2
Description of the Health Hazard Evaluation Program

INTRODUCTION

The primary charge to the Health Hazard Evaluation (HHE) Program, as described in Section 20(a)(6) of the 1970 Occupational Safety and Health Act (OSH Act; P.L. 91-596),1 is to respond to written requests to investigate workplace health hazards. The program conducts field evaluations and consultations, responds to emergencies, and provides training for health professionals. These activities are conducted by staff trained as generalists in occupational medicine, epidemiology, and industrial hygiene, and by some specialists in areas such as pulmonary medicine (see Box 2-1 for definitions of some of these terms). HHE Program stakeholders include those at worksites where HHEs are conducted, workers and employers at similar workplaces, regulatory bodies, occupational and public health practitioners, other National Institute for Occupational Safety and Health (NIOSH) programs, and the research community more broadly.

The Committee to Review the HHE Program opted to separate the components to be evaluated as described in the HHE Program logic model (Figure 2-1). To be evaluated are the program’s inputs (strategic goals and objectives, program resources, and communication from stakeholders), activities (responses to HHE requests), outputs (such as HHE reports and NIOSH published documents),

1

P.L. 91-596, 91st Cong., S.2193, December 29, 1970, as amended through January 1, 2004 (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=2743, accessed March 21, 2008).



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2 Description of the Health Hazard Evaluation Program INTRODuCTION The primary charge to the Health Hazard Evaluation (HHE) Program, as de- scribed in Section 20(a)(6) of the 1970 Occupational Safety and Health Act (OSH Act; P.L. 91-596),1 is to respond to written requests to investigate workplace health hazards. The program conducts field evaluations and consultations, responds to emergencies, and provides training for health professionals. These activities are conducted by staff trained as generalists in occupational medicine, epidemiology, and industrial hygiene, and by some specialists in areas such as pulmonary medi- cine (see Box 2-1 for definitions of some of these terms). HHE Program stakehold- ers include those at worksites where HHEs are conducted, workers and employers at similar workplaces, regulatory bodies, occupational and public health practitioners, other National Institute for Occupational Safety and Health (NIOSH) programs, and the research community more broadly. The Committee to Review the HHE Program opted to separate the compo- nents to be evaluated as described in the HHE Program logic model (Figure 2-1). To be evaluated are the program’s inputs (strategic goals and objectives, pro- gram resources, and communication from stakeholders), activities (responses to HHE requests), outputs (such as HHE reports and NIOSH published documents), 1 P.L. 91-596, 91st Cong., S.2193, December 29, 1970, as amended through January 1, 2004 (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=2743, ac- cessed March 21, 2008). 20

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d e s c r i P t i o n o f 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 2 BOX 2-1 Definitions of Common Terms Epidemiology The study of the distribution of, and the physical, biological, social, cultural, and behavioral factors that influence, health-related states or events in specified popula- tions. Epidemiology also includes the application of this study to control of health problems (SOURCE: Last, 2001). Industrial hygiene The science and art devoted to the recognition, evaluation, and control of the environmental factors or stresses arising from or in the workplace that may cause sickness, impaired health and well-being, or significant discomfort and inefficiency among workers or among persons in the community; the profession that anticipates and controls unhealthy conditions of work to prevent illness among employees (SOURCE: Last, 2001). Occupational medicine The specialized practice of medicine, public health, and ancillary health professions in an occupational setting in order to promote health and prevent oc- cupationally related disease and injury (SOURCE: Last, 2001). Surveillance The systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health (SOURCE: MMWR, 2001b:2). intermediate outcomes (such as reductions in hazardous exposures), and end out- comes (reduction in occupational illness). A simplified version of the logic model (shown in Appendix A, Figure 2) has been used in reviews of the other NIOSH research programs. This chapter provides a historical context for the program and describes HHE Program inputs, activities, and outputs. The relevance of these components is assessed in Chapter 3. Stakeholder response to and impacts resulting from HHE activities are discussed primarily in Chapter 4. HISTORICAL OvERvIEW The Occupational Safety and Health Administration (OSHA) is the federal agency charged with protecting worker safety and health by setting and enforcing workplace standards. However, many hazards, such as certain chemicals used in commerce or conditions that cause musculoskeletal disorders are not regulated by standards, and many existing standards may be obsolete. When occupational illness is suspected, OSHA workers and employers rely on the HHE Program to identify illness-causing hazards and to recommend control solutions.

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22 Bitmapped 2-1 Broadside FIguRE 2-1 Logic model of the HHE Program. SOURCE: NIOSH (2007b).

