[Federal Register Volume 84, Number 151 (Tuesday, August 6, 2019)]
[Proposed Rules]
[Pages 38177-38180]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-16609]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

42 CFR Part 88

[NIOSH Docket 094]


World Trade Center Health Program; Petition 022--Monoclonal 
Gammopathy of Undetermined Significance; Finding of Insufficient 
Evidence

AGENCY: Centers for Disease Control and Prevention, HHS.

ACTION: Denial of petition for addition of a health condition.

-----------------------------------------------------------------------

SUMMARY: On March 11, 2019, the Administrator of the World Trade Center 
(WTC) Health Program received a petition (Petition 022) to add 
``monoclonal gammopathy of undetermined significance (MGUS)'' to the 
List of WTC-Related Health Conditions (List). Upon reviewing the 
scientific and medical literature, including information provided by 
the petitioner, the Administrator has determined that the available 
evidence does not have the potential to provide a basis for a decision 
on whether to add MGUS to the List. The Administrator also finds that 
insufficient evidence exists to request a recommendation of the WTC 
Health Program Scientific/Technical Advisory Committee (STAC), to 
publish a proposed rule, or to publish a determination not to publish a 
proposed rule.

DATES: The Administrator of the WTC Health Program is denying this 
petition for the addition of a health condition as of August 6, 2019.

ADDRESSES: Visit the WTC Health Program website at https://www.cdc.gov/wtc/received.html to review Petition 022.

FOR FURTHER INFORMATION CONTACT: Rachel Weiss, Program Analyst, 1090 
Tusculum Avenue, MS: C-48, Cincinnati, OH 45226; telephone (855) 818-
1629 (this is a toll-free number); email [email protected].

SUPPLEMENTARY INFORMATION:

Table of Contents

A. WTC Health Program Statutory Authority
B. Procedures for Evaluating a Petition
C. Petition 022
D. Review of Scientific and Medical Information and Administrator 
Determination
E. Administrator's Final Decision on Whether To Propose the Addition 
of Monoclonal Gammopathy of Undetermined Significance to the List
F. Approval To Submit Document to the Office of the Federal Register

A. WTC Health Program Statutory Authority

    Title I of the James Zadroga 9/11 Health and Compensation Act of 
2010 (Pub. L. 111-347, as amended by Pub. L. 114-113), added Title 
XXXIII to the Public Health Service (PHS) Act,\1\ establishing the WTC 
Health Program within the Department of Health and Human Services 
(HHS). The WTC Health Program provides medical monitoring and treatment 
benefits for health conditions on the List to eligible firefighters and 
related personnel, law enforcement officers, and rescue, recovery, and 
cleanup workers who responded to the September 11, 2001, terrorist 
attacks in New York City, at the Pentagon, and in Shanksville, 
Pennsylvania (responders), and to eligible persons who were present in 
the dust or dust cloud on September 11, 2001, or who worked, resided, 
or attended school, childcare, or adult daycare in the New York City 
disaster area (survivors).
---------------------------------------------------------------------------

    \1\ Title XXXIII of the PHS Act is codified at 42 U.S.C. 300mm 
to 300mm-61. Those portions of the James Zadroga 9/11 Health and 
Compensation Act of 2010 found in Titles II and III of Public Law 
111-347 do not pertain to the WTC Health Program and are codified 
elsewhere.
---------------------------------------------------------------------------

    All references to the Administrator of the WTC Health Program 
(Administrator) in this document mean the Director of the National 
Institute for Occupational Safety and Health (NIOSH) or his designee.
    Pursuant to section 3312(a)(6)(B) of the PHS Act, interested 
parties may petition the Administrator to add a health condition to the 
List in 42 CFR 88.15. Within 90 days after receipt of a valid petition 
to add a condition to the List, the Administrator must take one of the 
following four actions described in section 3312(a)(6)(B) of the PHS 
Act and Sec.  88.16(a)(2) of the Program regulations: (1) Request a 
recommendation of the STAC; (2) publish a proposed rule in the Federal 
Register to add such health condition; (3) publish in the Federal 
Register the Administrator's determination not to publish such a 
proposed rule and the basis for such determination; or (4) publish in 
the Federal Register a determination that insufficient evidence exists 
to take action under (1) through (3) above.

