1
Introduction

The National Institute for Occupational Safety and Health (NIOSH) has requested that the National Academies, through the National Research Council (NRC) and the Institute of Medicine (IOM), conduct a series of reviews of its research portfolio. The charge is discussed in detail in a subsequent section, but in general it is to evaluate the relevance and impact of a NIOSH research program and to provide recommendations for future research. This report contains a review and evaluation of the NIOSH Traumatic Injury (TI) Research Program. NIOSH defines work-related traumatic injury as “any damage inflicted to the body by energy transfer during work with a short duration between exposure and the health event” (NIOSH, 2007a, p. 3). Safety research is an interchangeable term in NIOSH publications for traumatic injury research. Traumatic injury is distinguished from psychological trauma and from musculoskeletal injuries caused by repetitive trauma.

This chapter begins with an overview of the impact of occupational injury, and the mission and organization of NIOSH and the TI Research Program, including the relationship of NIOSH to other relevant agencies. The chapter progresses to discuss the TI Research Program goals. A discussion of the charge to the committee and the framework under which it completed this review concludes the chapter.

IMPACT OF OCCUPATIONAL INJURIES

Occupational injuries continue to be a significant public health problem in the United States, imposing a substantial human and economic burden. Although



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1 Introduction T he National Institute for Occupational Safety and Health (NIOSH) has requested that the National Academies, through the National Research Council (NRC) and the Institute of Medicine (IOM), conduct a series of reviews of its research portfolio. The charge is discussed in detail in a subsequent section, but in general it is to evaluate the relevance and impact of a NIOSH re- search program and to provide recommendations for future research. This report contains a review and evaluation of the NIOSH Traumatic Injury (TI) Research Program. NIOSH defines work-related traumatic injury as “any damage inflicted to the body by energy transfer during work with a short duration between exposure and the health event” (NIOSH, 2007a, p. 3). Safety research is an interchangeable term in NIOSH publications for traumatic injury research. Traumatic injury is distinguished from psychological trauma and from musculoskeletal injuries caused by repetitive trauma. This chapter begins with an overview of the impact of occupational injury, and the mission and organization of NIOSH and the TI Research Program, including the relationship of NIOSH to other relevant agencies. The chapter progresses to discuss the TI Research Program goals. A discussion of the charge to the committee and the framework under which it completed this review concludes the chapter. IMPACT OF OCCUPATIONAL INJURIES Occupational injuries continue to be a significant public health problem in the United States, imposing a substantial human and economic burden. Although 9

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t R au m at I C I n j u Ry R e s e a R C h nIosh 20 at rates of both fatal and nonfatal occupational injuries have declined since the pas- sage of the OSH (Occupational Safety and Health) Act in 1970, much remains to be done. In 2006, 5,840 workers—more than 110 workers each week—died as a result of injuries sustained on the job. These deaths occurred across all industry sec- tors (BLS, 2007a). Nonfatal work-related injuries far outnumber fatalities and are much more difficult to count. According to the Bureau of Labor Statistics (BLS), in 2006, 3.9 million nonfatal injuries were sustained by U.S. workers in private-sector employment (BLS, 2007b). The injury rate based on this number was 4.2 per 100 full-time workers. More than half of these injuries required workers to transfer to another job, restrict their duties at work, or take time off from work to recuperate. These BLS estimates are widely recognized to underestimate the full extent of the problem. They exclude nonfatal injuries among the 22 percent of the workforce that are not in private-sector employment, and there is also evidence that private-sector injuries are undercounted. One population-based study of work injuries (Smith et al., 2005) estimated that counts of injuries resulting in days away from work were 1.4 times higher than BLS workplace-based estimates for the private sector. Direct workers’ compensation costs for occupational injuries and illnesses that occurred in the United States in 2005 were estimated to be $88.4 billion, a 2.3 percent increase over the estimate for 2004 (Sengupta et al., 2007). This number reflects only a portion of the economic costs of workplace injuries and illnesses. Researchers have found that many injuries never enter the workers’ compensation system and that workers’ compensation benefits cover only a fraction of lost earn- ings (Boden and Ozonoff, 2008; Rosenman et al., 2006; Silverstein et al., 1997). A recent study shows that in five states studied, only between 29 and 46 percent of lost earnings were replaced (Reville et al., 2001). Finally there may be substantial additional costs related to the disruption of work and the hiring and training of new workers (Leigh et al., 2000). In recent years, researchers have also begun to conceptualize and demonstrate empirically the social and economic consequences of occupational injuries for the lives of individual workers and their families. Long-term financial hardship, changes in injured worker domestic function as well as ability to perform activities of daily living, and shifts in family dynamics associated with loss of income and disability are among the outcomes that have been noted (Dembe, 2001; Hensler et al., 1991; Morse et al., 1998; Pransky et al., 2000; Strunin and Boden, 2004). MISSION AND ORGANIZATION OF NIOSH AND THE TI RESEARCH PROGRAM NIOSH is a component of the Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services (HHS). Cre-

