Summary

ABSTRACT In 2005, the National Institute for Occupational Safety and Health (NIOSH) asked the National Academies to evaluate the relevance, impact, and future directions of up to 15 of its research programs, including the Health Hazard Evaluation (HHE) Program. The HHE Program does not conduct traditional research but is mandated to respond to requests for assistance in identifying specific workplace conditions that pose health hazards to workers. In 2007, the Committee to Review the NIOSH Health Hazard Evaluation Program was formed. The committee finds the HHE Program to be highly relevant to and to have a major impact on improving occupational health, and it believes that the program should be allowed to continue to provide its services and be expanded as resources become available.

In addition to its work to improve workplace conditions, the HHE Program responds well to emergencies, such as the terrorist attack on 9/11 and disasters related to hurricanes. Program staff are uniquely qualified to serve in leadership roles under such conditions. Training programs conducted by the HHE Program offer excellent opportunities for increasing expertise in occupational health, and the committee recommends more extensive tracking of alumni so that they can be called on for their expertise, assistance in identifying emerging issues, and emergency response.

The consensus of the committee is that the HHE Program is highly effective in investigating and advising workplaces when requested. The program fills a special need in the occupational health community by investigating



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Summary ABSTRACT In 2005, the National Institute for Occupational Safety and Health (NIOSH) asked the National Academies to ealuate the releance, impact, and future directions of up to 5 of its research programs, including the Health Hazard Ealuation (HHE) Program. The HHE Program does not conduct traditional research but is mandated to respond to requests for as- sistance in identifying specific workplace conditions that pose health hazards to workers. In 2007, the Committee to Reiew the NIOSH Health Hazard Ealuation Program was formed. The committee finds the HHE Program to be highly releant to and to hae a major impact on improing occupational health, and it beliees that the program should be allowed to continue to proide its serices and be expanded as resources become aailable. In addition to its work to improe workplace conditions, the HHE Pro- gram responds well to emergencies, such as the terrorist attack on 9/ and disasters related to hurricanes. Program staff are uniquely qualified to sere in leadership roles under such conditions. Training programs conducted by the HHE Program offer excellent opportunities for increasing expertise in occupational health, and the committee recommends more extensie track- ing of alumni so that they can be called on for their expertise, assistance in identifying emerging issues, and emergency response. The consensus of the committee is that the HHE Program is highly effec- tie in inestigating and adising workplaces when requested. The program fills a special need in the occupational health community by inestigating 

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 2 unexpected or underestimated workplace hazards and relating them to worker exposures or circumstances. Howeer, certain occupational groups might not fully benefit from program actiities, particularly those from small businesses and undersered populations. The committee recommends that the HHE Program take steps to acquaint such groups with its serices and elicit more requests for inestigations from them. In addition, funding limitations and obligations associated with emergency response might dilute program efforts and reduce effectieness. Finally, the committee beliees that the HHE Pro- gram could help to deelop a national occupational health sureillance system to facilitate recognition of emerging hazards. On the basis of a scoring system of  to 5, with 5 being the highest, the committee rates both the releance and the impact of the HHE Program as 4. If the committee had not been restricted to the use of integers, both scores would hae been between 4 and 5. OvERvIEW In 2005, the National Institute for Occupational Safety and Health (NIOSH) asked the National Academies to evaluate the relevance, impact, and future direc- tions of up to 15 of its research programs. One of the programs was the Health Hazard Evaluation (HHE) Program, which does not conduct traditional research but is mandated to respond to requests for assistance to identify specific workplace conditions that pose health hazards to workers. In 2007, the National Research Council formed the Committee to Review the NIOSH Health Hazard Evaluation Program. The mission of the HHE Program is to respond to written requests to in- vestigate potential occupational health hazards in workplaces, as defined by the Occupational Safety and Health Act of 1970 and the Federal Mine and Safety Act of 1977, and in federal agencies, including the military. The law defines who may submit requests for investigations: a request must be from an employer, a union, an employee representing at least two other employees, a single employee if the work area of concern has three or fewer employees, a federal agency health and safety committee or federal employees not covered by such a committee, or the secretary of labor (NIOSH, 2007b). Responses to requests vary from written or oral consultations on technical matters to full-scale onsite investigations. The program conducts field evaluations and consultations, responds to emergencies, and pro- vides occupational health training for health professionals. The committee had several discussions about how to evaluate the relevance of the HHE Program (Does the program address the right issues?) separately from its impact (Does the program address the issues effectively?). The committee evaluated

