The Health Hazard Evaluation Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health (2009)

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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 82 

I m pac t s 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 83 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. This simple exercise yields  See http://www.cdc.gov/niosh/hhe/ (accessed July 9, 2008). 

84 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 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. 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.  The number of relevant HHEs identified by the search engine for a given search term varied over the course of committee deliberations. 

I m pac t s 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 85 1.  HEALTH HAZARD EVALUATION PROGRAM IMPACT ON REDUCING WORKER RISK AND PREVENTING OCCUPATIONAL ILLNESS IN INVESTIGATED WORKSITES F  inding 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. 

86 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 TABLE 4-2  Examples of HHEs Resulting in Wide Impacts (1978-2006) Hazard HHE Reporta 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 • HETA-2005-0032- Research and Training (CPWR)b uses this 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) 

I m pac t s 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 87 TABLE 4-2  Continued Hazard HHE Reporta 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 

88 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 TABLE 4-2  Continued Hazard HHE Reporta 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) 

I m pac t s 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 89 TABLE 4-2  Continued Hazard HHE Reporta 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). 

90 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:  The followback surveys should be modified for use in assessing the relevance, feasibility, and impact of recommendations made by the HHE Program. F  inding 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. F  inding 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 

I m pac t s 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 91 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). 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   Worksafe 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). 

92 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 e ­ mployment 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 F  inding 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 

HHE Program Produced Outputs (HHE reports, CDs, Internet materials, etc.) S T NIOSH-Generated Documents Other NIOSH A and Materials Based on HHEs Program Materials K E H O Industries in Workers in NIOSH-funded OSHA and Disaster L Specific Specific Training NIEHS Worker Planners and World Health D Labor Unions Hazardous Hazardous Centers/Grantsb Training Response Organization E Areas Areasa for Professionals Centersc Personnel R S Students (industrial hygiene, Research Faculty medical, nursing, Activities engineering) HHE Responses International I Management Resolution Thousands Thousands Program- Employed Advancement planned to community M access to of specific of workers of workers generated within of knowledge avoid hazards; informed of P materials on occupational trained trained information industries for future leadership solutions to A prevention of health- using HHE- using HHE- incorporated where HHEs potential provided occupational C hazardous related generated generated into are relevant impact during health T conditions problems information curriculum information response hazards FIGURE 4-1  Routes of HHE Program impact beyond investigated workplaces. NOTE: NIEHS = National Institute of Environmental Health Sciences. aWhile the Internet is not currently accessed by all workers, more will have computer experience as the population ages, and this source of information will have broader impact. Figure 4-1.eps b17 training centers; 35 training grants. broadside cMore than 50 OSHA and NIEHS Training Centers. 93 

94 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 have been prepared, when funds were available, and provided free of charge to students in training in industrial hygiene, in occupational medicine and nursing, and as industrial safety specialists. Professionals in the field (including members of this evaluation committee) have also received such CDs. Members of the NIOSH Education and Research Centers (ERCs) training programs in master’s and doc- toral programs regularly use information collected in the conduct of HHEs (Carol Rice, Deputy Director, Education and Research Center for Occupational Safety and Health, University of Cincinnati, personal communication, April 2008). NIOSH has relationships with the International Labor Organization and the World Health Organization and shares hard copy and electronic documents for distribution to workplaces internationally (Paul Schulte, Director, Education and Information D ­ ivision, NIOSH, personal communication, April 2008). The committee encourages relationships with these groups and with international NIOSH counterparts. Because there are no U.S. Department of Labor regulations in place covering the use of many of the hazards identified in HHEs, these documents are valuable resources for employers, employees, consultants, and educators seeking to reduce illness and death in workplaces (see Table 4-2 for examples such as those related to metalworking fluids [MWFs] and musculoskeletal disorders). Annual reports, which might include information on the numbers and categories of HHE requests, industries and hazards involved, types of responses, resources required for re- sponses, summaries of key findings from selected HHE reports, data on timeliness goals, and outcomes and impacts, might also prove useful tools for disseminating information about the program and its activities. F  inding 2.2:  There is variable penetration of information into some communities. Table 4-2 illustrates industries in which there has been widespread dissemina- tion and transfer of information to relevant employers and employees. There is little to suggest, however, that HHE-generated information is received by employers and employees in small workplaces or by members of underserved populations. For this reason, the committee necessarily relied largely on anecdotal information. Below, the committee cites three examples of incomplete dissemination of HHE Program information. Example 1: Trade Organizations The committee heard from the vice president of manufacturing of a small flavor and fragrance manufacturing company in California (Speakman, 2008). An HHE was conducted at his facility to determine the cause and prevention of 