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IntRoduCtIon 2 ated in 1970 by the OSH Act along with the Occupational Safety and Health Admin- istration (OSHA) in the Department of Labor (DOL), NIOSH was authorized to • Conduct research on worker safety and health, including new safety and health problems; • Develop recommendations for occupational safety and health standards; • Conduct training and employee education; • Develop information on safe levels of exposure to toxic materials and harmful physical agents and substances; • Conduct onsite investigations to determine the toxicity of materials used in workplaces; and • Fund research by other agencies or private organizations through grants, contracts, and other arrangements. Congress has clearly distinguished OSHA’s functions of regulation and enforce- ment from NIOSH’s primary research mandate. OSHA’s mission is to “assure the safety and health of America’s workers by setting and enforcing standards; provid- ing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health” (DOL, 2008). Although both agencies have a mandate regarding training and education, and NIOSH is charged to recommend standards to OSHA,1 in general NIOSH is a research agency and OSHA a regulatory agency. This distinction in mandate allows NIOSH research to proceed without pressures regarding the financial or regulatory implications. NIOSH offices are located across the country, specifically in Washington, D.C.; Pittsburgh, Pennsylvania; Spokane, Washington; Cincinnati, Ohio; Atlanta, Georgia; and Morgantown, West Virginia (see Figure 1-1). The primary organizational units are divisions and laboratories. The programmatic organization, however, recently underwent changes and now reflects a matrix-management approach2 (see Table 1-1). The organization currently consists of sector programs (e.g., construction, mining) and cross-sector programs (e.g., traumatic injury, respiratory diseases).3 Most of the work in traumatic injury occurs through the Division of Safety Re- search (DSR), which conducts or oversees most of the research that is represented 1 NIOSH has issued few recommendations for standards, known as Criteria Documents, in recent years, presumably because it is a resource-intensive activity toward which OSHA paid demonstrably little attention. 2A discussion of the pros and cons of matrix management can be found in Chapter 2. 3At the time of the development of its evidence package and as depicted in Table 1-1, NIOSH described its organizational structure as also including coordinated emphasis areas (e.g., economics, occupational health disparities). These areas now are included under cross-sector programs.

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t R au m at I C I n j u Ry R e s e a R C h nIosh 22 at Office of the Director Washington, DC Deputy Director for Management Office of the Associate Atlanta, GA Director for Science Washington, DC Office of Administration and Management Services Atlanta, GA Office of Health Communication Office of Extramural Washington, DC Programs (OEP) Atlanta, GA Office of Mine Safety Office of Emergency and Health Research Preparedness and Response Washington, DC Atlanta, GA Pittsburgh Research Office of Compensation Laboratory Analysis and Support Pittsburgh, PA Atlanta, GA Division of Respiratory Spokane Research Disease Studies Laboratory Morgantown, WV Spokane, WA Division of Safety Division of Applied Research (DSR) Research and Technology Morgantown, WV Cincinnati, OH Health Effects Division of Surveillance, Laboratory Division (HELD) Hazard Evaluation, and Morgantown, WV Field Studies Cincinnati, OH Education and National Personal Protective Information Division Technology Laboratory Cincinnati, OH Pittsburgh, PA FIGURE 1-1 Organizational components of NIOSH. SOURCE: NIOSH, 2007c, p. 15 Figure 1-1.eps

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IntRoduCtIon 23 TABLE 1-1 Matrix Management Components of the NIOSH Program Portfolio NIOSH Cross-Sector NIOSH Coordinated Emphasis Areasa NORA Sector Programs Programs Agriculture, Forestry Authoritative Economics and Fishing Recommendations Engineering Controls Construction Cancer, Reproductive and Exposure Assessment Cardiovascular Healthcare and Occupational Health Social Assistance Communications and Disparities Information Dissemination Manufacturing Small Business Assistance Emergency Mining and Outreach Preparedness/Response Services Surveillance Global Collaborations Transportation, WorkLife Initiative Health Hazard Evaluation Warehousing (HHE) and Utilities Hearing Loss Prevention Wholesale and Retail Trade Immune and Dermal Musculoskeletal Disorders Personal Protective Technology Radiation Dose Reconstruction Respiratory Diseases Training Grants Traumatic Injury Work Organization and Stress-Related Disorders aSee Footnote 3. SOURCE: NIOSH, 2007i, p. 16. by the TI Research Program. The TI Research Program consists of intramural research and related activities and extramural research conducted often, but not exclusively, through universities. The TI Research Program also supports state- based surveillance programs. These funds go to state health agencies or state labor departments. Research on traumatic injury from the mining industry, however, is

