4
Impacts of the Health Hazard Evaluation Program: Reductions in Harm and Transfer of Knowledge

DEFINITION OF IMPACT

The committee is charged with evaluating the impact of the National Institute for Occupational Safety and Health (NIOSH) Health Hazard Evaluation (HHE) Program. Specifically, the committee is asked to determine the impact of the HHE Program on

  1. Reducing worker risk and preventing occupational illness in investigated workplaces;

  2. Transferring program-generated information to relevant employers and employees beyond the investigated workplaces;

  3. NIOSH research and policy development programs; and

  4. The activities of regulatory agencies, occupational safety and health professionals and organizations, state and local health agencies, and others in the occupational health community, as achieved by transferring program-generated hazard and prevention information.

This chapter is organized into seven major sections. This section defines impact and the context in which the program is being evaluated. The next four sections are analyses of each of the four types of impact described above, addressing both proximal and distal impacts of HHE Program activities, as well as program limitations. The committee then evaluates the impact of the HHE Program’s emergency



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 82
4 Impacts of the Health Hazard Evaluation Program: Reductions in Harm and Transfer of Knowledge DEFINITION OF IMPACT The committee is charged with evaluating the impact of the National Institute for Occupational Safety and Health (NIOSH) Health Hazard Evaluation (HHE) Program. Specifically, the committee is asked to determine the impact of the HHE Program on 1. Reducing worker risk and preventing occupational illness in investigated workplaces; 2. Transferring program-generated information to relevant employers and employees beyond the investigated workplaces; 3. NIOSH research and policy development programs; and 4. The activities of regulatory agencies, occupational safety and health pro- fessionals and organizations, state and local health agencies, and others in the occupational health community, as achieved by transferring program- generated hazard and prevention information. This chapter is organized into seven major sections. This section defines impact and the context in which the program is being evaluated. The next four sections are analyses of each of the four types of impact described above, addressing both proximal and distal impacts of HHE Program activities, as well as program limita- tions. The committee then evaluates the impact of the HHE Program’s emergency 2

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m  response activities. The final section of this chapter describes the committee score and rationale for program impact. Ideally, a review of the HHE Program would yield quantitative evidence of the reduction of illness or death (earlier defined as “end outcomes”) at specific inves- tigated worksites or similar workplaces throughout the country. Such quantitative evidence of impact is generally unavailable. In the field of occupational health, however, there is solid evidence that exposure to certain chemical or physical agents causes illness, injury, or death. In general, a reduction in the level or frequency of exposures is expected to reduce the number of workers who develop disease. Elimination of exposures can reduce the number of cases of disease in those al- ready exposed, prevent disease in new hires, or both. Based on this cause-and-effect relationship, attempts are made to reduce disease risk by reducing or eliminating exposures to various agents. Sometimes, based on reduced exposure, it is possible to make estimates of disease or deaths avoided. Reductions in exposure at one workplace as a result of HHE Program recom- mendations can lead NIOSH or other agencies to take action to reduce exposures in similar workplaces nationwide. Information regarding exposure reduction mea- sures can be provided to employees at a site where an HHE was conducted, and then to occupational health professionals, public health practitioners, and state and federal regulators elsewhere through reports, hazard alerts, and other publications. It is conceivable that NIOSH would have the data to estimate the number of lives saved and the reductions in diseases that can be direct or indirect results of HHEs conducted. For example, HHE recommendations describe the actions needed to reduce exposures of elevated chemical or physical hazards identified during an investigation. Follow-up with employers, and especially employees, could yield information about actions taken to reduce exposures. With sufficient evidence that harmful exposures have been reduced or eliminated (for example, by substitution of one chemical or process for another), it may be possible to develop quantitative estimates of occupational illness or death avoided. Existing occupational health and safety data are insufficient to support robust analyses of impacts of the HHE Program. This is not to say that the HHE Program does not have impact, but that there are inadequacies in the reporting system. Because occupational disease and death statistics in particular are limited in the U.S. health data systems, other evidence is examined by the committee to estimate HHE impacts. The committee began this process by looking at the HHE Program’s strategic goals and determining the number of HHEs conducted relevant to each strategic goal and by hazard type (Table 4-1). Starting with a table provided by the HHE Program (NIOSH, 2007b:Table 3-1), the committee used the program’s online HHE search engine to identify related reports.1 This simple exercise yields 1 See http://www.cdc.gov/niosh/hhe/ (accessed July 9, 2008).

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 4 TABLE 4-1 Distribution of HHE Investigations by Strategic Goal and Hazard Type Strategic Goal Hazard Type HHEs (numbered reports) 1. Prevent occupational Biological Biosolids (1) illnesses through Brucellosis (3) reduced exposure to Latex allergy (7) workplace hazards Tuberculosis (46) Chemical Tertiary amines (3) Asphalt (37) Chlorinated compounds (28) Lead in construction (13) Physical Musculoskeletal hazards (77) Noise (244) Mixed Global health (0) Indoor environmental quality (200) Metalworking fluids (23) 2. Promote occupational Flock, respiratory (7) safety and health Flavorings (10) research on emerging Severe acute respiratory syndrome (0) issues Silica in roofing (9) Carbon monoxide and houseboats (5) Surface wipe methods for chemical decontamination (1) 3. Protect health and Anthrax (2) safety of workers Irradiated mail (1) during public health Natural disasters (0) emergencies Hurricane Katrina (3) World Trade Center (3) SOURCE: NIOSH (2007b; HHE search engine [http://www.cdc.gov/niosh/hhe/, accessed July 9, 2008]). somewhat different results with different search terms used for the same issues, but the exercise illustrates that the HHE Program likely has had impact in areas relevant to its strategic goals.2 The HHE Program provided the committee with information on activities related to disease reduction, such as data sent to the Oc- cupational Safety and Health Administration (OSHA) used for federal standard setting, which can be expected to result in lower exposures and, therefore, reduc- tions in disease. 2 The number of relevant HHEs identified by the search engine for a given search term varied over the course of committee deliberations.

