Oak Ridge Reservation: Public Health Assessment Work Group
Public Health Assessment Work Group
August 18, 2003 - Meeting Minutes
ORRHES Members attending:
George Gartseff (acting chair), David Johnson, Don Box, Karen Galloway, Kowetha Davidson, LC Manley, Tony Malinauskas, Pete Malmquist, and James Lewis
Public Members attending:
Danny Sanders, Roger Macklin, Tim Joseph, John Merkle, and Gordon Blaylock
ATSDR Staff attending:
Jack Hanley (telephone), Bill Taylor, and Melissa Fish
The PHAWG chair, Bob Craig, was out of town and did not attend the meeting. George Gartseff chaired the meeting.
George Gartseff called the meeting to order and attendance was noted for the record.
There were six items on the agenda for discussion.
- Discussion/Approval of Meeting minutes for July 8, 2003
- Request for EPA representatives to attend ORRHES meeting
- PHA project plan
- Meeting minutes procedures
- Mercury: past exposures, part 2: Adding doses
- Other Business
The Draft meeting minutes for the July 8, 2003 PHAWG meeting were accepted as written without any modifications.
Request for EPA Representatives to Attend ORRHES Meeting
Bill Taylor explained that the request for EPA representatives to attend a future ORRHES meeting is an agenda item that will be brought up for discussion during the August 26th ORRHES meeting. A draft letter has been prepared and most of the wording for the letter was obtained from the PHAWG meeting in which the issue was raised. The letter has been forwarded to ORRHES where it will be presented and discussed for approval and the Chair's signature.
PHA Project Plan
Bill Taylor provided PHAWG with a heads-up relating to the PHA project plan and explained that the PHA project plan is a topic that will be discussed during the August 26th ORRHES meeting. Bill Taylor stated that the project plan for all PHAs will be extended. Bill explained that the original project plan did not have adequate time factored in for the document review process. The Oak Ridge site is considered by ATSDR to be a focus site, which means that Oak Ridge is being watched carefully. Because of this, extra PHA reviews within the agency are required. Bill Taylor provided an example of the internal review process. Before the Red cover PHA is presented to PHAWG the document is reviewed by the Assistant Director for Science in the Division for Health Assessment and Consultation and the Associate Administrator for Science, who reports to Dr. Falk. These additional reviews were not built into the process when the project plan was originally developed. Bill added that the minimum delay for internal review will be 3 to 4 weeks per review and FFAB staff does not have control over the schedules of upper management.
James Lewis asked if the Uranium PHA went through the process that Bill Taylor previously described. Bill Taylor responded that the Uranium PHA was pushed through the process very quickly with a lot of effort so that it would meet the schedule.
James Lewis said that the Project Manager should explain the PHA review process in detail because ORRHES members need to know where they stand as far as project plan slippages are concerned. James Lewis added that he would like Jerry Pereira to bring Bob Williams to the table because issues such as the internal review should have been factored in and considered when developing the original project plan timeline.
Bill Taylor told James Lewis that ATSDR did not initially recognize this situation and that it will be discussed further during the August ORRHES meeting. Bill Taylor told James that he would pass James's comments on to the Project Manager.
Meeting Minutes Procedures
Bill Taylor provided some background regarding the Changes to ORRHES Work Group Draft Meeting Minutes document. Bill explained that at the PHAWG meeting when this issue was first discussed, PHAWG members asked him to put a procedure in writing and to take the procedure to the Guidelines and Procedures Work Group. Bill explained that he had developed a draft procedure and that there was an internal relay within ATSDR regarding the wording of the document. It was the internal changes that resulted in two versions of the Changes to ORRHES Work Group Draft Meeting Minutes document.
Karen Galloway discussed both versions (Handout 1 and 2) of the Changes to ORRHES Work Group Draft Meeting Minutes document. Karen Galloway described the differences between both versions of the document. The major difference between the two documents is that the text relating to correction or clarifications submitted by the speaker. Handout 1 suggests leaving the text of the original minutes and reflecting the corrections and clarifications in the footnotes of the same meeting minutes. With the exception of minor typographical errors, the original meeting minute text will not change. Handout 2, which Karen received from Burt Cooper and Sandy Isaacs, is similar to what has been seen before in which clarifications and corrections can be made by attending a subsequent meeting. In this situation, corrections are made part of the next meeting's minutes rather than being corrected in the minutes of the meeting in which the correction or clarification is needed. This version also suggests that a person may submit corrections or clarifications to the work group chair and Field Office staff so that the corrections are discussed and a decision is reached through a work group vote.
