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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 67
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 68
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 69
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 70
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 71
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 72
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 73
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Page 74
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 75
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 76
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 77
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 78
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 79
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
×
Page 80
Suggested Citation:"3 Relevance of the Health Hazard Evaluation Program." National Research Council and Institute of Medicine. 2009. The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health. Washington, DC: The National Academies Press. doi: 10.17226/12475.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

3 Relevance of the Health Hazard Evaluation Program EVALUATION OF RELEVANCE As discussed in Chapter 1, a relevant program can be described as an integrated program involving interrelated surveillance, research, and transfer activities. The relevance of its activities can be determined by the severity or frequency of hazards addressed and the number of people at risk, the extent to which the program ad- dresses gender-related issues and those of underserved populations (see Box 1-1 for definition), and the extent to which the health and safety needs of small busi- nesses are addressed. Program structure and content must also increase program relevance. The Health Hazard Evaluation (HHE) Program primarily serves a legislated, public health practice mission, and its relevance must be evaluated in that context. HHEs address issues that, by definition, are in the early stages of investigation and intervention. One important function of an HHE is to provide preliminary data that may lead to a more extensive research program. The mandate of the program, however, requires it to respond to requests, whether or not more in-depth research may follow. Within this constraint, the committee believes the program can elicit and prioritize requests to fit into an interrelated surveillance, research, and trans- fer matrix involving the rest of the National Institute for Occupational Safety and Health (NIOSH). One of the challenges faced by the HHE Program is weighing the need to be responsive to individual requests with the need to develop strategic approaches to identifying emerging health threats in the workplace. A careful bal- ance serves both functions. Through response to requests the program may identify 42

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 43 emerging issues, and identifying emerging issues helps in priority-setting among investigations. To assess program relevance, the committee begins this chapter with a review of major inputs to the program, including the strategic planning and stakeholder processes, and considers whether resources have been appropriately allocated and used to meet strategic needs. The chapter continues with an evaluation of the HHE Program’s activities and outputs, a discussion of how the program handles emerging issues, and then a discussion of the relevance of the program’s emergency response activities. The committee’s findings related to each of these topics are highlighted in bold. Recommendations related to the improvement of program relevance are found within the body of the text throughout the chapter and are organized and summarized in Chapter 5. The final section of this chapter provides the committee’s rating for relevance. RELEVANCE OF INPUTS (PLANNING AND RESOURCES) Strategic Planning F  inding 1:  The HHE Program’s strategic plan is highly relevant to the program mission. The HHE Program’s strategic and intermediate goals are summarized in Ta- ble 3-1. These were developed by the HHE Program in response to a recommenda- tion by the NIOSH Board of Scientific Counselors (BSC) to “improve the efficiency of processes, prioritization of tasks and overall management of the program [in- cluding to … d]evelop annual goals and measurable objectives regarding the work products, priorities and work processes of the HHE Program that are practical, cost effective, and consistent with resources” (NIOSH BSC, 2006). The committee finds that the HHE Program has made a serious effort to respond to this recommenda- tion. The goals are well targeted and relevant, and can be measured by the number and types of HHE requests received, the number of reports and field investigations conducted related to each of these goals, and their effects as determined through followback surveys (described in Chapter 2). Appropriate performance measures for each intermediate goal have been chosen, given the limited resources of the program. The committee believes, however, that with additional resources, perfor- mance measures could be made more specific and ambitious. There is no indication that surveillance or workers’ compensation data were used to formulate the HHE Program’s strategic plan. Given more resources, onsite follow-up investigations to assess the impact of interventions would help the program assess and revise its goals and performance measures as necessary. The committee comments on individual performance goals and measures in Table 3-1.

44 TABLE 3-1  HHE Program Strategic and Intermediate Goals, Performance Measures, and Committee Comments Strategic goal 1: Prevent occupational illnesses through reduced exposure to workplace hazards. Intermediate Goals Performance Measures Committee Comments 1.1.  Increase 1.1.1.  Annual goal: Conduct a targeted marketing campaign The committee endorses this intermediate the number of 1.1.1.1.  2007: Award one contract for a customer survey FY goal, which is the core of the HHE Program HHE requests 1.1.1.2.  2007: Stimulate two valid HHE requests through outreach FY mission. In addition to enhancing awareness, concerning to physicians in the Cincinnati area appropriate performance measures include important 1.1.2.  Annual goal: Enhance awareness of the HHE Program establishing partnerships to develop occupational 1.1.2.1.  2007: Increase the percentage of national union websites FY valid requests from small businesses and health problems that include a link to the HHE Program website (obtain underserved worker populations. Partnerships baseline data) with nonprofit organizations, community 1.1.2.2.  2007: Increase the percentage of state Occupational Safety FY development organizations, and worker and Health Administration (OSHA) websites that include a centers could be explored, and specific metrics link to the HHE Program website (obtain baseline data) concerning requests could be generated and 1.1.2.3.  2007: Establish links to the HHE Program website on the FY tracked. The use of international, national, website of three government agencies or trade associations state, and local surveillance data would providing services to small business facilitate identifying and focusing resources 1.1.2.4.  2007: In the 16 states in which an HHE was announced in FY in areas of emerging need and underserved Epi-X in FY 2004-2006, assess awareness of the HHE Program populations. among state epidemiologists 1.2.  Facilitate 1.2.1.  Annual goal: Provide a service that is valued by HHE participants While the committee agrees there is a need for implementation of 1.2.1.1.  2007: 80% of respondents to the HHE followback survey FY continued commitment to process evaluation, recommendations report that the NIOSH evaluation was “good” or “excellent” return site visits that offer the ability to at facilities one year after the report was issued (baseline: 82% for FY provide objective evaluation of impact investigated 2001-2005)a are critically important, though adequate through the HHE 1.2.2.  Annual goal: Provide a service that results in improved workplace resources may need to be obtained. Program conditions 1.2.2.1.  2007: 80% of respondents to the HHE followback survey FY The committee notes a decrease in field report that workplace conditions have improved since the investigations, which may at least partially NIOSH evaluation (baseline: 81% for FY 2001-2005)a explain the decrease in response time for

1.2.3.  Annual goal: Produce timely reports for HHE requests addressed investigations that are being conducted. The with a field investigation timeliness of the responses to HHE requests 1.2.3.1.  2007: Complete 50% of reports within 6 months of the last FY is critical to the success of the program. With site visit (baseline: 36% for investigations with a last visit in FY the diminishing number of HHE requests, the 2005)a program should be able to set more timely 1.2.4.  Annual goal: Produce useful reports for HHE requests addressed response goals. with a field investigation 1.2.4.1.  2007: 95% of respondents to the HHE followback survey FY Follow-up with technical assistance after report that the Recommendations section of the report was report issuance should be carefully evaluated “very or somewhat useful” to them (baseline: 94% for FY 2001- for knowledge transfer and exchange to other 2005)a relevant facilities. 1.2.4.2.  2007: 95% of employees responding to the HHE followback FY survey report that the Highlights section of the report was “very or somewhat useful” to them (baseline: 96% for FY 2001- 2005)a 1.2.5.  Annual goal: Provide continuing technical assistance after the issuance of the final report 1.2.5.1.  2007: Make onsite, post-investigation presentations for two FY HHEs 1.2.5.2.  2007: Develop a partnership with one facility to assist in FY implementation and evaluation of recommendations 1.2.6.  Annual goal: Assess implementation of HHE recommendations through followback surveys 1.2.6.1.  2007: Carry out a mailed survey regarding FY recommendations 1 year after issuing a final report for 100% of onsite HHEs 1.2.6.2.  2007: Successfully obtain information from 70% of FY participants in the mailed survey 1.2.6.3.  2007: Complete at least four onsite followback surveys FY continued 45

46 TABLE 3-1  Continued Strategic goal 1: Prevent occupational illnesses through reduced exposure to workplace hazards. Intermediate Goals Performance Measures Committee Comments 1.3.  Provide 1.3.1.  Annual goal: Provide timely informational letters Performance measure 1.3.3 would greatly appropriate 1.3.1.1.  2007: Complete 90% of letters within 6 months of the FY free up resources while informing a wide technical request (baseline: 87% for FY 2005 requests)a range of workplaces about ways to reduce assistance for 1.3.2.  Annual goal: Provide helpful informational letters poor IEQ. It should be possible to produce HHE requests 1.3.2.1.  2007: 65% of HHE requestors completing a followback FY similar educational materials for other areas addressed without survey report that the letter was helpful (baseline: 60% for FY of high-frequency requests in which the HHE a field visit 2001-2005)a Program has considerable experience. 1.3.2.2.  2007: 65% of HHE requestors completing a followback FY survey report that they shared information in the letter with others at the worksite (baseline: 59% for FY 2001-2005)a 1.3.3.  Annual goal: Develop standard informational materials for common concerns 1.3.3.1.  2007: Two draft indoor environmental quality (IEQ) FY NIOSH-numbered documents will be submitted for external peer review 1.4.  Employees 1.4.1.  Annual goal: Enhance the dissemination of HHE reports This intermediate goal should further and employers 1.4.1.1.  2007: Announce all HHE reports in eNews and Epi-X FY increase program relevance. Additional at facilities not within 2 months of distributing to the investigated facility avenues for disseminating information may investigated 1.4.1.2.  2007: Post HHE reports on the NIOSH website within 2 FY include video-sharing websites or public through the months of distributing to the investigated facility service announcements. County agriculture HHE Program 1.4.2.  Annual goal: Develop communication products based on HHEs extension services may be used to disseminate are aware of (e.g., NIOSH-numbered documents, trade publications, and agriculture-related findings. Similarly, some hazards identified presentations) states have engineering extension services to and controls 1.4.2.1.  2007: Prepare and disseminate 1-2 new written products FY work with small manufacturing facilities and recommended by 1.4.2.2.  2007: Present HHE findings at 2-3 trade meetings FY economic development councils. HHE Program 1.4.2.3.  2007: Prepare and disseminate an annual report of FY investigators highlights from the HHE Program