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 5 1. HEALTH HAzARD EvALuATION PROgRAM IMPACT ON REDuCINg WORKER RISK AND PREvENTINg OCCuPATIONAL ILLNESS IN INvESTIgATED WORKSITES Finding 1.1: HHEs generally have a positive impact on improvement of occupational health at investigated worksites. There are many relevant examples of HHE reports that contain information useful to reasonably estimate reductions of health risk in the workplace. Numer- ous examples exist of workplace changes that have occurred as a result of HHEs. These include some fairly minor alterations in processes or in the use of control technologies or housekeeping procedures (for example, hazard-specific cleanup procedures) that reduce exposures and possibly result in a rapid reduction in ill- nesses. Table 4-2 illustrates several examples of impact-producing HHEs conducted from 1978 through 2006. The HHE Program tracks data about HHE requests through a management system including, since 2005, the approximate number of people exposed to haz- ards (NIOSH, 2007f). HHE Program staff estimate that nearly 400,000 employees have been at risk at sites where HHEs were requested between fiscal years 2005 and 2008. This is based on information received from 87 percent of all requestors (information is missing for the remainder of the requests) (NIOSH, 2007g). The management tracking system could be improved with greater follow-up to obtain initially unreported data, and with better estimates of the exposed worker popula- tion in field-investigated sites. A previous program evaluation by the Research Triangle Institute (RTI, 1997) recommended that the HHE Program systematically survey employers and em- ployees in workplaces where HHEs, technical assistance, or consultation had been provided to learn whether HHEs satisfied customer needs, resulted in improved workplace health and safety, and identified emerging problems. As described earlier in this report, the HHE Program may conduct a followback survey at the comple- tion of an HHE. One program staff person is responsible for followback survey activities. The survey response rate is about 60 percent (NIOSH, 2007b). Among followback survey responders (289) who indicated they knew about the actions resulting from an HHE, 62 percent reported actions to implement HHE recommendations, and another 12 percent reported that actions were planned. Corrective actions taken were primarily housekeeping (85 percent), whereas per- sonal protective equipment, engineering or administrative controls, and exposure monitoring varied from 50 to 75 percent of the remainder. In a survey of 68 respondents, 62 percent reported that employee health had improved (NIOSH, 2007b). This information, although not rigorously confirmed as representative, is important evidence in evaluating whether HHEs reduce risks in the workplace.

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  TABLE 4-2 Examples of HHEs Resulting in Wide Impacts (1978-2006) HHE Reporta Hazard Impact Dibromochloropropane • HHE-77-103-474 • DBCP, once widely used as a nematocide, (DBCP) (Occidental Chemical has been found to cause sterility among Company, Lathrop, agricultural workers. Ohio) • HHE Program data were used by OSHA • HETA-78-004-1511 to promulgate a standard in 1979 (U.S. (Shell Chemical Department of Labor, 2008a) to require Company, Axis, reduced exposures. Alabama) • HETA-81-040-1315 (Dole Pineapple Corporation, Lanai, Hawaii) • HETA-81-162-1935 (Maui Land and Pineapple Inc., Kahuli, Hawaii) Lead 337 HHEs were • HHE Program data were used by OSHA conducted between 1978 in promulgating lead standards (U.S. and 1995 in a wide array Department of Labor, 2008a, b). of industries • For 25 years, HHEs provided information regarding exposures and control measures used by evaluated industries, OSHA consultation, and enforcement activities. Silica, roofing tiles, • HETA-2003-0209- NIOSH Publication 2006-110 (NIOSH, construction 3015 (Diversified 2006h), based on four HHEs, describes Roofing Inc., Phoenix, hazard silicosis and how to protect workers. Arizona) CPWR—The Center for Construction Research and Training (CPWR)b uses this • HETA-2005-0032- 2985 (Petersen-Dean publication in a curriculum to train 20,000 Roofing Systems, roofers (P. Stafford, CPWR Executive Phoenix, Arizona) Director, personal communication, • HETA-2005-0031- April 2008). 3055 (C & C Roofing, Phoenix, Arizona) • HETA-2005-0030- 2968 (Headlee Roofing, Mesa, Arizona)