James Lewis said that the logic behind generating a procedure for making changes to the meeting minutes is very important and it is crucial that the group endorse something that is logical and rationale so that ORRHES, ATSDR, and the community avoid hours and hours of arguing about who said what. James Lewis likes the definition of the record of discussion and would like any new procedure to be combined with the previous procedure written by Bill Pardue. James also pointed out that work group members have a responsibility to review the minutes.
Kowetha Davidson stated that for historical purposes, written minutes should be verifiable via audiotape. Any changes to the minutes must be verifiable so that years from now, people can go back and listen to what was said. It is important that people are able to match the written minutes with the audiotapes.
Bill Taylor feels that the group is in agreement that there must be an audio record of the meeting proceedings. Bill Taylor said that the difficulty arises because of the interpretation of the minutes. The minutes are not verbatim nor are the minutes a brief summary, the minutes are somewhere between the two extremes which requires interpretation. Bill added that this same issue also applies to ORRHES meeting minutes because ORRHES meeting minutes are not verbatim.
Regarding Handout two, Karen Galloway commented that if she were going to read the meeting minutes of a particular meeting it would not occur to her that she would also need to pick up the subsequent meeting minutes. Karen believes that the clarification or change needs to be finalized or amended in the minutes that pertain to the actual discussion that requires clarification and/or change.
In response to Karen Galloway, John Merkle stated that if there were subsequent clarifications to the original minutes, the change could be noted as a footnote of the original minutes. The footnote would refer to subsequent changes. John Merkle feels that this would alleviate the problem of looking at meeting minutes and not knowing if there are clarifications or changes identified in the following minutes. John Merkle added that there is more than one reason to change meeting minutes and that the minutes require continuity and connection.
James Lewis stated that the quality of the minutes has improved; this improvement has reduced the need for people to challenge the minutes. James would like ATSDR to acknowledge that fewer challenges occur when a high quality product is being produced.
George Gartseff pointed out that any process regarding changes to meeting minutes would impact all work groups and not just PHAWG. Is it PHAWG's place to make a recommendation that will impact all work groups?
After further discussion the group seemed to agree that the procedure regarding changes to meeting minutes would be discussed at ORRHES during the work group reports.
Mercury: Past Exposures, Part 2: Adding Doses
The purpose of Bill Taylor's presentation is to discuss topics that were brought up at the last PHAWG meeting and to continue with the mercury discussion. In his presentation, Bill Taylor specifically addressed and responded to comments made by Gordon Blaylock, James Lewis, and Peggy Adkins.
In response to Gordon Blaylock's question in the July PHAWG meeting concerning the FDA action level of mercury, Bill Taylor pointed out that the FDA mercury action level is 1 ppm (1 part per million). Bill Taylor provided a brief history explaining what the FDA has to say regarding mercury and fish.
This chart depicted the differences between the USEPA Reference Dose (RfC) and the ATSDR Minimal Risk Level (MRL).
Bill Taylor pointed out that James Lewis had asked for additional information about the differences between EPA and ATSDR comparison values, specifically for inhalation of elemental mercury because ATSDR's MRL is lower that the USEPA RfC.
Bill Taylor provided background information regarding the ATSDR MRL and USEPA RfC for the inhalation of elemental mercury and explained the sources from which the numbers are derived. ATSDR's MRL is based on one study with the endpoint being hand tremors. USEPA's RfC is based on six studies with the endpoints being hand tremors, memory disturbances, and autonomic dysfunction.
Bill Taylor explained the process that results in USEPA and ATSDR using different comparison values. Both agencies are considering the same limitations of the original studies but are weighing the limitations somewhat differently. In the end, the uncertainty factors that both agencies use have the same magnitude. The RfC is 0.0003 mg/m3 (USEPA) and the MRL is 0.0002 mg/m3 (ATSDR). Both values may be converted to units of mg/kg/day using standard breathing rates and body weights.
Kowetha Davidson pointed out that, in converting from worker data to the general population ATSDR is assuming the breathing rate for a worker and the general population is the same. EPA does not make the same assumption. Bill agreed, and stated that the differences in the magnitude of the comparison values of the two agencies can be traced to this assumption.