1.5.  Professional 1.5.1.  Annual goal: Transfer information generated from the HHE The committee applauds the HHE Program’s practices, Program to other occupational safety and health professionals recognition of the critical role it can play guidelines, 1.5.1.1.  2007: Submit 4 to 6 peer-reviewed manuscripts based on FY in knowledge transfer, and encourages an policies, HHEs increased focus on knowledge exchange to standards, and 1.5.1.2.  2007: Make 20 to 25 presentations based on HHE Program FY increase relevance in identifying emerging regulations are work at scientific or agency meetings issues. influenced by 1.5.1.3.  2007: Participate as requested in agency workgroups FY information generated from the HHE Program Strategic goal 2: Promote occupational safety and health research on emerging issues. Intermediate Goals Performance Measures Committee Comments 2.1.  Customers 2.1.1.  Annual goal: Use the internal HHE review process and HHE The approach described could be augmented will have project officer surveys to identify emerging issues by developing a tickler file of unusual requests information about 2.1.1.1.  2007: Prepare and disseminate an annual list of new FY for which no clear findings have been made. emerging issues findings from HHEs These could be reviewed periodically in a process that includes intramural and extramural scientists to identify new patterns. 2.1.2.  Annual goal: Transfer information regarding emerging issues to Interaction with NORA sector councils will appropriate internal and external partners increase recognition of the HHE Program 2.1.2.1.  2007: Complete and accurate information regarding new FY within these industries as well as the HHE HHE requests and closed projects is entered in the HHE Program’s understanding of potential hazards database within each industry. Sectors chosen by 2.1.2.2.  2007: Prepare and disseminate annual HHE summary data FY the HHE Program are certainly relevant, to National Occupational Research Agenda (NORA) research but the program could also consider being councils for the manufacturing, construction, service, and represented on the NORA transportation healthcare and social assistance sectors council. This industry has high injury and 2.1.2.3.  2007: Provide timely summary information generated from FY illness rates, particularly within trucking, and the HHE Program to all NORA sectors few HHEs have been conducted (n = 3, with the last one in 1989). 47 continued

48 TABLE 3-1  Continued Strategic goal 3: Protect the health and safety of workers during public health emergencies. Intermediate Goals Performance Measures Committee Comments 3.1.  Partners 3.1.1.  Annual goal: Develop and disseminate information anticipating The HHE Program has been effective in and customers likely chemical, biological, or radiological threats this arena and should communicate the have the 3.1.1.1.  2007: Complete 100% of tasks related to pandemic flu FY importance of this role to ensure resources are information they planning according to schedule available to continue these activities. need regarding high-priority occupational health issues likely to arise during public health emergencies 3.2.  HHE 3.2.1.  Annual goal: Maintain adequate numbers of trained and certified Emphasis should be placed on recognizing Program staff policy implications of HHEs in this arena. personnel respond 3.2.1.1.  2007: A minimum of 25 personnel are enrolled in a FY Explicit training should be given on how to appropriately respiratory protection program, maintain Hazardous Waste recognize and appropriately seek guidance on to requests for Operations and Emergency Response Standard (HAZWOPER) handling HHE requests with broader policy assistance certification, complete incident command system training, and implications. are aware of information resources regarding specific potential hazards 3.2.1.2.  2007: Assurance is received from the Office of Health and FY Safety that HHE emergency responders have appropriate medical oversight

3.3.  Ensure that 3.3.1.  Annual goal: Emergency response-related equipment is available This is an important goal. The committee the HHE Program for field deployment within 24 hours of request to respond recognizes the need for sufficient resources. is ready to respond 3.3.1.1.  2007: The electronic inventory of industrial hygiene FY to requests for equipment is complete and current assistance 3.3.1.2.  2007: Calibrations are up-to-date for 100% of industrial FY hygiene equipment likely to be used in an emergency deployment, and records of current calibration dates are maintained 3.3.1.3.  2007: The Hazard Evaluations and Technical Assistance FY Branch (HETAB) emergency response vehicle is appropriately equipped and maintained, records are up-to-date, and a minimum of two drivers have commercial drivers licenses 3.3.1.4.  2007: At least three HHE Program staff members are FY currently certified to ship dangerous goods 3.3.2.  Annual goal: Management systems are in place to facilitate efficient response to requests for assistance 3.3.2.1.  2007: Database of responders is current and complete with FY regards to home, work, and cellular telephone numbers for responder and emergency contact, respirator fit test results, and security clearance status 3.3.2.2.  2007: Develop standard operating procedures for FY communications and preparation for responding aBased on the three most recent years for which data are available. SOURCE: NIOSH (2007b:Appendix 2.7, HHE Program Strategic Plan). 49

50 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH R  ecommendation:  Conduct regular assessments of performance mea- sures to determine whether available resources allow more ambitious goals. Use of Resources The Framework Document (Appendix A) directs the committee to consider how planning, production, and other input data support and promote program goals and activities, and to determine whether input is obtained from stakeholders, including from underserved populations and small companies. Planning inputs include surveillance data; advice from advisory committees, National Occupational Research Agenda (NORA) research partners, and other stakeholders; reports from the Fatality Assessment Control and Evaluation (FACE) program; and extramu- ral health outcome, exposure assessment, or similar data from federal, state, and other program partners. Production inputs, including budget, staff, facilities, and management, play major roles in the program. F  inding 2: For the most part, the HHE Program has judiciously used its resources to meet its mission in the face of the changing economy, the changing nature of HHE requests, and increased responsibilities related to emergency response. HHE Program activities have been modified over the past 10 years because of events such as the September 11, 2001 (9/11) attacks; specific HHE topics such as diacetyl; the influence of the NORA process; and response to program evaluations. The 1997 BSC evaluation (NIOSH BSC, 1997) prompted the formalization of the HHE Program triage process, described in Chapter 2, and the procedures manual, which have resulted in improved program efficiency and other improvements. Health Hazard Evaluation Requests and Resource Allocations Figure 3-1 shows the change in the number of HHE requests and program responses between 1997 and 2006. The number of requests during this period peaked in 2001 at about 580. At the end of the time frame, HHE requests declined to approximately 390, which is only approximately 15 percent more than in 1997. By the end of the period, more responses to HHE requests took the form of written  Triage is the system for allocating scarce resources to cases or problems based on a priority scheme, especially in emergency medicine and public health. The term comes from battlefield medicine where the wounded are separated into three categories—those who are likely to die even with care, those who are likely to recover even without care, and those for whom care would be effective.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 51 600 500 400 Number 300 200 100 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Technical asstance/ Field investigation consultation Figure 3-1.eps FIGURE 3-1  Distribution of HHE requests by response category. NOTE: Category 1 and 2 requests are combined under technical assistance/consultation. Category 3 and 4 requests are combined under field investigation (see Box 2-2 for a description of the HHE request categories and responses). SOURCE: NIOSH (2007b). information and telephone communication rather than field investigations. These forms of follow-up were specifically developed in response to external reviews and indicate HHE Program success in redirecting resources to provide appropriate in- formation in response to routine questions. However, this increased proportion of routine requests may also suggest that the HHE Program now has the opportunity to conduct more outreach and encourage more requests (for example, those that meet strategic needs or represent new or emerging hazards) that would require site visits (if sufficient funding is available to conduct them). The committee asked the HHE Program to provide information regarding all HHE requests, including types of requestor, hazard and sector involved, and the types of responses. Tables 3-2 and 3-3 were derived by the HHE Program in response (NIOSH, 2007g). The data were drawn from the program’s management tracking system, which was 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 tabulation of hazard class of requests: • Indoor environmental quality (IEQ)—any request that included an IEQ issue, regardless of other issues also present

52 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH • 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 tuberculosis, histoplasmosis, biosolids, or brucellosis issues • All Other—any other request not assigned to the classes above In its response to the committee, the HHE Program recognized the limitation of this methodology. Table 3-2 lists the type of HHE response by source of request, hazard, and percentages of resulting field investigations by requestor type between 1998 and 2007. During this time, approximately half the requests were related to IEQ issues and were largely addressed without field investigations. Among the five sectors with more than 100 requests, the correlation between the percentage of field in- vestigation responses and the percentage of IEQ requests is –0.82. There were very few requests related to biological issues; thus it was appropriate that the greatest proportion of requests resulting in field investigations occurred in this area. Many requests in the physical hazards category are likely related to musculoskeletal haz- ards, which is appropriate given the magnitude of the problem in most industries. The committee wanted to explore trends in requests, both with and without con- sideration of IEQ requests, to determine if those requests potentially skew the data. The HHE Program databases could not provide the data in a manner that would allow more robust analysis. The effect of the changing economy can be seen in Figure 2-3, which indicates a greater than 50 percent decline in the number of requests from the manufacturing sector since the 1990s. One might expect this change to allow the program greater flexibility to respond more efficiently to the increasing number of HHE requests in health services, trade, and transportation and to conduct unexpected emergency response activities. Telephone, fax, and written responses to HHE requests have increased in the past 10 years (NIOSH, 2007b). The percentage of field investiga- tions generated by IEQ and service-sector requests is very low compared with those from manufacturing (see Table 2-2). To facilitate efficiency when responding to requests, HHE Program staff review available reports from other parties who have investigated the issue or site and pro- vide opinions regarding the methods, data interpretation, and appropriateness of conclusions and recommendations. HHE Program staff may then gather additional information from employer and employee representatives during the triage process to determine the request category and HHE Program response. HHE Program staff consult with other NIOSH scientists, review the scientific literature, and prepare written responses summarizing their activities. These steps improve efficiency and provide consistency in HHE outputs.