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summary  the relevance of the program in terms of program inputs, activities, and outputs, as outlined in the logic model used by NIOSH to summarize the program. Program inputs evaluated include strategic planning and use of resources such as funding and staffing. Activities evaluated include the marketing of program services to all parts of the workforce, including small businesses and underserved populations, and the setting of priorities, through a triage process, for allocation of resources in response to requests for investigations. HHE Program efforts to identify emerging hazards are also evaluated. Program outputs evaluated for relevance include both formal and informal responses by the HHE Program to requests for assistance. The committee also evaluated HHE Program emergency response activities. The impacts to be evaluated include the outcomes as listed in the HHE Pro- gram logic model, such as the reduction in worker risk and the prevention of occupational illness, the transfer of program-generated information to relevant employers and employees beyond the investigated workplaces, the influence of the HHE Program on NIOSH research and policy development, and the effect of the program on the general occupational health community, including activities of regulatory agencies, organizations of occupational safety and health professionals, and state and local health agencies. Overall, the committee considers the program to be highly relevant and to have a major impact on improving occupational health. The program should be continued and expanded as resources become available. RELEvANCE OF THE HEALTH HAzARD EvALuATION PROgRAM Inputs The strategic plan and objectives of the HHE Program are found by the com- mittee to be highly relevant, but the committee believes that program performance measures are of necessity restricted by available resources. The committee recom- mends that performance measures be reviewed regularly with respect to available resources to determine whether more ambitious goals are possible. For the most part, the HHE Program uses its resources judiciously to meet its mission in the face of a changing economy, the changing nature of HHE requests, and increased responsibilities related to emergency response. The committee rec- ommends that the HHE Program continue to provide guidance during public health emergencies but also recommends the development of a mechanism to en- sure that regular program functions continue during the deployment of key staff. The HHE Program could make better use of available surveillance data to assist in targeting field investigations to recognize previously unknown hazards. There is no national occupational health surveillance system, but the HHE Program might

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 4 influence the development of such a system, perhaps elsewhere in NIOSH, such as the Surveillance Branch of the Division of Respiratory Disease Studies. The committee finds the extent and effectiveness of relationships between the HHE Program and federal and state health agencies to be variable and recommends the program work toward consistently effective relationships with these different groups. Activities One of the most important activities of the HHE Program is its response to requests for evaluation of potential occupational health hazards. The program has been a passive recipient of such requests. The committee recommends a more ac- tive approach to stimulating valid requests, especially from small businesses and underserved populations. Innovative techniques are necessary to acquaint such populations with the services offered by the HHE Program. Another important activity is priority setting among requests for investiga- tions. For that purpose, the HHE Program has developed a triage process to determine whether a request meets regulatory requirements and whether a site visit and full investigation are warranted. The committee finds the development of this process a program improvement, but notes that the process is neither well documented nor transparent to the requestor. The committee recommends the development of an explicit, transparent written process for triage of requests. Outputs The major outputs of the HHE Program are reports written in response to requests. The committee finds that the reports are generally well written, present relevant information supported by appropriate documentation, and reflect a high level of expertise. However, the committee recommends the development of a well- defined quality assurance program that incorporates expert review from elsewhere in NIOSH and externally from the professional and research communities. Such a program could ensure consistently high quality outputs. An outcome of the HHE Program should be the detection of emerging hazards based on requests received. The committee finds no systematic approach to achiev- ing such an output and recommends the HHE Program initiate a formal periodic assessment of new and emerging hazards.