Bill Taylor stated that the take-home message from the overhead is that the numbers are pretty much the same because the values are not orders of magnitude different.
Kowetha Davidson added that toxicologically the EPA RfD and ATSDR MRL are considered to be the same numbers.
Jack Hanley added that the EPA reference dose is used to regulate industry and the ATSDR MRL is used as a screening value. Just because a concentration is above the MRL does not mean that ATSDR would consider the dose to be a health problem.
James Lewis thanked Bill Taylor for providing an excellent answer to his question.
Jack Hanley asked the group if they think an appendix explaining the difference between ATSDR and EPA values would be a useful addition to the Public Health Assessments.
In response to Jack Hanley's question, the group felt that an appendix explaining the reasons for the differences between agency values would be useful.
Tim Joseph said that when presenting data, it is helpful to keep the units the same.
Kowetha Davidson stated that it is important to remember that when converting air concentrations to doses, there is a large degree of uncertainty and a lot of assumptions are being made. Bill Taylor agreed and added that uncertainty and/or variability is added each time a conversion step is made.
Tim Joseph said that it would be helpful to have the data also presented in pounds because most people still think in terms of pounds.
Kowetha Davidson pointed out that another assumption that is being made is 100% uptake.
Tim Joseph stated that all assumptions should be detailed and explained up front because many people do not understand the assumptions without some type of explanation.
Bill Taylor explained that this overhead is the ATSDR plan for discussing the historical mercury releases from the Oak Ridge facilities with the PHAWG. The point of discussing the steps in the plan is to consider the technical areas where ATSDR may want to reconsider the Dose Reconstruction results. Bill told the group that there is always room for input from work group members and ORRHES members.
Because the document with all of the technical reviewer comments is not currently available, Bill Taylor distributed a list of seven ATSDR Technical Reviewers' major concerns (Handout 3). Bill explained that for the purposes of tonight's meeting the group would be discussing the first comment on the list: “The authors may have underestimated the health risks of certain populations by considering the risks of different species of mercury independently.” Bill Taylor explained that the list might change and that the group can add to the list and that ATSDR is trying to get the compilation of reviewer's comments ready for distribution.
Bill Taylor stated that at the last PHAWG meeting Peggy Adkins had asked if it is appropriate to add mercury doses together. Bill's response at the last meeting was that adding mercury doses might be appropriate if the doses had a common target organ. Tonight Bill Taylor will explain to the group why adding mercury doses might be appropriate and how ATSDR may be able to add the mercury doses.
Bill Taylor explained that the table on this overhead describes exposure pathways and population groups and is taken directly from the Dose Reconstruction project. Bill Taylor pointed out that the top row is the only place in which inhalation of elemental mercury occurs and that the bottom row is the only place in which the consumption of methyl mercury occurs and this occurs via fish consumption. All exposures between the first and last row are inorganic exposures. The chart shows that there are populations that were exposed to all three species of mercury.
LC Manley asked where the data comes from that indicates that the residents of Scarboro were exposed to all three species of mercury and exposed to more mercury than a resident of another community. Bill Taylor responded that the population-pathway pairs in the table were assumptions made by the people who completed the Dose Reconstruction.
John Merkle asked if the population exposures in the table resulted from outright assumptions or if they resulted from a plume analysis. Bill Taylor responded that it could be both and that this table is one simplification of the majority of data presented in the Dose Reconstruction. In addition to this table, the Dose Reconstruction presents various scenarios regarding different levels of fish consumption that could be applied to any population.
Overhead Seven and Eight
Bill Taylor then identified the primary target organs for each species of mercury.
Gordon Blaylock asked if methyl mercury would accumulate in the central nervous system/brain. Bill Taylor responded that methyl mercury would accumulate in the central nervous system/brain.
Regarding elemental mercury, Kowetha Davidson stated that the central nervous system is the primary target and the most sensitive target.
Overhead Nine and Ten
Bill Taylor explained what happens to mercury inside the body. Bill read the text at the bottom of the overhead. Mechanisms for the toxic effects of inorganic and organic mercury are believed to be similar. It has been suggested that the relative toxicities of different forms of mercury are related, in part, to its differential accumulation in sensitive tissues.