TABLE 3-2  Frequency of HHE Field Investigations by Source of Request and Hazard Class: Fiscal Years 1998-2007a Source of Request (Requestor) Employee Governmentc Management Union Joint Other Total N Total N Total N Total N Total N Total N Total N Total Hazardb (%)d Ne (%)d Ne (%)d Ne (%)d Ne (%)d Ne (%)d Ne (%)d Ne Biological 1 12 26 30 8 15 2 5 0 0 0 5 37 67 (8) (87) (53) (40) (55) IEQ 62 1,332 17 51 49 223 24 189 4 13 3 118 159 1,926 (5) (33) (22) (13) (31) (3) (8) Physical 35 158 14 21 45 62 18 47 7 7 2 20 121 315 (22) (67) (73) (38) (100) (10) (38) All Other 102 817 89 164 116 260 82 214 16 22 6 147 412 1,624 (13) (54) (45) (39) (73) (4) (25) Total 200 2,319 146 266 218 560 127 455 27 42 11 290 729 3,932 (9) (55) (39) (28) (64) (4) (19) aIncludesall HHE requests with a completed response as of November 28, 2007. bSee text for an explanation of hazard classes. cThis group may include some HHE requests more appropriately classified as management due to a change in coding over time. dPercentage of HHE requests resulting in a field investigation. eNumber of HHE requests. SOURCE: NIOSH (2007g). 53

54 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH The committee notes that the percentage of field investigations tends to vary by requestor type. For example, Table 3-2 indicates there were large numbers of employee requests (n = 2,319), of which 9 percent (n = 200) resulted in field in- vestigations, whereas 39 percent of the far fewer management requests (n = 560) resulted in field investigations. More than 1,300 of the employee requests were for IEQ issues. As described below, NIOSH appears to have used appropriate discretion in providing extensive information on control measures to the vast majority of IEQ requestors in the form of technical assistance and consultations. Table 3-3 addresses the type of HHE response by source and sector. There were very few requests from agriculture and mining. The proportion of requests result- ing in field investigations was less for healthcare and social assistance (13 percent) and services (15 percent) than for most other sectors. While this is likely related to IEQ requests identified in Table 3-2, these sectors may be growing and also reflect a higher proportion of underserved populations, again potentially indicating the need for the program to assist stakeholders in developing meaningful and valid requests. Similarly, industries generating few requests might benefit from HHE Program exploration into the reasons so few requests are made followed by ap- propriately directed outreach activities. As noted in Table 3-1, the committee endorses the HHE Program’s inter- mediate goal of increasing the number of HHE requests concerning important occupational health problems (intermediate goal 1.1). The committee agrees that an increase in valid requests will increase the scope and penetration of the HHE Program into more industries and allow better transfer of information to more workers, including those from underserved populations and those employed by small businesses. During discussions with the committee, HHE Program staff ap- peared aware that with an increase in the number of requests comes the potential for increased constraints on resources. Program Resources and Emergency Response In the last decade, the HHE Program has received a number of requests that involved assessing risks, measuring exposures, and providing guidance to workers and the general public during disasters (NIOSH, 2007b). These assignments often involved the onsite presence of HHE staff working in concert with partners from the Federal Emergency Management Agency (FEMA), the Department of Health and Human Services Department of Emergency Response, the Center for Disease Control and Prevention (CDC) National Center for Environmental Health, the CDC Director’s Emergency Operations Center (DEOC), and several global agencies and manufacturers. Response to domestic disasters, such as Hurricanes Katrina, Floyd, and Isabel, and to massive flooding required mobilization of up to 18 HHE

TABLE 3-3  Frequency of HHE Field Investigations by Source of Request and Sector: Fiscal Years 1998-2007a Source of Request (Requestor) Employee Governmentc Management Union Joint Other Total N Total N Total N Total N Total N Total N Total N Total Sectorb (%)d Ne (%)c Nd (%)e Nd (%)c Nd (%)c Nd (%)c Ne (%)d N Agriculture, Forestry, & Fishing 4 16 6 11 8 13 0 1 0 0 0 5 18 46 (25) (55) (4) (39) Construction 4 28 4 6 19 29 6 12 0 0 0 11 33 86 (14) (67) (66) (50) (38) Healthcare & Social Assistance 21 319 11 26 23 83 7 39 2 5 0 36 65 508 (7) (42) (28) (18) (40) (13) Manufacturing 69 355 17 36 39 76 60 105 16 19 1 62 202 654 (21) (47) (51) (57) (84) (2) (31) Mining 0 3 4 13 2 3 6 16 0 0 0 0 12 35 (31) (67) (38) (34) Services 73 1,146 73 139 98 289 33 185 5 13 10 140 283 1,913 (6) (53) (34) (18) (39) (7) (15) Transportation 18 243 26 29 24 45 15 90 4 5 0 16 87 428 (7) (90) (53) (17) (80) (20) Trade 11 207 5 6 5 22 0 7 0 0 0 19 21 261 (5) (83) (23) (8) Total 200 2,319 146 266 218 560 127 455 27 42 11 289 729 3,931 (9) (55) (39) (28) (64) (4) (19) aIncludesall HHE requests with a completed response as of November 20, 2007. b Sector is based on Standard Industrial Classification codes or North American Industry Classification System codes, depending on the year of the request. cNumber of HHE requests. dPercentage of HHE requests resulting in a field investigation. eThis group may include some HHE requests more appropriately assigned to the management group due to a change in coding over time. SOURCE: NIOSH (2007g). 55

56 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH Program staff responders, smaller numbers of public health professionals for onsite investigations, or long-distance support from HHE Program staff through confer- ence calls (NIOSH, 2008b). HHE Program staff also responded to events such as 9/11 and the subsequent anthrax investigations. Emergency response activities create competing demands on limited resources within the HHE Program. Routine program operations continued during these unplanned activities, but significant coordination and additional outside funding were required to maintain continuity. Requests for assistance during disasters have so significantly impacted the workload of HHE Program staff that the BSC was prompted to recommend major process changes to improve efficiency (NIOSH BSC, 1997). The triage process and a procedures manual developed in response to the evaluation have created flexibility and efficiency to effectively respond to public emergencies while maintaining normal program operations. More discus- sion on HHE Program emergency response activities is found in a later section of this chapter (Finding 9). R  ecommendation: Continue to provide guidance and recommendations during public health emergencies. The HHE Program would benefit from the development of a mechanism to reduce the impact of emer- gency response activities on routine program functions. Expertise With the exception of pulmonologists on staff in the Field Studies Branch (FSB), the HHE Program, out of necessity, is staffed primarily by generalists (NIOSH, 2007b) and must rely on resources beyond the HHE Program for spe- cialized expertise. HHE Program staff informed the committee how necessary expertise is identified during the triage process and indicated that many areas of expertise are readily available through existing, relatively informal arrangements within and external to NIOSH. It was not made clear how certain areas of expertise, such as dermatology or clinical toxicology, are accessed, or how HHE staff acquire information in such areas as health services or intervention effectiveness research. Nor was it made clear whether there was explicit understanding of the economic environment of a worksite—important for assessing the economic feasibility of recommended control solutions. The HHE Program’s ability to utilize expertise  The BSC recommended that the HHE Program include estimates of costs and savings associated with implementing HHE recommendations (NIOSH BSC, 2006). The committee agrees that feasibil- ity is an important consideration when making recommendations. The expertise needed to provide cost estimates, however, does not reside within the program, and providing such estimates could delay dissemination of results and potentially detract from the HHE Program mission.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 57 from other parts of NIOSH could be enhanced by a formal mechanism to contract externally for needed clinical, toxicologic, or other specific expertise, especially as resources become limited and experienced individuals retire. Formalized relation- ships for cooperation may be helpful, but should be negotiated carefully to ensure continued flexibility when people, expertise, or analytical services beyond the terms negotiated are needed. A program that addresses the wide array of issues that the HHE Program does, including during emergency situations, would not be successful without residing in and having access to the expertise in NIOSH. A review of the authorship of HHE reports and subsequent peer-reviewed journal articles indicates that the HHE Pro- gram uses expertise from elsewhere in NIOSH for a wide variety of occupational health issues, and that successful collaborations have resulted in peer-reviewed publications. However, as in many other agencies, programs, and institutes that employ public health professionals, many NIOSH senior professionals are ap- proaching retirement. The HHE Program and NIOSH could prepare for this shift through succession planning, contemplated reassignments, and identification of key resources needed in the near future (see the committee’s discussion of the training of new professionals in Chapter 4). F  inding 3: The HHE Program has not made sufficient use of available surveillance data to assist in targeting field investigations to recognize previously unknown hazards or to identify new or increased hazards caused by changes in the workforce and work environment. The committee was informed that the HHE Program uses traditional methods, such as results from investigations, literature reviews, case files, or other internal documents, and contacts within the scientific community to identify emerging, previously unknown, or increased hazards in the workplace. There is no indication that surveillance or workers’ compensation data are used to formulate the HHE Program’s strategic plan, or that intervention effectiveness data are examined prior to making recommendations. The program’s strategic plan may have been influenced by surveillance data, given the extent to which NORA and the overarching NIOSH strategic goals may be influenced by surveillance data. There is also little evidence that the HHE Program conducts environmental scans and routinely monitors various state and federal databases (for example, OSHA’s Integrated Management Information System database [IMIS] or Bureau of Labor Statistics [BLS] databases), reports, or websites on which surveillance information may be available to identify potential emerging hazards (see Box 3-1). An envi- ronmental scan is more than a review of injury and illness statistics. It takes into account societal and economic changes and pressures, demographic changes, and

