D
Stakeholder Input: Key Recommendations and Emerging Health Hazards

RECOMMENDATIONS FROM STAKEHOLDERS REGARDING THE HHE PROGRAM

In response to requests for input via an online questionnaire (see Chapter 1 and Appendix C) and during committee meeting discussions, stakeholders made useful comments and suggestions regarding the Health Hazard Evaluation (HHE) Program. The comments are summarized in this appendix. A table of original responses is available through the Public Access Records Office of the National Academies (Stakeholder Response Table, 2008).

Comments were received from occupational, environmental, and internal physicians, medical directors, and nurses; environmental safety specialists and administrators; industrial hygienists; toxicologists; epidemiologists; research psychologists; engineers; academics; compliance officers; investigators; nonprofit health organization representatives; union and worker representatives; and federal and state representatives. Some respondents have worked with the National Institute for Occupational Safety and Health (NIOSH) or the Occupational Safety and Health Administration (OSHA). Some have had direct experience with HHE investigations.

Comments and recommendations related to program improvement are divided into the following categories: strategic planning, interactions with the occupational health community, surveillance, conduct of evaluations, evaluation reports, product dissemination, and training. Comments related to emerging issues are summarized in the final section of this appendix. It should be noted that the comments



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D Stakeholder Input: Key Recommendations and Emerging Health Hazards RECOMMENDATIONS FROM STAKEHOLDERS REgARDINg THE HHE PROgRAM In response to requests for input via an online questionnaire (see Chapter 1 and Appendix C) and during committee meeting discussions, stakeholders made useful comments and suggestions regarding the Health Hazard Evaluation (HHE) Program. The comments are summarized in this appendix. A table of original responses is available through the Public Access Records Office of the National Academies (Stakeholder Response Table, 2008). Comments were received from occupational, environmental, and internal physi- cians, medical directors, and nurses; environmental safety specialists and adminis- trators; industrial hygienists; toxicologists; epidemiologists; research psychologists; engineers; academics; compliance officers; investigators; nonprofit health organiza- tion representatives; union and worker representatives; and federal and state represen- tatives. Some respondents have worked with the National Institute for Occupational Safety and Health (NIOSH) or the Occupational Safety and Health Administration (OSHA). Some have had direct experience with HHE investigations. Comments and recommendations related to program improvement are divided into the following categories: strategic planning, interactions with the occupational health community, surveillance, conduct of evaluations, evaluation reports, prod- uct dissemination, and training. Comments related to emerging issues are sum- marized in the final section of this appendix. It should be noted that the comments 9

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aPPendix d 97 summarized here do not necessarily reflect the views or opinions of the committee, although they may have influenced the deliberations that led to the committee’s conclusions. HHE Program Improvements Strategic Planning • Improve the connection between NIOSH management and the front-line science staff to allow the program to become more science oriented; • Prioritize hazards to be studied, balancing larger issues with other issues needing to be addressed; • Conduct targeted investigations within certain industries, such as poultry and food service; and • Establish rapid response teams to encourage timeliness in response to HHE requests. Interaction with the Occupational Health Community • Communicate better with safety professionals in industry; • Market the value of HHEs through collaborations with relevant pro- fessional associations and employer or business groups (e.g., National Business Group on Health); • Partner with community institutions, worker advocate groups, faith-based centers, and day labor organizations to relate to immigrant workers; • Improve the visibility of the HHE Program to employers, unions, occupa- tional medicine physicians and nurses, health departments, and workers to make the program more accessible; • Encourage state-based programs to make referrals for HHEs; • To assist local health department occupational health professionals, con- sult with local experts in nearby field offices in order to clarify procedures related to the advisability of referrals to the HHE Program (Determining which of the federal, state, and local agencies responsible for responding to specific issues is difficult); • Work with OSHA to communicate particularly with small- and midsized organizations and encourage employers with an evaluation program to use the OSHA consultation program; • Develop partnerships with the Centers for Disease Control and Prevention and the Environmental Protection Agency to collaborate with the federally designated pediatric environmental health specialty units to conduct HHEs in day cares and schools;

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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 9 • Improve adherence to notification protocol for informing local public health agencies of HHEs being conducted in their jurisdictions. Such communication could result in access to relevant historical and recent testing data; • Encourage the use of pollution prevention or toxic use reduction strate- gies to reduce hazards at the source, and seek the advice of other public technical assistance agencies that might be able to help; • Ensure that OSHA compliance officers are informed about the HHE Program and how it can be accessed by employers; • Market the HHE Program and reports to faculty and students of NIOSH- funded Education and Research Centers; • Reach out to state and local public health officers and OSHA programs to promote better public health infrastructure; • Send reports to state and local government agencies and to for-profit and nonprofit organizations; • Promote the HHE Program to unions, workers (organized and unor- ganized), businesses, nongovernmental organizations, occupational and environmental health professionals, healthcare providers, and state and local health departments; • Target the construction sector because of its limited resources and high risks in both safety and health issues; and • Educate healthcare facilities about exposures in the hospital environment and collaborate with NIOSH researchers to follow up on issues identified through HHEs. Surveillance • Create a national surveillance system for occupational illness; • Strengthen ties between NIOSH and state health departments (e.g., fund- ing, cooperative agreements) to create surveillance programs in as many states as possible; • Look to workers’ compensation for trend data; • Collect and study the trend data to determine sentinel events; • Work with the U.S. Chemical Safety and Hazard Investigation Board to address chemical hazards; and • Actively solicit reports of unusual illnesses or patterns of illnesses among workers from occupational physicians, companies, and workers.