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d e s c r i P t i o n o f 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 2 During the June 19, 1968, Senate hearings on the proposed OSH Act, Phillip R. Lee, M.D., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare, testified: We are dealing with hidden health hazards. Many occupational illnesses occur only after long periods of exposure to one or more hazards in the environment so that the link between hazard and frank disease is not dramatic and overt. . . . Moreover, a large part of the problem lies in small establishments which employ fewer than 100 workers. . . . The vast major- ity of these workplaces have no safety engineers, doctors, nurses, hygienists, or meaningful safety and health programs. . . . The villain is not greed; it is ignorance. One of the basic objectives of the legislation before you today . . . is to remove those barriers of ignorance that result in so much needless suffering and economic loss (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1968:270-271). Congress ultimately recognized that the nation needed a mechanism to in- vestigate health hazards in the workplace, regardless of compliance with specific standards. The OSH Act of 1970 (P.L. 91-596) included provisions in Section 20 (Research and Related Activities, 29 USC 669)2 to be carried out by the Secretary of Health, Education and Welfare through a new NIOSH, which was established in Section 22 of the act.3 Section 20(a)(6) provides that The Secretary of Health and Human Services shall publish within six months of enactment of this Act and thereafter as needed but at least an- nually a list of all known toxic substances by generic family or other useful grouping, and the concentrations at which such toxicity is known to occur. He shall determine following a written request by any employer or autho- rized representatie of employees, specifying with reasonable particularity the grounds on which the request is made, whether any substance normally found in the place of employment has potentially toxic effects in such concentrations as used or found [emphasis added]; and shall submit such determination both to employers and affected employees as soon as possible. If the Secre- tary of Health and Human Services determines that any substance is poten- tially toxic at the concentrations in which it is used or found in a place of employment, and such substance is not covered by an occupational safety 2 http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=3374 (accessed March 21, 2008). 3 29 USC 671 (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table =OSHACT&p_ id =3376 (accessed March 21, 2008).

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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 or health standard promulgated under section 6, the Secretary of Health and Human Services shall immediately submit such determination to the Secretary [of Labor], together with all pertinent criteria. The organization that conducts these investigations became the HHE Program, which responds to requests from employers, employees, and their representatives, and other agencies4 to conduct workplace evaluations. Through HHEs, NIOSH identifies current health hazards and makes recommendations to reduce exposures and prevent disease and disability. HHEs may be conducted in any private, federal, or other government workplace. Authority is governed by laws (P.L. 91-596,5 P.L. 95-1646), federal regulations (29 CFR 1960,7 42 CFR 858), and Executive Order 12196 of February 26, 1980. The language of the law is important because it implies that the HHE Program should address hazards not heretofore recognized or levels of exposure not previously deemed hazardous. The present committee concludes that Congress intended to fill data gaps present in 1970, when OSHA adopted wholesale as permissible exposure limits (PELs) (Robinson, 1991) many of the existing American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit values (TLVs) (ACGIH, 1989). NIOSH was given authority to enter the workplace following a written request, and legislation required certain employ- ers to cooperate with an investigation by allowing exposure measurements, making employees available for medical evaluation, and providing available information. While right of access resembles that for an OSHA inspection, the HHE Program conducts evaluations rather than inspections. There are important differences. OSHA inspects for known hazards and seeks to enforce safety and health regulation by issuing citations and fines as appropriate. By contrast, the HHE Program has not been given regulatory authority; its mission is intended to evaluate unknown situations with the goal of identifying previously unrecognized hazards and devel- oping new control strategies. Who may submit requests for investigations is defined by law: the request must be from an employer; a union; an employee representing at least two other employ- ees; a single employee if the work area of concern has three or fewer employees; 4 29 CFR 1960, Basic Program Elements for Federal Employees Occupational Safety and Health Programs and Related Matters. Section 1960.35 of these regulations describes the procedures for requesting HHEs in federal agency workplaces. NIOSH follows the procedures outlined in the regu- lations governing HHEs (42 CFR 85) when evaluating federal agency workplaces (http://www.osha. gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=11284, accessed October 10, 2008). 5 29 USC 667 (Section 18(c)(6)), 29 USC 668 (Section 19), and 29 USC 669 (Section 20(a)(6)). 6 Section 501(a). 7 Section 1960.35. 8 Requests for HHEs.

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d e s c r i P t i o n o f 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 25 a federal agency health and safety committee, or federal employees not covered by such a committee; or the Secretary of Labor. The legislative authority and limitations are important input to the HHE Program and are also external factors that affect the ability of the program to maximize its impact. Although authority has been broadly interpreted since enactment, NIOSH is legislatively conferred authority for investigation of only a specific subset of occupational health and safety conditions. NIOSH has the ability to compel workplace entry only for toxic substance exposure. When entry is not an issue, the HHE Program evaluates the full spectrum of hazards. The committee infers that the original vision included the notion that chemical exposures that did not violate existing OSHA PELs might be causing health problems that could be identified through medical and exposure evaluation. NIOSH was expected both to intervene in the requesting workplace and to provide data to support new or modified PELs or other health standards. Over nearly four decades since the act was passed, the scope of hazards that the HHE Program addresses has expanded beyond chemical exposures. The scope of activities to which HHE resources are applied was also extended to provide techni- cal assistance to requesters from other governmental agencies such as OSHA, the U.S. Postal Service, and the U.S. Department of Transportation. INPuTS As noted in the HHE Program logic model (Figure 2-1), inputs include plan- ning and the program’s use of resources. A challenge facing the HHE Program is balancing the need to be responsive to individual requests against the need to develop strategic approaches to identifying emerging health threats in the work- place. The HHE Program conducted a strategic planning process in the mid-1990s that “focused largely on internal process issues” (NIOSH, 2007b:29). In 2007, the program revised its strategies in response to a 2006 Board of Scientific Counselors (BSC) program evaluation and guidance from the NIOSH Office of the Director (OD). The mission of the HHE Program is “to protect worker health through prob- lem solving, research, risk communication, and dissemination of findings and recommendations by responding to external requests for hazard evaluations and technical assistance” (NIOSH, 2007b:16). To that end, the program established the following strategic goals: 1. Prevent occupational illnesses through reduced exposure to workplace hazards; 2. Promote occupational safety and health research on emerging issues; and

