The implementation of medical monitoring programs following potentially hazardous exposures: a medico-legal perspective

Figures & data

Table 1. Agency for toxic substances and disease registry (ATSDR) criteria for appropriateness of medical monitoring programs as a public health activity.

Phase 1	Phase 2
Exposure criteria	System criteria
A. There should be evidence of contaminant levels in environmental media that would suggest the high likelihood of environmental exposure to a hazardous substance and subsequent adverse health outcomes B. There should be a well-defined, identifiable target population of concern in which exposure to a hazardous substance at a sufficient level has occurred	A. The general requirements for a medical screening program should be satisfied B. An accepted treatment, intervention, or both, for the condition (outcome or marker of exposure) must exist and a referral system should be in place prior to the initiation of a medical monitoring program C. The logistics of the system must be resolved before the program can be initiated
Outcome criteria
A. There should be documented human health research that demonstrates a scientific basis for a reasonable association between an exposure to a hazardous substance and a specific adverse health effect B. The monitoring should be directed at detecting adverse health effects that are consistent with the existing body of knowledge and amenable to prevention or intervention measures

Figure 1. U.S. Preventive Services Task Force Grades for clinical preventive services. Adapted from http://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions.

Figure 2. U.S. Preventive Services Task Force analytic framework for evaluation of a clinical preventive service. Adapted from: United States Preventive Services Task Force, Procedure Manual, Agency for Healthcare Research and Quality, 2008.

Figure 3. Example of an outcomes table for a medical monitoring program.

Table 2. Initial monitoring protocols for the C-8 medical monitoring program.

Probable link condition	Protocol
Pregnancy-induced hypertension	Normal prenatal care (blood pressure and urinalysis at every prenatal visit)
Kidney cancer	Questionnaire in class members age 20–39 years; Questionnaire, abdominal examination and urinalysis in class members age 40 years and older
Testicular cancer	Questionnaire and testicular examination in male class members age 15–50 years; questionnaire only in male class members age 50 years and older
Thyroid disease	Serum thyroid stimulating hormone test in class members age 18 years and older; females who become pregnant or decide to try to become pregnant should be tested a second time at the first prenatal visit
Ulcerative colitis	Questionnaire in class members age 15 years and older
Hypercholesterolemia	Fasting serum lipid profile in all class members

Table 3. Estimated total cancer cases attributable to Fernald-related radiation exposure compared with background cancer cases.

	Expected number of background cases		Upper bound estimate for number of cases due to Fernald-related exposure
Type of cancer	Median	90% Credibility Interval	Median	90% Credibility Interval
Bone	32	27–38	1	0–4
Breast	2,296	1945–2717	1	0–3
Kidney	367	311–435	1	0–4
Leukemia	367	311–435	5	3–23
Lung	2,601	2257–3014	85	25–309

Adapted from Fernald Risk Assessment Project. 2010. at http://www.cdc.gov/nceh/radiation/fernald/default.htm. Due to the nature of the data published by the CDC, bone, breast, kidney and leukemia cancer are expressed as cases, whereas lung cancer is expressed as cancer-related deaths.