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t R au m at I C I n j u Ry R e s e a R C h nIosh 24 at located in the Mining Safety and Health Program and was not reviewed by this committee. NIOSH is not the only federal agency to sponsor research on traumatic in- juries. A companion unit of the CDC, the National Center for Injury Prevention and Control (NCIPC) addresses nonoccupational injuries that are unintentional and those that are due to violence (intentional). NCIPC is located in the CDC headquarters in Atlanta, Georgia. Other federally sponsored surveillance and research relevant to the TI Research Program is carried out by the BLS (DOL), which gathers important data on the incidence of fatal and nonfatal work-related injuries; the National Highway Traffic Safety Administration (Department of Transportation), which funds research on transportation-related occupational traumatic injuries; the Department of Defense; and the National Institute of Jus- tice (Department of Justice), which funds research on workplace violence. Non-federally sponsored research in traumatic injuries occurs throughout the country, generally but not exclusively in universities. Funding comes from foun- dations (e.g., Traffic Injury Research Foundation, the National Safety Council), industry (e.g., Ford Motor Company), insurance companies (e.g., Liberty Mutual Research Institute for Safety, the Insurance Institute for Highway Safety), labor unions (e.g., Laborer’s International Union of North America), and state govern- ments, although some of these state funds come to the state health and labor departments from the federal government. The National Occupational Research Agenda On its twenty-fifth anniversary, NIOSH unveiled the National Occupa- tional Research Agenda (NORA) as an “effort to guide and coordinate research nationally—not only for NIOSH, but for the entire occupational safety and health community” (NIOSH, 1998). Diverse parties collaborated to identify the most critical issues in workplace safety and health. Partners then worked together to develop goals and objectives for addressing those needs. Participation in NORA was broad and included stakeholders from many areas such as universities, large and small businesses, professional societies, government agencies, and worker organizations. NORA identified 21 priority areas, one of which was traumatic injury. Partnership teams were created to develop research agendas for each pri- ority area. The NORA-TI team released its report in 1998. The report’s goal was to pre- sent a broad framework of the objectives and research needed to begin filling the gaps in knowledge and furthering progress toward safer workplaces and practices. NORA-TI issued three findings (NIOSH, 1998):

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IntRoduCtIon 25 1. Priorities for research and prevention efforts should be based on relevant data. The criteria for setting priorities should include the magnitude of the problem (frequency of injury and size of affected workforce), the risk to workers (rates of injury), injury severity, and amenability to prevention, including cost-effectiveness and likelihood of adoption of prevention strategies by industry. 2. Collaboration among multiple professional disciplines, industries, agencies, and groups is essential to developing research priorities and implementing prevention strategies aimed at reducing occupational injuries. 3. New methods of data collection, data analysis, and information dis- semination need to be developed to advance the field of occupational injury research. Using a five-component public health approach as an organizing framework,4 the NORA-TI report identified 45 specific research objectives intended to advance occupational injury prevention. Funding for NORA-related projects derived from congressional appropriations earmarked for NORA projects and from other federal agencies. Research teams within NIOSH competed for NORA funds. NORA recently entered its second decade (often denoted as NORA II) with a sector-based structure, intended to better move research to practice in workplaces. The national agenda will be developed and implemented through eight councils,5 which will oversee aggregates derived from the 20 North American Industry Clas- sification System sectors. NORA II also includes a Cross-Sector Council, which will set priorities that affect multiple sectors and groups of workers. Overview of NIOSH and TI Research Program Resources In fiscal year (FY) 1997 the TI Research Program had 71.62 full-time equiva- lent (FTE) staff devoted to the eight major TI research goals (to be discussed later). Intramural TI research funding—including the cost of intramural FTEs— was $6,543,305 and extramural research funding was $2,156,591, for a total TI research budget of $8,699,896. (The total NIOSH budget that year was $173 million.) In FY2005, TI Research Program FTEs numbered 87.71; its intramural 4 Surveillance; analytic risk factor research; prevention and control research; communication, dis- semination, and technology transfer; and evaluation. 5Agriculture, forestry, and fishing; construction; health care and social assistance; manufacturing; mining; services; transportation, warehousing, and utilities; and wholesale and retail trade.