B. Procedures for Evaluating a Petition

    In addition to the regulatory provisions, the WTC Health Program 
has developed policies to guide the review of submissions and 
petitions,\2\ as well as the analysis of evidence supporting the 
potential addition of a non-cancer health condition to the List.\3\
---------------------------------------------------------------------------

    \2\ See WTC Health Program [2014], Policy and Procedures for 
Handling Submissions and Petitions to Add a Health Condition to the 
List of WTC-Related Health Conditions, May 14, 2014, http://www.cdc.gov/wtc/pdfs/WTCHPPPPetitionHandlingProcedures14May2014.pdf.
    \3\ See WTC Health Program [2017], Policy and Procedures for 
Adding Non-Cancer Conditions to the List of WTC-Related Health 
Conditions, February 14, 2017, https://www.cdc.gov/wtc/pdfs/policies/WTCHP_PP_Adding_NonCancers_14_February_2017-508.pdf.
---------------------------------------------------------------------------

    A valid petition must include sufficient medical basis for the 
association between the September 11, 2001, terrorist attacks and the 
health condition to be added; in accordance with WTC Health Program 
policy, reference to a peer-reviewed, published, epidemiologic study 
about the health condition among 9/11-exposed populations or to 
clinical case reports of health conditions in WTC responders or 
survivors may demonstrate the required medical basis.\4\ Studies 
linking 9/11 agents or hazards \5\ to the petitioned health condition 
may also provide sufficient medical basis for a valid petition.
---------------------------------------------------------------------------

    \4\ See supra note 2.
    \5\ 9/11 agents are chemical, physical, biological, or other 
hazards reported in a published, peer-reviewed exposure assessment 
study of responders, recovery workers, or survivors who were present 
in the New York City disaster area, or at the Pentagon site, or the 
Shanksville, Pennsylvania site, as those locations are defined in 42 
CFR 88.1, as well as those hazards not identified in a published, 
peer-reviewed exposure assessment study, but which are reasonably 
assumed to have been present at any of the three sites. See WTC 
Health Program [2018], Development of the Inventory of 9/11 Agents, 
July 17, 2018, https://wwwn.cdc.gov/ResearchGateway/Content/pdfs/Development_of_the_Inventory_of_9-11_Agents_20180717.pdf.
---------------------------------------------------------------------------

    After the Program has determined that a petition is valid, the 
Administrator must direct the Program to conduct a review of the 
scientific literature to determine if the available scientific 
information has the potential to provide

[[Page 38178]]

a basis for a decision on whether to add the health condition to the 
List.\6\ The literature review is a keyword search of relevant 
scientific databases; peer-reviewed, published, epidemiologic studies 
(including direct observational studies in the case of health 
conditions such as injuries) about the health condition among 9/11-
exposed populations are then identified from the initial search 
results. The Program evaluates the scientific quality of each peer-
reviewed, published, epidemiologic study of the health condition 
identified in the literature search; the Program then compiles the 
scientific results of each study to assess whether a causal 
relationship between 9/11 exposures and the health condition is 
supported, and evaluates whether the results of the studies are 
representative of the 9/11-exposed population of responders and 
survivors. A health condition may be added to the List if peer-
reviewed, published, epidemiologic studies provide support that the 
health condition is substantially likely \7\ to be causally associated 
with 9/11 exposures. If the evaluation of evidence provided in peer-
reviewed, published, epidemiologic studies of the health condition in 
9/11 populations demonstrates a high, but not substantial, likelihood 
of a causal association between the 9/11 exposures and the health 
condition, then the Administrator may consider additional highly 
relevant scientific evidence regarding exposures to 9/11 agents from 
sources using non-9/11-exposed populations. If that additional 
assessment establishes that the health condition is substantially 
likely to be causally associated with 9/11 exposures among 9/11-exposed 
populations, the health condition may be added to the List.
---------------------------------------------------------------------------

    \6\ See supra note 3.
    \7\ The ``substantially likely'' standard is met when the 
scientific evidence, taken as a whole, demonstrates a strong 
relationship between the 9/11 exposures and the health condition.
---------------------------------------------------------------------------

