5
Vision and Recommendations

In previous chapters, the committee evaluated the relevance and impact of the Health Hazard Evaluation (HHE) Program. In this chapter, the committee describes its vision of what the HHE Program should be. The description provides a picture of what the ideal program would look like, including elements of the existing HHE Program. The committee concludes the chapter by summarizing recommendations provided in Chapters 3 and 4 of the report.

VISION FOR THE HEALTH HAZARD EVALUATION PROGRAM

The ideal HHE Program, as envisioned by the committee, would respond promptly to requests for evaluation of the chemical, physical, and biological hazards within the HHE legislative scope, serving all workers, including underserved populations. The program would do what the National Institute for Occupational Safety and Health (NIOSH) can do uniquely—emphasize identification of health effects by combining medical investigation and industrial hygiene (exposure assessment) techniques with epidemiological and clinical toxicological perspectives, which may also involve development of new measurement and control techniques. The program would communicate results promptly to the target workplace, to workplaces with common exposures, and more broadly, to the public health community. In addition, the program would respond to requests from clinicians and community organizations with ties to workers, in addition to the current legislatively supported requests. After completion of investigations, staff would follow



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5 Vision and Recommendations I n previous chapters, the committee evaluated the relevance and impact of the Health Hazard Evaluation (HHE) Program. In this chapter, the commit- tee describes its vision of what the HHE Program should be. The description provides a picture of what the ideal program would look like, including elements of the existing HHE Program. The committee concludes the chapter by summarizing recommendations provided in Chapters 3 and 4 of the report. vISION FOR THE HEALTH HAzARD EvALuATION PROgRAM The ideal HHE Program, as envisioned by the committee, would respond promptly to requests for evaluation of the chemical, physical, and biological haz- ards within the HHE legislative scope, serving all workers, including underserved populations. The program would do what the National Institute for Occupational Safety and Health (NIOSH) can do uniquely—emphasize identification of health effects by combining medical investigation and industrial hygiene (exposure as- sessment) techniques with epidemiological and clinical toxicological perspectives, which may also involve development of new measurement and control techniques. The program would communicate results promptly to the target workplace, to workplaces with common exposures, and more broadly, to the public health com- munity. In addition, the program would respond to requests from clinicians and community organizations with ties to workers, in addition to the current legisla- tively supported requests. After completion of investigations, staff would follow 2

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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 22 back on individual investigations to document and report abatement of hazards as well as follow back on grouped investigations to document abatement on a national basis. The ideal program would appeal to company and industry leaders, drawing them in as partners to prevent illness and injury industry-wide. Ideally, the HHE Program would be at the cutting edge of identification of emerging occupational health hazards. This could be done through systematic use of scientific literature and surveillance data, including those generated by NIOSH, and effective knowledge management. In this way, the HHE Program could identify heretofore unrecognized hazards as well as known hazards for which permissible exposure limits (PELs) appear inadequate or for which an HHE would facilitate Occupational Safety and Health Administration (OSHA) standard setting when information is limited. The program would also work toward identifying new industries or workplaces where there are limited data on potential hazards and toward providing opportunities for application of other NIOSH resources, such as toxicology or control technology design responses, to emerging workplace issues. HHEs would consider opportunities to confirm or deny health effects aris- ing from occupational exposures. HHEs are opportunities to identify gaps in protection at target workplaces, and are indicators of possible problems at similar workplaces generally. HHEs are opportunities to describe problematic exposure circumstances that may be used as teaching examples. The program would be used to train field investigators, including NIOSH employees and those from partner agencies, academic institutions, and international counterparts. Finally, the HHE Program would continue to provide guidance and recom- mendations during public health emergencies. In contrast, the HHE Program would not provide what others can do, such as routine industrial hygiene measurements or standardized responses to common problems like indoor environmental quality. For such situations, the best use of HHE expertise would be to develop generalized protocols for response to common problems. RECOMMENDATIONS Within current legislative funding constraints, the HHE Program has managed to perform well. The HHE Program is a highly relevant program that has had and promises to continue having a valuable impact on improving worker health. The committee recommends the program be continued and, as possible, expanded to conduct more field investigations over a greater range of hazards, especially among underserved populations. In this section, the committee makes general recom- mendations for program improvement. The recommendations are organized into eight categories and presented in an order consistent with the HHE Program logic