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t R au m at I C I n j u Ry R e s e a R C h nIosh 26 at budget was $11,836,905 and its extramural research budget was $5,369,171, for a total of $17,206,076. (The total NIOSH budget that year was $286 million.) See Figure 1-2 for TI Research Program funding from 1997 to 2005. In FY2005, the total CDC budget was more than $4 billion, the National Institutes of Health budget was over $28 billion, and the total HHS budget was more than $570 billion (HHS, 2005). After adjusting for inflation and earmarks for NORA priorities, the NIOSH budget appears to have stayed relatively stable (see Table 1-2 for a yearly breakdown of TI research resource allocation). Chapter 2 includes a description of TI resources by strategic goal. The committee focuses its review beginning with the establishment of NORA and does not review the entire funding history of NIOSH. Resources attributed to the TI Research Program are those reported by NIOSH in its evidence package and include relevant resources attributed to other NIOSH programs (e.g., construction; agriculture, forestry, and fishing). NIOSH TI RESEARCH PROGRAM GOALS NIOSH asked the committee to review its TI Research Program in eight goal areas (Box 1-1).6 Within each of the eight goals are also two to three subgoals, with the exception of the goal for workplace violence, which does not have any subgoals. The goals outlined in the evidence package provided to the committee represent the four leading causes of occupational injury and death (motor vehicles, machines, violence, and falls); three additional areas shaped by congressional interest (work- ers in Alaska, emergency responders, and working youth); and a long-standing program in back injury. DSR and the TI Research Program conduct work in areas not represented in this review (e.g., electrocutions and burns), because they are not a substantial part of the portfolio. According to the evidence package, programmatic focus on motor vehicles, falls, workplace violence, machines, back injury, and workers in Alaska emerged principally from surveillance data on fatal and nonfatal traumatic injuries (NIOSH, 2007a, p. 2). Sources of fatality data include the BLS Census of Fatal Occupational Injuries, as well as NIOSH’s National Traumatic Occupational Fatality Surveillance 6 The TI Research Program presented their portfolio in the evidence package according to these goals in order to conform to the Framework Document (e-mail from N. Stout to K. Stratton, No- vember 30, 2007). Prior to this configuration, the organizing structure for describing the project portfolio were three program areas that reflected (1) the four leading causes of occupational injury death (motor vehicles, machines, violence, and falls), (2) four high-risk industries (construction, transportation, agriculture/forestry/fishing, and services), and (3) five NIOSH/CDC crosscutting priority areas (disparities, economic impact, emergency response, NORA implementation, and emerging issues). Individual projects had relevance to one or more of the 13 elements that comprise those three program areas.

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IntRoduCtIon 27 Goal 1: Reduce Injuries and Fatalities Due to Motor Vehicles 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Goal 2: Reduce Injuries and Fatalities Due to Falls from Elevations Figure 1-2a.eps 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Goal 3: Reduce Injuries and Fatalities Due to Workplace Violence Figure 1-2b.eps 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year FIGURE 1-2 Combined intramural and extramural funding for individual goals and for all goals Figure 1-2c.eps combined.

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t R au m at I C I n j u Ry R e s e a R C h nIosh 28 at Goal 4: Reduce Injuries and Fatalities Due to Machines 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Goal 5: Reduce1-2d.eps Figure Acute Back Injury 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Figure 1-2e.eps Goal 6: Reduce Injuries and Fatalities Among Workers in Alaska 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Figure 1-2f.eps FIGURE 1-2 (continued)

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IntRoduCtIon 29 Goal 7: Reduce Injuries and Fatalities to Emergency Responders 7,000,000 6,000,000 Total Funding ($) 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year Goal 8: Reduce Injuries and Fatalities to Working Youth 7,000,000 Total Funding ($) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Fiscal Year FIGURE 1-2 (continued) Figure 1-2h.eps System. Sources of nonfatal injury data include the BLS Annual Survey of Occupa- tional Injuries and Illnesses and the National Electronic Injury Surveillance System managed by the Consumer Product Safety Commission (NIOSH, 2007b, p. 6). In addition to surveillance data, programmatic focus evolved from findings from the Fatality Assessment and Control Evaluation Program, pilot or exploratory studies, and strategic planning work groups or action teams7 (see Box 1-2 for a snapshot of the evidence of the burden of traumatic injury within the eight programmatic goals). A more detailed picture is presented in Chapter 2. 7 E-mail from N. Stout to K. Stratton, November 30, 2007.

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t R au m at I C I n j u Ry R e s e a R C h nIosh 32 at TABLE 1-2 TI Research Program Budget by Research Goal Goal FY1997 FY1998 FY1999 FY2000 1. Reduce injuries and fatalities due to motor vehicles FTE 5.44 4.27 7.99 4.93 Intramural $318,528 $364,968 $497,628 $669,190 Extramural $253,962 $244,912 $229,942 $69,679 Total $572,490 $609,880 $727,570 $738,869 2. Reduce injuries and fatalities due to falls from elevations FTE 8.31 8.03 13.42 15.43 Intramural $1,276,334 $922,468 $907,054 $1,459,034 Extramural $253,962 $463,061 $229,942 $225,879 Total $1,530,296 $1,385,529 $1,136,996 $1,684,913 3. Reduce injuries and fatalities due to workplace violence FTE 8.02 4.51 7.28 6.98 Intramural $602,689 $482,026 $509,517 $653,934 Extramural $253,962 $511,907 $1,043,966 $1,229,205 Total $856,651 $993,933 $1,553,483 $1,883,139 4. Reduce injuries and fatalities due to machines FTE 11.21 9.63 12.77 14.43 Intramural $993,113 $1,044,805 $941,902 $1,283,376 Extramural $253,962 $235,037 $365,826 $365,942 Total $1,247,075 $1,279,842 $1,307,728 $1,649,318 5. Reduce acute back injury FTE 13.54 15.74 14.72 6.00 Intramural $1,196,364 $1,356,204 $1,150,931 $597,615 Extramural $620,369 $654,095 $628,253 $392,677 Total $1,816,733 $2,010,299 $1,779,184 $990,292 6. Reduce injuries and fatalities among workers in Alaska FTE 10.58 9.74 6.56 6.58 Intramural $1,023,592 $1,109,425 $405,931 $757,099 Extramural $253,962 $228,024 $229,942 $575,870 Total $1,277,554 $1,337,449 $635,873 $1,332,969 7. Reduce injuries and fatalities to emergency responders FTE 2.60 2.45 15.03 13.77 Intramural $154,230 $187,711 $1,074,781 $1,284,491 Extramural $12,450 $390,299 $480,565 $494,238 Total $166,680 $578,010 $1,555,346 $1,778,729