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aPPendix d 99 Conduct of Evaluations • Make suggestions at the time of worksite investigations, initiate more direct telephone contact, and provide interim reports to ensure rapid implemen- tation of recommended hazard control solutions; • Have more sophisticated neuropsychological testing of workers exposed to neurotoxic metals, solvent, and pesticides; and • Follow up with individual workplaces and requestors regarding the feasibil- ity and implementation of recommendations on an ongoing basis. Evaluation Reports • Improve the short summaries of completed work products; • Prepare both short and full reports; • Prepare one-page summaries of reports in layperson language for more wide distribution of the reports; • Stress with an additional paragraph in each HHE report that the causes of all injuries (e.g., fatigue, work organization, equipment failures, training) should be identified and solutions implemented to prevent their recur- rence; and • Prioritize HHE recommendations by effectiveness and provide a prioritized listing of available literature to assist OSHA in more specific rule-making. Product Dissemination Online Dissemination • Improve the online search engine, including provision of an alphabetical categorization by main topic (exposure or disease); • Increase links of HHE reports to OSHA and NIOSH webpages; • Post HHE Program success stories on the OSHA website; • Post online fact sheets and other materials for workers in languages other than English; • Provide online content to elicit more commentaries from safety and health practitioners; and • Provide subscriptions to selective e-mail HHE-specific brief reports (e.g., NIOSH eNews).

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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 200 Other Dissemination • Make information available to all stakeholders, including employers and workers including websites and pamphlets for occupational safety and health departments to stimulate further exploration of specific problems; • Provide public information that distinguishes NIOSH from Immigration and Customs Enforcement and other government agencies; • Post information in all workplaces; • Bring more attention to publication of sentinel new findings, case reports, analyses of trends, and so forth, in peer-reviewed professional journals, including the publication of summaries of HHE reports of particular interest; • Reference and link to HHEs as “one-liners” in Morbidity and Mortality Weekly Report in a timely manner to provide immediate access to information; • Publicize more, including dissemination through trade organizations and journals, trade and union fairs, and conferences; • Advertise through better business bureaus, wholesale marketers, day labor organizations, and Telemundo to reach immigrant populations; and • Advertise in local newspapers. Training • Provide field placement training in NIOSH for students and inform pro- fessors about the HHE Program to help promote the field of occupational health; and • Provide training to OSHA staff about the HHE Program. Emerging Health Hazards Stakeholders identified emerging health hazards with broad comments about a number of wide-ranging issues and concerns, as follows: • All-hazards disaster preparedness, emergency response, and terrorist- related defense or assessments; • Unforeseen issues associated with climate change, water shortages, and other environmental extremes; • Continuing development of new compounds and chemicals, including the use of chemicals about which there are limited or no health data; • The downsizing of health and safety staffs across the country and weak enforcement of safety and health laws; • Emerging issues related to the aging workforce;

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aPPendix d 20 • The identification of broad causes of injury in each plant and industry; • The effect of abuse by supervisors and work stress on the reporting of problems in the workplace; • The organization of work and resulting stress, including stresses caused by workload, shifts, shift work, and their consequences; • Unrecognized or uncharacterized respiratory hazards related to work organization, job stress, psychosocial disorders, and musculoskeletal disorders; • Cultural and civility issues, expectations such as inappropriate public be- haviors or workplace violence; and • Communication. Specific hazardous exposures and health effects were cited by stakeholders, including • impulse noise; • serum chromium or beryllium among welders with metal on metal hip implants; • welding fumes; • lead; • respiratory disease and exposures in many industries; • work-related asthma; • silica and coal dusts; • fiberglass dust; • sugar dust; • new technologies in nanotechnology, pharmaceuticals, and biotechnology; • bioaerosol exposure and organic dust; • radiation; • surgical smoke plumes from all types of sources; • chemical and hazardous drug exposures (including exposures associated with chemotherapy); • solvents; • isocyanates and aziridine (for example, as used in golf ball manufacturing and rubber coating); • cadmium; • pesticide application; • neurotoxicants and their effect on pregnant or breastfeeding women; • unregulated or under-regulated toxins identified as carcinogens; • multiple chemical exposures during and after hardwood floor finishing;

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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 202 • indoor environmental quality issues, including water-damaged buildings, mold growth, and poor air quality; • mycotoxins and endotoxins; • bacteria (e.g., methicillin-resistant Staphylococcus aureus) and emerging infectious diseases; • formaldehyde in particle board furniture; • mixed low-level exposures; • long-standing hazards not covered by OSHA standards including cleaning products (e.g., disinfectants), hexavalent chromium in portland cement and concrete, and diesel exhaust; • carbon monoxide exposure (e.g., from gasoline generators or gas-powered washers); • establishment of occupational exposure limits; • dermatitis; • effects of food additives; • behavioral modification for the protection against needlesticks and other contaminated sharps injuries in hospitals; • hazards associated with construction and warehousing; • agricultural hazards; • sources of autoimmune diseases in women and healthcare provider immune system problems; and • musculoskeletal issues (e.g., ergonomic issues related to text messaging and small-computer use or associated with multiple operators of the same piece of equipment).