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v i s i o n a n d r e c o m m e n dat i o n s 2 model. The chapter and page numbers where recommendations appear in the text are provided. The committee does not set priorities among its recommendations; it prefers encouraging implementation of any of the recommendations 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. The next step for the HHE Program is to consider how to allocate resources. Recommendation 1: Conduct regular assessments of performance mea- sures to determine whether available resources allow more ambitious goals (Chapter , page 50; see Table - for recommendations related to specific 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. Systematic use of professional meetings, scientific conferences, sci- entific literature, and surveillance data, including those generated by NIOSH, to assist in prioritizing field investigations and recognizing emerging issues (Chapter , page 59). b. Implementing, as part of the triage process, a formal technical assis- tance mechanism to help requestors to formulate valid HHE requests. In cases where an HHE is not appropriate or where resource limita- tions prohibit an investigation, technical assistance should include referral to more appropriate NIOSH divisions or government agencies (Chapter , page 9). c. Development of an explicit, written process for classifying and pri- oritizing HHE requests. Priority should be based on the gravity of the potential harm, the number of employees potentially at risk at similar workplaces or using similar work processes, the urgency of the problem, the potential to assess health outcomes, and the pos- sibility of identifying emerging issues. Potential impact on standards and policy should also enhance the priority of an HHE request in the triage process. Relationship of the HHE to current research may be considered, but should not be the only or primary factor. The process should provide guidance on weighting these varying factors (Chapter , page 9). d. Better formalizing of the triage process, including the identification of needed expertise, and improving the transparency of the process

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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 24 to HHE requestors, while maintaining flexibility and speed (Chapter , page 70). e. Establishment of formal relationships with organizations represent- ing underserved populations, small businesses, and their employees (Chapter , page ). f. Enhancing HHE Program outreach to OSHA national and regional of- fices and to state 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 (Chapter , page 2). Recommendation 3: Ensure that recommendations in HHEs are relevant, feasible, effective, and clearly explained. Such steps may include a. Explanation of the relevance, feasibility, and impact of each recom- mendation in the text of HHE reports (Chapter , page 74). b. Priority-setting among recommendations in all reports to indicate those requiring immediate action in the targeted workplace (Chapter , page 74). c. Debriefing in NIOSH after site visits and report dissemination for de- termination of relevance and impact on a systematic basis (potentially missed opportunities to identify emerging health hazards could also be identified) (Chapter , page 74). d. Modification of the followback surveys for use in assessing the rel- evance, feasibility, and impact of recommendations (Chapter , page 74; Chapter 4, page 90). e. Enhancement of internal quality assurance by development of a formal program that may include the external review of a sampling of recent reports and technical assistance letters for scientific content, report completeness, and appropriateness of recommendations (Chapter , page 74). Recommendation 4: use the HHE Program to develop occupational health professional resources. This could be accomplished through a. Increased recruitment of new investigators from universities, the Epidemic Intelligence Service (EIS), the Commissioned Officer Student Training and Extern Program (COSTEP), occupational medicine resi- dencies, Education and Research Centers for Occupational Safety and Health (ERCs), and state and local health departments into HHE Program training rotations. This will require ongoing development