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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 3. Protect the health and safety of workers during public health emergencies (NIOSH, 2007b:1). Intermediate goals and performance measures were established in 2007 in response to the BSC 2006 evaluation and are described and assessed in Chapter 3. The HHE Program stated that performance measures will be reviewed annually and revised as appropriate (NIOSH, 2007b). The strategic goals and activities of the HHE Program are influenced by a variety of factors, including program and agency resources, legislative mandates, HHE requests, and stakeholder needs. The Framework Document (Appendix A) divides inputs into two categories: production and planning. Production inputs (also called program resources in the Framework Document) include program structure and management, funding, staffing, and physical facilities. Planning inputs include input from stakeholders, surveillance and intervention data, and risk assessments. What follows are brief descriptions of various inputs to the HHE Program. These descriptions are intended to orient the reader to the internal and external factors that shape the program. More detail about each of these inputs is provided as warranted throughout the report. Production Inputs Program Organization The HHE Program summarizes the organization of its activities in the logic model shown in Figure 2-1 (assessed in Chapters 3 and 4 of this report). The program’s role in the protection of worker health and safety during public health emergencies is not reflected in the logic model, but is included as an important ele- ment in the program’s strategic goals. This is also addressed in Chapters 3 and 4. The HHE Program mission is carried out by employees of the Hazard Evalu- ations and Technical Assistance Branch (HETAB) in the Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS) in Cincinnati, Ohio, and the Field Studies Branch (FSB) in the Division of Respiratory Disease Studies (DRDS) in Morgantown, West Virginia. The administrative lead of the HHE Program resides within HETAB. The HHE Program coordinator also serves as the HETAB branch chief. All HHE requests are logged and tracked within HETAB, which serves as the primary point of contact within the HHE Program for OSHA and for state and local agencies. There appears to be considerable support from and collaboration with staff throughout NIOSH on specific investigations. The HHE Program described

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d e s c r i P t i o n o f 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 27 collaboration with NIOSH scientists engaged in many of the priority research areas established by the National Occupational Research Agenda (NORA) including both cross-sector (health outcome) and sector-specific (industry-related) priorities (NIOSH, 2007b). According to the HHE Program, interbranch coordination within the program is facilitated through “joint participation by conference call in regular meetings to discuss and assign incoming HHE requests and by informal exchanges about procedural, policy, and scientific issues” (NIOSH, 2007b). The HHE Program staff informed the committee that the program regularly partners with the NIOSH Division of Applied Research and Technology and with the Health Effects Laboratory. To fulfill its responsibilities in the area of emergency response, the HHE Program partners with the Emergency Response and Prepared- ness Branch of the NIOSH OD. In a small number of cases, researchers from other NIOSH programs may be given primary responsibility for carrying out an HHE. When needed technical expertise is unavailable within NIOSH, the HHE Program works with experts in other government agencies or contracts with individuals in the private sector. These collaborations are essential in view of the diversity of potential workplace hazards that require evaluation. Budget Table 2-1 shows the HHE Program budget by branch and class over fiscal years 2000 through 2007. The committee did not consider an evaluation of the adequacy or appropriateness of budget allocations as part of its charge, nor was it given the data to conduct such an evaluation. The committee considers funding only in terms of the resources available to the program. Aspects of the program budget are discussed in greater detail as warranted throughout the report text. HETAB is the administrative home of the HHE Program and bears the costs for program administration. HETAB logs and tracks all HHE requests, maintains a central file of HHE requests and reports, and carries out routine communication functions, such as notifying OSHA and state and local health departments of HHE requests. It also prepares supporting documentation for Office of Management and Budget (OMB) approval pursuant to the Paperwork Reduction Act. The NIOSH OD allocates funds to the DSHEFS and DRDS, which then allocate funds to their respective branches (NIOSH, 2007b). Approximately $7.7 million were allocated to the HHE Program in 2007 (approximately 3 percent of the total NIOSH budget). Approximately 77 percent of the funding covers personnel costs, while the remainder is intended for discretionary spending. During the past 10 years, most of the program budget has come from the NIOSH base budget, though some funding has been received from earmarks, to offset expenses arising from emergency response activities, or was received from NORA research funding to support core activities.