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 7 TABLE 4-2 Continued HHE Reporta Hazard Impact Diacetyl See Box 3-2 for HHE • Recognition of a pulmonary disease caused history 1985-2006 by diacetyl. • Publications in public health literature. • Data currently being used by the California OSHA to develop a standard to protect workers. • ConAgra, a major manufacturer, initiated pulmonary surveillance and industrial hygiene reviews to reduce exposure (J. E. Lockey, M.D., Professor, University of Cincinnati, written communication, February 18, 2008). • States alerted pulmonary physicians to diacetyl and bronchiolitis obliterans. • These HHEs caused NIOSH’s pulmonary research unit to perform extensive research regarding bronchiolitis obliterans and focused international attention on this occupational hazard. • Voluntary removal of diacetyl from manufacturing processes in some facilities. Silica flour • HHE-78-104- • Recommended exposure controls used in 107 (Tammsco U.S. Department of Labor Mine Safety and Incorporated, Tamms, Health Regulation, 1980 (U.S. Department Illinois) of Labor, 2008c). • HHE-79-103-108 • Health Effects of Synthetic Silica (Illinois Mineral Particulates, a symposium sponsored by Company, Elco, ASTM Committee E-34 on Occupational Illinois) Health and Safety and the Industrial Health Foundation, American Society for Testing and Materials (ASTM), Benalmadena-Costa (Torremolinos), Spain, November 5-6, 1979. • NIOSH Current Intelligence Publication (NIOSH, 1981) recommended to Indian Silica Flour Industries by C. Rice, Deputy Director, and S. Clark, Director, Education and Research Center, Department of Environmental Health, University of Cincinnati. • HHE site recommended to Dr. A. El-Safty, Cairo University, Cairo, Egypt, 2008, by C. Rice. continued

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  TABLE 4-2 Continued HHE Reporta Hazard Impact Synthetic fibers, flock See Box 3-3; 8 HHEs High-hazard HHEs and NIOSH follow-up were conducted between research are only warnings. OSHA does not 1972 and 2004: have a regulation. • HETA-96-0093-2685 (Microfibres Inc., Pawtucket, Rhode Island) • HETA-98-0212- 2788 (Claremont Flock Corporation, Claremont, New Hampshire) • HETA-98-0238-2789 (Spectro Coating Corporation, Leominster, Massachusetts) • HETA-2004-0013- 2990 (Hallmark Cards, Inc., Lawrence, Kansas) • HETA-2004-0186- 3011 (Claremont Flock Corporation, Claremont, New Hampshire) • HHE-77-114-529 (The Standard Products Company, Lexington, Kentucky) • HHE-72-33-129 (Barker Greeting Card Company, Cincinnati, Ohio) • HHE-80-214-799 (M and B Metal Products, Inc., Leeds, Alabama)

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 9 TABLE 4-2 Continued HHE Reporta Hazard Impact Musculoskeletal Numerous HHEs The HHE Program identified hazards causing disorders from 1980 to 2007 (see disorders of muscles, tendons, and joints Box 3-4) in diverse industries, with 50 percent in manufacturing. These HHEs led to reviews and practice documents and have informed OSHA and other regulatory bodies in rule- making (for example, U.S. Department of Labor, 2000). The HHE Program’s body of work on this topic has stimulated major research activities within and outside NIOSH on work-related musculoskeletal disorders. NIOSH has used these HHEs as bases of other investigations among underreported populations (farm workers). Metalworking fluids The HHE Program An array of industries use MWFs, from (MWFs) website indicated 19 aircraft and automobile plants to missile HHEs were published and hydraulic plants. NIOSH estimates between 1981 and 2006c 1.2 million American workers are exposed (NIOSH, 1998b). Exposures are associated with a range of illnesses, from dermatitis to asthma and other pulmonary effects. A publication coauthored by HHE staff described an investigation and associated hypersensitivity pneumonitis (HP), a rare but severe condition, with MWF exposure (MMWR, 1996). Another HHE identified a severe outbreak of HP at a small plant and was instrumental in abating exposures at the facility and quelling the outbreak (NIOSH, 2002d). Both investigations were published in a short time in Morbidity and Mortality Weekly Report. HHEs have been important in defining the effects of MWFs and providing control technologies in hazardous workplaces where no OSHA standards or guidelines have been established to control exposures. Latex allergy Numerous HHEs from NIOSH identified powdered latex gloves HHE Program website as the risk factor for latex allergy. Massive adoption of powder-free latex gloves followed. aSpecific HHE Program reports mentioned in this table can be accessed at the HHE Program website. See http://www.cdc.gov/niosh/hhe/ (accessed July 25, 2008). bFormerly known as the Center to Protect Workers’ Rights. cSee http://www.cdc.gov/niosh/hhe/HHEprogram.html (accessed July 25, 2008).

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 90 Recommendation: The followback surveys should be modified for use in assessing the relevance, feasibility, and impact of recommendations made by the HHE Program. Finding 1.2: The number of HHE investigations completed in the last decade has declined dramatically. Therefore, fewer sites receive the posi- tive benefits that accrue as a result of completed HHE investigations. The HHE Program received an average of 372 requests for investigations per year between 1997 and 2006 compared with a historic average of 498 per year prior to 1997. The number of field investigations declined from 126 in 1997 to 58 in 2006 (NIOSH, 2007b). One reason for the decrease in field investigations was an increase in the proportion of requests concerning indoor environmental qual- ity (IEQ) issues that could be addressed by telephone calls and letters. In the same period, invalid requests increased from 15 to 46 percent. One can speculate that reductions over the past 10 years in both total and valid HHE requests have resulted from loss of jobs in the industrial sector, fewer health and safety personnel among union and non-union industries, or fewer hazards in workplaces. The number of full-time equivalents (FTEs) on staff dropped from 63 in 1998 to 52 in 2006 (NIOSH, 2007b). The budget for travel to perform HHEs remained essentially the same from 2000 to 2007 at the NIOSH Hazard Evalua- tions and Technical Assistance Branch (HETAB) (NIOSH, 2007b), indicating that less money is available for field investigations given increases in travel costs. Not only does the budget create problems for hiring adequate numbers of personnel, but the infrastructure (such as equipment and physical infrastructure) needed for HHE field investigations is capital intensive, potentially limiting the number of field investigations. The reasons for the drop in field investigations are difficult for the commit- tee to assess with confidence. However, the number of completed HHEs has been reduced. As a result, the potential impact of HHEs could also be reduced. The committee concludes that there likely are budgetary constraints in terms of person- nel and equipment necessary to carry out HHEs given the decrease in FTEs and relatively flat budget between 2000 and 2007. Finding 1.3: Large portions of the labor force—particularly those from traditionally underserved populations—are unaware of HHEs. Hence, they do not request the service and are unaware that a substantial body of HHE work exists to assist them. One factor that may contribute to the decrease in HHE requests is that relatively fewer workers may be knowledgeable about the role HHEs can have in making their