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v i s i o n a n d r e c o m m e n dat i o n s 25 of more attractive training, mentoring, and rotations (Chapter 4, page 0). b. Tracking and mobilizing the extensive talent and commitment repre- sented in the HHE 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 assist the program in leveraging resources, serve a recruiting and retention func- tion, assist in identifying emerging issues, and provide expert advice during normal program operations and when normal program opera- tions are interrupted by emergency response activities (Chapter 4, page 07). c. Engagement and use of ERCs and other university-based training programs to involve trainees in HHE field investigations (Chapter 4, page 07). d. More formal collaboration with ERC faculty and other extramural researchers to assist in field investigation, dissemination, and training opportunities (Chapter 4, page 07). Recommendation 5: Develop a proactive, comprehensive information- transfer strategy for HHE Program outputs with better approaches to reaching wider audiences, including traditionally underserved popula- tions. The HHE Program could a. Use innovative techniques to reach small businesses and underserved populations, creating 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 (Chapter , page ; Chapter 4, page 97). b. Improve the searchability of the online HHE search engine by devel- oping a list of standardized key words (an alphabetized list of hazards and diseases would be beneficial) (Chapter 4, page ). c. Develop distribution mechanisms that are not Internet-dependent to complement Internet distributions (Chapter 4, page 97). d. Disseminate HHE results more broadly to groups likely to be affected, including distribution of HHE reports in the geographic regions where investigations are conducted (Chapter 4, page 97). e. Increase efforts to compile compendia of findings (such as those devel- oped for isocyanates, noise, tuberculosis, and lead) when generalized process-oriented findings can be gleaned from the experience of the

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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 HHE Program in a variety of workplace settings (Chapter 4, pages 97 and ). f. Develop improved methods of outreach to stakeholders so that work- ers and workplaces affected by new and emerging occupational health problems will be alerted quickly (Chapter 4, page 97). g. Supplement program outreach efforts by using community and small- business groups to translate HHE results and findings for their con- stituencies (Chapter 4, page 97). h. Leverage existing NIOSH, Centers for Disease Control and Prevention (CDC), and Department of Health and Human Services (HHS) resources to enhance technology transfer (Chapter 4, page 97). i. Evaluate, in a formal manner, the effectiveness of information-transfer programs, including knowledge transfer to employers and employees at worksites where HHEs have not been conducted (Chapter 4, page 97). Recommendation 6: Develop more extensive formal linkages and mech- anisms with other parts of NIOSH, CDC, and HHS to enhance the capac- ity for involvement in policy-relevant impacts through a. Promotion and increase in direct communication, especially with OSHA and state occupational safety and health agencies (Chapter 4, page 0). b. Alerts to NIOSH and CDC about HHEs that are relevant to policy- making outside the CDC system (Chapter 4, page 0). c. Continued regular use of the National Occupational Research Agenda (NORA) sector councils and the NIOSH Board of Scientific Counselors to disseminate information about the HHE Program (Chapter 4, page 0). d. Pursuit of a change in the HHE Program’s legislative and regulatory authority to improve 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 expo- sures other than chemical agents (Chapter 4, page 0). Recommendation 7: Initiate formal periodic assessment of new and emerging hazards. To accomplish this, the HHE Program could a. Evolve from a program that passively receives requests to a proactive program that seeks opportunities for field investigations (Chapter , page 7).

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v i s i o n a n d r e c o m m e n dat i o n s 27 b. Develop systematic approaches to identify hazards where OSHA per- missible exposure limits are inadequate or nonexistent, to identify unknown hazards, and to identify known hazards encountered under new circumstances (Chapter , page 7). c. Establish and periodically review a tickler file of inconclusive or un- expected evaluation results to determine whether new trends or prob- lems may be emerging (Chapter , page 7). d. Periodically meet with intramural and extramural research scientists and stakeholders in government, academe, labor, and industry to dis- cuss specific unresolved evaluations, to review aggregate findings, and to solicit input about new or emerging hazards or interventions. The HHE Program could establish one or more stakeholder groups to as- sist in identifying exposure circumstances or types of workplaces that could be the object of HHE requests likely to have high relevance and impact. The NORA sector councils may serve this function (Chapter , page 7). Recommendation 8: Continue to provide guidance and recommenda- tions during public health emergencies. To accomplish this, the HHE Program could a. Remain diligent by working with NIOSH management to avoid nega- tive impact on routine activities of the HHE Program as a result of emergency response activities (Chapter 4, page 9). b. Develop a mechanism, such as the enlistment of help from training program participants and alumni, to ensure continuation of routine operations in the absence of staff involved in emergency response (Chapter 4, page 9).