Bill Taylor explained that the “bad player” is the mercuric ion (Hg++). In all three species of mercury, it is the mercuric ion which causes damage in the kidneys as well as in the central nervous system—whichever is the primary target organ. Mercuric ion does not readily cross the blood-brain barrier, but elemental mercury and methylmercury both cross the blood-brain barrier. Once inside the central nervous system, elemental mercury and methylmercury are oxidized to the mercuric (ionic) form of mercury—the form in which they do damage. The mercuric ions in the central nervous system also cannot readily travel outside the blood-brain barrier and are essentially trapped there. In the blood circulation, mercuric ions are attracted to sulfhydryl groups, which are found everywhere in the body, and to metallothionein which is particularly associated with the kidneys. When mercury binds to metallothionein it causes more metallothionein to be produced which in turn binds more mercury. Thus, mercury in the bloodstream accumulates in the kidneys, which is the most sensitive target organ for mercuric (inorganic) mercury.
Bill Taylor feels that it is appropriate to add mercury doses because there are primarily two main target tissues. However, Bill does not feel that it is appropriate to simply take the external doses and add them together because the doses listed in the Dose Reconstruction do not take into consideration differential absorption and distribution inside the body.
Bill Taylor has been looking into methods of converting external doses into numbers that can be combined and evaluated as one. Methyl and elemental mercury data may be able to be evaluated together. Bill is waiting to talk to the Toxicological Profile manager at ATSDR. Typically, different mercury species are handled separately. However, from a public health standpoint, it is appropriate to look at mercury in terms of the target tissue effects.
Kowetha Davidson raised the issue that from a theoretical point of view, the blood concentrations of mercury can be more related to kidney toxicity than to the central nervous system. Is this the direction that you will be going?
Bill Taylor stated that he is wondering if that information can be used if there is additional information regarding the rate of transfer from the blood to the central nervous system for methyl and elemental mercury.
Bill Taylor and Kowetha Davidson agreed that the uptake of elemental mercury to the brain seems very rapid because the circulation of the blood to the brain is rapid and there is no delay for crossing the blood-brain barrier. However, with methylmercury there is somewhat more delay because methylmercury seems to hang around with the red blood cells for a longer period of time; elemental mercury may diffuse in the blood independently of the red blood cells.
Bill Taylor stated that in combining mercury doses, broad and conservative assumptions might need to be made, such as assuming that all of the absorbed elemental mercury crosses the blood-brain barrier.
In response to John Merkle's comments about elemental mercury and the lungs, Bill Taylor stated that the reason that more kidney effects from elemental mercury have not been observed is perhaps because the elemental vapors go right through the lungs very rapidly and through the central nervous system very rapidly. In addition, there is likely a fairly rapid conversion to the mercuric ion which traps it in the central nervous system.
For clarification, Bill Taylor agreed with John Merkle's comment that the process includes the lungs, the blood, and the brain. Bill understands that mercury cannot go from the lungs to the brain without going through the blood.
Kowetha Davidson said that inhaling mercury is different than ingesting mercury. Bill Taylor agreed and added that there are numbers for many processes (e.g., absorption and distribution of mercury in the body) but not all. Bill Taylor intends to bring back to the PHAWG as much information as possible regarding the issue of combining doses.
Don Box wondered about mercury and if mercury enters the lymph system. Bill Taylor responded that he does not have specific information regarding the lymph system. However, Bill thinks that mercury could enter the lymph system because mercury goes everywhere else throughout the body.
Gordon Blaylock asked for clarification regarding the purpose of adding doses and asked if Bill was thinking of obtaining a single dose.
Bill Taylor said that combining doses should not be to fewer than two values because it is not appropriate to mix the central nervous effects with the kidney effects. Some populations have only one route of exposure but other populations have different combinations of exposures. When looking at various populations, it is important to consider the dose to the kidneys and the dose to the central nervous system rather than focusing on the three species of mercury having separate doses.
Bill Taylor feels that the concern of the technical reviewer that the effects of mercury could have been underestimated in the Dose Reconstruction is legitimate because the Dose Reconstruction considered the three species of mercury separately.
Bill Taylor told the group that he will follow-up with any new information and that he hopes to have the document with the technical reviewers' comments available soon.
Discussion Regarding Mercury
Jack Hanley and Bill Taylor assured the group that ATSDR's PHA will include years on the X-axis of the graphs that it produces.
Bill Taylor stated that the group must be selective about material that ATSDR would like more of. Bill expects that ATSDR will be most concerned with doses that exceed the NOAELs as well as the doses that exceed ATSDR's MRLs. Bill Taylor also told the group that consideration of the technical reviewer comments might change the estimated doses that ATSDR uses. The doses could either be raised above or lowered below the comparison values depending on the technical comments.