58 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH BOX 3-1 Surveillance and the HHE Program A strong national occupational health surveillance system could be of benefit to the HHE Program, which itself is not a surveillance program. Greater HHE Program relevance and national impact may be achieved if HHE Program findings were incorporated into a national surveillance system in which active searching and reporting of trends and clusters are possible. The HHE Program could influence NIOSH management regarding the impor- tance of a national surveillance system, perhaps implemented in the Surveillance Branch of the Division of Respiratory Disease Studies (DRDS). The NIOSH Sentinel Event Notification System for Occupational Risk (SENSOR) program might be used to feed data to the system. A good example of an existing system is the reporting of asthma by providers to the Mas- sachusetts Occupational Health Surveillance Program (Massachusetts Office of Health and Human Services, 2008). Access to comprehensive surveillance data could allow the HHE Program to more effectively prioritize HHE requests, make more informed triage decisions, and identify emerging workplace health hazards. the ways industry uses new technology and the workforce, as well as how govern- ment action and international trade may affect hazardous exposure in an industry. Perhaps HHE Program physicians routinely participate in occupational health professional meetings or electronic dialogues from which they receive informal information regarding trends observed in occupational medicine clinics and in field investigations. They may then suggest HHE requests as a means to a solution. The extent to which such informal channels are used is not known. The committee was not provided evidence that the HHE Program conducts detailed explorations of workers’ compensation or other data to gain insight into the magnitude and severity of an issue or to reveal circumstances that could con- tribute to specific hazards. For example, a significant increase in proportionate mortality from respiratory disease among cooks was identified in the Washington State Department of Health Occupational Mortality Database (Washington State Department of Health, 2008). Such systems may be useful to identify industries or workplaces in need of investigation or to identify those who need information regarding the control of hazards. Additionally, outreach to workers’ compensation carriers and loss control consultants may generate new requests for HHEs from clients for which hazards are identified. HHE Program staff members are engaged in professional meetings and na- tional conferences but more could be done to reach a greater diversity of employers and industries. The HHE Program could use such opportunities to play a more active role in identifying potential hazards in emerging industries or processes. For

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 59 example, a formal program of seminars, discussion groups, or other mechanistic science routes might enable the HHE Program to link hazardous substances to various industrial uses and to identify groups of exposed workers with adverse health effects, more than would routine monitoring of national and international databases. Furthermore, the HHE Program could keep track of chemicals used in the workplace and the potential for hazardous exposure through other sources. Spencer and Schaumburg (2000), for example, list a large number of neurotoxic materials. The HHE Program could then actively inform companies, worker ad- vocates, and healthcare professionals who may be aware of exposures or apparent health effects in specific populations about the program and request process to encourage evaluation of these exposure situations. R  ecommendation:  The HHE Program should make systematic use of professional meetings, scientific conferences, scientific literature, and surveillance data, including those generated by NIOSH, to assist in pri- oritizing field investigations and recognizing emerging issues. F  inding 4:  The extent and effectiveness of relationships between the HHE Program and federal and state agencies are variable. The committee observed both positive and inadequate interactions of the HHE Program with state and federal agencies. Through formal and informal reporting relationships with state departments of health, labor, unemployment, environment, and workers’ compensation pro- grams, the HHE Program may help identify worker clusters that could benefit from the conduct of HHEs. Trends analyses in unemployment and industry-sector shifts, including identification of pockets of underserved contingent workers, might enhance the HHE Program’s ability to reach high-risk populations. Maximizing HHE Program potential in this area, however, depends on the ability of the pro- gram to maintain appropriate staffing levels. These relationships may also allow the program to better communicate its mission and activities and to provide better and timelier feedback. Three examples demonstrate ways to maximize federal and state resources and to enhance the HHE Program’s ability to perform its mission. During the committee’s third meeting (see Appendix C for agenda), a stakeholder from the California Department of Public Health spoke with the committee regarding the long-standing and strong relationship between California’s Occupational Health  Such databases include those of the Environmental Protection Agency, OSHA, the National Cen- ter for Environmental Health, the International Agency for Research on Cancer, and the Health and Safety Executive in Great Britain.

60 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH Branch (OHB) and the HHE Program (Materna, 2008). The relationship has re- sulted in capacity building at OHB in a number of issues, including most recently, those associated with diacetyl (see Box 3-2 for a discussion of diacetyl). During the same meeting, management of a worksite at which an HHE was conducted (NIOSH, 2007i) discussed how useful HHE recommendations had been in the eventual elimination of diacetyl in their processes. In this case, three organizations worked cooperatively to maximize resources and the result was a positive impact. BOX 3-2 Bronchiolitis Obliterans (Popcorn Lung) and Diacetyl In 1985, the HHE Program conducted an investigation in an Indiana food processing plant where two employees were diagnosed with bronchiolitis obliterans, a severe and sometimes fatal lung disease (NIOSH, 1986). Investigators failed to determine the causative agent and recom- mended general industrial hygiene controls. In 1999 and 2000, several current and former workers from a Missouri microwave popcorn plant were diagnosed with bronchiolitis obliterans, and some of these workers were awaiting lung transplants. Bronchiolitis obliterans is rare in the general population, so the workers’ physician notified the state health department, which inspected the facility in March of 2000 for risks to public—but not worker—health (Michaels et al., 2008). In May 2000, the health department contacted the Occupational Safety and Health Admin- istration (OSHA) in Kansas City, described an alleged cluster of bronchiolitis obliterans, and requested an inspection for compliance with regulations. The request was made of OSHA because it was felt that OSHA could “address this situation, and if there is an obvious hazard to workers, address it quickly” (Roberts, 2000). The health department did not have the statutory authority to inspect the facility without a clear determination of a health hazard. An OSHA inspector visited the plant and focused the inspection on well-recognized respiratory hazards: dust and oil mist. The inspector declined to sample for dust because the company’s insurance carrier had done so earlier. Oil mist samples were collected, but OSHA lab methodologies were incompatible for use with vegetable oils. Although OSHA was aware of the bronchiolitis obliterans cases, the OSHA area office determined the company to be in compliance and closed the file (OSHA, 2000). In August 2000, the Missouri health department contacted NIOSH. Over the next several months, the HHE Program conducted comprehensive industrial hygiene sampling and a health assessment of current employees. The investigation found that rates of adverse respiratory symptoms were significantly higher than in the general population and that the likely cause was the artificial butter flavoring diacetyl (NIOSH, 2006b). In December 2000, NIOSH issued interim recommendations to help prevent exposure to harmful flavorings (NIOSH, 2000). Over the next three years the HHE Program revisited the plant every four to six months to conduct follow-up air sampling and medical testing and to evaluate the effectiveness of the controls it recommended (NIOSH, 2006b). Following its initial investigation at the Missouri plant, the HHE Program also conducted evaluations in other locations (Kanwal et al., 2006), issued an alert that provides guid- ance to the industry and its workers (NIOSH, 2003e), and generally worked to better understand

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 61 Though there are many successes, as described above, stakeholders from both local and state public health departments told the committee of the need for more information about the HHE Program. The commissioner of health of a major East Coast city health department told the committee he knew nothing about the HHE Program or of the multiple HHEs conducted in his city over the years (Sharfstein, 2007). A Massachusetts Occupational Health Surveillance Program industrial hygienist indicated her personal hesitancy in filing HHE requests for and communicate the risk to workers who produce or apply flavorings, their employers, and the occupational health community. Diacetyl has generated widespread media attention, perhaps because it is a food additive with exposures possible not only among workers who manufacture flavorings, but also among consumers. The Food and Drug Administration (FDA) was alerted in 2007 that a consumer was diagnosed with severe lung disease, whose clinical findings and exposure levels were noted to be similar to workers diagnosed with bronchiolitis obliterans (Rose, 2007). An investigative reporter looked beyond flavor manufacturing for possible harmful worker exposure downstream among professional cooks (see, e.g., Schneider, 2008). HHEs are pending on diacetyl exposure among professional cooks, but none have been conducted to date. The King County, Washington, Health Department has requested fact sheets for cooks that their restaurant inspectors can distribute during restaurant inspections (Washington State Department of Labor & Industries, 2008a). In a report from the U.S. House of Representatives Committee on Appropriations dated July 2007, concern was expressed about the potential hazards to workers and consumers exposed to diacetyl. NIOSH data were cited as compelling evidence of a real threat (U.S. Congress, House of Representatives, Committee on Appropriations, 2007:98). According to that report, the FDA should conduct further studies to examine the safety of diacetyl. In response to public concern and pressure from organized labor, OSHA announced in September 2007 that it would initi- ate rule-making (Steenhuysen, 2007). In that same month, the U.S. House of Representatives passed a bill entitled the Popcorn Workers Lung Disease Prevention Act, directing OSHA to issue a standard regulating worker exposure to diacetyl (U.S. Congress, House of Representatives, House Education and Labor, 2007), which is currently on the Senate calendar. At the state level, legislation was introduced in California to ban the use of diacetyl in the workplace, but the bill has been put into an inactive file of the California Senate (California Assembly, 2007). As of January 2008, four major popcorn manufacturers had voluntarily decided to remove diacetyl from their products (Associated Press, 2007; Schneider, 2007). The example of diacetyl and bronchiolitis obliterans illustrates the HHE Program’s unique ability to conduct epidemiological investigations and identify previously unknown hazards. OSHA and other agencies do not have this same authority or capacity. The program’s findings and recommendations have had an immediate effect on the worksites investigated, have instigated research in other parts of NIOSH, have influenced voluntarily changes within industry to remove the hazards, and have had at least some influence on policy setting and rule-making.

62 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH other asthma-related issues “because, in some cases HHE requests have resulted in long, drawn out processes, in which the referring state agency may not be apprised of the process, local expertise is not used, the report is not issued for a long time, and the end results may not address the most compelling questions in a timely way” (Pechter, 2008). These comments suggest the need for both outreach and ongoing communication. Better CDC acknowledgement of the depth and breadth of the occupational health expertise available to state health departments through the HHE Program may result in greater cooperation between the HHE Program and states in identi- fying emerging occupational health issues. For example, the recent identification of a new form of progressive inflammatory neuropathy among workers process- ing pig brains (MMWR, 2008) might have benefitted from earlier attention to the work-relatedness of the initial complaints. A number of prior CDC investiga- tions, including the initial evaluation of a case of pulmonary anthrax in Florida (MMWR, 2001a), suggest a pattern of delay in including appropriate occupational health expertise in investigations. The HHE Program could more broadly influence workplace health assessments conducted by other CDC institutes by working more closely with CDC overall. Additionally, public recognition of the HHE Program may be diminished as the 1-800-66-NIOSH telephone number formerly used for contacting NIOSH about occupational safety and health issues is subsumed under the general CDC call line. NIOSH could maintain visibility with other agencies and the public if it were able to reinstate that telephone number. R  ecommendation: Enhance HHE Program outreach to OSHA national and regional offices and to state health and labor departments to better communicate the function and activities of the HHE Program, increase cooperation with these agencies, and provide more complete and timely feedback. RELEVANCE OF ACTIVITIES F  inding 5: The HHE Program has responded well to HHE requests as mandated, although mechanisms for eliciting a broader array of HHE requests are needed. There is strong evidence the HHE Program has conducted relevant field investigations and has performed well in identifying emerging hazards, serious  HHE Program staff indicated that currently available communication pathways within the CDC (such as Epi-X) may lack timeliness or completeness (NIOSH, 2007c, 2008b).