I m pac t s 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 95 ­ ulmonary disease among workers (NIOSH, 2007i). The company representa- p tive had not heard of the flavoring-related illness prior to the investigation at his worksite. The committee noted that a relevant trade association was already aware of the hazard at the time the HHE was conducted. The representative informed the committee that he was not a member of the particular trade association from which he may have received relevant information but, because of cost, was a member of a different trade association. Discussion led the committee to conclude that reliance on trade associations as a means for the HHE Program to reach small business may not be sufficient. After reviewing the list of HHE Program presentations made at trade confer- ences (NIOSH, 2007b:Appendix 2.14), the committee agreed that appearances in such venues are important and useful. However, the committee also received verbal and written stakeholder input that the HHE Program may need to increase its range of trade- and business-related venues. This is discussed in greater detail in Section 4 of this chapter. Example 2: Small Residential Construction Companies A representative of the CPWR—The Center for Construction Research and Training (CPWR) noted that HHE Program success stories include HHEs that have resulted in better control technologies to reduce exposures to, for example, lead and silica (Gittleman, 2007). These HHEs were conducted primarily in union settings. Because of the mobile and contingent nature of the construction industry, however, many workers may still be exposed to risks that are well understood. The CPWR representative described a need to target high-risk residential construction by small companies that do not have the resources to investigate and solve their work-related safety and health problems. Example 3: The Immigrant Labor Workforce A stakeholder spoke to the committee on behalf of the Interfaith Worker ­ ustice National Workers’ Centers Network and noted a general lack of knowledge J and understanding among the immigrant population it represents of what the HHE Program does, how it differs from the Department of Homeland Security’s  The California Department of Public Health requested the HHE in 2006 with the company’s cooperation, when two cases of pulmonary disease were identified at the facility. The HHE resulted in two additional cases of the illness being identified (NIOSH, 2007k).  Formerly known as the Center to Protect Workers’ Rights.  Interfaith Worker Justice is a network of people of faith established to educate, organize, and mo- bilize the religious community to act to protect the rights of, and improve working conditions and benefits for, workers, especially low-wage workers (http://iwj.org, accessed June 1, 2008). 

96 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 I ­ mmigration and Customs Enforcement (ICE) office, and how the HHE Program can benefit workers (Olíva, 2007). The inability of workers’ centers to file HHE requests on behalf of workers, as well as the fear of government and negative experi- ences, indicates the need for special outreach to worker centers, community-based and faith-based institutions, and day labor organizations. The need for materials to be translated and for information to be transferred in culturally effective ways was also stressed by this individual. In general, the committee finds evidence that HHE findings are disseminated widely to occupational health professionals, industries represented at technical meetings, certain trade associations, and a portion of the general public health community and worker training programs. The HHE Program stated in a written response to questions from the committee that it does not receive many requests from the agriculture and construction sectors. This was attributed to the temporary nature of the work, the mobility of the labor force, and the immigrant status of large parts of this labor force (NIOSH, 2007g:question #22). HHE Program staff members also indicated their awareness of the need to extend outreach, especially among the contingent workforce. The HHE Program has no formal mechanism to evaluate the effectiveness of knowledge transfer to employers and employees in facilities that have not been investigated. Boxes 3-2 and 3-3 describe the occupational hazards of diacetyl and flock, respectively, and the HHE Program’s essential role in determining the relation- ship between workers’ exposure to these substances and serious respiratory dis- eases. However, the public and policy responses to these two substances have been completely different. There has been widespread media and regulatory attention focused on diacetyl, while flock has continued in production with relatively little attention. In some respects, the attention to diacetyl may be due to potential expo- sure among the general public as well as to workers. The HHEs related to diacetyl were an important part of a chain of events that will likely result in rule-making and have already led to limited voluntary substitution with other flavoring agents. In contrast, the HHEs related to flock exposure generated recommendations by NIOSH, but no attention at OSHA. The extent to which the flock industry follows the NIOSH guidelines is not known to the committee. It may be instructive to the HHE Program to assess the differences between the public responses to diacetyl and flock and to use these findings to improve information dissemination for similar issues in the future. R  ecommendation:  Develop a proactive, comprehensive information- transfer strategy for HHE Program outputs with better approaches to reaching wider audiences, including traditionally underserved popula- tions. The HHE Program could 