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IntRoduCtIon 33 FY2001 FY2002 FY2003 FY2004 FY2005 Total 7.90 9.95 10.80 14.18 14.79 80.25 $855,111 $1,318,354 $1,229,997 $1,606,772 $1,907,736 $8,768,284 $927,921 $984,331 $877,727 $299,919 $1,250 $3,889,643 $1,783,032 $2,302,685 $2,107,724 $1,906,691 $1,908,986 $12,657,927 13.56 9.39 14.03 10.79 15.25 108.21 $1,315,445 $1,237,968 $1,568,049 $1,693,086 $1,769,344 $12,148,782 $289,011 $278,004 $285,319 $275,532 $250 $2,300,960 $1,604,456 $1,515,972 $1,853,368 $1,968,618 $1,769,594 $14,449,742 6.66 7.75 7.56 9.48 8.61 66.85 $839,148 $1,490,096 $1,063,828 $1,273,771 $1,102,187 $8,017,196 $997,606 $2,224,849 $2,233,579 $2,430,217 $1,312,103 $12,237,394 $1,836,754 $3,714,945 $3,297,407 $3,703,988 $2,414,290 $20,254,590 12.81 14.78 10.48 13.13 12.09 111.33 $1,160,389 $1,593,009 $1,169,991 $1,514,190 $1,479,104 $11,179,879 $289,011 $278,004 $933,245 $890,920 $1,033,342 $4,645,289 $1,449,400 $1,871,013 $2,103,236 $2,405,110 $2,512,446 $15,825,168 5.16 4.46 5.05 4.83 3.60 73.10 $615,257 $625,395 $647,926 $618,559 $521,036 $7,329,287 $194,526 $99,990 $107,222 $0 $231,250 $2,928,382 $809,783 $725,385 $755,148 $618,559 $752,286 $10,257,669 12.04 12.80 11.09 11.49 11.81 92.69 $1,493,700 $1,546,891 $1,494,324 $1,400,061 $1,701,203 $10,932,226 $729,000 $568,419 $296,425 $275,532 $0 $3,157,174 $2,222,700 $2,115,310 $1,790,749 $1,675,593 $1,701,203 $14,089,400 12.32 12.49 18.49 15.02 13.84 106.01 $1,521,576 $2,305,996 $1,932,990 $1,780,148 $1,848,856 $12,090,779 $300,972 $376,491 $101,250 $726,364 $806,938 $3,689,567 $1,822,548 $2,682,487 $2,034,240 $2,506,512 $2,655,794 $15,780,346

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t R au m at I C I n j u Ry R e s e a R C h nIosh 34 at TABLE 1-2 (continued) Goal FY1997 FY1998 FY1999 FY2000 8. Reduce injuries and fatalities to working youth FTE 11.92 9.71 13.28 12.63 Intramural $978,455 $1,586,394 $1,778,041 $1,697,255 Extramural $253,962 $1,559,694 $1,470,082 $3,896,916 Total $1,232,417 $3,146,088 $3,248,123 $5,594,171 Total FTEs for all 71.62 64.08 91.05 80.75 research goals Total intramural $6,543,305 $7,054,001 $7,265,785 $8,401,994 budget Total extramural $2,156,591 $4,287,029 $4,678,518 $7,250,406 budget Total budget for all $8,699,896 $11,341,030 $11,944,303 $15,652,400 research goals BOX 1-1 Goals and Subgoals of the NIOSH Traumatic Injury Research Program a Reduce injuries and fatalities due to motor vehicles (2000b) 1. 1.1. Reduce occupational injuries and fatalities due to highway motor vehicle crashes 1.2. educe occupational injuries and fatalities due to motor vehicle incidents in high- R way and street construction work zones Reduce injuries and fatalities due to falls from elevations (1993 b) 2. 2.1. Reduce worker falls from roofs 2.2. Improve fall-arrest harnesses 2.3. Reduce worker falls from telecommunications towers Reduce injuries and fatalities due to workplace violencec (1991b) 3. Reduce injuries and fatalities due to machines (1990b) 4. 4.1. educe injuries and deaths caused by tractor rollovers by increasing availability R and use of effective rollover protective structures 4.2. Reduce worker injuries and deaths caused by paper balers 4.3. educe injuries and deaths caused by machines through the conduct of fatality R investigations and the dissemination of prevention strategies Reduce acute back injury (1985b) 5. 5.1. Reduce acute injuries caused by patient handling 5.2. valuate interventions used to prevent acute injuries caused by material handling E