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 9 jobs safer. The structural shifts in the labor force away from unionized settings and toward the service sector, as well as the increase in contingent workers, have not been addressed by the HHE Program with additional outreach resources. The HHE Program lacks personnel to provide outreach to these workers who may benefit from HHEs. As an agency, NIOSH is strong in its abilities to conduct outreach when funds are available (for example, successful outreach to former nuclear workers funded by the U.S. Department of Energy through NIOSH; NIOSH and OERP, 2001). In response to the committee’s request for stakeholder input (see Chapter 1 and Appendix D), many respondents indicated they did not know about the HHE Program. Others indicated they knew about the program and suggested outreach methods. At a December 2007 Worksafe Conference in California, several commu- nity and worker groups indicated no knowledge of what an HHE was or how to request one (Worksafe, 2007).3 Recommendations from stakeholders about how to better communicate with these populations are included in the closing section of this chapter and in Appendix D. A recent journal article by NIOSH investigators Cummings and Kreiss (2008) described the potential health risks of contingent workers, noting that there may be a lack of health and safety training and limited personal protective equipment for them. Contingent workers have nontraditional employment relationships; for example, they may be temporary or part-time workers or independent contract workers employed in refineries, agriculture, mining, or construction. The authors note that these workers are frequently young, female, African American, or His- panic and have lower incomes and fewer benefits. This assessment was also made during a stakeholder presentation at the committee’s second meeting (Gittleman, 2007). An exception to this characterization is construction workers who are mem- bers of the national building trades unions. These workers typically receive health and safety training and understand their rights. During presentations to the committee, HHE Program staff acknowledged the need to give attention to shifts in the demographics and composition of the labor force. There may be sectors and employment groups not being served by HHEs that should be, and the committee suggests that day laborers, immigrant groups, some service industry workers, and low-wage workers may be examples. The HHE Program has had some success in reaching such underserved populations (see Box 1-1 for the definition of underserved populations). An HHE conducted for the Alameda County, California, Public Authority for In-Home Support Services, for example, led to successful and important HHE impact on a new kind of 3Worksafe is a California-based nonprofit organization established to promote occupational safety and health through education, training, technical and legal assistance, and advocacy. Members in- clude labor and community groups, workers, occupational safety and health and other professionals, environmentalists, and others (http://www.worksafe.org, accessed March 30, 2008).

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 92 employment group—the home healthcare workers that the county office is serv- ing (NIOSH, 2004a). The state contracts with the agency to use local independent contractors for home healthcare. Worksites are as varied as the clients needing home healthcare, and the workers are not in contact with one another. This par- ticular HHE is also an excellent example of leveraging resources with state and local partners: a successful partnership among the federal, state, and local employment partners was necessary to conduct the HHEs, and innovative ways of communicat- ing the results to multicultural workers working in multiple sites were required. 2. TRANSFER OF PROgRAM-gENERATED INFORMATION TO RELEvANT EMPLOYERS AND EMPLOYEES BEYOND INvESTIgATED WORKPLACES Finding 2.1: The HHE Program disseminates its findings, sometimes widely. Based on discussion with the HHE Program staff, program information is disseminated to employers and employees beyond the investigated workplace through • HHE reports on the Internet accessed through the NIOSH website; • CD-ROMs of HHEs available free to industries, workers, professors, and students; • notification of subscribers by e-mail about various types of free documents; • appropriate OSHA regional offices; • scientific articles in technical journals; • NIOSH documents such as Health Hazard Alerts released when a new body of information requires a special report to be brought to relevant communities (approximately one to five times per year); • articles in trade publications; • presentations at conferences and workshops; and • alerts to other government agencies, including OSHA, at federal and state levels that may be in contact with employers and employees at similar workplaces. Listed above are examples of mechanisms to transfer program-generated infor- mation to relevant employers and employees. Figure 4-1 is a flow diagram showing the potential transfer paths of HHE Program outputs to stakeholders and potential impacts they may have in general terms. HHE reports themselves, searchable on the NIOSH website, are important vehicles for affecting workplaces other than those investigated, given appropriate transfer mechanisms. CDs of HHE reports

