Requirements for X Ray B Read Certificate
J Occup Environ Med. Author manuscript; available in PMC 2022 Apr 29.
Published in final edited class equally:
PMCID: PMC7189962
NIHMSID: NIHMS1552444
The National Institute for Occupational Safety and Health B Reader Certification Program—An Update Report (1987 to 2018) and Future Directions
Cara N. Halldin
Respiratory Health Sectionalization, National Institute for Occupational Safety and Health, Centers for Affliction Control and Prevention, Morgantown, Westward Virginia.
Janet M. Hale
Respiratory Health Division, National Institute for Occupational Safe and Wellness, Centers for Disease Control and Prevention, Morgantown, West Virginia.
David North. Weissman
Respiratory Health Division, National Constitute for Occupational Rubber and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia.
Michael D. Attfield
Respiratory Health Sectionalisation, National Institute for Occupational Safety and Health, Centers for Affliction Control and Prevention, Morgantown, West Virginia.
John East. Parker
Departments of Radiology, Medical Instruction, and Internal Medicine, School of Medicine, Westward Virginia University, Morgantown, W Virginia.
Edward Fifty. Petsonk
Respiratory Health Sectionalisation, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia.
Departments of Radiology, Medical Education, and Internal Medicine, Schoolhouse of Medicine, West Virginia University, Morgantown, West Virginia.
Robert A. Cohen
Respiratory Health Division, National Institute for Occupational Safety and Wellness, Centers for Disease Command and Prevention, Morgantown, West Virginia.
Section of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois, Chicago, Illinois
Travis Markle
Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Affliction Command and Prevention, Morgantown, West Virginia.
David J. Blackley
Respiratory Health Partitioning, National Plant for Occupational Safety and Health, Centers for Affliction Control and Prevention, Morgantown, Westward Virginia.
Anita L. Wolfe
Respiratory Wellness Division, National Institute for Occupational Prophylactic and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia.
Robert J. Tallaksen
Respiratory Health Segmentation, National Institute for Occupational Safe and Wellness, Centers for Disease Command and Prevention, Morgantown, Due west Virginia.
Departments of Radiology, Medical Education, and Internal Medicine, School of Medicine, West Virginia University, Morgantown, Westward Virginia.
A. Scott Laney
Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, W Virginia.
Abstract
Objective:
The National Institute for Occupational Prophylactic and Health (NIOSH) B Reader Program provides the opportunity for physicians to demonstrate proficiency in the International Labour Office (ILO) system for classifying radiographs of pneumoconioses. We summarize trends in participation and examinee attributes and performance during 1987 to 2018.
Methods:
Since 1987, NIOSH has maintained details of examinees and examinations. Attributes of examinees and their test functioning were summarized. Simple linear regression was used in trend analysis of passing rates over time.
Results:
The mean passing rate for certification and recertification for the study period was xl.4% and 82.half-dozen%, respectively. Since the mid-1990s, the number of B Readers has declined and the hateful age and years certified have increased.
Conclusions:
To address the declining B Reader population, NIOSH is currently taking steps to modernize the program and offer more than opportunities for training and testing.
Keywords: B Reader, International Labour Office, National Institute for Occupational Safe and Health, pneumoconiosis
In 1950, the International Labour Role (ILO) beginning published Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses in an attempt to improve and standardize the recognition and recording of radiographic abnormalities caused by the inhalation of dusts.1 Following several modifications and revisions,2 the ILO Classification System has become a well-accepted scientific tool that facilitates international comparability of chest radiographic data used in pneumoconiosis research, occupational health surveillance, and bounty systems.3 In applying the ILO Classification Organization, readers use a systematic process of comparison the examinees' breast radiograph to a fix of standard (prototype) radiographs that illustrate the various types and severities of dust-caused changes. The ILO provides these standard radiographs, also as a guide to procedures for applying the System to allocate chest radiographs and record the results.2
In 1969, the United states Congress passed the Federal Coal Mine Health and Safety Act, which required that coal miners be offered periodic chest radiographic screening. I objective was to detect early radiographic evidence of coal workers' pneumoconiosis (CWP) so that steps could be taken to prevent affliction progression in individual miners. In addition, radiographic screening results take been analyzed to runway temporal and geographic trends in CWP. Since 1970, the National Institute for Occupational Rubber and Wellness (NIOSH), Centers for Illness Control and Prevention (CDC) has operated the Coal Workers' Health Surveillance Programme (CWHSP)4 to administer the congressionally-mandated medical examination surveillance program for monitoring the wellness of coal miners using chest radiography. From the beginning, the CWHSP has used the ILO Classification System to standardize reporting of abnormalities on chest radiographs.