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 63 occupational health problems, and hazards affecting large numbers of workers. Examples of such cases include (1) bronchiolitis obliterans (popcorn lung) asso- ciated with diacetyl in the manufacture of flavorings, (2) interstitial pneumonitis and flock exposures, (3) work-related musculoskeletal disorders associated with cumulative trauma, and (4) biological and chemical hazards in the meat and poultry industries. These examples are described more fully in Boxes 3-2, 3-3, 3-4, and 3-5, respectively. All four examples included multiple field investigations and successful transfer of knowledge to the occupational health community by the HHE Program. BOX 3-3 Interstitial Pneumonitis (Flock Worker’s Lung) and Flock Flock refers to fine, small-diameter synthetic fibers such as those applied to adhesive- coated fabrics to produce a pleasing surface similar to velvet. Breathing flock can cause a serious lung disease called interstitial pneumonitis, which causes inflammation and scarring in the lungs. Flock-related illness was first seen in 1991 at a nylon flock processing plant in Ontario, although the causative agent was not identified. Investigators initially speculated that the condition was caused by mold-contaminated adhesive, which was replaced. However, in 1995 the plant reported two additional cases. In 1995 and 1996, two workers from a Rhode Island plant owned by the same company were diagnosed with interstitial lung disease by the same physician (Lougheed et al., 1995; Eschenbacher et al., 1999). At the physician’s urging, the company asked NIOSH to conduct an HHE. The investigation included industrial hygiene surveys of a variety of potential exposures, respiratory tests, and a medical questionnaire. NIOSH identified flock dust as the causative agent and recommended “decisive, proactive action to install effective engineering controls, to enforce good work practices, to assure appropriate use of proper respiratory protection, to establish a medical screening/surveillance program, and to implement effective admin- istrative controls” (NIOSH, 1996a:33). Flock has since been implicated in other outbreaks of occupational lung disease and has been the subject of a workshop and recommendations by NIOSH. HHEs have been per- formed in several other flock processing plants. However, flock never generated the press attention that diacetyl has, perhaps because it is not a food additive and not a hazard to consumers. Flock has never been considered for rule-making by OSHA; the only mention of flock on OSHA’s website refers to the explosion hazard related to flock dust (OSHA, 1998). One recent follow-up report indicates that while some industrial hygiene controls have been implemented, flock exposures remain high (NIOSH, 2006a).

64 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH BOX 3-4 Work-Related Musculoskeletal Disorders Work-related musculoskeletal disorders (WMSDs) are disorders of the muscles, ten- dons, joints, and associated neurovascular structures that occur over time rather than in response to an acute traumatic event. Examples include rotator cuff syndrome at the shoulder, lateral epicondylitis at the elbow (tennis elbow), carpal tunnel syndrome at the wrist, sciatica, and back pain. While these disorders can be unrelated to work activities, their work-relatedness is associated with repetitive work, awkward postures, and overexer- tion in lifting, pushing, pulling, or carrying, as well as hand-arm vibration. The likelihood of WMSDs increases with the intensity, duration, or frequency of exposure to these risk factors or when multiple risk factors occur simultaneously. These disorders represent 30 to 40 percent of all reported occupational injuries and illnesses, lost work days, and workers’ compensation costs. In an example from Washington State, a 26-year-old female nursing assistant employed in an adult family home for seven years developed back problems lifting and transferring residents. She missed 180 days of work and required $5,200 of medical treatment (Silverstein and Adams, 2007). The HHE Program has played a pivotal role in the area of WMSDs, demonstrating very high relevance for their HHE findings related to hazard identification and abatement. Eighty- two WMSD-related HHEs were conducted between 1980 and 2007 (19 of them between 2000 and 2007). Early HHEs in food processing and other manufacturing brought public, research, and regulatory attention to the area. Experiences gained in the HHE Program resulted in a se- ries of peer-reviewed and practice-oriented publications, including a comprehensive review of the literature on WMSDs (NIOSH, 1997b). The comprehensive review was referenced in the European Union (Buckle and Devereau, 1999), was used extensively in the development of regulations at the national level, and was used to justify the making of ergonomic rules in at least one statea (Washington State Department of Labor & Industries, 2000). Many of these HHEs were also used in various rule-making efforts for both evidence of hazards and viable solutions (Washington State Department of Labor & Industries, 2008b), demonstrat- ing a high degree of regulatory relevance. A later, congressionally requested review by the National Academies substantiated the earlier HHE Program work (NRC and IOM, 2001). Other documents based on HHE Program outputs include several manuals to assist employers and employees in the development of effective ergonomics programs, including those intended for underserved populations such as farm workers (NIOSH, 1997a, 2001e, 2007j). These documents have been widely circulated within the health and safety practitioner community, as well as to small and large employer and worker organizations at professional conferences. A number of these ergonomics publications have been adapted and distributed by the HHE Program. aWashington State adopted an ergonomics rule in May 2000 (WAC 296-62-05101) (http://www.lni.wa.gov/WISHA/Rules/GeneralOccupationalHealth/PDFs/ErgoRulewithAppen- dices.pdf, accessed August 9, 2008).

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 65 BOX 3-5 Biological and Chemical Hazards in the Meat and Poultry Industries The HHE Program has identified and addressed several emerging hazards and continues to play a major role in investigating risks in the expanding meat and poultry processing industry, an industry increasingly comprised of a non-union, minority, immigrant, and contingent workforce characterized by low wages and high risk (GAO, 2005b). The HHE Program, working with the State of North Carolina and the U.S. Department of Agriculture (USDA), identified the occupational transmission of brucellosis to workers in swine process- ing facilities (NIOSH, 2007b). Brucellosis is an infectious bacterial disease that can cause “a range of symptoms that are similar to the flu and may include fever, sweats, headaches, back pains, and physical weakness. Severe infections of the central nervous systems or lining of the heart may occur. Brucellosis can also cause long-lasting or chronic symptoms that include recurrent fevers, joint pain, and fatigue” (NIOSH, 2007b:57). An HHE investigation (NIOSH, 1994) provided the information needed for the USDA to develop and implement a formal rule change that provides compensation for swine herds destroyed because of infection, effectively eliminating the hazard by removing disease-carrying animals from the food chain. This outcome reflects an extraordinary level of cooperation among both federal and state agencies. In another case, the HHE Program conducted initial and full follow-up investigations of a management-initiated request to evaluate respiratory complaints in a poultry processing area in which hyperchlorinated water was used in the evisceration process (NIOSH, 2003a, 2006g). The report related to an initial HHE investigation demonstrating excess levels of chlorine and trichloramines generated by this process and the subsequent reduction of exposure following elimination of hyperchlorinated water. The final report clearly documents the impact of an aggressive workplace management approach that went beyond the initial HHE Program recommendations and effectively reduced the hazard and improved outcomes in that plant. During the initial investigation, NIOSH engineers encouraged plant manage- ment and engineers to take the issue seriously. However, there is no indication that these recommendations have been applied more broadly in the poultry processing industry. Reported more recently in the news is an outbreak of progressive inflammatory neu- ropathy among swine slaughterhouse workers (CNN.com/health, 2008; MMWR, 2008). The CDC was called to investigate this as a potential contagious disease. The inclusion of the HHE Program in the investigation has facilitated the broader evaluation of the condition as an occupational illness and further demonstrates the relevance of the HHE Program. “Casting a Larger Net” Based on information submitted to the committee, it is not possible to deter- mine whether the needs of underserved populations and small businesses are be- ing met or whether the lack of anonymity or the fear of legal or political reprisals