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 0 Health, Critical Reiews in Toxicology); occupational health (American Industrial Hygiene Association Journal, Applied Occupational Enironmental Hygiene, Journal of Occupational and Enironmental Hygiene); and environmental health (Journal of Enironmental Monitoring, Enironmental Health Perspecties), among others. It is particularly noteworthy that HHE Program scientists have published 28 articles in Morbidity and Mortality Weekly Report (MMWR). Though MMWR is not peer reviewed, it has been a highly visible and respected publication in public health for many years (NIOSH, 2007b). These publications served to document advances in our knowledge of specific occupational illnesses and have had impacts on the development of treatment and intervention techniques to prevent or ameliorate the incidence of these illnesses. Program transfer activities can be very thorough in some areas, and transfer occurs in a variety of ways. Since 1990, for example, there have been 39 numbered HHE reports, 20 journal articles, and 3 NIOSH numbered documents published— including proceedings of a workshop and a manual of analytical methods—all related to tuberculosis (NIOSH, 2007b). Additionally, seven items, such as chapters in books, and two items related to OSHA rule-making on occupational exposure to tuberculosis have been published. A more recent example is related to flavor- ings. Since 2002, 6 HHE reports, 10 journal articles (including in the New England Journal of Medicine), and 1 NIOSH numbered document have been published. Transfer Material Type: Academic Presentations Finding 4.4: The HHE Program presents research findings and staffs informational booths at major academic conferences related to occu- pational health. The committee reviewed an extensive 10-year record of regular presenta- tions at major academic conferences, many of which were later published in the peer-reviewed literature. In addition to their substantial activities in the national occupational health community, HHE Program scientists have presented research at international conferences in Austria, Brazil, Canada, China, Finland, Germany, Italy, Mexico, Scotland, Sweden, South Africa, and South Korea. Examples of do- mains and specific academic-focused conferences include the following: • General: American Industrial Hygiene Conference and Exposition; Amer- ican Occupational Health Conference; World Congress on Safety and Health at Work; and American Statistical Association • Medical: American Thoracic Society; American Academy of Allergy, Asthma and Immunology; Society of Diagnostic Medical Sonography

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m  These presentations have been an effective mechanism for transfer of information from the NIOSH HHE Program to the public health community. The information communicated in the presentations can be expected to impact occupational health in a positive manner. Transfer Material Type: Trade Presentations Finding 4.5: There is evidence that the HHE Program publishes in trade journals and makes presentations to trade association meetings, but more can be done to reach a wider audience and a greater diversity of employer and industry types. The committee reviewed a list of many presentations at trade conferences (NIOSH, 2007b). Examples of such presentation audiences include those • in manufacturing: the American Automobile Manufacturers Association, the National Cotton Council of America, and the International Roofing Exposition; • at professional associations: the National Hearing Conservation Association; and • at regional meetings: the Kentucky-Tennessee Water Environment Association, the Phoenix Roofing Industry Silica Meeting, and the New England Biological Safety Association. Appearances at such venues are important and useful. However, the committee received stakeholder input from invited speakers and in response to the committee’s written request for input that the HHE Program may not be presenting at a wide enough range of trade- and business-related venues. In particular, it was noted that the HHE Program could do more to reach out to small-business associations. Furthermore, the characteristics of the construction industry and agricultural labor forces may require special outreach efforts. The associate director for Safety and Health Research at CPWR noted a need to target small, high-risk residential construction companies that do not have the resources to investigate and solve their work-related safety and health problems (Gittleman, 2007). It was noted that HHE Program success stories include lead and silica, but the speaker cautioned that the mobile and contingent nature of the construction industry may result in worker exposure to well-understood risks. The speaker suggested that additional venues likely to provide good opportunity for dissemination of program informa- tion are the annual NIOSH Build Safe Conference and the Chicago Safety Council Conference.

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 2 As described earlier in this chapter, the vice president of manufacturing for a small flavoring and fragrance company in California responded to questions dur- ing a committee meeting discussion (Speakman, 2008). Discussion led the com- mittee to conclude that presentations made at trade association meetings are one important mechanism to transfer information, but many small businesses do not join their trade association or participate in association activities. Furthermore, the social dynamic at trade association meetings may make it difficult for business owners to have open dialogue about problems experienced with their production processes. Transfer Actiity Type: Interagency Cooperation Finding 4.6: The HHE Program participates in a variety of intergov- ernmental activities that promote knowledge about occupational health matters. The committee finds substantial evidence of engagement by the HHE Program with some parts of the federal government. Examples include involvement—some- times over long periods—with single or ongoing working groups, such as the EPA Biosolids Exposure Measurement Workshop, the OSHA-NIOSH Interagency Health Outcomes, the Navy Occupational Health and Preventive Medicine Work- shop, and the NORA Industry Sector Meeting. Most such efforts appear targeted at the federal level. As discussed in Chapter 3, the committee heard from some state and local health officials who were unaware of HHE Program activities, including those occurring within their own jurisdic- tions. One e-mail respondent to the committee’s request for input noted that the HHE Program was perhaps the “best kept secret in occupational safety and health” (Kiefer, 2007). A particularly poignant example of the program’s “best-kept secret” status came from the commissioner of health of a major East Coast city. This in- dividual had not heard of the HHE Program prior to being invited to speak to the committee, in spite of his former employment on the staff of U.S. Representative Henry Waxman (California), who is known for his activities related to health and healthcare reform. The idea was reinforced in a majority of the responses to the committee’s written request for input (see Appendixes C and D). Although many respondents were quite familiar with the HHE Program, the most common sug- gestion for improvement was for the program to increase its outreach and visibility so that its services would be extended. HHE Program staff responded that the program has regular contact with the Council of State and Territorial Epidemiolo- gists; the Epidemic Intelligence Service; state and federal OSHAs; and other parts of NIOSH and CDC (NIOSH, 2007h:response to question #21). The response further