The "ABC system" of multiple readings was initially used for the first few years of the CWHSP, where the first interpretation of a miner's chest radiograph was completed by an "A Reader" at the facility (local clinic or hospital) where the radiograph was obtained. A Readers were physicians who had taken a two-day seminar from NIOSH or the American College of Radiology, or had submitted films to NIOSH with ILO classifications which were judged by NIOSH to be interpreted correctly. The 2d nomenclature on a miner's radiograph was completed by a B Reader. At the time B Readers were among a pool of 24 radiologists with "long experience with pneumoconiosis" from 1 of three radiology departments in the United States. If the A Reader and B Reader'south classifications agreed, the final decision of pneumoconiosis was made. If they did not agree, the radiograph was sent to a "C Reader" for a last decision. C Readers were seven staff radiologists experienced in determining pneumoconiosis at one of the three radiology departments as previously described.five
Soon afterwards the establishment of the CWHSP, information technology became apparent that at that place was substantial variability between physicians in chest radiograph classification results fifty-fifty with the "ABC System" of multiple independent classifications.5 To reduce this variability, and to establish a pool of physicians with demonstrated competence in classifying chest radiographs using the ILO system of chest radiographs, NIOSH developed the B Reader Program. The Program endeavors to railroad train physicians and identify those with competence in the utilize of the ILO Classification Organisation. An initial proficiency examination to certify new B Readers was developed between 1974 and 1976 by Johns Hopkins University nether contract with NIOSH, and validated by the American Higher of Radiology Task Force on Pneumoconiosis.vi This examination focused largely on radiographic findings associated with lung disease acquired by coal mine dust. The first B Reader certification examinations were given in 1976 using the 1971 version of the ILO Classification System. Later, a recertification examination was instituted in 1984 for periodic re-exam of B Readers. The recertification examination more prominently featured findings associated with asbestos-induced lung disease in comparison to the certification test.
The examination is divided into six components, three of which address pocket-size opacity profusion: (a) agreement on the presence or absence of modest opacities on each movie, (b) assessment of the examinee's over/underreading tendency or the degree an examinee's small opacity profusion classifications systematically diverge from that of the proficient panel, and (c) an inconsistency index which is based upon the standard deviation of differences between the examinee and practiced panel classifications. The last three examinations sections address (d) the presence or absenteeism of large opacities, (east) presence or absence of pleural abnormalities, and finally (f) the classification of the other symbols. Further details on the training and certification procedures for B Readers have been previously described6 and Wagner et al7 provided updated information on the B Reader Program, and an overview of the candidates' attributes and scores for the years 1987 to 1990.
TRANSITIONING THE CWHSP TO DIGITAL RADIOGRAPHY
Until the most recent version of the ILO Classification System was published in 2011,2 the arrangement could just be applied to analog flick-based chest radiographs. Even so, long before that, digital radiography had go the dominant modality used in US radiographic facilities. Thus, it was disquisitional for the CWHSP to enable the apply of digital chest radiographic images for ILO classification. To facilitate this, NIOSH (i) conducted research studies demonstrating that digital breast radiographs acquired on systems widely used in clinical exercise could provide similar results to traditional motion picture-screen radiographs when used for classification of pneumoconioses using the ILO arrangementviii–12; (2) provided detailed guidance on appropriate methods for image conquering and viewing when using digital engineering for ILO classificationthirteen; and (three) developed the BViewer© Software (a freeware computer program that enables standardized viewing of digitally-caused chest images for classification purposes, alongside digital versions of the ILO standards, and includes software for electronically recording classification results).14
With this foundation in identify, NIOSH worked with the ILO in updating its classification system to enable use of digital chest radiographs2 and amended NIOSH regulations to enable use of digital chest radiography in addition to traditional moving-picture show radiographs in the CWHSP.4 By 2018, more than than 98% of chest radiographs submitted to the CWHSP were digitally acquired. NIOSH is now focusing on transitioning the B Reader Program's educational and testing materials to digital format by developing an entirely new exam using modernistic, digitally-acquired chest radiographs. As an acting measure, the B Reader examinations are currently available in digital format using digitized versions of the existing film-based certification and recertification examinations.