Peggy Adkins asked if there is a plan to take actual people from high dose areas who have been shown by a legitimate source to have high levels of mercury and actually study those people to find out what type of mercury poisoning they have or to look at the symptoms and test the people to see what type of mercury poisoning they have?
Bill Taylor told the group that currently there is not a plan to test individual people for mercury poisoning. Bill said that the exposure must first be evaluated in the PHA. After an exposure is evaluated and if warranted, ATSDR can make recommendations and then form an action plan.
Jack Hanley provided an example of the process that Bill Taylor mentioned. Jack Hanley said that modeling and risk assessments performed by various agencies indicated that PCBs could be a problem on Watts Bar and the Clinch River/Poplar Creek. Previous assessments showed an excess of one cancer in 1000. Based on that, ATSDR performed its own assessment and had similar conclusions. So, in 1997, to validate the models and risk assessments, ATSDR went out and drew the blood from 116 people who consumed large quantities of fish.
Jack Hanley stated that once a population is identified, ATSDR can perform additional tests. However, the population must be narrowed down. ATSDR cannot draw blood from every person. If a biological indicator is known, ATSDR might perform follow-up activities. Bill Taylor and Jack Hanley stated that a Public Health action plan would come after the Public Health Assessment.
James Lewis asked Peggy Adkins to define and explain the term “legitimate source.” Peggy Adkins defined a legitimate source as a 24-hour urine analysis followed by agitation with a compound that combines with positive mercury ions.
James Lewis asked if Peggy Adkins was referring to the test being performed by a physician or a reputable lab.
Peggy Adkins explained to the group that she has had mercury testing performed from at least three different labs and all the tests have shown extremely elevated levels of mercury. Peggy Adkins feels that she has the symptoms and is a textbook case. Peggy does not know what type of mercury poisoning she has and is someone that could be tested further. Peggy added that there are people who lived around her who have some of the same symptoms that she is experiencing. Peggy worries that mercury poisoning is being misdiagnosed as Multiple Sclerosis.
Peggy Adkins said that it seems that the group is always looking at old data and making nice charts but is never really helping anyone. There are some sick people who are still alive who were exposed to mercury. Many people were constantly eating fish that may have had high levels of mercury. Thus, the 95% confidence is frustrating because so many people have died and the group is not trying to do anything new. The group continues to rehash old studies and put new labels on them.
James Lewis appreciated the background and information that Peggy provided but still wants to know what the group considers to be a legitimate source or a legitimate technique. James feels that it is important to clarify what is considered legitimate and what is not considered legitimate.
Jack Hanley stated that ATSDR does not perform clinical diagnosis of individuals. If an individual is looking for diagnosis, ATSDR refers them to board certified occupational specialists.
James Lewis understands what Jack Hanley is saying. His point is that a procedure for identifying mercury poisoning should be laid out. James asked whether there are certain types of tests or procedures that are considered credible that are used for evaluating or monitoring mercury poisoning.
Jack Hanley told the group that perhaps ATSDR can look further into the methodologies used for monitoring mercury. ATSDR can present information regarding standard methodologies and standard protocols (if there are standard methods) that are used when testing and monitoring mercury.
Janet Michel told the group that Dr. John Rosen at Mount Sinai Hospital in New York is the world's leading expert in chelating lead out of children. Janet also said that there is a woman at John Hopkins who is doing a lot of research. In addition there are a lot of doctors on the occupational and environmental list serve that could respond and provide information regarding the protocol for evaluating mercury poisoning.
Jack Hanley told the group that ORRHES has developed comment sheets. Jack encourages everyone to use the comment sheets to describe their issue and concerns so that ATSDR can specifically address individual concerns in presentations and/or in the PHA.
Commenting on a statement that James Lewis made earlier, R.L. Ayers explained that if one set of doctors makes a decision, that does not mean that the decision will coincide with the decision of another group of doctors because doctors have different ideas. R.L. Ayers said she worked with physicians for 47 years at the Veterans Medical Center and knows quite a few physicians and knows how their minds work. Mrs. Ayers knows that all physicians are not going to agree with each other, especially if there is an important issue that they should not always agree on.