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2 TABLE 2-1 Budget for the HHE Program by Branch and Class: Fiscal Years 2000-2007 Class (thousands of dollars) Mobile Year Salaries Benefits Travel Mail Communications Printing Contracts Supplies Equipment Fellows Total Hazard Evaluations and Technical Assistance Branch 2000 3,431 1,047 316 11 18 65 55 87 44 99 5,173 2001 3,529 1,115 314 6 19 26 107 86 130 5,332 2002 3,340 1,203 335 23 34 10 529 145 774 174 6,567 2003 3,866 1,381 376 34 37 6 234 108 124 6,166 2004 3,583 1,275 360 27 14 6 304 114 57 5,740 2005 3,360 1,124 265 20 7 374 129 10 5,289 2006 3,253 1,084 203 18 4 2 199 85 199 5,047 2007 3,502 1,176 198 25 2 1 366 74 105 5,449 Field Studies Branch 2000 935 232 128 8 0 4 430 34 147 40 1,959 2001 1,324 320 218 1 9 1 359 36 111 61 2,441 2002 1,402 335 256 1 14 0 476 68 49 54 2,655 2003 1,372 350 180 0 12 1 401 31 100 65 2,512 2004 1,382 414 160 5 2 5 446 32 64 0 2,509 2005 1,393 496 158 0 3 3 365 65 5 0 2,489 2006 1,188 395 92 13 3 0 284 59 21 48 2,101 2007 1,195 400 109 0 5 1 210 85 7 21 2,033 SOURCE: NIOSH (2007g).

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d e s c r i P t i o n o f 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 29 Personnel As shown in Figure 2-2, there has been a substantial reduction in the total num- ber of full-time equivalents (FTEs) since a peak in 2001. Some of this decline can be attributed to reorganization by the Centers for Disease Control and Prevention (CDC) involving clerical staff, but staff reductions within HETAB alone approach 20 percent. Periodic staff increases have occurred since 2001, commensurate with specific projects, such as those related to flavorings. The number of FTEs in 2007 was 61 (NIOSH, 2007b). Staff members are generalists in the areas of occupational medicine, epidemiol- ogy, industrial hygiene, ergonomics, engineering, behavioral science, pulmonary and other areas of medicine, toxicology, occupational health nursing, and statistics. Communication with HHE Program staff indicates program staff are distributed by discipline or role within HETAB and FSB in the disciplines needed to conduct HHEs, especially given the collaborative efforts within NIOSH (NIOSH, 2007g). Table 2-1 indicates a relatively flat budget in real dollars for the HHE Program over the past eight years. Personnel costs have remained nearly constant over this period of time, while contract costs have shown considerable variation. Thus, it appears that the relatively flat budget can be associated with decreases in FTEs for the program over the same time. 80 70 60 50 Number 40 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year HETAB FSB Figure 2-2.eps FIguRE 2-2 Total HHE Program FTEs. SOURCE: NIOSH (2007b).

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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 Facilities The HHE Program maintains offices and facilities for the storage and mainte- nance of scientific equipment used in field investigations at both HETAB and FSB facilities. Equipment includes sampling and monitoring equipment for exposure assessment, personal protective equipment for HHE investigators, and logistical support equipment and supply. A trailer designed as a staging facility for field investigations during emergency response and large-scale nonemergency field in- vestigations is maintained at the program’s Cincinnati facilities. A medical trailer in Morgantown is equipped to assess pulmonary effects of workplace exposures. The HHE Program does not maintain its own suite of chemical and biological analytical equipment but relies on resources elsewhere in NIOSH or on NIOSH- funded contract laboratories for sample analyses. Planning Inputs: Previous Evaluations Between 1972 and 2006, the HHE Program received planning input in the form of 12 internal and external evaluations (NIOSH, 2007b). Evaluation methods included expert review panels, key informant interviews, and customer satisfac- tion surveys. The three most recent evaluations were conducted by the Research Triangle Institute (RTI, 1997) and the NIOSH BSC (1997, 2006). While the com- mittee reviewed these evaluations as an aid to understanding the evolution of the HHE Program and its elements, it was not part of the committee’s charge to provide an assessment of these evaluations. Nonetheless, pertinent elements of the prior evaluations and the HHE Program responses are discussed in more detail in Chapters 3 and 4. The 1997 review, developed through a contract with RTI, elicited feedback from a wide range of stakeholders. Problems or classes of criticisms identified include • lack of timeliness, • procedural bias (specifically, concerns that employers had greater input into the process than employees), • overemphasis on routine investigations, and • lack of practicality in recommendations (NIOSH, 2007b:Appendix 2.3, 14). RTI recommendations led to the establishment of the HHE followback program, which was fully implemented in October 1999. The goals of the followback pro- gram are to “(1) provide feedback to improve the process by which HHEs are conducted and improve the worksite-specific outputs of the HHE Program; and