Pre-test Preparation
NIOSH strongly recommends pre-examination grooming for test (pre-test training improves the likelihood of success for new candidates; if candidates fail the initial test NIOSH requires a waiting menses of 90 days earlier re-testing on the initial test) to assure familiarity with the ILO Classification Arrangement and associated Chest Radiograph Nomenclature Class. In 1983, a Home Study Syllabus on Pneumoconiosis was developed by the American College of Radiology under NIOSH contract. The syllabus, revised in 2002, includes 80 radiographs, instructions, and answer keys. In 2011, the film images used in the teaching syllabus were digitized into Digital Imaging and Communications in Medicine (DICOM) format and made available for free download from the NIOSH website.15 Over the years, physicians accept besides prepared for examinations past attending American College of Radiology Symposia on Radiology of the Pneumoconioses, which were offered intermittently, or domestic or international courses taught on occasion by NIOSH.
Initial Certification and Recertification Processes, Examinations, Format, and Grading System
The initial B Reader certification examination consists of 125 film chest radiographs to be classified in 6 hours. The recertification examination consists of 50 radiographs to be classified in 3 hours. United states of america licensed physicians who reach a score of fifty% or more than on the initial examination are certified as NIOSH B Readers. B Readers are certified for 4 years from the date of blessing, after which passing the recertification examination is required to maintain the B Reader certification.
Since the programme'southward inception, images used in the examinations have consisted of flick chest radiographs demonstrating various types and severities of pneumoconiosis, as well as several films without pneumoconiosis. These were displayed on lighted view boxes, with ILO classification results manually entered onto paper forms. Recently, examinations have also been offered using high quality scanned and digitized versions of the current films, displayed on medical class monitors using BViewer© Software (NIOSH, Morgantown, WV)14 for viewing and data entry. Candidates may thus take the examination in a completely computerized format. Physicians currently have the choice to take either the picture or digitized examinations. Grading and scoring of the certification and recertification examinations have not changed since the 1992 paper by Wagner et alvii The objectives of this written report are to summarize B Reader examination results from 1987 to 2022 and to describe time to come directions of the B Reader Plan.
MATERIALS AND METHODS
Forms used to record examinee attributes have varied throughout the program. Since Jan 1, 1987, NIOSH has maintained a database with details of examination attempts, scores, and demographics of physicians taking the B Reader examination. Prior to that date, just candidate age was recorded consistently. The Interpreting Medico Certification Document, used to record an examinee's contact information and demographics, was modified in 1992 to include optional items asking (i) the boilerplate number of chest radiographs the examinee classified monthly using the ILO system; and (ii) how the candidate anticipated using their B Reader certification (response options: individual patient intendance, industry programs, medical–legal activities, regime programs, other).16 Using this NIOSH examination database, examinee numbers and demographics, overall scores, laissez passer/fail rates, and simulated positive and false negative answers were summarized using SAS 9.4 (Cary, NC). Elementary linear regression was used in trend analysis of initial and recertification passing rates over fourth dimension, slopes (β) and the corresponding significance levels (P values) were calculated.
RESULTS
Examination Participation and Candidate Characteristics
Including the initial testing in 1976, 2684 United states licensed physicians have taken the examination. From January ane, 1987 through Dec 31, 2018, 5454 examinations (2857 certification and 2597 recertification) have been administered. During this time, 1202 physicians (53.0%) take taken an test once, 378 (16.seven%) twice, 220 (nine.7%) three times, and the remaining 468 examinees (twenty.vi%) take taken a certification or recertification more than 3 times.
Offset in 1992 data was collected from B Readers estimating the number of ILO classifications they consummate per month over the previous twelvemonth. For their about recent examination, 82.ii% of certified B Readers responded to this question and on boilerplate reported classifying seventy (range, 1–500) chest radiographs per calendar month using the ILO system. Amongst the responders, individual patient care (53.4%) and medical–legal activities (47.3%) were the nearly common anticipated usages of B Reader certification, followed past industry programs (38.5%), government programs (29.7%), and other uses (5.4%).