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m  noted, however, that these efforts have not been formally evaluated. To the extent that this committee has conducted its own evaluation, it seems that the HHE Pro- gram has had significant involvement with some parts of the federal government and with some states. The evidence suggests that the HHE Program could enhance these efforts to encompass all potential federal and state partners. Furthermore, additional attention to local government agencies is also warranted. Transfer Material: Compendia of Known Findings Finding 4.7: The HHE Program has made progress in developing com- pendia of findings and recommendations about well-understood oc- cupational health risks. The HHE Program has developed four compendia of findings about occu- pational health risks associated with isocyanates, noise, tuberculosis, and lead (NIOSH, 2004e, 1998c, 2001b, and 2001a, respectively). The program is currently working on compendia on health risks faced by firefighters and those in the health- care sector. The HHE Program tabulated the type and frequency of HHE recommenda- tions, including 82 field investigations between 2000 and 2005 for which followback surveys were conducted (NIOSH, 2007f:Table G [a]). Of the reports, 65 percent recommended engineering controls, 33 percent recommended exposure moni- toring, and 28 percent suggested medical surveillance. Although HHEs are often thought of as hazard-specific approaches to occupational health, the distribution of recommendation types suggests that the compilation of general process guidelines for use by employers, such as those already written for hazards including lead and tuberculosis (NIOSH, 2001a, b), may be an efficient use of program resources. For example, more than half of HHE reports recommended administrative controls (79 percent), and a large number of reports also recommended housekeeping controls (44 percent), labor-management communication (28 percent), and use of personal protective equipment (27 percent). If generalized process-oriented findings can be gleaned from the experience of the HHE Program across a variety of settings, then the program may consider compiling compendia of such findings. Recommendation: Increase efforts to compile compendia of findings (such as those developed for isocyanates, noise, tuberculosis, and lead) when generalized process-oriented findings can be gleaned from the experience of the HHE Program in a variety of workplace settings.

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 4 Dissemination Strategies Finding 4.8: A wide variety of dissemination mechanisms, includ- ing the Internet, are targeted to the professional occupational health workforce. The committee has already noted significant program strengths in dissemina- tion through peer-reviewed scientific literature and academic, professional, and trade association meetings. This section focuses on the ability of the HHE Program to disseminate findings to occupational health stakeholders beyond the profes- sional labor force. The primary dissemination mechanism for HHE reports and other published materials is by e-mail and the Internet. Reports are posted on the HHE Program website and Epi-X, and are announced in eNews, a NIOSH e-mail newsletter. They are sent to, and made available through, the National Technical Information Service and federal OSHA regional offices. All of these mechanisms require (1) knowledge of the program and (2) a sophisticated ability to conduct an electronic search. The issue of whether people know about the HHE Program has already been discussed in detail. This section addresses the issue of an Internet- based dissemination strategy. An Internet-based dissemination strategy does not serve people who do not have regular access to or knowledge about using the Internet. Such populations may include non-native language speakers, the working poor, and ethnic and racial minorities. The committee also notes that the program’s Internet-based dissemina- tion mechanism is difficult to maneuver, even for well-educated and well-informed healthcare professionals. Several respondents to the committee’s request for input mentioned difficulty using the HHE Program website and emphasized the difficulty in finding HHE reports (see Appendix D for a summary of comments). Several written comments emphasized the difficulty of finding HHEs and also addressed the need for improvements to the search engine. An illustrative comment from an anonymous occupational and environmental physician and industrial hygienist in academe follows: The online search mechanism at the CDC website could be more user- friendly. In addition to the search by terms, an alphabetical categorization by main topic (exposure and/or disease) would be helpful. Also, the avail- ability of HHE data could be better publicized. I have been aware of HHEs for years, but rarely do I hear about them from other sources. Although the committee commends the HHE Program for making HHEs available online, committee members have had similar difficulty using the HHE search engine. In the preparation of Table 4-1, the committee noted apparent

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 5 inconsistencies in the way keywords are assigned to HHEs. For example, in an effort to locate HHEs related to work-related musculoskeletal disorders in the program’s online search engine (http://www.cdc.gov/niosh/hhe/), 77 matches were found when a search was conducted using the search term “musculoskeletal hazards,” 113 matches with “musculoskeletal,” and 92 matches with “ergonomic.” Approximately 63 percent of the “ergonomic” results appeared within the results of the search under “musculoskeletal.” Similar results were observed using search terms such as “indoor environmental quality,” “IEQ,” “indoor air quality,” “respiratory indoor environmental quality,” and “respiratory IEQ.” As early as the 1997 evaluation of the HHE Program by the Board of Scientific Counselors (NIOSH BSC, 1997), there were recommendations to improve link- age to extant occupational websites at OSHA, labor unions, and other interested stakeholders. Eleven years later, such measurable performance goals appear in the HHE Program strategic plan. Several respondents to this committee’s request for input also noted the need for better linkage between the HHE Program and OSHA and other NIOSH websites. One respondent suggested that linkage between the HHE Program and local health departments, state occupational safety agencies, and industry associations could be improved, and an invited speaker to a committee meeting from OSHA Region 1 suggested that HHE Program success stories could be posted on the OSHA website (Kent, 2007). The committee encourages the HHE Program to work toward its performance measures of increasing the percentage of relevant websites with links to its own website (see Table 3-1). The committee was told by HHE Program leadership that NIOSH is respon- sible for HHE webpages, editorial and graphics staff, and some administrative staff services. Although seeking economies of scale makes sense for a program as small as the HHE Program, it is also important that NIOSH provide adequate support to assist in the program mission. As revealed by its difficulty of use, it would seem that the HHE Program website is not a high priority for NIOSH. The HHE Program appears aware of the limitations of reliance on the Internet for dissemination, as reflected in the program’s strategic priorities and program descriptions of outreach activities. Respondents to the committee’s request for input identified a number of ways in which dissemination could be expanded, especially to reach underserved populations. The responses are summarized in Appendix D. In brief, the HHE Program appears aware of the need to diversify its social marketing efforts, and program staff informed the committee that it has engaged in pilot networking in Cincinnati, has conducted limited customer surveys, and is currently planning a targeted marketing campaign as part of its strategic plan. The recent employment of a full-time health communications expert will likely help move the program in the right direction. Participation in the NIOSH r2p