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d e s c r i P t i o n o f 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  (2) assess the effectiveness of HHEs in effecting change in the workplace and in im- proving the health of workers” (NIOSH, 2007b:23). Because of financial constraints that limit followback field investigations, followback evaluations consist of self- reported satisfaction questions to management and employees in the facility served, yielding primarily process rather than outcome information. Questionnaires are distributed for all field investigations and for 50 percent of those receiving techni- cal assistance or consultation. Followback field investigations are conducted for a very limited number of HHEs per year, resources permitting. This is an ongoing process intended to assist the HHE Program with its evaluation of customer service, relevance, and impact. In response to another RTI recommendation, compendia of HHE reports on lead, tuberculosis, noise, and isocyanates were developed (NIOSH, 2001a, 2001b, 1998c, and 2004e, respectively). The 1997 BSC review was conducted at the request of the NIOSH director (NIOSH, 2007b). Recommendations were made related to • problems identifying the agenda of the requestor, including labor- management difficulties and work organization issues; • personnel training needs, especially communication; • the need to better prioritize HHE requests; • documentation of HHE impacts, including effectiveness of recommendations; • the need to identify emerging hazards, less routine work, and more useful summaries of investigations in areas of more extensive experience; and • maximizing the ability to accomplish the preceding recommendations within the constraints of limited resources. The HHE Program responded with significant changes to address the second and third of these issues. To improve communication, the program restructured its numbered HHE reports into a uniform format that clearly identifies author- ship and responsible personnel. The first page of the reports includes a plain- language discussion of recommendations for employers and employees, followed by a clear summary. Letter reports written by the HHE Program have not been similarly structured, although authorship and telephone contact information fa- cilitate communication. The second major response was to formally introduce a “triage system” to pri- oritize incoming requests for HHEs. A mechanism has been developed that allows the HHE Program to respond to routine questions through telephone and fax-back information sharing when program leadership determines that a field investigation would not increase the body of knowledge on a given topic. The triage process itself was described to the committee by HHE Program staff. The committee notes that the criteria for triage, apart from the straightforward assessment of the validity of

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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 the request as determined by regulation, do not explicitly outline how HHE per- sonnel determine whether field investigations are necessary or distinguish complex investigations or those yielding research opportunities. In further response to BSC (NIOSH BSC, 1997) recommendations, the HHE Program developed and twice updated a procedures manual used as a reference for all program staff. Report dissemination, via websites, announcements in NIOSH eNews, announcements to all state epidemiologists and epidemic intelligence of- ficers through Epi-X,9 NIOSH alerts, and summary documents on particular topics, was enhanced. The ability to triage routine requests by definition frees up scarce resources for enhanced focus on emerging issues; however, metrics to assess the impact of these changes were not formally introduced until after a subsequent BSC program evaluation in 2006. The 2006 evaluation by the BSC was undertaken at the request of the NIOSH director (NIOSH, 2007b). Recommendations include • restating HETAB and DRDS missions and increasing the amount of priori- tization of HHE requests (triage) to reduce the number of open projects per project officer—the responsibility for responding to routine indoor environmental quality (IEQ) requests was recommended to be removed from the HHE Program;10 • improving the efficiency of processes, prioritization of tasks, and overall management of the program, including development of annual goals and performance measures, production of annual reports to demonstrate pro- gram outcomes, and utilization of outside consultants; • identification of the critical mass of staff and specific disciplines necessary to perform essential functions; • promotion of the HHE Program more widely in an effort to capture more emerging issues and selection of HHEs that will serve program goals; and • inclusion of estimated health-related savings as a result of HHE recommendations.11 Given the short amount of time since these recommendations were made, the HHE Program has not had the opportunity to respond fully to many of them. The program has developed annual goals and performance measures, which are discussed and evaluated in Chapter 3 of this report. Discussions among HHE 9 Epi-X is a secure electronic communication network maintained by CDC for public health agen- cies nationwide. 10 Note: This committee does not fully agree with this recommendation. 11 Note: This committee questions the feasibility of this recommendation.

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d e s c r i P t i o n o f 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  40 30 Percent 20 10 0 1980s 1990s 2000s Agriculture & mining Construction Manufacturing Transportation Trade Health services Other services Public administration FIguRE 2-3 HHE requests by decade by SIC sector. Figure 2-3.eps SOURCE: NIOSH (2007b). Program managers have taken place regarding how to proceed with others of these recommendations. HHE Requests As already discussed, the HHE Program receives requests for assistance in ad- dressing workplace health issues from stakeholders and applies triage criteria to determine whether a field investigation is warranted. The annual number of HHE requests has remained relatively flat for the past 10 years, with an average of ap- proximately 370 requests each year (NIOSH, 2007b:35). Figure 2-3 shows the distri- bution of requests made by decade, organized by Standard Industrial Classification (SIC).12 The distribution of HHE requests by sector has changed over time. For example, from the 1970s through the 1990s, the manufacturing sector accounted for 30 to 40 percent of HHE requests. Today, manufacturing accounts for less 12 The SIC system (replaced by the North American Industry Classification System [NAICS] in 1997) was developed for use by federal statistical agencies to classify business establishments for sta- tistical analysis purposes (http://www.census.gov/epcd/www/naicsdev.htm, accessed April 16, 2008). HHE Program staff provided data to the committee referring to the SIC system. For the sake of consistency, the committee opted to use SIC rather than NAICS.