The number of B Readers in the United States on December 31 each year since 1970 is shown on Fig. 1. The number of B Readers increased from virtually 100, after the initial examination in 1976 (during 1970 to 1976, a non-examination process for appointing B Readers existed), to a peak of about 750 in 1993, and has steadily declined since and then. In December 2018, 165 U.s.a. physicians were NIOSH certified B Readers. The distribution of clinical specialties is shown in Tabular array 1. The hateful age of the certified B Reader population has increased since the mid-1970s, with a mean age of 62.4 in 2022 (Fig. 2; blackness circles corresponding to the left y-axis). The mean number of years private B Readers have been certified likewise continues to increase (Fig. 2; grayness circles corresponding to the right y-axis) with 22 years as the mean number of years certified in 2018, further demonstrating that the current population of B Readers is generally an aging survivor population.
Number of certified B Readers on registry on December 31 each year.
Mean age of certified B Readers past year, 1970 to 2018, represented by black circles corresponding to the left y-axis. Mean number of years individual B Readers accept been certified, past yr, 1970 to 2018, represented by grey circles respective to the right y-axis.
TABLE 1.
Primary Medical Specialty of Currently Certified B Readers in 2018
| N | % | |
|---|---|---|
| Radiology | 109 | 66.ane |
| Pulmonology | 27 | 16.four |
| Internal Medicine | 13 | 7.ix |
| Other | 9 | 5.5 |
| Occupational Medicine | seven | iv.2 |
Pass/Neglect Rates and Distribution of Scores
The passing rates for the initial certification and recertification examinations have fluctuated since 1987 (Fig. iii). The mean passing rate for certification for the period 1987 to 2022 was 40.4% and has significantly decreased over this time period (β = −0.4, P = 0.002). In contrast, the mean passing charge per unit for recertification examinations in this catamenia was 82.six% and has significantly increased over time (β = 1.0, P < 0.0001).
B Reader passing rates for certification and recertification examinations 1987 to 2018.
The distributions of total scores for the certification and recertification examinations taken between 1987 and 2022 are displayed in Fig. 4. For the certification examination, scores were normally distributed effectually the median (44.3). Recertification scores were significantly higher (median 59.ii) and the overall distribution was skewed toward higher scores. Component scores are presented in Table 2 and the grading system has been described in detail previously.7 Candidates who passed scored about twice as many points as those who failed and this was generally consistent across all examination components.
B Reader final scores, 1987 to 2018. Percentage distribution, certification versus recertification examination.
TABLE 2.
Mean and Standard Departure for Component Scores by Pass/Fail, Certification Versus Recertification Exam, B Readers 1987 to 2018
| Certification Examination | Recertification Test | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Pass Observed | Neglect Observed | Laissez passer Observed | Fail Observed | |||||||
| Maximum | Mean | (SD) | Mean | (SD) | Maximum | Mean | (SD) | Hateful | (SD) | |
| Small opacity | ||||||||||
| Understanding | 20 | ten.8 | (2.6) | v.4 | (3.5) | 20 | 9.6 | (three.5) | 4.5 | (iii.4) |
| Over/under reading | ten | 7.five | (1.8) | 4.iv | (3.ane) | ten | half-dozen.8 | (2.4) | 3.0 | (2.9) |
| Inconsistency index | 30 | xix.ii | (4.2) | 10.0 | (5.7) | xxx | 21.vii | (4.half-dozen) | 13.three | (v.7) |
| Large opacity | 20 | 9.6 | (iii.viii) | 5.3 | (iv.iv) | twenty | 13.iv | (4.5) | 9.four | (5.9) |
| Pleural disease | 10 | ii.4 | (ii.0) | 1.viii | (1.9) | xx | eleven.vi | (three.2) | 8.4 | (4.0) |
| Other symbols | x | 7.4 | (1.6) | 5.8 | (2.2) | 0 | — | — | — | — |
| Total | 100 | 56.9 | 5.nine | 33.2 | 10.9 | 100 | 63.1 | 8.eight | 38.v | 8.2 |
Minor Opacity False Positives and False Negatives
The mean percentage of pocket-sized opacity imitation positives and false negatives are displayed in Fig. 5. False positives are more commonly found by examinees than false negatives for those passing the examination (~2.iii fold difference) and among those failing the exam (~ four.five fold departure). The percentage of faux negatives reported for both certification and recertification examinations accept remained consequent throughout the years at around 7%. Taken together, those who pass and those who fail misclassify an equivalent amount as faux negative. Notwithstanding, candidates who fail tend to have about twice the number of faux positives as those who pass.