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  initiative10 may be promising, but depends greatly on the adequacy of funding and support for that effort, about which the committee collected no information. Recommendation: Improve the searchability of the online HHE search engine by developing a list of standardized key words (an alphabetized listing of hazards and diseases would be beneficial). Finding 5.1: The HHE Program is a recognized federal leader in its ability to respond quickly and effectively to new and emerging hazards, particularly in emergencies. As is the case for other activities of the HHE Program, measuring the impact of its emergency response activities is difficult. Data related to impact do not exist, and impact in this area is more difficult to assess because the HHE Program does not serve as the lead agency during emergency response. HHE staff often work in concert with staff from other agencies, and often under unusual circumstances, making contributions by the HHE Program difficult to quantify. However, anec- dotal evidence exists that can inform about the contributions of the program. As described in Chapters 2 and 3, HHE Program staff members are uniquely qualified to respond to emergencies and are often asked to assume leadership roles during emergency response. An important impact of the HHE Program, especially dur- ing emergency response, has been the subjective and effective validation of worker experiences and concerns. HHE Program procedures are established that allow staff to listen to workers in order to effect change and improve conditions. Some noteworthy examples of the HHE Program’s recognized excellence in emergency response are the prominent roles of staff in response to the World Trade Center disaster on September 11, 2001 (9/11). HHE staff participated in etiologic investigations of occupational exposures and the health effects among workers in a building close to the disaster site three months after 9/11 (Trout et al., 2002) and in later investigations of stress-related symptoms throughout the city (MMWR, 2002). The program also made important contributions in response to the 2001 anthrax attacks made through the U.S. Postal Service (USPS), highlighted in Box 4-1, and responding to issues related to the health effects of handling and opening mail ir- radiated to defend against biohazards (NIOSH, 2002c, e). In response to natural disasters, the HHE Program conducted investigations of the mental and physical health of the New Orleans Police and Fire Department personnel following Hurricane Katrina (NIOSH, 2006d, e). As part of a CDC team, 10 Research to Practice (r2p) is a NIOSH initiative focused on the transfer and translation of re- search findings, technologies, and information into highly effective prevention practices and products adopted in the workplace (http://www.cdc.gov/niosh/r2p/, accessed October 10, 2008).

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 7 BOX 4-1 HHE Program Response to Anthrax Contaminations In October 2001, Bacillus anthracis (anthrax) spores were received in the mail by a news media office in Florida. HHE staff members were part of the response team that con- ducted the environmental evaluations of the affected building and of USPS offices where the mail was processed (NIOSH, 2007b). Ultimately, HHE investigators participated in 26 more emergency response investigations involving potential anthrax contamination in Washington, D.C., Florida, Connecticut, New Jersey, New York, Missouri, and Texas in a short period of time. Fifty-five separate sites were evaluated in New Jersey alone. HHE staff collaborated with researchers inside and outside NIOSH to design reliable standardized protocols for collecting samples and to use existing sampling technologies in innovative ways. Onsite technical assistance was delivered as part of the initial response to suspected biological threats (NIOSH, 2002b). NIOSH worked with other CDC offices, OSHA, and USPS to develop and disseminate guidelines on engineering controls and personal protective equipment for postal workers, mail handlers, and first responders (CDC, 2001; NIOSH, 2001c, 2002c), and helped design cleanup adequacy standards, implement decontamination procedures, and conduct post-cleanup assessments. NIOSH also trained Federal Bureau of Investigation and U.S. Coast Guard personnel, independent contractors, and others in appropriate anthrax decontamination procedures. Information transfer was conducted by a variety of means. The emergency response teams communicated directly with teams at the investigated sites and helped staff the CDC command center, which provided 24-hour assistance for workers, employers, and the general public for an extended period of time. It is presumed that information disseminated through these mechanisms was based largely on the findings and expertise of HHE staff participating in the investigations. Additionally, HHE investigators authored or coauthored 17 peer-reviewed publications on the topic of anthrax; made 38 technical presentations; published 1 numbered HHE report and 3 web-based guidance documents; and testified to a congressional subcommittee regarding microbiological sampling methods for anthrax (NIOSH, 2007b). Within CDC, an educational video was produced for the benefit of postal workers (CDC, 2002). Development of training tools and research in anthrax detection methodologies contin- ued, stemming from the results of initial investigations. OSHA developed an illustrated and interactive web-based training tool on anthrax (OSHA, 2003). Sandia National Laboratories collaborated with Lawrence Livermore National Laboratories to develop a tool to assist cleanup personnel and officials at airports, other transportation centers, and high-traffic public buildings in the reoccupation of buildings following biological contamination, and tested the tool with the assistance of NIOSH staff (Sandia National Laboratories, 2005). The research for this tool was sponsored by the Department of Homeland Security and included partnerships with the San Francisco Bay area airports. Reoccupation of facilities contaminated with anthrax and remediated and tested by investigative teams resulted in no new cases of the disease, indicating successful remedia- tion efforts.