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IntRoduCtIon 35 FY2001 FY2002 FY2003 FY2004 FY2005 Total 12.71 8.16 8.14 8.29 7.72 92.56 $1,839,280 $1,561,840 $1,607,812 $1,597,210 $1,507,439 $14,153,726 $4,297,638 $3,192,059 $2,832,167 $2,373,118 $1,984,038 $21,859,674 $6,136,918 $4,753,899 $4,439,979 $3,970,328 $3,491,477 $36,013,400 83.16 79.78 85.64 87.21 87.71 731 $9,639,906 $11,679,549 $10,714,917 $11,483,797 $11,836,905 $84,620,159 $8,025,685 $8,002,147 $7,666,934 $7,271,602 $5,369,171 $54,708,083 $17,665,591 $19,681,696 $18,381,851 $18,755,399 $17,206,076 $139,328,242 Reduce injuries and fatalities among workers in Alaskac (1991b) 6. 6.1. Reduce injuries and fatalities in commercial fishing 6.2. Reduce injuries and fatalities in helicopter logging operations 6.3. Reduce injuries and fatalities in Alaska aviation Reduce injuries and fatalities to emergency responders (1997 b) 7. 7.1. Reduce injuries and fatalities to firefightersc 7.2. Improve protection for ambulance workers in patient compartments 7.3. mprove protection for emergency workers responding to large-scale disasters and I terrorist attacks Reduce injuries and fatalities to working youth (1994b) 8. 8.1. Influence legislative changes to protect young workers 8.2. Reduce child agricultural injuriesc 8.3. oster the development and widespread use of safety materials and intervention F strategies to protect young workers a The numbering of the goals here is consistent with the numbering of the goals as presented   in the evidence package prepared by NIOSH for the committee. The numbering is not a ranking of goals by research priority. b The date indicates the year this work was established as a strategic research program area. The committee’s review covers only the period of 1996-2005. c Goals/subgoals established or otherwise shaped by congressional initiative.  

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t R au m at I C I n j u Ry R e s e a R C h nIosh 36 at BOX 1-2 Selected Data on Burden of Traumatic Injury Motor Vehicles • Transportation incidents are the leading cause of occupational fatalities in the United States. • Of the 5,734 fatal occupational injuries that occurred in 2005, 2,493 (43.4 percent) were due to transportation incidents and, of those, more than half (57.6 percent) were highway incidents (BLS, 2007a). • BLS data indicate that for the period 1995-2002, three out of four worker deaths on road construction sites involved a worker being struck by a vehicle or mobile equipment (Pegula, 2004). Falls from Elevations • Falls disable 313,000 American workers each year (NIOSH, 2007d, p. 69) and for the period 1992-2006 resulted in an average of more than 700 occupational fatalities each year (BLS, 2007a). • Falls from roofs are a common cause of nonfatal injury in the construction industry and are the leading cause of fall fatalities (Hsiao, 2007; NIOSH, 2007d, p. 70). • Fatality rates due to falls among tower erectors have been estimated to be between 10 and 100 times the average fatality rate across all industries (NIOSH, 2007d, p. 78). Workplace Violence • Workplace homicide has been between the second and fourth leading cause of oc- cupational fatalities for the last 15 years (Amandus, 2007). • In 2005, there were 14,560 nonfatal occupational injuries in private industry involving lost work days due to assaults and violent acts by persons (BLS, 2007a). Machines • Based on BLS data through 2005, approximately 770 workers are fatally injured by a machine, plant or industrial powered vehicle, or tractor each year in the United States. Tractors were the leading cause of such deaths (NIOSH, 2007e, p. 97). • Of the 49 deaths that occurred between 1986 and 2002 due to operation of recycling industry balers, 59 percent involved balers that were baling paper and cardboard (NIOSH, 2007e, p. 104). Back Injury • Back injury is one of the most common work-related injuries, accounting for one in five of all private-sector work injuries and illnesses requiring days away from work in 2005 (BLS, 2007a).