66 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH inhibits the request for HHEs. Targeted outreach to state health, labor, and envi- ronmental departments; small business and their employees; labor unions; health centers providing care to underserved populations; community and ethnic organi- zations; and nongovernmental worker centers serving immigrant and contingent workers would increase the likelihood of meeting the needs of these populations. It is especially important to produce educational materials in multiple languages appropriate to these diverse populations. HHE Program outreach would benefit from provisions for assisting requestors, particularly those who are not unionized or who belong to underserved populations, in formulating valid requests. Communication with non-unionized and underserved populations could be enhanced through collaboration with emerging worker centers that address the needs of new immigrant workers; public service announcements geared toward truck drivers and agricultural and construction workers on radio stations and website links (for example, trucker websites); or targeted outreach to health centers providing care to underserved populations. The BSC recommendation to “cast a larger net” to enable the program to “select only the evaluations that truly serve program goals” (NIOSH BSC, 2006:5) deserves attention here: while many attempts have been described to increase the overall number of HHE requests, there has been no systematic effort to ascertain either the relative success of these efforts or the reasons for any failures. Specific approaches to identify and encourage new sources of appropriate and valid requests do not appear to have been evaluated. It would be useful if outreach programs could be evaluated for effectiveness. Ongoing systematic scanning of surveillance data could assist the HHE Pro- gram in identifying emerging hazards in underserved populations. While there are no specific plans to identify and control hazards that specifically affect underserved populations, it is possible to focus resources in industries and workplaces that employ a significant proportion of underserved workers. R  ecommendation:  Establish formal relationships with organizations representing underserved populations, small businesses, and their employees. R  ecommendation: 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.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 67 The Health Hazard Evaluation Program Triage Process F  inding 6: The HHE triage process is generally efficient but requires more structure. Formalization of the Triage and Response Processes Program evaluations by the Research Triangle Institute (RTI) and the BSC emphasized the need for the HHE Program to conserve scarce resources when addressing its core mission (RTI, 1997; NIOSH BSC, 2006). In response to BSC recommendations, the HHE Program introduced the triage system described in Chapter 2 (NIOSH BSC, 1997). The HHE Program developed structured triage mechanisms that allow the delivery of standard information packages to request- ors when full investigations were not warranted (for example, requests triaged as Category 1 or 2; see Box 2-2). Many IEQ-related requests may fall under this category. The criteria applied during triage, apart from the straightforward assessment of request validity as determined by regulation, do not explicitly outline when field investigations are necessary, nor do they assist in distinguishing those requests that require complex investigations or that may yield future research opportunities. Classification appears to be handled informally. Initial determinations are not always final; project officers can change the category of response to a request after additional information is obtained. A clear understanding of an HHE request and the implications of a potential response should be explicit in any triage decision. For example, a letter response to a requestor reviewed by the committee documented an attempt by HHE Program staff to provide thoughtful review and useful reference information, but included conclusions based on limited information when resources may have been available elsewhere to address the concerns in greater depth. The report involved a request from management of a multinational petroleum company to explore a possible cluster of esophageal cancer (NIOSH, 2005e). The HHE Program was asked “to evaluate the strengths, weaknesses, and validity of [a prior industry-conducted study at the worksite] and to give suggestions or recommendations for further investigation.” A thorough in-house response to this request would have consumed excessive HHE Program resources. The HHE letter report provided a general ex- planation about the limitations of cancer cluster investigations and recommended no further investigation of the suspected cancer cluster. Conveying this type of information effectively via telephone and written con- tact poses a difficult risk communication challenge, but this communication means may be useful when scarce HHE resources are unlikely to provide useful new information for workers. It could be perceived, however, that the HHE Program

68 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH was used to validate the company’s research without sufficient critical perspective being brought to bear. If neutral third-party expertise is required, large entities with adequate resources could be encouraged to develop tripartite oversight (by NIOSH, labor, and industry) of external experts and formally sponsor a thorough review. If the information is potentially of major interest, this could be triaged to other areas of NIOSH. It is unclear how many letter reports generated by the HHE Program would raise similar issues. The decision against using scarce resources to conduct full site investigations (for Category 3 or 4 requests) should not be used to provide ap- proval or premature conclusions. A description of the needed resources—includ- ing, when appropriate, independent extramural research expertise—and alternative approaches to addressing the issue would also be useful. The HHE Program would benefit from a formal mechanism to respond by recommending tripartite stud- ies, funded by the requesting entity when appropriate. General guidelines should exist for referral to higher-level review, particularly for requests involving large companies with multiple resources or requests that would result in the provision of recommendations for which HHE staff may not be sufficiently expert or have the appropriate certifications. When sufficient information about the hazard or issue is readily available, requestors might be referred to the Occupational Safety and Health Administration (OSHA) Small Business Consultation Program or ap- propriate OSHA directorate (for example, the Directorate of Cooperative and State Programs or the Directorate of Science Technology and Medicine). Identification of Needed Expertise A review of several HHE letter reports by the committee indicates that the triage process may not be effective in determining whether staff expertise is suit- able for the range of potential program responses to a request. The triage program would ideally involve epidemiologists, toxicologists, engineers, and other relevant specialists, as well as HHE Program staff, to ensure that qualified personnel are handling responses. For example, the committee reviewed a close-out memo from an HHE Program file regarding a state health department request for assistance related to possible worksite metals contamination (NIOSH, 2007a). The memo documented a medical review by HHE Program staff and the provision of diag- nostic information by telephone, although the recipient of the information was the public health official who requested the assistance, not a clinician responsible for the individual with the health concerns. HHE Program personnel, of necessity, are generalists. Slightly more than half of HHE personnel have basic certification, such as certified industrial hygienist or medical board certification in a primary specialty, but none have additional toxicological certification (NIOSH, 2007b). Further, the

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 69 provision of clinical advice requires a therapeutic relationship with a patient. The memo does not state whether the HHE Program provided the individual’s treating physician with contact information for an appropriately qualified medical toxicolo- gist for a clinical consultation. Inclusion of specialists in the triage process would also help identify requests where exposure responses are potentially unusual or not readily explicable on the basis of current knowledge, potentially leading to a higher categorization of the HHE request. Transparency of the Process The committee reviewed input from numerous program stakeholders. In gen- eral, HHE Program guidance and recommendations were considered well reasoned and sound, but some comments from stakeholders raised issues related to the triage process. Multiple stakeholders did not understand why their HHE requests failed to result in investigations. The committee does not have enough information to determine whether this concern is widespread, but it did determine that greater transparency in the triage process would, at the very least, help the program deter- mine whether the confusion is avoidable. Responding to HHE requests with a sys- tematic approach of defining the request, identifying the implications of potential responses, and identifying justifiable resources and necessary expertise based on the triage criteria would provide the means for the program to better communicate the outcomes of the triage process to requestors. A more transparent triage process could potentially help requestors understand why their requests may be considered invalid and help them form valid requests in the future. R  ecommendation:  Implement, as part of the triage process, a formal technical assistance mechanism to help requestors to formulate valid HHE requests. In cases where an HHE is not appropriate or where re- source limitations prohibit an investigation, technical assistance should include referral to more appropriate NIOSH divisions or government agencies. R  ecommendation:  Develop an explicit, written process for classifying and prioritizing HHE requests. Priority should be based on the gravity  The American Board of Medical Specialties defines medical toxicology as specialization in the “prevention, evaluation, treatment and monitoring of injury and illness from exposures to drugs and chemicals, as well as biological and radiological agents” (http://www.abms.org/Who_We_Help/ Consumers/About_Physician_Specialties/preventive.aspx, accessed September 18, 2008). Three years of specialized training is required to receive a certificate in the subspecialty of preventive medicine.

70 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH 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 possibility 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. R  ecommendation:  Better formalize the triage process, including the iden- tification of needed expertise, and improve the transparency of the process to HHE requestors, while maintaining flexibility and speed. RELEVANCE OF OUTPUTS F  inding 7:  HHE reports are generally well written, present relevant in- formation supported by appropriate documentation, and reflect a high level of expertise. However, the committee did not find evidence that a well-defined quality assurance process is in place to ensure consistently high-quality outputs and recommendations. Review of Numbered Reports The HHE Program provided the committee with several examples of num- bered HHE reports as well as less formal letter responses to HHE requests on a variety of occupational health-related issues. The committee also reviewed several other numbered HHE reports obtained directly from the HHE Program website. The majority of listed authors of numbered HHE reports reviewed held advanced degrees and certifications, which enhances credibility and professionalism. The report formats were uniform and straightforward, with specific recommendations provided in clear language at the outset, followed by a plain-language summary, then the body of the report. All HHE field investigation reports were dated, and nearly all include both the date of the initial request and the source of the request (for example, management, employees, union). Report timeliness, a major concern expressed in all previous HHE Program evaluations, continues to vary, with the most rapidly delivered reports delivered four to six months from the request date and the majority appearing within a year of the field investigation. One outlier, the final report for an incident that recog- nized the association between flavorings and lung disease (NIOSH, 2006b), ap- peared 5½ years after the initial request and 2½ years after the final follow-up visit.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 71 Reasons for the delay were not apparent to the committee. Timeliness, however, was an issue only for the final numbered report. This particular investigation was highly relevant and productive. The hazard was identified and reported to workers and management in a series of timely letter reports. The investigation resulted in new research activities, peer-reviewed publications, and policy efforts. The final report included all results in tabular form and an exhaustive set of appendixes that captured relevant correspondence and other materials, comprising nearly 200 pages of clear information. Many other reports delivered more quickly also contained clear information, tables of exposure and outcome data, and relevant references. Public accessibility to more complete data is extremely important for program relevance and impact. It would be useful to determine whether the traditional HHE numbered report is the appropriate venue to provide this access, given the time taken to produce some of these reports, or whether more rapid access to ap- propriately vetted data and reports might provide a more effective and efficient alternative. Providing comprehensive, accessible data is now a requirement for large-scale National Institutes of Health-sponsored extramural research, and the online provision of questionnaires, methods descriptions, and workplace diagrams allows accessibility of a more complete data set than that available through peer- reviewed published sources. Peer-reviewed publication, however, is also a criti- cally important feature of all scientific discovery including HHEs, and the HHE Program has been successful in producing such outcomes as a result of some of its investigations. The HHE Program could potentially increase the relevance (and impact) of its activities by determining whether data and information collected, or recommendations made, during the course of an HHE should be publicly released prior to the publication of its numbered reports. The numbered and letter reports in the committee’s sample demonstrate the depth of expertise available to the HHE Program. Expertise from other parts of NIOSH was included in the investigation of hazards such as noise and electro- magnetic field exposures. A high level of interagency cooperation and interaction with a variety of stakeholders in developing outreach materials was displayed, and these interactions were often relevant for policy development within NIOSH and beyond. The quality and depth of interaction between HHE Program staff and stakeholders is evident in major examples described in Boxes 3-2 through 3-5, as well as for information developed by the HHE Program concerning latex exposure (NIOSH, 1997c, 1998d), publications related to carbon monoxide as a prevalent and lethal hazard in outdoor settings (NIOSH, 1996b; U.S. Coast Guard, 2001, 2008; U.S. National Park Service, 2005); and the enhancement of understanding of indoor air quality issues (EPA and NIOSH, 1998; Mendell et al., 2002; Kreiss, 2005), among other topics.