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summary 5 IMPACT OF THE HEALTH HAzARD EvALuATION PROgRAM Reducing Worker Risk and Preventing Occupational Illness In the field of occupational health, evidence suggests that exposure to certain chemical or physical agents causes illness, injury, or death. Elimination of exposure can reduce the number of cases of disease in those already exposed, prevent disease in new hires, or both. On the basis of the cause-effect relationship, attempts are made to reduce disease risk by reducing or eliminating exposure to specific agents. Numbers of cases of disease or numbers of deaths avoided can be estimated on the basis of reduction in exposure, but ideally one would have quantitative evidence of the reduction in illness or death at specific investigated worksites or similar work- places throughout the country. Such quantitative evidence of impact is generally unavailable. Transferring Program-generated Information to Relevant Employers and Employees Beyond Investigated Workplaces The HHE Program uses a wide variety of mechanisms to disseminate informa- tion, including information posted on the NIOSH website; free CDs made available to industries, workers, professors, and students; published articles in technical, trade, and scientific journals; and when required, Health Hazard Alerts to other government agencies at both state and federal levels, such as the Occupational Safety and Health Administration (OSHA). The committee finds, however, that the penetration of this information into some communities is variable, with less penetration into small businesses unaffiliated with trade organizations and under- served populations, including migrant workers. The committee recommends the development and use of innovative techniques to reach such populations. Influence of the Health Hazard Evaluation Program on NIOSH Research and Policy Development The HHE Program does not have the authority to promulgate regulations, but it does inform and support NIOSH-recommended guidelines and policies and NIOSH testimony regarding proposed OSHA rules. These activities have included guidance on a variety of occupational hazards, including those associated with tuberculosis, ergonomics, biosolids, latex, indoor air, metalworking fluids, histo- plasmosis, hexavalent chromium, body art, hearing loss, and respirator selection decision logic. Thus, the HHE Program has had an impact on a broad array of is- sues related to development of NIOSH policy to reduce worker risk associated with

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  occupational hazards. As stated earlier, quantitative data are not available to deter- mine exact reductions in illness and death (the end outcomes), but there can be no doubt that the HHE Program is a major contributor to the development of policies expected to lead to a safer working environment (an intermediate outcome). The HHE Program has also had both direct and indirect impacts on NIOSH research programs as well as the body of scientific knowledge in general. HHE Program reports influence the direction taken by the NIOSH Respiratory Diseases Research Program through the identification of unexpected workplace hazards. Examples of research influenced by the HHE Program are studies of the respira- tory problems caused by flavorings, flock,1 waterproofing spray, vaporized viruses, and more recently, nanoparticles. Extensive publications of those studies can be found in the open literature. HHE Program staff indicated to the committee that its reports also influence research in other NIOSH programs, such as the Cancer, Reproductive, and Cardiovascular Diseases Program; the Engineering Controls Program; the Exposure Assessment Program; the Hearing Loss Prevention Pro- gram; the Musculoskeletal Disorders Program; and the Personal Protective Tech- nology Program. Important additional impacts of the HHE Program result from the develop- ment of occupational expertise through its training programs. These are major contributions, and program impact could be expanded by increasing recruitment of trainees and by maintaining contact with training program alumni. Training program participants and alumni could be enlisted to provide expertise, assistance in identifying emerging hazards, and assistance in maintaining routine program operations during emergency response. Transfer of Program-generated Hazard and Prevention Information to the Occupational Health Community Program-generated hazard and prevention information is transferred in part by HHE Program reports and technical assistance letters generated in response to requests for assistance. In addition, HHE Program staff publish in the peer- reviewed literature, present research at major academic conferences related to occupational health, publish in trade journals, and make presentations at trade as- sociation meetings. HHE Program staff have developed compendia of findings and recommendations about well-understood occupational health risks. Completed compendia include those on isocyanates, noise, tuberculosis, and lead (NIOSH 2004e, 1998c, 2001b, and 2001a, respectively). The committee encourages the program to continue the development of such compendia as a valuable method 1 Fine, small-diameter synthetic fibers—the breathing of which can cause respiratory problems.