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h  the HHE Program assisted local, state, and federal agencies in addressing occupa- tional safety and health issues, performing surveillance and exposure assessments among workers, performing outreach to vulnerable workers, and disseminating occupational health data as the State of Louisiana and City of New Orleans rebuilt the city’s public health system. The HHE Program also provided international as- sistance in the aftermath of the 2004 Indonesian tsunami that killed more than 225,000 people. HHE investigators coordinated and prioritized donations to speed the selection and manufacturing of personal protective and other equipment (NIOSH, 2007b). The committee regards the information revealed through investigations con- ducted during the course of emergency response as useful and believes it will likely help responders in the event of similar future emergencies. Some emergencies, such as future anthrax or other biohazard attacks, may be avoided or their damaging effects mitigated, because of the guidelines and definitive recommendations es- tablished by NIOSH and the HHE Program. The U.S. Government Accountability Office (GAO) submitted a report to the House Subcommittee on National Secu- rity, Emerging Threats, and International Relations on agencies’ need to validate sampling activities in order to increase the confidence in negative sampling results (GAO, 2005a). Although this report examined USPS, CDC, and EPA sampling methodologies, NIOSH provided guidance to USPS during its sampling and was consulted by GAO during preparation of the report. Other NIOSH programs may have been informed by HHE Program activi- ties, as exhibited by such publications as Guidance for Filtration and Air-Cleaning Systems to Protect Building Enironments from Airborne Chemical, Biological, or Radiological Attacks (NIOSH, 2003c) and NIOSH Interim Recommendations for the Cleaning and Remediation of Flood-Contaminated HVAC Systems: A Guide for Building Owners and Managers (NIOSH, 2005d). The NIOSH National Personal Protective Technology Laboratory contracted with the RAND Science and Tech- nology Policy Institute to review available databases related to disease, injury, and fatality data associated with personal protective technologies in emergency response (Houser et al., 2004). Any evaluation of the impact of the HHE Program should consider that the program’s resources (for example, funding, staff, scientific capacity) can and will be commandeered during a national emergency. The committee is not able to ex- amine the effect of emergency response activities on day-to-day program activities in great detail because of the non-routine nature of emergency response. Financial repercussions of individual responses may differ depending on how the program is compensated for response activities. While emergency response may result in important positive impacts for those affected by the emergency, the program and

OCR for page 82
i m Pa c t s o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 9 NIOSH should remain diligent to avoid negative impact on the protection of hu- man health in more routine occupational settings. Recommendation: Continue to provide guidance and recommenda- tions during public health emergencies. To accomplish this, the HHE Program could a. Remain diligent by working with NIOSH management to avoid neg- ative impact on routine activities of the HHE Program as a result of emergency response activities. b. Develop a mechanism, such as the enlistment of help from training program participants and alumni, to ensure continuation of routine operations in the absence of staff involved in emergency response. IMPACT SCORE As noted in the initial part of this chapter, it is difficult to find quantitative data to support an estimation of the degree of impact of the HHE Program in terms of decreases in numbers of workplace illnesses. Yet there is evidence that workers in investigated or similar workplaces have experienced reductions in exposures to health hazards and inappropriate work practices as a result of activities of the HHE Program. Because these reductions would be expected to lead to improved health for the workers, the scoring of impact of the HHE Program by the committee is based on intermediate outcomes, namely reductions in exposures to health hazards or an improvement in work practices. The consensus of the committee is that the HHE Program can be highly effec- tive in investigating hazards and providing advice to workplaces that make requests. The HHE Program is unique in the occupational health community in investi- gating unanticipated or underappreciated hazards in the workplace and relating them to the exposure or occupational circumstances of the worker. However, the committee is concerned that the program is not reaching all occupational groups, particularly employees of small businesses and underserved populations. There is also a concern that limited funding and obligations for emergency responses might dilute the effectiveness of the program and cause it to veer from more routine industrial hygiene reviews. The transfer of information to workplaces other than those investigated and to other agencies in the occupational health community has been extensive; however, the transfer is incomplete in that many people interviewed by the committee were unaware of the HHE Program. Therefore, more emphasis needs to be placed on reaching out to the whole occupational health community.

OCR for page 82
t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 20 The HHE Program is found to have a strong impact on the development of NIOSH-recommended occupational guidelines and on the support of NIOSH testimony for proposed OSHA rules. The HHE Program also contributes signifi- cantly to the advancement of scientific knowledge through its publications in the open literature and interactions with research programs within NIOSH and other government agencies. Training programs through the HHE Program are thought to offer an excellent opportunity for increasing expertise in occupational health, and such programs, as well as the use of alumni from these programs in emergen- cies, should be expanded. Based on the scoring system developed by the Framework Committee (see Chapter 1, Box 1-1) the committee ranks the impact of the HHE Program as 4. If the committee had not been restricted to using integer scores, it would have scored the impact of the HHE Program as between 4 and 5.