C. Petition 022

    On March 11, 2019, the Administrator received a petition (Petition 
022) requesting the addition of ``monoclonal gammopathy of undetermined 
significance (MGUS)'' to the List.\8\ The petition included a 2018 
study by Landgren et al.,\9\ which provided sufficient medical basis 
for the petition to be considered valid because it is a peer-reviewed, 
published, epidemiologic study about the health condition among 9/11-
exposed populations; Landgren et al. is a scientific source that 
demonstrates a potential link between exposure to a 9/11 hazard (in 
this case, the identified 9/11 agents polychlorinated biphenyl (PCB), 
dioxins, polycyclic aromatic hydrocarbons (PAHs), and asbestos) \10\ 
and the requested health condition, MGUS.
---------------------------------------------------------------------------

    \8\ See Petition 022, WTC Health Program: Petitions Received, 
http://www.cdc.gov/wtc/received.html.
    \9\ Landgren O, Zeig-Owens R, Giricz O, Goldfarb D, Murata K, 
Thoren K, Ramanathan L, Hultcrantz M, Dogan A, Nwankwo G, Steidl U, 
Pradhan K, Hall CB, Cohen HW, Jaber N, Schwartz T, Crowley L, Crane 
M, Irby S, Webber MP, Verma A, Prezant DJ [2018], Multiple Myeloma 
and its Precursor Disease Among Firefighters Exposed to the World 
Trade Center Disaster, JAMA Oncol 4(6):821-827.
    \10\ See supra note 5.
---------------------------------------------------------------------------

D. Review of Scientific and Medical Information and Administrator 
Determination

    The Program policy on the addition of non-cancer health conditions 
to the List directs the Program to conduct a literature review of the 
health condition(s) petitioned.\11\ Petition 022 requested the addition 
of MGUS, an asymptomatic condition characterized by the presence of a 
monoclonal immunoglobulin (Ig), also called an M-protein, in the blood 
without any evidence of multiple myeloma or another lymphoproliferative 
disorder. MGUS is not a cancer, and the vast majority of people with 
MGUS never develop the types of cancer for which it is a precursor. 
Immunoglobulin subtypes involved may be IgM, non-IgM (e.g., IgA and 
IgG), or light-chain.\12\ All pose a slight risk of progression (1-2 
percent per year) to a malignant disorder. Typically, IgG and IgA MGUS 
are the precursors of multiple myeloma, IgM MGUS is the precursor of 
Waldenstrom macroglobulinemia or other lymphoproliferative conditions, 
and light-chain MGUS is the precursor of light-chain multiple 
myeloma.\13\
---------------------------------------------------------------------------

    \11\ Supra note 3.
    \12\ ``Light-chain'' refers to the antibody components made by 
malignant plasma cells in patients with multiple myeloma.
    \13\ Fanning SR, Hussein MA [2018], Monoclonal Gammopathies of 
Undetermined Significance, Medscape, https://emedicine.medscape.com/article/204297-overview.
---------------------------------------------------------------------------

    In response to Petition 022, the Program conducted a review of the 
scientific literature on MGUS to identify peer-reviewed, published, 
epidemiologic studies of the health condition in the 9/11-exposed 
population.\14\ Only one study meeting the Program's criteria for 
further evaluation was identified in this literature review, Landgren 
et al. [2018], referenced above.
---------------------------------------------------------------------------

    \14\ Databases searched include: CINAHL, Embase, NIOSHTIC-2, 
ProQuest Health & Safety, PsycINFO, Ovid MEDLINE, Scopus, Toxicology 
Abstracts/TOXLINE, and WTC Health Program Bibliographic Database. 
Keywords used to conduct the search include: MGUS, monoclonal 
gammopathy of undetermined significance, premalignant clonal plasma 
cell disorder, lymphoplasmacytic proliferative disorder, monoclonal 
gammopathy, monoclonal gammopathies. The literature search was 
conducted in English-language journals on April 25, 2019.
---------------------------------------------------------------------------