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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 than 20 percent (NIOSH, 2007b). Table 2-2 shows the frequency of investigations compared by NORA industry sectors and hazard (NIOSH, 2007g).13 Comparing the two sectors with the largest number of requests (services and manufacturing), manufacturing-sector requests were more likely to have resulted in field investiga- tions than service-sector requests. The HHE Program also reported a change in the nature of requests over time. The number of IEQ-related requests, for example, significantly increased following a 1992 CBS evening news segment that encouraged viewers with IEQ problems to contact NIOSH (NIOSH, 2007b). More recently, IEQ requests have typically been made with regard to nonindustrial worksites, such as government buildings, private- sector offices, schools, healthcare facilities, and hotels and resorts (NIOSH, 2007b). ACTIvITIES Response to Requests The HHE Program responds to requests for HHEs or consultation and techni- cal assistance in the form of letter or telephone responses and field investigations. HHE Program managers generally make decisions regarding the appropriate re- sponse to incoming HHE requests. As described earlier, the HHE Program has developed a process to prioritize incoming HHE requests and direct resources and responses. The decision processes for triage and response are summarized by HHE Program staff in Figure 2-4 (NIOSH, 2008c). HETAB and FSB managers and supervisors regularly meet to specify under which of four response categories an HHE request may fall (see Box 2-2), following criteria outlined in the HHE Program Procedures Manual (NIOSH, 2006c) as described by program staff and summarized in Box 2-3 (NIOSH, 2007f).14 Contact with the requestor may be 13 Table 2-2 was derived by the HHE Program in response to information requests from the com- mittee (NIOSH, 2007h). The data were drawn from the program’s management tracking system, developed primarily for record retrieval and not data analyses. Because most HHE requests are related to multiple hazards or hazard classes, the HHE Program developed the following strategy for the tabulation of hazard class of requests: • IEQ—any request that included an IEQ issue, regardless of other issues also present • Physical—if not IEQ, and if keywords were present indicating ergonomic, musculoskeletal, radiation, or noise issues • Biological—if not assigned to IEQ or Physical, and keywords were present relating to tuberculo- sis, histoplasmosis, biosolids, or brucellosis issues • All Other—any other request not assigned to the classes above 14 Box 2-3 represents the HHE categorization strategy per the 1994 procedures manual, which was superseded by a new procedures manual produced in 2006. The 1994 criteria were used over most of the time period being evaluated.

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d e s c r i P t i o n o f 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 5 TABLE 2-2 Frequency of HHE Field Investigations by Sector and Hazard: Fiscal Years 1998-2007a Hazardc IEQ Physical Biological All Other Total N Total N Total N Total N Total N Total Sectorb (%)d Ne (%)d Ne (%)d Ne (%)d Ne (%)d Ne Agriculture, 2 7 5 8 1 2 10 29 18 46 Forestry, & Fishing (29) (63) (50) (34) (39) Construction 0 14 2 7 1 2 30 63 33 86 (29) (50) (47) (38) Healthcare & 23 305 13 31 4 11 24 161 64 508 Social Assistance (8) (42) (36) (15) (13) Manufacturing 15 119 36 76 2 4 149 455 202 654 (13) (47) (50) (33) (31) Mining 2 3 0 1 1 2 9 29 12 35 (66) (50) (31) (34) Services 108 1,203 44 113 12 25 128 572 292 1,913 (9) (39) (48) (22) (16) Transportation 8 147 12 48 16 19 51 214 87 428 (5) (25) (84) (24) (20) Trade 1 129 9 31 0 1 11 100 21 261 (1) (29) (11) (8) Total 159 1,927 121 315 37 66 412 1,623 729 3,931 (8) (38) (56) (25) (19) aIncludes all HHE requests with a completed response as of November 20, 2007. bSectoris based on SIC codes or NAICS codes, depending on year of the request. cSee text for an explanation of hazard classes. dPercentage of HHE requests resulting in a field investigation. eNumber of HHE requests. SOURCE: NIOSH (2007g). for referral to a different agency or to obtain additional information, assist in the formulation of a valid request, or provide readily available information regarding the request. Alternatively, HHE staff may decide that a site visit is warranted, which may result in a letter report with findings and recommendations applicable to the given worksite or a numbered report that may be applicable to other workplaces. The number of field investigations declined from 126 in 1997 to 58 in 2006 (NIOSH, 2007b). HHE Program staff explained the decrease as due, in part, to 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  Received HHE request at HETAB a received Branch Office Held every Tuesday and Friday morning Triage by teleconference between HETAB a and meeting FSBb managers and supervisers Category assignedd; Branch assigned (HETAB a or FSBb); need for site visit determined; professional disciplines needed discussed No site visit Site visit needed needed Category 1 Category 2 Category 3 and 4 HHE requests HHE requests HHE requests Change to category 3 or 4 Within scope of the Outside scope of Within scope of the if site visit HHE Program; Branch the HHE Program; HHE Program; Branch needed; change (HETAB a or FSBb) assigns assigned to HETAB a (HETAB a or FSBb) to category 2 POc and additional Branch Office assigns POc if site visit project staff not needed Letter sent to PO contacts requestor POc contacts requestor requestor; refer within 30 days; within 30 days; requestor to the obtains additional obtains additional appropriate information; if invalid, information; schedules agency may validate initial site visit Closeout memo Invalid Valid Initial site visit to file Contact Informational Additional site employer; letter sent to visit(s) if needed Employer informational Yes requestor request letter sent to employer No HHE findings No warrant a numbered final report Contact employer; Requestor informational Yes Yes wants employer letter sent to contacted employer; copy to requestor If requestor’s Letter report sent concerns answered to employer No by telephone, closeout memo to file Informational letter Numbered final sent to requestor report issued FIguRE 2-4 Flow diagram representing the HHE Program triage process for prioritizing HHE re- Figure 2-4.eps quests and allocating resources for response. a Hazard Evaluations and Technical Assistance Branch (of NIOSH) b Field Studies Branch (of NIOSH) c Project Officer d See Box 2-2 for category descriptions SOURCE: NIOSH (2008c).