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summary 7 of transferring information to the general occupational health community. The program also participates in a variety of interagency activities related to occupa- tional health. The HHE Program is a recognized federal leader in responding quickly and ef- fectively to new and emerging hazards, particularly in emergencies. A challenge for the program is continuing routine operations while responding to emergencies. Despite the activities described above, the committee believes that more could be done to reach a broader variety of people, trades, and businesses, such as small, high-risk residential construction companies, small businesses, and immigrant or temporary workers. The committee heard from some state and local health officials who were unaware of the existence of the HHE Program. The program should not be a secret to those interested in the safety of the workplace. Evaluation of the impact of the HHE Program would be greatly enhanced by the establishment of a disciplined, after-the-fact evaluation of the relevance, impact, and quality of responses to HHE investigations. A “followback” program was initiated on the advice of an earlier evaluation committee, but it should be expanded to include more complete information on the impact of the program. FuTuRE DIRECTIONS OF THE HEALTH HAzARD EvALuATION PROgRAM The committee’s “vision” for the future of the HHE Program is that the pro- gram would serve to identify heretofore unrecognized workplace hazards, as well as known hazards for which permissible exposure limits or other control measures appear inadequate. The HHE Program of the future would continue to do what NIOSH can do uniquely—for example, emphasizing health effects identification that combines medical investigation and industrial hygiene (exposure assessment) techniques with epidemiological and toxicological perspectives, which may lead to the development of new measurement and control techniques. To achieve such goals, the HHE Program must become better known in the workplace and in the occupational health community. The program can only re- spond to requests from others, but such requests cannot be generated if potential requestors have not heard of the program. A major challenge will be to make its services more widely known to small businesses, underserved populations, and others. In the committee’s vision, the HHE Program of the future would expand its role as a major source of training of occupational health professionals, not only for NIOSH, but for other government agencies, academic institutions, and inter- national groups as well. The program would maintain good working relationships with local, state, and national organizations with ties to occupational health so

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  that it would be a primary resource when health problems arise in the workplace. The HHE Program of the future would make full use of its recently instituted followback program and maintain records of the effectiveness of recommended workplace interventions. In that way, HHE Program staff could evaluate how well the program meets its strategic goals and learn which techniques are most effective. Finally, the HHE Program of the future would continue to provide guidance and recommendations during public health emergencies. In contrast, the HHE Program of the future would not expend its limited re- sources doing what others can do, such as conducting routine industrial hygiene measurements or providing standardized responses to common problems. The expertise in the HHE Program is better used in developing generalized protocols for responding to common problems, rather than investigating routine industrial hy- giene matters. HHE Program investigations must also be distinguished from OSHA compliance inspections and small-business consultations. The HHE Program is designed to address emerging hazards, not to supplement the OSHA enforcement process or small-business consultation program. The committee’s recommendations are summarized in Box S-1. SCORINg The scoring system developed by the Committee to Review NIOSH Research Programs is based on a five-point scale in which 5 is the highest score (see Box S-2). The committee believes that the HHE Program scores somewhere above a 4 for both impact and relevance, but notes where the program could be improved. Because the committee was required to provide integer scores, the HHE Program received a 4 for both relevance and impact.

