was more efficient than an x-ray in evaluating or detecting presence of CWP, especially if there are conflicting interpretations or inferior quality of an x-ray. Dr. Wheeler stated that the "B" reader program was intended to be an impartial tool to detect specific patterns consistent with CWP. He said CWP on x-ray looks similar to that of birdshot and that it appears centrally located and symmetrical on an x-ray. Dr. Wheeler said CWP and silicosis are the only two diseases that produce the very specific birdshot pattern on the lungs.
Dr. Wheeler concluded his comments by stating that a CT scan was still the most efficient method of detection for pulmonary disease, and suggested that when there are differences of opinion in reading an initial x-ray, the next step should be to get a good quality CT scan, and to have it read by an experienced reader.
Senator Adams requested clarification of Dr. Wheeler's letter provided to the committee in which he stated that the important thing to understand was that microscopic evidence of early black lung is present before the first signs on a chest x-ray. He asked if that meant that one's susceptibility was a factor in determining how quickly one would demonstrate changes on an x-ray. Dr. Wheeler said that was not the case, but that disease can be readily diagnosed microscopically before it is detected radiographically.
In response to a question from Senator McGaha about making the CT scan a part of the evaluation process for black lung, Dr. Wheeler said if there is a normal chest x-ray, a CT scan is not needed. However, if there is a dispute about the x-ray interpretation, a second opinion should be sought from a "B" reader. If the dispute continues, he would suggest using a CT scan to resolve the dispute.
There were no further questions. Senator Stine thanked the guests for appearing before the committee and reminded the members about the October meeting. The meeting adjourned at 3:45 p.m. by voice vote.