72 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH Review of Letter Reports The HHE Program provided the committee with 10 letter reports written in response to full site visit investigations, and 5 examples of letter and fax responses provided when site visits were considered unwarranted. The letters included names and contact information of the program personnel responsible for generating the report, and telephone contact was freely offered. Two of the letter responses were apparently written using a template, indicating efficient use of resources. Each was appropriately adapted to the specific concerns of the complainant and included useful references to bolster the generalized response. All the letter reports could benefit from a short list of recommendations in priority order, similar to those in numbered reports, so that clear and immedi- ate information may be provided. Apart from this distinction, the letter reports reviewed were generally of as high a quality as the numbered reports and often included appropriate references and extensive reports of findings in tables and ap- pendixes. The examples provided reflect a response to customer service needs for direct contact and timeliness. Seven of the 10 site visit letter responses indicated the date of the request. The time from request to final response ranged from 1 to 11 months, including four letters issued 5 or more months after the request. One letter report appeared extremely helpful because it included contact infor- mation for local and state personnel who could address specific requestor concerns. In another report, a nonspecific recommendation for medical evaluation for per- sonnel with indoor air quality complaints (NIOSH, 2007a) would have been more helpful if accompanied by a link to professional resources such as the Association of Occupational and Environmental Clinics. The letter reports related to IEQ is- sues (NIOSH, 2007d, for example) described but did not provide reference to an Institute of Medicine (IOM) report. A website link to the IOM report could have been provided. Stakeholder Satisfaction and the Followback Program To determine the level of satisfaction with HHE field investigations and reports, the committee reviewed the responses to followback questionnaires (NIOSH, 2007b, e). The HHE process and reports were generally highly valued and useful, and some recommendations were being implemented. Timeliness of reporting still needed improvement, and stakeholders sometimes raised concerns regarding the feasibility or technical accuracy of HHE recommendations. Some stakeholders said they did not understand why their HHE requests were not deemed appro­priate for field investigations. A high percentage of followback questionnaire respon- dents indicated that HHE Program staff members were very professional and

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 73 k ­ nowledgeable and that the HHEs were conducted in a professional manner. Nearly all stakeholders who provided information to this committee were impressed with the level and breadth of expertise demonstrated by HHE staff. Based on reports reviewed by this committee, HHE Program staff members are well aware of the literature regarding different hazards or potential hazards associated with the r ­ equests they are receiving. Improvements could be made to avoid selection bias in followback program results by identifying similar facilities for which HHEs were not requested and by comparing health hazards before and after investigations. Follow-up health ques- tionnaires, examinations, or exposure monitoring could show significant improve- ment. These exercises, however, require resources the HHE Program may not have. Nonetheless, the committee believes the followback program is an important tool for program process improvement and could be made more valuable with input from program evaluation expertise. Current strategic goals include performance measures that would expand the current followback questionnaire feedback loop to address program impact and improve customer satisfaction. Continued efforts to improve the timeliness of reports, improve written and telephone communication, and enhance dissemination efforts were listed by the HHE Program as measurable objectives to improve customer response (see Table 3-1). No information was re- layed regarding the resources required to accomplish the objectives. Quality of Recommendations The committee assessed the quality of recommendations contained in HHE reports, and many were excellent. As one example, in response to an employee- generated request for an HHE, the HHE Program conducted an evaluation of a government-owned, contractor-operated hazardous waste “tank farm.” A great deal of negotiation with workplace management was required to conduct this investigation, but the result was a rapidly produced, thoughtful, and thoroughly referenced report that provided an overarching recommendation embedded with very specific recommendations (NIOSH, 2004b). This approach created a frame- work for managing specific problems across a complex worksite with multiple layers of responsibility. It provided a model that synthesized both the problems and the approaches to solving them. The committee found several reports and recommendations that do not exhibit the same level of quality. For example, in one reviewed report that was focused on musculoskeletal issues and recommendations, a variety of other potential safety hazards were identified, such as inadequately plumbed eyewashes and slippery surfaces. Only superficial recommendations to control these hazards were provided and did not include references for more detailed information (NIOSH, 2005a).

74 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH Another report, issued 18 months after the initial request, clearly described serious outdoor carbon monoxide exposures, but offered only generic recommendations for remediation despite the evidence of ongoing work by other scientists in NIOSH to develop engineering controls (NIOSH, 2004c). The quality and utility of the HHE Program recommendations have been targeted for improvement during previous program reviews (NIOSH BSC, 1997, 2006; RTI, 1997). A systematic response on the part of the HHE Program to en- hance the quality of recommendations does not appear to have been made. The mixed quality of the recommendations in the reports and letters reviewed by this committee suggests that quality control measures could be upgraded. At present, technical and policy review is conducted at the branch level within NIOSH: only rarely, and at the discretion of the branch chief, is other scientific quality review obtained. Given the understandable tension between timeliness and the inevitable delays that additional layers of review would entail, the committee recommends a sampling strategy of recent reports for review for scientific content and especially for accuracy of recommendations. The strategy would be used primarily as a qual- ity improvement or training mechanism. Such reviews could be obtained from scientists elsewhere in NIOSH, from extramural scientists, from practitioners in labor and industry, and perhaps from OSHA or the Mine Safety and Health Ad- ministration (MSHA). Toxicologists, epidemiologists, engineers, and others from academic research institutions or from prioritized industry sectors might review reports both for quality and to identify emerging issues. R  ecommendation: 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. b. Priority-setting among recommendations in all reports to indicate those requiring immediate action in the targeted workplace. c. Debriefing in NIOSH after site visits and report dissemination for determination of relevance and impact on a systematic basis (po- tentially missed opportunities to identify emerging health hazards could also be identified). d. Modification of the followback surveys for use in assessing the rel- evance, feasibility, and impact of recommendations. e. Enhancement of internal quality assurance by development of a for- mal 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.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 75 EMERGING ISSUES F  inding 8:  The HHE Program is an effective tool for uncovering emerg- ing issues. Emerging issues in occupational health include newly created hazards such as those arising from nanotechnology; newly discovered hazards such as diacetyl flavoring; and known hazards in new or previously overlooked populations, such as silica exposure among roofers. Nanoparticles are recognized as a potential health hazard and have been identified as an emerging issue by the National Academies Committee to Review the NIOSH Mining Safety and Health Research Program (NRC and IOM, 2007). As described in Chapter 2, OSHA has the lead in control- ling well-understood hazards through legally enforceable standards. NIOSH has the responsibility to investigate new and emerging hazards for which standards do not exist or may be inadequate. The HHE Program is an important mechanism within NIOSH for identifying and investigating emerging issues. The results of HHEs are similar to case reports in the medical literature; they are not always as definitive or as easily generalized to other workplaces as are the results of epidemiological research. But the HHE Program can take action on emerging issues in much less time, for much less money, and with much more flexibility to modify investigations in response to changing circumstances. One of the difficulties NIOSH and the HHE Program face in adapting the program to address emerging issues is that HHEs are done in response to requests, rather than being self-initiated. Nevertheless, NIOSH and the HHE Program could do more to track emerging issues and promote appropriate requests to address emerging issues. A resource for stimulating HHE requests related to emerging hazards is the 26 state OSHA programs, all of which have enforcement and consultation resources, and all of which are members of the Occupational Safety and Health State Plan Association. To date, however, there is no evidence of interaction with this orga- nization. The program could establish a stakeholder group or groups to assist in identifying exposure circumstances or types of workplaces that could be the object  Nanotechnology, sometimes called molecular manufacturing, is a branch of engineering that deals with the design and manufacture of extremely small electronic circuits and mechanical devices built at the molecular scale. Nanotechnology is often discussed together with microelectromechanical systems (MEMS), a subject that usually includes nanotechnology but may also include technologies higher than the molecular level (http://whatis.techtarget.com/definition/0,,sid9_gci213444,00.html, accessed March 28, 2008).  Nanoparticles are microscopic particles with an aerodynamic diameter of less than 100 nm. They are sometimes referred to as ultrafine particles (http://sis.nlm.nih.gov/enviro/iupacglossary/ glossaryn.html, accessed August 6, 2008).

76 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH of HHE requests likely to have high relevance or impact. The NORA sector councils may serve this function. Newly Identified Hazards Work Organization Issues Work organization describes how work is managed and organized. Issues include long or irregular hours, awkward or repetitive motion, job changes due to new technologies, and excessive or conflicting job demands. Twenty years ago, work organization issues were all but ignored; today, there is a growing recogni- tion that work organization can have a major impact on worker health. Two of the most common problems are musculoskeletal disorders and stress-related condi- tions. Work organization issues can arise in any working population, but they are especially important in the healthcare and other service industries and in disaster response. A number of HHEs have addressed work organization and its impact on health. They include HHEs of musculoskeletal disorders at the Los Angeles Times (NIOSH, 1990); of electronic headset noise exposure among transcribers at Kai- ser-Permanente in California (NIOSH, 2005b); of respiratory, gastrointestinal, dermal, and stress-related disorders among members of the New Orleans Police Department after Hurricane Katrina (NIOSH, 2006e); and of respiratory disease and mental disorders among New York transit workers exposed in the 9/11 attack on the World Trade Center (NIOSH, 2005c). NIOSH has recognized that work organization issues are doubly relevant to its mission: even if they themselves do not cause death and disability, they may increase an afflicted worker’s vul- nerability to more traditional health and safety hazards. The HHE Program is instrumental in identifying and responding to emerging issues associated with work organization. Chemical Hazards To be more proactive, the HHE Program and NIOSH might consider certain classes of chemical compounds as emerging issues. For example, organic aldehydes such as acrolein are highly reactive compounds and widely used in certain indus- trial processes. Acrolein, used in the production of acrylic acid, has known toxic properties and may be carcinogenic (ATSDR, 2007). Quinones are another group of chemicals of potential concern. Occupational exposure to quinones may occur in the dye, textile, chemical, tanning, photographic processing, and cosmetic indus- tries (OSHA, 2007). NIOSH and the HHE Program could determine the industries