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summary 9 BOX S-1 Committee Recommendations The committee organizes its recommendations in eight categories, presented in an order consistent with the HHE Program logic model. The committee does not set priorities among its recommendations; it prefers encouraging implementation of any of them as resources are available. The committee recognizes that implementation of many of these recommendations will depend on the availability of resources, but at the request of NIOSH, it refrains from making recommendations regarding resource allocations. Therefore, general recommendations are made for program improvement. The next step for the HHE Program is to consider how resources could be allocated to allow implementation. Recommendation 1: Conduct regular assessments of performance measures to determine whether available resources allow more ambitious goals. Recommendation 2: Improve the mechanisms by which requests for HHEs are sought and prioritized to include a broader array of requests from a wider variety of requestors. The program could achieve this through a. ystematic use of professional meetings, scientific conferences, scientific literature, S and surveillance data, including those generated by NIOSH, to assist in prioritizing field investigations and in recognizing emerging issues. b. mplementing, as part of the triage process, a formal technical assistance mechanism to I help requestors to formulate valid HHE requests. In cases where an HHE is not appropri- ate or where resource limitations prohibit an investigation, technical assistance should include referral to more appropriate NIOSH divisions or government agencies. c. evelopment of an explicit, written process for classifying and prioritizing HHE D requests. d. etter formalizing of the triage process, including the identification of needed expertise, B and improving the transparency of the process to HHE requestors, while maintaining flexibility and speed. e. stablishment of formal relationships with organizations representing underserved E populations, small businesses, and their employees. f. nhancing HHE Program outreach to OSHA national and regional offices and to state E health and labor departments to better communicate the functions and activities of the HHE Program, increase cooperation with these agencies, and provide more complete and timely feedback. Recommendation 3: Ensure that recommendations in HHEs are relevant, feasible, effective, and clearly explained. Such steps may include a. xplanation of the relevance, feasibility, and impact of each recommendation in the text E of HHE reports. b. riority-setting among recommendations in all reports to indicate those requiring im- P mediate action in the targeted workplace. c. ebriefing in NIOSH after site visits and report dissemination for determination of rel- D evance and impact on a systematic basis (potentially missed opportunities to identify emerging health hazards could also be identified). continued

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 0 BOX S-1 Continued d. odification of the followback surveys for use in assessing the relevance, feasibility, and M impact of recommendations. e. nhancement of internal quality assurance by development of a formal program that may E include the external review of a sampling of recent reports and technical assistance letters for scientific content, report completeness, and appropriateness of recommendations. Recommendation 4: Use the HHE Program to develop occupational health professional re- sources. This could be accomplished through a. ncreased recruitment of new investigators from universities, the Epidemic Intelligence I Service (EIS), the Commissioned Officer Student Training Extern Program (COSTEP), oc- cupational medicine residencies, Education and Research Centers for Occupational Safety and Health (ERCs), and state and local health departments into HHE Program training rotations. b. racking and mobilizing the extensive talent and commitment represented in the HHE T Program-trained occupational health workforce. A network of HHE Program alumni could be fostered to help develop HHE opportunities. A program-level advisory board could as- sist the program in leveraging resources, serve a recruiting and retention function, assist in identifying emerging issues, and provide expert advice during normal program operations and when normal program operations are interrupted by emergency response activities. c. ngagement and use of ERCs and other university-based training programs to involve E trainees in HHE field investigations. d. ore formal collaboration with ERC faculty and other extramural researchers to assist in M field investigation, dissemination, and training opportunities. Recommendation 5: Develop a proactive, comprehensive information-transfer strategy for HHE Program outputs with better approaches to reaching wider audiences, including traditionally underserved populations. The HHE Program could a. se innovative techniques to reach small businesses and underserved populations, creating U a broad array of mechanisms for communicating with diverse constituencies and attending to issues of literacy, language, and national-origin barriers. The effectiveness of applied outreach should be evaluated in a formal manner. b. mprove the searchability of the online HHE search engine by developing a list of standard- I ized key words (an alphabetized list of hazards and diseases would be beneficial). c. evelop distribution mechanisms that are not Internet-dependent to complement Internet D distributions. d. isseminate HHE results more broadly to groups likely to be affected, including distribution D of HHE reports in the geographic regions where investigations are conducted. e. ncrease efforts to compile compendia of findings (such as those developed for isocyanates, I noise, tuberculosis, and lead) when generalized process-oriented findings can be gleaned from the experience of the HHE Program in a variety of workplace settings. f. evelop improved methods of outreach to stakeholders so that workers and workplaces D affected by new and emerging occupational health problems will be alerted quickly.