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IntRoduCtIon 37 • Nurses and other patient caregivers are at increased risk for back injury because of the bending and lifting requirements of patient handling. Among nurses, back pain has been found to be a major factor in choice to leave the profession (NIOSH, 2007f, p. 114). Alaska • For the period 1980-1989, the average annual traumatic occupational fatality rate in Alaska was close to 35 deaths per 100,000 workers, almost five times the U.S. average of 7 deaths per 100,000 in the same period (NIOSH, 2007g, p. 126). • Factors contributing to Alaska’s high occupational fatality rate include high-risk com- mercial fishing and helicopter-logging industries, and aviation crashes associated with the state’s dependence upon air transportation, unique terrain and weather challenges, and incomplete radar coverage (NIOSH, 2007g, pp. 126-145). Emergency Responders • Each year more than 50 firefighters die in the line of duty from traumatic injury, and another 95,000 sustain a nonfatal injury (NIOSH, 2007h, p. 148). • Ambulance workers are at risk for crash-related injuries because the use of lap belts in patient compartments does not allow workers the mobility needed to access patients. In addition, equipment in ambulances is often not secured and poses a second hazard to ambulance workers should a crash occur (NIOSH, 2007h, p. 157). • Ensuring the safety and health of all emergency workers (including firefighters, police, emergency medical service workers, etc.) during large-scale disasters and terrorist attacks is important, yet can be very challenging given unknown risks and competing demands. Working Youth • In 2005, there were 54 deaths of workers younger than 18 years of age (BLS, 2007a; NIOSH, 2007i, p. 171). • In 2003, there were approximately 54,800 visits by youth to emergency depart- ments for work-related injuries. Rates of nonfatal injuries treated in emergency departments generally decrease with age, with rates for youth 15 to 17 years of age exceeded only by rates for workers 18 to 19 years of age (NIOSH, 2007i, p. 171). • The agricultural industry typically accounts for about 40 percent of young worker fatali- ties. Most of these deaths occur on family farms. Fatalities among youth working in agriculture are more than 3.5 times higher than for youth working in other industries (Castillo, 2007). • Child labor laws do not currently apply to children working on family farms or to youth 15 years and older working in agriculture (Castillo, 2007).

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t R au m at I C I n j u Ry R e s e a R C h nIosh 38 at a. An assessment of the relevance of the program’s activities to the improvement of occupational safety and health. b. An evaluation of the impact that the program’s research has had in reducing work-related hazardous exposures, illnesses, and injuries. The evaluation committee will rate the performance of the program for its relevance and impact using an integer score from 1 to 5. Impact may be assessed directly (for example, on the basis of reductions in ill- nesses or injuries) or, as necessary, by using intermediate outcomes to estimate impact. Qualitative narrative evaluations should be included to explain the numerical ratings. 2. Assessment of the program’s effectiveness in targeting new research areas and identifying emerging issues in occupational safety and health most relevant to future improvements in workplace protection. The committee will provide a qualitative narrative assessment of the pro- gram’s efforts and suggestions about emerging issues that the program should be prepared to address. Using an evaluation framework developed by the National Academies Com- mittee to Review the NIOSH Research Programs (see Appendix A), the committee was to evaluate the relevance, impact, and future directions of the TI Research Pro- gram. In addition to an evaluation of what the TI Research Program is producing, the committee was to assess whether the program can be credited with changes in workplace practices, exposures, or occupational injuries or whether such changes or the lack of such changes, are the result of external factors. The committee was comprised of 10 members and one Framework Committee liaison.8 The committee had expertise in the areas of occupational health, public health education, medicine, injury prevention and control, epidemiology and biostatistics, labor, industry, program evaluation, ergonomics, and bioengineering. The committee met three times between March and September 2007. Committee subgroup deliberations were held by conference calls prior to the committee’s final meeting. EVALUATION PROCESS The committee evaluated the TI Research Program for the period from 1996 to 2005, the first decade of NORA. The information evaluated consisted primarily 8 The Framework Committee liaison is a member of the National Academies Committee to Review the NIOSH Research Programs, which is the committee that developed the framework (see Appendix A of this report) for review of NIOSH research programs.

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IntRoduCtIon 39 of materials—organized by traumatic injury goals and subgoals—included in an evidence package provided by NIOSH to the committee. At its first meeting, the committee also heard presentations from NIOSH staff on the overall TI Research Program as well as each of the eight TI Research Program goal areas. A question- and-answer session followed each presentation. IOM project staff also sought the input of stakeholders who had been identified by NIOSH as having an interest in traumatic injury research and prevention. (Additional details on methods and information gathering can be found in Appendix B of this report.) The committee performed its assessment of program relevance and impact using an evaluation flowchart developed by the Framework Committee (Figure 1-3). The flowchart is based on the NIOSH operational plan of the path from inputs to outcomes for all NIOSH research programs (see Appendix A, Figure 1, p. 148). For each of the eight program goals, the committee conducted a qualitative assessment for each box in the evaluation flowchart. Assessment of relevance was based on the committee’s review of program challenges, strategic goals and objec- tives, inputs, and activities (Boxes A-C), while assessment of impact was based on review of outputs, intermediate outcomes, and end outcomes (Boxes D-F). The Framework Document provides guidance on evidence to be considered in each of these categories. The committee also considered the possible roles of external factors at all steps in the evaluation process. The committee’s findings and ratings of overall program relevance and impact are discussed in Chapter 2. For its assessment of the NIOSH process for targeting new research areas and identifying emerging issues in occupational safety and health, the committee relied primarily on a review of the TI Research Program’s strategic goals for the future (a list of these goals was included in the evidence package provided by NIOSH to the committee). A review of these findings, including strengths and weaknesses of the current list of future goals as well as goals to be added or eliminated, is discussed in Chapter 3. The report concludes with a final chapter in which the committee makes recommendations for program improvement. These recommendations are

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40 bitmap image Figure 1-3.eps FIGURE 1-3 NIOSH Research Program evaluation flowchart.