I m pac t s 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 97 a  . Use innovative techniques to reach small businesses and under- served populations, creating a broad array of mechanisms for com- municating with diverse constituencies and attending to issues of literacy, language, and national-origin barriers. b Develop distribution mechanisms that are not Internet-dependent  .  to complement Internet distributions. c Disseminate HHE results more broadly to groups likely to be af-  .  fected, including distribution of HHE reports in the geographic regions where investigations are conducted. d  . Increase efforts to consolidate findings of multiple HHEs for specific hazards (for example, the compendia compiled for lead and other topics). e Develop improved methods of outreach to stakeholders so that  .  workers and workplaces affected by new and emerging occupational health problems will be alerted quickly. f Supplement program outreach efforts by using community and  .  small-business groups to translate HHE results and findings for their constituencies. g Leverage existing NIOSH, Centers for Disease Control and Preven-  .  tion (CDC), and Department of Health and Human Services (HHS) resources to enhance technology transfer. h  . Evaluate, in a formal manner, the effectiveness of information-trans- fer programs, including knowledge transfer to employers and em- ployees at worksites where HHEs have not been conducted. 3.  IMPACT OF THE HEALTH HAZARD EVALUATION PROGRAM ON NIOSH RESEARCH AND POLICY DEVELOPMENT PROGRAMS The HHE Program is a relatively small unit within NIOSH, which itself is a relatively small unit within CDC, which is a relatively small unit of HHS. A program of such small size and such a diverse mission needs to use the resources of its parent agencies to fulfill some of its functions. Furthermore, because the HHE Program itself does not have regulatory authority, its ability to have larger policy impacts is a function of its integration into the policy communication and decision-making structures of the agencies authorized to engage in policy development. In brief, the ability of the HHE Program to have impacts on other related research portfolios and policy development must in part flow through higher-level policy chains to have an impact on worker safety at the macro level (for example, beyond that of the individual HHE site level). This section of the report is divided into findings related to policy impact and findings related to impact on research programs. 

98 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 Policy-Related Impact F  inding 3.1:  The HHE Program does not have the authority to promul- gate regulation but does inform the setting of regulations. The HHE Program has had substantial impact on policy and the develop- ment of regulation to protect workers in several high-profile areas. Furthermore, in several high-profile areas, the HHE Program contributed knowledge that led to changes beyond those required by law or regulation on the part of industry. These changes have led to positive impacts on worker health and safety. Policy is a multifaceted concept that is particularly complicated in the domain of public health. Federal policy-making and implementation are ultimately the responsibility of elected or appointed officials in the executive, legislative, and judicial branches. The HHE Program is part of HHS, a large and diverse executive cabinet agency, which is superordinate to CDC, which is superordinate to NIOSH, which in turn is superordinate to the HHE Program. As with all cabinet agencies, the policy agenda is ultimately set by the President of the United States. External political and organizational factors govern the types of policy impact that the HHE Program can have and are the dominant factors limiting the program’s ability to have policy impact. The HHE Program is quite small in both budgetary authority and personnel. Furthermore, its legislative mandate has been interpreted—through regulation—as very narrow with respect to the definition of what constitutes a valid request. Chapter 2 describes the regulatory interpretation. In this chapter, the committee interprets how the HHE Program leverages the resources of other occupational health actors to perform its mission and extend the impact of its activities and outputs. The committee found substantial evidence that the HHE Program is positioned to provide high-quality technical advice—when requested—with some policy implications at the state level and for other parts of the federal government. For example, the HHE Program is represented on the National Occupational Research Agenda (NORA) sector councils and other federal occupational health committees with other agencies, such as OSHA, the Environmental Protection Agency (EPA), and the U.S. Navy (NIOSH, 2007b). In one case, the HHE Program teamed up with the Federal Highway Administration to evaluate asphalt exposure during paving (NIOSH, 2002a) and with the Transportation Security Administration to assess ra- diation exposure of baggage screeners (NIOSH, 2006i). In general, it would appear that most of such efforts are targeted at the federal level, but it is beyond the scope of the committee’s charge to evaluate the impact of these mechanisms outside the HHE Program. Discussions with HHE Program staff during committee meetings 