Mean percentage of false positive and false negatives, minor opacities by pass/fail for B Reader certification and recertification examinations, 1987 to 2018.
DISCUSSION
Chest radiographic imaging is a widely applied and of import tool for assessing lung wellness in inquiry investigations and evaluations of workers exposed to dusts capable of producing pneumoconiosis. Monitoring of respiratory health using chest radiography remains one of the essential tools in the recognition and secondary prevention of occupational lung diseases.
In the early 1970s, shortly after the initiation of the Congressionally-mandated radiographic screening program for hush-hush coal miners,17 it became articulate that results of ILO classifications of miner chest radiographs showed excessive inter-reader variability. Felson et alv described that early classification results indicated readers had difficulty in distinguishing between healthy lungs and the threshold for classifying small opacities every bit consistent with pneumoconiosis. In full general, readers with less preparation tended to identify more pneumoconiosis than experienced readers,5 a trend that has been observed across several dust exposed worker populations in multiple countries over the terminal 3 decades.x,18–22 This finding is consistent with the high rate of false positives among examinees who fail the exam observed in the present study (Fig. 5).
Felson et al5 also constitute that a number of physicians performing classifications were not fairly familiar with the various radiographic manifestations of pneumoconiosis, the Guidelines for the utilize of the ILO Nomenclature Organisation, nor the affect of radiograph quality in assigning a pneumoconiosis classification. To accost these concerns, NIOSH instituted the B Reader Program, to provide appropriate training, and examinations to identify readers who were proficient in using the ILO Classification System to interpret chest radiographs for pneumoconiosis. Passing the test conferred B Reader certification.6 Over the past 40 years, B Readers have played an essential role in public wellness surveillance, secondary disease prevention, medical–legal proceedings, and compensation determinations in the Usa, with other countries adopting similar requirements following sit-in of similar concerns.23
Since the institution of B Reader training and exam in the 1970s, the Program has undergone a limited number of changes, including introduction of a recertification examination (1984) and the release of digitized versions of the film-based training syllabus (2011) and examinations (2015), allowing for completely digital study and testing environments. Having tools to train physicians and certify that they are able to classify chest radiographic images for presence and severity of changes consistent with pneumoconiosis using the ILO system still remains important for inquiry, surveillance, and compensation. In addition to past needs, we conceptualize increasing need for B Readers able to perform ILO classifications under the United states Occupational Safety and Health Administration's recent Silica Standard.24
Modern radiology is predominantly digital and contemporary physicians no longer work with older film-based radiographs. Thus, in addition to transitioning NIOSH'southward surveillance services to digital radiography,4 NIOSH is besides moving to modernize doc grooming and certification testing. To have an adequate supply of modern, digitally-acquired chest radiographs for this purpose, NIOSH adult a digital prototype repository able to collect anonymized digitally-caused radiographs and computed tomography (CT) scans depicting unlike types of abnormality associated with the pneumoconioses. The repository contains images derived from NIOSH activities and from those supplied by external partners, both domestic and international. In partnership with the American College of Radiology, a modern B Reader certification test is existence adult using this large repository of images as source material. This effort is identifying fundamental noesis and competencies to be taught and tested, developing and validating new education and testing materials that address the key knowledge and competencies, and establishing plans for ongoing quality assessment and improvement of the teaching and testing program. We anticipate that the new examination currently under evolution, based entirely on modern digitally-acquired images, will be administered solely in electronic format.
Recent research continues to confirm that readers who are trained and demonstrate ongoing competence in the ILO Classification System (NIOSH B Readers), and who are subjected to regular quality control, are desirable to provide reliable pneumoconiosis classifications, equally other readers are more likely to misclassify aspects of pneumoconiosis.ix Although breast computerized tomography provides more detailed images and is often the diagnostic process of selection for patients with known or suspected diseases of the chest in clinical settings, plain chest radiography's low radiation dose, economic system, and gear up availability continue to make information technology a very important screening tool for pneumoconiosis worldwide.