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IntRoduCtIon 4 not specific to the research goals, but derive from the committee’s observations across the goal-oriented reviews. REFERENCES Amandus, H. 2007. Reducing occupational injuries and fatalities due to workplace violence. PowerPoint presented at the Institute of Medicine’s first meeting of the Committee to Review the NIOSH TI Research Program. BLS (U.S. Bureau of Labor Statistics). 2007a. Census of fatal occupational injuries: Current and revised data. http://www.bls.gov/iif/oshcfoi1.htm#2006 (accessed October 24, 2007). BLS. 2007b. News release: Workplace injuries and illnesses in 2006. Washington, DC: DOL. Boden, L. I., and A. Ozonoff. 2008. Capture-recapture estimates of nonfatal workplace injuries and illnesses. Annals of Epidemiology 18(6):500-506. Castillo, D. N. 2007. Reduce injuries and fatalities to working youth. PowerPoint presented at the Institute of Medicine’s first meeting of the Committee to Review the NIOSH TI Research Program. Dembe, A. E. 2001. The social consequences of occupational injuries and illnesses. American Journal of Industrial Medicine 40(4):403-417. DOL (Department of Labor). 2008. OSHA’s mission. http://www.osha.gov/oshinfo/mission.html (accessed July 21, 2008). Hensler, D. R., M. S. Marquis, A. Abrahamse, S. H. Berry, P. A. Ebener, E. Lewis, E. Lind, R. MacCoun, W. G. Manning, J. Rogowski, and M. E. Vaiana. 1991. Compensation for accidental injuries in the United States. Santa Monica, CA: RAND. HHS (Department of Health and Human Services). 2005. Budget in brief: FY2005. http://www.hhs. gov/budget/05budget/fy2005bibfinal.pdf (accessed November 16, 2007). Hsiao, H. 2007. Reduce injuries and fatalities due to falls from elevations. PowerPoint presented at the Institute of Medicine’s first meeting of the Committee to Review the NIOSH TI Research Program. Leigh, J. P., S. Markowitz, M. Fahs, and P. Landrigan. 2000. Costs of occupational injuries and illnesses. Ann Arbor, MI: University of Michigan Press. Morse, T. F., C. Dillon, N. Warren, C. Levenstein, and A. Warren. 1998. The economic and social consequences of work-related musculoskeletal disorders: The Connecticut upper extremity surveillance project (CUSP). International Journal of Occupational and Environmental Health 4:209-216. NIOSH (National Institute for Occupational Safety and Health). 1998. NORA: Traumatic occupational injury research needs and priorities. Washington, DC: HHS. NIOSH. 2007a (unpublished). Introduction to briefing book. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007b (unpublished). Executive summary of briefing book. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007c (unpublished). Overview of TI Research Program. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007d (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities due to falls from elevations. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH.

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t R au m at I C I n j u Ry R e s e a R C h nIosh 42 at NIOSH. 2007e (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities due to machines. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007f (unpublished). Current TI research goals and sub goals: Reduce acute back injury. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007g (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities among workers in Alaska. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007h (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities to emergency responders. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007i (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities to working youth. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. Pegula, S. 2004. Fatal occupational injuries at road construction sites. Monthly Labor Review December:43-47. Pransky, G., K. Benjamin, C. Hill-Fotouhi, J. Himmelstein, K. E. Fletcher, J. N. Katz, and W. G. Johnson. 2000. Outcomes in work-related upper extremity and low back injuries: Results of a retrospective study. American Journal of Industrial Medicine 37(4):400-409. Reville, R. T., L. I. Boden, J. E. Biddle, and C. Mardesich. 2001. Comparing New Mexico PPD outcomes with PPD outcomes in other states. In An evaluation of New Mexico workers’ compensation per- manent partial disability and return to work. Arlington, VA: RAND Corporation. Rosenman, K. D., A. Kalush, M. J. Reilly, J. C. Gardiner, M. Reeves, and Z. Luo. 2006. How much work-related injury and illness is missed by the current national surveillance system? Journal of Occupational and Environmental Medicine 48(4):357-365. Sengupta, I., V. Reno, and J. F. Burton, Jr. 2007. Workers’ compensation: Benefits, coverage, and costs, 2005. Washington, DC: National Academy of Social Insurance (NASI). Silverstein, B. A., D. S. Stetson, W. M. Keyserling, and L. J. Fine. 1997. Work-related musculoskeletal disorders: Comparison of data sources for surveillance. American Journal of Industrial Medicine 31(5):600-608. Smith, G. S., H. M. Wellman, G. S. Sorock, M. Warner, T. K. Courtney, G. S. Pransky, and L. A. Fingerhut. 2005. Injuries at work in the U.S. adult population: Contributions to the total injury burden. American Journal of Public Health 95(7):1213-1219. Strunin, L., and L. I. Boden. 2004. Family consequences of chronic back pain. Social Science and Medicine 58(7):1385-1393.