I m pac t s 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 99 suggest that staff hold a narrow view of the HHE Program role in policy develop- ment, either within or outside of NIOSH. The impression is one of purposefully keeping a low profile. The committee has already noted the substantial evidence that supports the HHE Program’s centrality in policy-relevant emerging hazard areas such as emer- gency response, and with hazards associated with diacetyl, MWFs, and latex gloves. During the course of this evaluation, the HHE Program became actively involved in a study of inflammatory neuropathy among swine slaughterhouse workers in Minnesota (MMWR, 2008). The committee considers this an example of how the HHE Program is positioned to respond quickly to emerging health hazards; at the beginning of this committee’s deliberations, the issue was not of particular concern, but toward the end, the problem was nationally prominent. The findings emerging from HHE involvement are being used to develop safeguards in such facilities and may extend to other kinds of production involving high-pressure treatment of brain material. The committee concludes that the HHE Program has a very good reputation (among those who know about it) and that it is readily called upon in the event of new, emerging, and poorly understood problems. At the time this report was being prepared, there was substantial evidence that HHE Program activity on the topic of diacetyl (a butter flavoring) has led to significant legislative efforts geared toward eliminating diacetyl from production processes. For example, California Assemblywoman Sally Lieber (D) introduced a bill to ban diacetyl use by 2009 (California Assembly, 2007). In September 2007, the U.S. House of Representatives passed a bill to require OSHA to set a standard limiting diacetyl exposure (U.S. Congress, House of Representatives, House Edu- cation and Labor, 2007); as of June 2008, the bill was on the Senate Legislative Calendar. It is still not clear how the HHE Program participates in developing specific policy and research recommendations. For example, the committee was not able to determine exactly how the HHE Program originally became involved in the diacetyl issue. Diacetyl is used to flavor popcorn and a variety of other food products (see Box 3-2); however, it remains unclear how the HHE Program will expand knowledge about the hazards in the absence of HHE requests (for example, NIOSH, 2007i) or the very high profile cases related to popcorn manufacturing. This case perhaps highlights the difficulty the HHE Program has in proactively influencing policy development because it must be asked to conduct investigations or be called on by policy-makers for advice. The program’s enabling regulations limit its ability to be proactive in participating in the regulatory process.  This bill was approved by the California Assembly but was put into an inactive file of the California Senate in February 2008. As of June 4, 2008, no new action had been taken on this bill (California Assembly, 2008). 

100 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 In an early case of high policy impact, in 1977, an HHE conducted in col- laboration with the University of California developed evidence that dibromoch- loropropane (DBCP) caused sterility among workers at a facility in California (NIOSH, 1977). Several months later, OSHA used these program-generated data and experimental carcinogenesis data to regulate this chemical. This reduced the risk of sterility in people exposed to DBCP. Since DBCP is a component of pesti- cides, the impacts are far reaching for a number of different industries and worker groups. These efforts also contributed to the placement of this chemical on the EPA pesticide registry. The body of MWF HHE reports had a significant input to the NIOSH Cri- teria for a Recommended Standard: Occupational Exposure to Metalworking Fluids (NIOSH, 1998b), which recommended the first authoritative exposure limit for MWFs. The findings led an MWF Standards Advisory Committee to recommend that an OSHA standard be set based on the NIOSH recommended exposure limit (REL), medical surveillance, and other provisions (Sheehan, 1999). OSHA declined to move forward with a standard, which is an external factor beyond the control of the HHE Program and NIOSH, limiting the impact of these findings. Nevertheless, the NIOSH REL, which is based in substantial part on these HHEs, has become the benchmark for equipment design and maintenance in significant industrial facilities. Committee members knowledgeable on this topic reported that new equipment manufactured in this industry complies with the NIOSH REL and that substantial progress has been made retrofitting older equipment to achieve this exposure limit. The HHE Program played an important role in efforts to develop regulation related to indoor air quality. Ultimately, this policy process did not progress to an established regulation, but the centrality of HHE Program work in the deliberative process is indicative of its excellent reputation when higher levels of policy-making are introduced. An OSHA employee who spoke with the committee suggested that prioritizing recommended controls in HHE reports would help OSHA to be more specific in standard setting (Kent, 2007). Overall, she highly commended the HHE Program, indicating that report findings are crucial for the regulatory process, but indicated that, regrettably, the HHE Program was not used to its fullest within OSHA or in industrial hygiene training communities. Ways of improving knowledge of the program are addressed in subsequent sections of this chapter and in Chapter 3. The penetration of powder-free gloves into the healthcare market and practice is a direct result of HHEs conducted in healthcare delivery settings. Prior to HHE involvement, there was widespread use in the healthcare industry of powdered latex gloves, which caused a latex-related allergic reaction among some users. Several HHEs were conducted; as a body, these HHEs associated latex rubber protein with 