NIOSH is working to address the precipitous decline in B Readers (Fig. v) and the yearly increase in mean age of those Readers (Fig. one). While a systematic study or investigation into why the B Reader population has decreased dramatically has non been conducted, the cause for this reject is probable multifactorial. Those in the field accept observed a shift in technology, grooming, and demand. CT became widely bachelor in the 1980s and gradually dedicated grooming in most medical training programs placed less focus on chest radiography. B Readers were near ordinarily used for screening among workers exposed to asbestos and coal mine dust and at the same time medical engineering and preparation was changing, industries with exposed workers were contracting, reducing the need for readers. Past modernizing the syllabus and test and partnering with academic institutions and professional person organizations, NIOSH is working to provide face-to-face training opportunities (including the opportunity to sit for the examination) at sites across the state with efforts to target residents and fellows in training equally well as specific specialties to address state-by-country needs. NIOSH is as well formally partnering with the American College of Radiology to ensure at to the lowest degree two B Reader Courses and Examinations will be offered at their preparation middle in Reston, VA starting in 2020. Additionally, NIOSH has recently expanded the recertification period from every 4 years to every v years.
Decision
Despite widely available and substantial scientific noesis regarding the hazards of respirable dust exposure, occupational dust-induced lung diseases remain substantial threats to health and life for many 21st century workers, in both established and emerging economies.25–32 Programs for monitoring respiratory wellness that include chest radiography have demonstrated public health utility in the identification, tracking, and secondary prevention of occupational pneumoconioses, only crave rigorous implementation.2,iv,thirteen,33 This current study describes contempo trends, refinements, and ongoing modernization of the B Reader Plan, with the goal of informing NIOSH partners in occupational medicine, industrial hygiene, and public wellness and, chiefly, enhancing preventive actions addressing these dust-induced lung diseases.
Footnotes
Publisher'south Disclaimer: Disclaimer: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Work conducted past federal employee authors was conducted during the normal course of their duties. The findings and conclusions in this report are those of the authors and do not necessarily correspond the official position of the National Institute for Occupational Safety and Wellness, Centers for Disease Control and Prevention.
Conflicts of Interest: None declared.
Correspondent Information
Cara Northward. Halldin, Respiratory Health Sectionalization, National Establish for Occupational Prophylactic and Wellness, Centers for Disease Command and Prevention, Morgantown, West Virginia.
Janet Grand. Hale, Respiratory Health Division, National Constitute for Occupational Safe and Health, Centers for Illness Command and Prevention, Morgantown, West Virginia.
David N. Weissman, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Command and Prevention, Morgantown, West Virginia.
Michael D. Attfield, Respiratory Health Sectionalization, National Institute for Occupational Safety and Health, Centers for Disease Command and Prevention, Morgantown, Westward Virginia.
John E. Parker, Departments of Radiology, Medical Education, and Internal Medicine, Schoolhouse of Medicine, Due west Virginia University, Morgantown, West Virginia.
Edward 50. Petsonk, Respiratory Health Partitioning, National Plant for Occupational Safety and Wellness, Centers for Disease Command and Prevention, Morgantown, West Virginia. Departments of Radiology, Medical Instruction, and Internal Medicine, School of Medicine, West Virginia University, Morgantown, W Virginia.
Robert A. Cohen, Respiratory Wellness Division, National Institute for Occupational Condom and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia. Department of Ecology and Occupational Health Sciences, Schoolhouse of Public Health, Academy of Illinois, Chicago, Illinois.
Travis Markle, Respiratory Wellness Division, National Institute for Occupational Rubber and Health, Centers for Disease Control and Prevention, Morgantown, W Virginia.
David J. Blackley, Respiratory Wellness Division, National Found for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, W Virginia.
Anita L. Wolfe, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, Due west Virginia.
Robert J. Tallaksen, Respiratory Health Sectionalization, National Institute for Occupational Safety and Wellness, Centers for Disease Control and Prevention, Morgantown, West Virginia. Departments of Radiology, Medical Education, and Internal Medicine, School of Medicine, Due west Virginia University, Morgantown, Westward Virginia.
A. Scott Laney, Respiratory Health Division, National Establish for Occupational Safety and Health, Centers for Illness Control and Prevention, Morgantown, West Virginia.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189962/
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