John Merkel stated that the calculations in the Dose Reconstruction that go from releases to doses should be reversible in the sense that if a person is assumed to have retained a certain amount of an element, it is probably possible to estimate the external concentration and duration of exposure that was required to produce the effect.
Gordon Blaylock told the group that the biggest source of mercury now for the average person is canned tuna. Gordon believes that the regulation for mercury in fish is 1 part per million and he wondered if the fish in East Fork Poplar Creek exceed that regulation. Bill Taylor told him that he does not know.
Susan Kaplan asked what the doses of mercury are today compared to those people who lived along the creek in the past? Gordon Blaylock said that it would depend on the years that people lived along the creek.
Gordon Blaylock said that if people fished in East Fork Poplar Creek during the years with the highest releases, those people would probably get a higher dose. Bob Craig added that very little mercury is coming down East Fork Poplar Creek today compared to the 1950s.
Susan Kaplan said that current mercury exposures are additive to the exposures of the 1950s. Bill Taylor responded that it would depend on how much mercury was eliminated from the body between the 1950s and present day.
Bob Peelle pointed out that nobody measured the mercury content of fish in the 1960s when it was most important.
Gordon Blaylock said that people in the United States did not get excited about levels of mercury until high levels of mercury were discovered in Canada. Gordon said that fish with high levels of mercury were collected from Poplar Creek in approximately 1974 or 1975.
Janet Michel told the group that she has seen a Y-12 document from the 1950's that discusses monitoring mercury in water four times a year.
Bob Peelle did not recall the document that Janet Michel is speaking of.
Gordon Blaylock stated that Y-12 was primarily concerned with atmospheric releases and inhalation. They did not consider releases to the East Fork Poplar Creek.
Peggy Adkins told the group that it would be wonderful to have marks on the (Extent of Mercury Contamination in East Fork Poplar Creek 100-Year Floodplain [prior to remediation in 1997] map that reflect the known burial sites for any type of mercury.
Jack Hanley told the group that most of the mercury was in buildings and it leaked out of pipes into the ground.
Peggy Adkins told the group that she would like to see the mercury seepage points marked on the map.
Bob Craig pointed out that most people did not purposely bury mercury.
Bob Peelle said that depending on the pH of the creek, the main source of mercury downstream was presumably the mercury cleaning device.
Action Items Regarding Mercury Discussion
- ATSDR will follow-up on Mrs. Ayers question about buried mercury wastes.
- ATSDR should identify the logic behind different agencies choosing different values, especially as it related to elemental mercury.
- ATSDR will look further into the methodologies used for detecting and monitoring mercury poisoning.
- ATSDR will find out the procedure that the Dose Reconstruction document used to derive estimated doses from fish.
New Business: Health Statistics Review
Pete Malmquist passed out copies of the draft Health Statistics Review Assessment of Cancer Incidence that Dee Williamson has created. Pete Malmquist would like any comments regarding the draft document. Pete told the group that there will be a conference call (yet to be scheduled) some time after the ORRHES meeting.
Regarding the health statistics review process, Kowetha Davidson asked that during the ORRHES meeting, Pete Malmquist mention where in the process the group is.
James Lewis said that if there is anything inside the draft health statistics review document that is in conflict with the task that the group was assigned, then the group needs to take advantage of the August ORRHES meeting so that the group can move forward with the health statistics review issue.
After some opposing views about whether or not ORRHES had approved the actual task of the health statistics review and because the work group appears to have veered off its original task of only reporting cancer incidence, Kowetha Davidson said that she would like the health statistics review issue to be brought before the ORRHES.
John Merkle stated that it is difficult to derive statistically meaningful conclusions from data of small populations.
Pete Malmquist stated that the State of Tennessee will not provide ORRHES with census tract data because the population is so small. In response to John Merkle’s statement, Pete said that Ed Frome and Dee Williamson will be working together on the Health Statistics review.
Danny Sanders reminded the group that in the 1940s there were transients who will not be included in the Tennessee registry.
Pete Malmquist and others said that those transients might be in another registry, but this data is what the group must work with.
James Lewis pointed out that in her draft, Dee Williamson has identified the limitations of the Health Statistics Review effort so that the work is not taken out of context.
Pete Malmquist told the group that to the best of his memory, there are 26 different cancers listed in the registry from 1986 on. The group is planning on breaking the data down and comparing it by areas/counties to the State of Tennessee.
The meeting was adjourned at 7:00 PM.