    Landgren et al. [2018] reported on two analyses conducted on 9/11-
exposed firefighters from the New York City Fire Department (FDNY). One 
was a case series (a descriptive report) of 16 multiple myeloma cases 
identified among white male WTC-exposed FDNY firefighters. Since this 
analysis does not provide dispositive evidence linking 9/11 exposures 
to MGUS, it is not relevant to this petition and will not be further 
described.
    The second analysis was a prevalence screening study of 781 9/11-
exposed FDNY white male firefighters aged 50 to 79 years. Patients with 
MGUS, light-chain MGUS, and overall MGUS (i.e., MGUS and light-chain 
MGUS combined) were diagnosed using a serum immunoglobulin assay. 9/11 
exposure was assessed based on initial arrival time at Ground Zero and 
five exposure groups were recognized (i.e., arriving the morning of 9/
11 [most highly exposed]; arriving the afternoon of September 11, 2001; 
arriving on September 12, 2001; arriving between September 13 and 24, 
2001; and arriving between September 25, 2001 and July 24, 2002 [least 
exposed]). 9/11 exposure was also assessed by length of time worked at 
Ground Zero (months in which a participant worked at least 1 day at 
Ground Zero).
    Findings in this study were compared to those of a population-based 
cohort of 7,612 white male residents of Olmsted County, Minnesota, aged 
50 years and older, previously assembled to estimate MGUS 
prevalence.\15\ Among FDNY firefighters, the age-standardized 
prevalence rate (ASR) of overall MGUS (i.e., MGUS and light-chain MGUS 
combined) was 7.63 per 100 persons (95% CI, 5.45-9.81). The ASR of 
light-chain MGUS was 3.08 per 100 persons (95% CI, 1.66-4.50), and for 
MGUS was 4.55 per 100 persons (95% CI, 2.90-6.21). The relative rate of 
overall MGUS (i.e., MGUS and light-chain MGUS combined) was 1.76 (95% 
CI, 1.34-2.29) when comparing FDNY firefighters with the Olmsted County 
reference population; the relative rate was 3.13 for light-chain MGUS 
(95% CI, 1.99-4.93) and 1.35 for MGUS (95% CI, 0.96-1.91).

[[Page 38179]]

The researchers evaluated the risk of overall MGUS (i.e., MGUS and 
light-chain MGUS combined) by 9/11 exposure; for each of the arrival 
times described above, the ASRs for the 9/11-exposed FDNY firefighters 
were greater than in the Olmsted County reference population, although 
the authors did not find an exposure gradient and did not provide risk 
estimates for these findings. Additionally, the authors reported that 
there were no statistically significant differences in ASRs when length 
of time worked at Ground Zero was included in the analyses (the authors 
did not report a risk estimate for this finding). In addition, the 
authors did not report the results of the association between 9/11 
exposures, expressed by time of arrival or duration of work at Ground 
Zero, and light-chain MGUS, nor for MGUS overall.
---------------------------------------------------------------------------

    \15\ Dispenzieri A, Katzmann JA, Kyle RA, et al. [2010], 
Prevalence and Risk of Progression of Light-Chain Monoclonal 
Gammopathy of Undetermined Significance: A Retrospective Population-
Based Cohort Study, Lancet 375(9727):1721-8.
---------------------------------------------------------------------------

    Among the strengths of Landgren et al. [2018] is that this is the 
first study to present the age-specific prevalence of MGUS or light-
chain MGUS in 9/11-exposed responders, and show an excess age-
standardized prevalence when compared to an unexposed reference 
population.\16\ Health outcomes were objectively assessed, since 
diagnosis was determined in all study participants by testing serum 
samples, collected between December 2013 and October 2015, in the 
laboratory.
---------------------------------------------------------------------------

    \16\ Among FDNY firefighters, the ASR of overall MGUS was 7.63 
per 100 persons (95% CI, 5.45-9.81) versus the ASR of overall MGUS 
among the Olmsted County reference population of 4.34 per 100 
persons (95% CI, 3.88-4.81 per 100 persons and RR, 1.76; 95% CI, 
1.34-2.29).
---------------------------------------------------------------------------

    However, Landgren et al. [2018] is subject to a number of 
limitations. The prevalence study design limits the interpretation and 
generalizability of findings. IgM MGUS and non-IgM MGUS were lumped 
together as ``MGUS'' and not reported separately. Risk estimates of the 
association between 9/11 exposure and MGUS were not reported. A 
temporal relationship between 9/11 exposure and the first occurrence of 
MGUS could also not be established; because MGUS is asymptomatic, it is 
possible that some FDNY members with MGUS had the condition prior to 
September 11, 2001 (no baseline samples were collected prior to 
September 11, 2001 to ascertain date of onset). Another limitation 
suggested by the authors is inadequate statistical power to detect a 
statistically significant exposure-response relationship. Landgren et 
al. [2018] addressed confounding by race, gender, and age by limiting 
the analysis to white men and standardizing the rates by age. However, 
family history of MGUS and other occupational exposures were not 
controlled for. A major limitation of this study is the use of the 
Olmsted County reference group,\17\ which is a general population 
selected from a mixed rural-urban setting and not comparable to the 
FDNY population, a predominantly urban working population. The authors 
acknowledged that a comparison group composed of firefighters with no 
9/11 exposure or a truly random sample of the U.S. (or the New York 
City) population would be desirable. Finally, the authors reported that 
they were unable to control for all of the potential confounders 
between the study and reference populations.
---------------------------------------------------------------------------