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d e s c r i P t i o n o f 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 7 BOX 2-2 Triage Response Categories In order to prioritize HHE requests, the HHE Program will assign each written request for assistance in one of the following described categories that drive the program response: Category 1. These requests do not meet the criteria for a valid request [per legislation], concern issues outside the scope of the HHE Program, and are therefore administratively invalid. The HHE Program notifies the requestor and refers the requestor to another agency, such as OSHA or a state or local health department. Category 2. These are valid or invalid requests for which technical information is supplied to the requestor without conducting a field investigation. Examples include well-recognized problems with readily apparent solutions, problems that have already been adequately evalu- ated by NIOSH or others. When the request is invalid but the HHE Program believes that a field investigation might be warranted, the requestor is contacted quickly and provided information about what constitutes a valid request. Category 3. These are valid requests for which a field investigation is necessary to ad- equately evaluate the occupational safety and health problem described. Category 4. These are valid requests that present a complex problem or an opportunity for research. These may take longer than Category 3 requests to complete due to required method development or other technical issues. SOURCE: NIOSH (2007b). program’s ability to respond without field investigations to requests for which there are well-established control solutions. Additional factors attributed to the chang- ing response pattern include the decreased size of HHE Program staff, decreased discretionary funding, increased complexity of field investigations, and increased demands for staff involvement in activities other than traditional HHEs. These activities include emergency response and preparedness, participation on agency and expert committees, document development and review, international technical assistance, and mentoring and training of non-NIOSH occupational health and safety professionals (NIOSH, 2007b). The HHE Program may conduct a followback survey at a facility where an HHE has been conducted. The surveys are distributed among management and employees and are designed to obtain feedback to improve the HHE process and assess the impact of the HHE in the workplace.

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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  BOX 2-3 HHE Program Triage Criteria Guidelines for categorizing and prioritizing HHE requests are summarized in a procedures manual (NIOSH, 2006c). Classification is based on information provided by the requestors and is largely dependent on the expertise of HHE Program staff and management. The following excerpted text was provided to the committee in response to questions regarding program prac- tices and represents the categorization strategy as defined by the HHE Program in 1994 (NIOSH, 2007f). Although this strategy was superseded in 2006 by a revised procedures manual, it was applicable over much of the time frame evaluated by this committee. HHE Categorization Strategy 1. Valid request? If the request is invalid, the requestor will be given the criteria for a valid request and given the opportunity to resubmit the updated request. 2. Does the request relate to a NIOSH special initiative or research project? For example, violence in the workplace, agricultural or construction industries would be placed in Category III or IV. 3. What type of exposures are present in the workplace? Unfortunately, the information included in the original request is frequently incomplete. Therefore, requests from industries with known exposure to extremely hazardous substances should be placed into Category III. In addi- tion, new industries, processes, or exposures not previously evaluated by the HHE Program, NIOSH in general, or other occupational safety and health professionals should be placed into Category III or IV. On the other hand, requests for compliance or routine monitoring would be placed into Category II with referral suggestions (e.g. OSHA). Finally, processes previ- ously evaluated by the HHE Program and found to have minimal opportunity for hazardous exposures should be categorized as either Category II or III. 4. Are adverse health effects being reported? Like the exposure information, information about alleged health effects is frequently misleading. Considerations used to categorize requests based on health effects are the 1) type of condition, 2) severity of the condition, 3) reversibility of the condition, and 4) amenability to control measures. If the condition has been evaluated by a physician, has a diagnosis been made? Severe symptoms causing hospitalization should be categorized into III or IV. Mild symptoms should be categorized into II or III. Previously unrecognized health effects from common exposures, or occupational groups not known to be at risk for a particular health effect should also categorized as III or IV. Requests intended only to provide medical or industrial hygiene evidence for a pending legal action should be placed in Category II.

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d e s c r i P t i o n o f 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 9 5. Is the workforce unique? For example, is the workforce composed of only women, only m inorities, migrant labor, etc. If yes, Category III should be considered. Criteria for Prioritizing HHE Requests in Category III 1. Does the request relate to a NIOSH special initiative or research project? For example, violence in the workplace, agricultural or construction industries. 2. Can the evaluation be done by someone else? Examples: Companies can hire private-sector consultants. Government agencies can use Federal Occupational Health (FOH); some agen- cies have their own health and safety staff. OSHA requesters can consult with their national Technical Assistance Directorate in Washington, DC. Some state health departments have the resources to investigate. In some cases, an OSHA technical consultation (for management) or inspection (employee) may be more appropriate than an HHE. 3. Who is the requestor? Employee, small business, and union requests will be given a higher priority given their resource and access limitations. 4. What types of exposures are present in the workplace? Requests from industries with known exposure to extremely hazardous substances should be given a higher priority than other Category III requests. In addition, new industries, processes, or exposures not previously evaluated by the HHE Program, NIOSH in general, or other occupational safety and health professionals should be ranked higher. Industries or processes previously evaluated by the HHE Program should be ranked lower. 5. Are adverse health effects being reported? Considerations used to prioritize requests based on health effects are similar to those used to categorize requests. Therefore, the 1) type of condition, 2) severity of the condition, 3) reversibility of the condition, and 4) amenability of control measures are important to consider. Has the condition caused the affected e mployees to seek medical care? Severe symptoms causing hospitalization should be given high priority. Mild symptoms should be categorized into II or III. Previously unrecognized health effects from common exposures, or occupational groups not known to be at risk for a particular health effect should be given higher priority. Requests intended only to provide medical or industrial hygiene evidence for a pending legal determination should have a low priority. 6. Geographic. In times of critical shortage of travel funds, is the request close to Cincinnati, Morgantown, or one of our regional offices, therefore incurring minimal travel expenses?