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summary  g. upplement program outreach efforts by using community and small-business groups to S translate HHE results and findings for their constituencies. h. everage existing NIOSH, Centers for Disease Control and Prevention (CDC), and Department L of Health and Human Services (HHS) resources to enhance technology transfer. i. valuate, in a formal manner, the effectiveness of information-transfer programs, including E knowledge transfer to employers and employees at worksites where HHEs have not been conducted. Recommendation 6: Develop more extensive formal linkages and mechanisms with other parts of NIOSH, CDC, and HHS to enhance the capacity for involvement in policy-relevant impacts through a. romotion and increase in direct communication, especially with OSHA and state occupa- P tional safety and health agencies. b. lerts to NIOSH and CDC about HHEs that are relevant to policy-making outside the CDC A system. c. ontinued regular use of the National Occupational Research Agenda (NORA) sector councils C and the NIOSH Board of Scientific Counselors to disseminate information about the HHE Program. d. ursuit of a change in the HHE Program’s legislative and regulatory authority to improve P the capacity to identify hazards in need of HHEs, improve the ability to gain entrance to facilities when requested by treating physicians or community representatives, and address exposures other than chemical agents. Recommendation 7: Initiate formal periodic assessment of new and emerging hazards. To ac- complish this, the HHE Program could a. volve from a program that passively receives requests to a proactive program that seeks E opportunities for field investigations. b. evelop systematic approaches to identify hazards where OSHA permissible exposure limits D are inadequate or nonexistent, to identify unknown hazards, and to identify known hazards encountered under new circumstances. c. stablish and periodically review a tickler file of inconclusive or unexpected evaluation results E to determine whether new trends or problems may be emerging. d. eriodically meet with intramural and extramural research scientists and stakeholders in gov- P ernment, academe, labor, and industry to discuss specific unresolved evaluations, to review aggregate findings, and to solicit input about new or emerging hazards or interventions. Recommendation 8: Continue to provide guidance and recommendations during public health emergencies. To accomplish this, the HHE Program could a. emain diligent by working with NIOSH management to avoid negative impact on routine R activities of the HHE Program as a result of emergency response activities. b. evelop a mechanism, such as the enlistment of help from training program participants and D alumni, to ensure continuation of routine operations in the absence of staff involved in emergency response.

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 2 BOX S-2 Committee Scoring Criteria Relevance 5 = ctivities are in high-priority subject areas and NIOSH is significantly engaged in ap- A propriate transfer activities for completed projects/reported results. 4 = ctivities are in priority subject areas and NIOSH is engaged in appropriate transfer A activities for completed projects/reported results. 3 = ctivities are in high-priority or priority subject areas, but NIOSH is not engaged in ap- A propriate transfer activities; or activities focus on lesser priorities but NIOSH is engaged in appropriate transfer activities. 2 = ctivities are focused on lesser priorities and NIOSH is not engaged in or planning some A appropriate transfer activities. 1 = ctivities are not focused on priorities and NIOSH is not engaged in transfer activities. A Impact 5 = ctivities have made major contribution(s) to worker health and safety on the basis of A end outcomes or well-accepted intermediate outcomes. 4 = ctivities have made some contributions to end outcomes or well-accepted intermedi- A ate outcomes. 3 = ctivities are ongoing and outputs are produced that are likely to result in improvements A in worker health and safety (with explanation of why not rated higher). Well-accepted outcomes have not been recorded. 2 = ctivities are ongoing and outputs are produced that may result in new knowledge or A technology, but only limited application is expected. Well-accepted outcomes have not been recorded. 1 = ctivities and outputs do not result in or are NOT likely to have any application. A NA = mpact cannot be assessed; program not mature enough. I