    \17\ Wi C, St Sauver JL, Jacobson DJ, et al. [2016], Ethnicity, 
Socioeconomic Status, and Health Disparities in a Mixed Rural-Urban 
US Community--Olmsted County, Minnesota, Mayo Clinic Proceedings 
91(5):612-622.
---------------------------------------------------------------------------

Evaluation of Study Using Select Bradford Hill Criteria

    Landgren et al. [2018] was assessed to determine whether a causal 
relationship between 9/11 exposures and MGUS is supported. As described 
in the policy on the addition of non-cancer health conditions to the 
List,\18\ the WTC Health Program uses the following Bradford Hill 
criteria to evaluate studies of 9/11-exposed populations: strength of 
association, precision of the risk estimate, consistency of 
association, biological gradient, and plausibility and coherence.\19\
---------------------------------------------------------------------------

    \18\ Supra note 3.
    \19\ Aschengrau A, Seage GR [2018], Essentials of Epidemiology 
in Public Health. 4th Edition, (Burlington, MA: Jones & Bartlett).
---------------------------------------------------------------------------

    Strength of association: \20\ Landgren et al. [2018] found a 
relatively strong association between being a 9/11-exposed FDNY member 
and an increased prevalence of MGUS, especially light-chain MGUS. 
However, Landgren et al. [2018] did not report risk estimates for the 
association between their measures of 9/11 exposure (initial arrival 
time and length of time worked at Ground Zero); the WTC Health Program 
would need such risk estimates in order to evaluate the strength of the 
association between 9/11 exposure and MGUS.
---------------------------------------------------------------------------

    \20\ It is generally thought that strong associations are more 
likely to be causal than weak associations; however, a weak 
association does not rule out a causal relationship. See supra note 
19.
---------------------------------------------------------------------------

    Precision of risk estimate: \21\ Landgren et al. [2018] reported 
reasonably precise risk estimates when comparing FDNY members with the 
Olmsted County reference population.\22\ Because Landgren et al. [2018] 
did not report risk estimates and their confidence intervals for the 
association between 9/11 exposure and MGUS, the WTC Health Program is 
unable to evaluate the precision of such risk estimates.
---------------------------------------------------------------------------

    \21\ The uncertainty inherent in estimating the strength of 
association between exposure and health effect (effect size) from 
observational data is expressed as a confidence interval, 
illustrating a range of values that contains the true effect size. A 
narrow confidence interval indicates a more precise measure of the 
effect size and a wider interval indicates greater uncertainty. See 
supra note 19.
    \22\ See supra note 16.
---------------------------------------------------------------------------

    Consistency of association: \23\ Multiple studies are not available 
to ascertain consistency. Only the Landgren et al. [2018] study is 
available.
---------------------------------------------------------------------------

    \23\ Consistent findings are demonstrated when they have been 
repeatedly reported by multiple studies. See supra note 19.
---------------------------------------------------------------------------

    Biological gradient: \24\ The exposure-response (biological 
gradient) information provided in Landgren et al. [2018] does not 
demonstrate an exposure gradient between 9/11 exposure and MGUS. In 
other words, the study does not provide evidence that the risk of MGUS 
increases with increasing levels of exposure.
---------------------------------------------------------------------------

    \24\ Studies establish an exposure-response relationship by 
demonstrating that increases in exposure (i.e., exposures of greater 
intensity and/or longer duration) are associated with a greater 
incidence of disease. A thorough evaluation of exposure-response 
requires analysis of multiple levels of exposure such that the 
investigator can demonstrate that the risk increases with increasing 
levels of exposure. See supra note 19.
---------------------------------------------------------------------------

    Plausibility and coherence: \25\ The findings of Landgren et al. 
[2018] do not demonstrate a basis for a potential relationship between 
9/11 exposure and MGUS. Some FDNY members with MGUS may have had the 
condition prior to September 11, 2001. This lack of temporal 
information severely limits an evaluation of the plausibility of an 
association between 9/11 exposure and MGUS.
---------------------------------------------------------------------------