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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 40 Emergency Response The HHE Program’s responsibilities in response to disasters and emergency preparedness have changed dramatically since the terrorist attacks on September 11, 2001 (9/11), and the program’s role is still evolving. Because of HHE Program staff ’s experience in assembling rapid field response, they provided leadership for NIOSH activities in the aftermath of the 9/11 attacks on the World Trade Center and for response to the subsequent anthrax contamination through the U.S. postal system. Fifteen HHE Program staff, along with other NIOSH staff, responded to the immediate protection needs of rescue and recovery workers in New York City. Such workers included firefighters, law enforcement personnel, emergency medical services, construction and demolition trades, health and safety personnel, volunteer workers, and local, state, and federal agency workers. The HHE Program provided technical assistance to local, state, and federal agencies related to personal protective equipment; assisted with air sampling to characterize the complex environment; and conducted several specific HHEs (NIOSH, 2007b). HHE Program staff described the training and resource development involved in preparing for their role in emergency response settings. The HHE Program pro- vides staff training, personal protective equipment and fit testing, and appropriate medical evaluations, using an all-hazards model. The model includes biological, chemical, explosive, and radiological events, as well as natural disasters, including hurricanes, earthquakes, and wildland fires. The HHE Program participates in tabletop exercises that include some staff training with partners in Top Officials (TOPOFF), a terrorism preparedness exercise involving officials from all levels of government, representatives from the international community, and the private sector.15 Before 9/11, the HHE Program responded to emergencies and managed the activities of deployed program staff. Subsequently, NIOSH and HHE Program roles in response have been prescribed by the National Response Framework (U.S. De- partment of Homeland Security, 2008).16 The HHE Program does not serve as the lead agency, but it has a defined responsibility. The program is one of the biggest contributors of technical leadership, but the organizational structure falls under the NIOSH OD. HHE Program staff members have often been asked to serve as team leaders because of their extensive field experience in difficult situations, for 15 Department of Emergency Management and Homeland Security (http://www.ct.gov/demhs/ cwp/view.asp?a=2017&q=290966&pp=12&n=1, accessed July 8, 2008). 16 The National Response Plan was replaced by the National Response Framework, effective March 22, 2008. The National Response Framework presents the guiding principles that enable all response partners to prepare for and provide a unified national response to disasters and emergencies. It es- tablishes a comprehensive, national, all-hazards approach to domestic incident response (http://www. dhs.gov/xprepresp/committees/editorial_0566.shtm, accessed July 8, 2008).

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d e s c r i P t i o n o f 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 4 example, in the response to Hurricane Katrina in 2005. Many of the people staffing the CDC operations center were HHE Program staff. After 9/11, the HHE Program received substantial funding for a truck and trailer for field deployment, and it is responsible for their maintenance and use. The program also received funding to construct a garage to house the vehicle and for staging purposes. The equipment is housed at the program’s Cincinnati facility. Pre- and post-deployment medical follow-up have been provided for program staff deployed in emergency response activities. Telephone guidance and other resources have been made available to assist staff with mental health issues when considered necessary (NIOSH, 2008a). OuTPuTS HHE Program outputs include official numbered reports and less formal letter reports in response to requests for HHEs and technical assistance. The program also produces articles for peer-reviewed publications, website content, and presen- tations at professional, trade, and agency conferences and meetings. The primary means by which the program communicates its findings is through numbered HHE reports. The current format of numbered reports includes a page of HHE “high- lights” written in lay terms, which includes information about the HHE request, program activities and findings, and bulleted lists of what managers and employees can do to minimize investigated hazards. A more technical summary follows the highlights section. The body of the report then provides background, investigation methodologies and criteria, results, discussion, conclusions, recommendations, and a list of references. Test results are also made available. Technical assistance and letter reports can be very similar in scope to num- bered HHE reports or may be much more focused and answer specific questions or provide referrals as necessary. Between 1996 and 2006, the HHE Program produced 495 numbered HHE re- ports, 503 letter reports for other field investigations, and 1,999 technical assistance or consultation letter reports (NIOSH, 2007b). The committee reviewed several numbered and letter reports provided by the HHE Program, as well as several HHE reports obtained elsewhere. These and other HHE Program outputs are discussed and evaluated at greater length in Chapters 3 and 4.