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 77 in which these and other potentially hazardous compounds are used and could determine whether existing permissible exposure limits (PELs) are adequate. New Technologies Few NIOSH HHEs have dealt with the hazards of major new technologies, and much more could be done in this area. For example, NIOSH has published only one HHE in the area of nanotechnology—an investigation of carbon fiber exposure in a University of Dayton research laboratory (NIOSH, 2006j). That investigation did not include medical evaluations and focused on traditional industrial hygiene con- trols for fine particulates. However, an increasing number of workers are exposed to nanomaterials, not only in laboratories, but in the manufacturing of products such as cosmetics. In the future, NIOSH will be challenged by a rapidly increasing use of nanotechnology in the workplace, and by other new technologies such as biologically engineered products and manufacturing methods. The HHE Program should be able to make use of the research in the respiratory program at NIOSH to address these issues. Other emerging issues could result from the use of genetic engineering in the pharmaceutical industry that may generate unforeseen chemical and biological exposures. The HHE Program could identify these issues through NORA sectors, improved links with local and state health departments, and surveillance data (see below). Emerging issues could also be identified through rapid response to requests in this area and by determining where these products may be generated and con- tacting employers and employee organizations about HHE requests. Known Hazards Affecting Underserved Populations and Small Businesses It is an HHE Program priority to honor HHE requests. However, if the program is to be fully relevant, it should seek out emerging issues by ensuring that workers and employers know about the HHE Program and understand the value of filing a request. For the most part, this has not been done. The program has passively relied on requests from a variety of sources rather than actively seeking out worksites with new and emerging hazards. Such worksites could be identified through the occupa- tional health literature, including international publications; engineering and trade association literature on new technology; databases of industrial chemicals and their uses; and the systematic use of state occupational health surveillance systems. A good first step might be the development of a systematic approach to facilitate identification of known hazards for which PELs may be inadequate or nonexistent and the identification of the workplaces where the hazards may be encountered. A rich source of ideas may be NIOSH’s own files. It would be especially useful for

78 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH NIOSH and the HHE Program to maintain and systematically review a tickler file of odd and unexplained findings to be reviewed periodically for follow-up and further investigation. Previous sections of this chapter have addressed the need for the HHE Program to better communicate with non-union workers and underserved populations. Emerging issues are particularly difficult to identify among these workers, specifi- cally because of lack of communication with them. Novel means of outreach to these populations might include community organization and worker centers, as well as publicly funded health clinics. R  ecommendation:  Initiate formal periodic assessment of new and emerging hazards. The committee recommends the following steps: a Evolve from a program that passively receives requests to a proactive  .  program that seeks opportunities for field investigations. b Develop systematic approaches to identify hazards where OSHA  .  permissible exposure limits are inadequate or nonexistent, to iden- tify unknown hazards, and to identify known hazards encountered under new circumstances. c Establish and periodically review a tickler file of inconclusive or  .  unexpected evaluation results to determine whether new trends or problems may be emerging. d  . Periodically meet with intramural and extramural research scien- tists and stakeholders in government, academe, labor, and industry to discuss specific unresolved evaluations, to review aggregate find- ings, and to solicit input about new or emerging hazards or interven- tions. The HHE Program could establish one or more stakeholder groups to assist 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. EMERGENCY RESPONSE F  inding 9:  The HHE Program is uniquely qualified to formulate in- formation needed to safeguard the workforce responding during and following a disaster. The program is well prepared to deploy during emergencies. Emergency preparedness is one of the most relevant aspects of the HHE Pro- gram. The strength of the HHE Program in emergency response comes from the

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 79 vast experience staff gain through day-to-day activities, particularly through engag- ing with employers, workers, and unions at workplaces throughout the country. Essential abilities are developed, such as improvisation and flexibility, which lend themselves to emergency response. As described in Chapter 2, the HHE Program has served an important role in the response to natural and manmade disasters. HHE personnel were essential to NIOSH’s response to Hurricanes Katrina and Rita, largely because of their expertise in staging investigations under adverse conditions and writing recommendations in clear language without technical jargon. The NIOSH response was rapid, efficient, and competent. Within days, NIOSH produced and disseminated onsite guidance for emergency responders, medical personnel, and cleanup workers. According to a retired employee of the U.S. General Services Administration, Office of Governmentwide Policy, Office of Mail Communications, the HHE Program had a role that was both relevant and appropriate during the anthrax crisis, helping to ensure the safety and security of federal employees (Bender, 2008). Since 9/11, the program has reasonably and appropriately focused on the all-hazards scenario—chemical, biological, radiological, nuclear, and high yield explosives events—working with other NIOSH programs responsible for informa- tion. The HHE Program works with OSHA in a joint operations capacity: the HHE Program provides advice and guidance to OSHA on health hazards and issues, while OSHA focuses primarily on safety. Review of Outputs Related to Emergency Response The committee reviewed two numbered reports related to emergency response submitted by the HHE Program (NIOSH, 2004d, 2006e). Both were considered extremely thorough. One report described multiple health hazards encountered by the New Orleans Police Department (NOPD), documented symptoms, and identi- fied clear risk factors for a number of outcomes, including respiratory illness, post- traumatic stress disorder, and depression (NIOSH, 2006e). This report, produced within seven months, includes 48 references and clearly identified findings. It is a model for exploring emerging issues in disaster settings. At the time of this writ- ing, the results from this report were in press in a peer-reviewed publication, and a follow-up field investigation had been requested by the NOPD. These outcomes demonstrated both the quality of the new knowledge developed and the relevance of the findings not only to the appreciative requesting entity but also to other public entities that may face similar disasters.

80 T h e H e a l t h H a z a r d E v a l u a t i o n P r o g r a m a t NIOSH RELEVANCE SCORE The program’s strategic goals are appropriate, although some intermediate goals and performance measures could be made more ambitious if resources were available. The committee finds that the HHE Program responds well to HHE requests, and that HHEs play a key role in addressing widespread occupational health issues, such as musculoskeletal disorders, and emerging issues, such as lung disease from diacetyl-based flavorings. However, the committee believes the pro- gram could do a better job of eliciting a broader array of requests, especially from underserved populations and those exposed to new or newly recognized hazards. Rapid changes in the economy and workforce have affected the nature of HHE requests. The HHE Program has generally met these challenges with a judicious use of its resources, while remaining true to its mission. The program could do even better by making greater use of available surveillance data and by sharpening its focus on emerging issues. The HHE Program has established a triage process to determine how to best meet the needs of each requestor within the limits of available resources. The triage process leads to improved efficiency, but it would benefit from increased trans- parency and more sophisticated site visit selection. Reports sent to the requestors and other interested parties and published on the NIOSH website are well written and relevant, reflecting a high level of expertise, and are supported by appropriate documentation. However, the quality and utility of some of the recommendations in the reports have not always met the same high standards. This could be cor- rected through a better quality assurance program. The timeliness of the reports has consistently been an issue in the past, but the HHE Program has shown some improvement in this area. The 9/11 attacks and Hurricanes Katrina and Rita put needed emphasis on emergency response. The HHE Program has responded well to these emergen- cies and is uniquely qualified to develop better ways to protect the U.S. workforce during such disasters. NIOSH and the HHE Program are well prepared to deploy during emergencies. After consideration of the criteria provided in the Framework Document (see Box 1-2), the committee assigns the HHE Program a score of 4 for relevance. The committee was asked to evaluate whether program activities are in priority areas and whether the program is engaged in relevant transfer activities. Although the committee makes multiple recommendations for improvement, it finds that pro- gram activities are in priority subject areas and that the program is engaged in ap- propriate transfer activities. A lower score, according to the scoring criteria, would indicate either a focus on lesser priorities or a lack of information dissemination.

R e l e va n c e o f t h e H e a l t h H a z a r d E v a l u a t i o n Program 81 Had the committee not been required to give an integer score, it might have rated the program between 4 and 5. In another example, an HHE was performed for an employer who managed home care services through a California county office (10,000 home care workers, primarily representing workers from underserved populations) (NIOSH, 2004a). Representatives from the county office reported a successful partnering of the HHE Program with the Labor Occupational Health Program (LOHP) of the University of California, Berkeley (Ayala, 2008). LOHP developed follow-up training to as- sist in implementation of HHE recommendations, which also contributed to the creation of a Labor Management Committee that discussed health and safety, as well as other issues. In this example, the HHE Program took advantage of local resources to maximize the effectiveness of HHE recommendations. A third example of HHE Program-state occupational health collaboration was provided in comments by an industrial hygienist working at the Massachu- setts Department of Public Health Occupational Health Surveillance Program (OHSP), which receives NIOSH funding for its occupational asthma surveillance activities (Pechter, 2008). Over time, three referrals for investigation of potentially hazardous exposures associated with work-related asthma were identified, and the industrial hygienist contacted the HHE Program to conduct investigations at these worksites. New-onset asthma associated with exposure to a particular compound (3-amino-5-mercapto-1,2,4-triazole) was identified (NIOSH, 2003b; Hnizdo et al., 2004). As noted by the stakeholder: “The identification of a new asthmagen is important, not only for the protection of workers currently exposed, but also to the process of scientific inquiry about respiratory sensitizers and asthma preven- tion” (Pechter, 2008). The HHE Program had previously identified asthma in flock workers at one company site (NIOSH, 1998a), while the OHSP request led to the identification of hazards in a second plant (NIOSH, 2006a; see Box 3-3 for a more detailed description of flock and related HHE Program activities).  These comments reflect personal opinions and are not necessarily those of the Massachusetts Department of Public Health.

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It is the unique mission of the Health Hazard Evaluation Program within the National Institute for Occupational Safety and Health (NIOSH) to respond to requests to investigate potential occupational health hazards. In contrast to other NIOSH programs, the Health Hazard Evaluation Program is not primarily a research program. Rather, it investigates and provides advice to workplaces in response to requests from employers, employees and their representatives, and federal agencies.

The National Research Council was charged with evaluating the NIOSH Health Hazard Evaluation Program and determining whether program activities resulted in improvements in workplace practices and decreases in hazardous exposures that cause occupational illnesses. The program was found to play a key role in addressing existing widespread or emerging occupational health issues. This book makes several recommendations that could improve a very strong program including more systematic use of surveillance data to facilitate priority setting, and greater interaction with a broader array of workers, industries, and other government agencies.

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