    \25\ Study findings demonstrate a basis in scientific theory 
that supports the relationship between the exposure and the health 
effect and do not conflict with known facts about the biology of the 
health condition. See supra note 19.
---------------------------------------------------------------------------

Evaluation of Representativeness of Study

    Landgren et al. [2018] was reviewed to determine whether both the 
WTC responder cohort studied is representative of the entire 9/11-
exposed population and whether the results can be extrapolated. MGUS 
screening study subjects were a subset of FDNY members who were exposed 
to 9/11 agents on or in the aftermath of September 11, 2001 until the 
Ground Zero site closed in July 2002. All study subjects were white 
males between the ages of 50 and 79 who had serum samples taken by the 
FDNY WTC Health Program from December 2013 through October 2015. The 
findings of this study represent only a subset of white male FDNY 
responders and may not be

[[Page 38180]]

generalizable to other 9/11-exposed groups.

Summary of Evaluation

    The study by Landgren et al. [2018] was evaluated to determine 
whether a causal relationship between 9/11 exposures and MGUS is 
supported. As described in the policy on the addition of non-cancer 
health conditions to the List,\26\ the WTC Health Program uses the 
Bradford Hill criteria described above to evaluate whether a causal 
relationship between 9/11 exposures and a health condition is 
supported. Although Landgren et al. [2018] speculated that the study 
results demonstrate an association between 9/11 exposure and MGUS, the 
information available in the study is insufficient to support a claim 
for causation using the Bradford Hill criteria. The study reported a 
reasonably strong and precise association between being a 9/11-exposed 
FDNY firefighter and an increased prevalence of MGUS; however, an 
exposure-response gradient was not found. Furthermore, the temporality 
of the findings was not established because some FDNY members with MGUS 
may have had the condition prior to September 11, 2001. Finally, the 
consistency of an association could not be assessed as Landgren et al. 
[2018] was the only relevant study that was identified. Given the lack 
of an exposure-response gradient, the questionable plausibility, the 
lack of other relevant studies, and the other limitations discussed 
above, the WTC Health Program considers the Landgren et al. [2018] 
study to be preliminary and insufficient to add MGUS to the List.
---------------------------------------------------------------------------

    \26\ Supra note 3.
---------------------------------------------------------------------------

E. Administrator's Final Decision on Whether To Propose the Addition of 
Monoclonal Gammopathy of Undetermined Significance to the List

    Pursuant to PHS Act, sec. 3312(a)(6)(B)(iv) and 42 CFR 
88.16(a)(2)(iv), the Administrator has determined that insufficient 
evidence is available to take further action at this time, including 
proposing the addition of MGUS to the List (pursuant to PHS Act, sec. 
3312(a)(6)(B)(ii) and 42 CFR 88.16(a)(2)(ii)) or publishing a 
determination not to publish a proposed rule in the Federal Register 
(pursuant to PHS Act, sec. 3312(a)(6)(B)(iii) and 42 CFR 
88.16(a)(2)(iii)). The Administrator has also determined that 
requesting a recommendation from the STAC (pursuant to PHS Act, sec. 
3312(a)(6)(B)(i) and 42 CFR 88.16(a)(2)(i)) is unwarranted.
    For the reasons discussed above, the Petition 022 request to add 
MGUS to the List of WTC-Related Health Conditions is denied.

F. Approval To Submit Document to the Office of the Federal Register

    The Secretary, HHS, or his designee, the Director, Centers for 
Disease Control and Prevention (CDC) and Administrator, Agency for 
Toxic Substances and Disease Registry (ATSDR), authorized the 
undersigned, the Administrator of the WTC Health Program, to sign and 
submit the document to the Office of the Federal Register for 
publication as an official document of the WTC Health Program. Robert 
Redfield M.D., Director, CDC, and Administrator, ATSDR, approved this 
document for publication on July 29, 2019.

John J. Howard,
Administrator, World Trade Center Health Program and Director, National 
Institute for Occupational Safety and Health, Centers for Disease 
Control and Prevention, Department of Health and Human Services.
[FR Doc. 2019-16609 Filed 8-5-19; 8:45 am]
 BILLING CODE 4163-18-P