I m pac t s 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 101 adverse allergic health reactions. The HHE investigators were among those who created the NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace (NIOSH, 1997c). These were distributed very broadly within the healthcare delivery sector. Healthcare professional organizations cited the alert in making recommendations to provide alternatives to powdered latex gloves (e.g., Nagel, 1997 [American Chemical Society]; New York State Department of Health, 1998; Natural Rubber Latex Allergy discussion group, 2008). R  ecommendation:  Develop more extensive formal linkages and mecha- nisms with other parts of NIOSH, CDC, and HHS to enhance the capac- ity for involvement in policy-relevant impacts through a Promotion and increase in direct communication, especially with  .  OSHA and state occupational safety and health agencies. b Alerts to NIOSH and CDC about HHEs that are relevant to policy-  .  making outside the CDC system. c Continued regular use of the National Occupational Research  .  Agenda (NORA) sector councils and the NIOSH Board of Scientific Counselors to disseminate information about the HHE Program. d  . Pursuit of a change in the HHE Program’s legislative and regula- tory authority to improve the capacity to identify hazards in need of HHEs, improve the ability to gain entrance to facilities when requested by treating physicians or community representatives, and address exposures other than chemical agents. F  inding 3.2:  The HHE Program provides data and personnel to sup- port NIOSH-recommended guidelines and NIOSH policy development activities. The HHE Program communicates occasionally with other policy-related orga- nizations, including those higher in the NIOSH hierarchy, to develop and forward policy recommendations. This activity may be limited by the organizational design of the agency (matrix management), the HHE Program’s narrow interpretation of policy-relevant problems, and political concerns. The program has made con- tributions to NIOSH policy development through interactions with the NIOSH Authoritative Recommendations (AR) Program. According to written response to questions from the committee, the HHE Program has provided staff to support AR activities, including the preparation of written and oral testimony in support of proposed OSHA standards, and has provided data to support NIOSH policy devel- opment (NIOSH, 2008e). The HHE Program provided the committee ­information 

102 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 on 15 different areas in which the HHE Program has made or is making contribu- tions toward NIOSH standards or policy developments (see Table 4-3). The participation of the HHE Program in AR Program activities is evidence of how NIOSH fulfills its policy functions using HHE Program research. Examples of NIOSH policy functions include providing testimony to Congress, participating in OSHA regulatory processes, publishing guidance documents, and developing public statements for dissemination on the Internet. The HHE Program provides valuable support to these policy activities, which are outside the HHE Program regulatory mandate, but within that of NIOSH. F  inding 3.3:  Relationships with certain state and local health depart- ments appear to be strong. The committee heard from stakeholders about important relationships be- tween the HHE Program and certain local and state health departments, but the committee also learned of some state and local governments with which the HHE Program does not sufficiently communicate. The HHE Program has participated in NIOSH-sponsored surveillance meetings to reach state surveillance programs. It has made presentations to state-based organizations (for example, the Council of State and Territorial Epidemiologists) and has made contact with specific states. It has used the CDC Epidemic Intelligence Service (EIS) program to reach some state health departments and has trained state-based EIS officers at the Morgantown facility. It would not be expected that the HHE Program would work closely with the NIOSH Fatality Assessment and Control Evaluation (FACE) program because of FACE Program focus on acute traumatic fatalities as opposed to occupational illness. Despite strong outreach efforts made in a general way and very good relation- ships developed in some specific cases (for example, with the California OSHA), outreach to state and local health departments is incomplete. Communicating with state health departments may not translate to communication with local health departments. Responses to the committee’s request for stakeholder input indicate similar concerns about outreach to local health departments (see Appendix D for a summary of responses). Research-Related Impact In this section, the committee focuses on two aspects of research impact: those related to the development of laboratory or field-related experimental research programs at NIOSH and elsewhere, and those related to the impact on training the occupational health labor force. Section 4 of this chapter examines the impact 

I m pac t s 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 103 TABLE 4-3  HHE Program Interaction with the NIOSH Authoritative Recommendations Program Subject Area HHE Contribution Tuberculosis HHE investigators and data supported NIOSH testimony related to proposed OSHA rule on occupational tuberculosis Ergonomics • HHE investigators and data supported NIOSH testimony related to proposed OSHA rule on ergonomics (http://www.cdc.gov/niosh/docs/2001-108/ pdfs/2001-108.pdf) • HHE investigators and data supported NIOSH guidance document (http:// www.cdc.gov/niosh/97-117pd.html) • HHE investigators and data supported NIOSH science review document (http://www.cdc.gov/niosh/docs/97-141/) Biosolids HHE investigators and data supported NIOSH guidance document (http://www. cdc.gov/niosh/docs/2002-149/pdfs/2002-149.pdf) Latex HHE investigators and data supported NIOSH guidance document (http://www. cdc.gov/niosh/latexalt.html) Indoor HHE investigators, drawing on their HHE field experience, helped develop environmental NIOSH testimony to the U.S. Department of Labor on indoor air quality quality (Rosenstock, 1996) Metalworking HHE investigators and data supported NIOSH policy document (http://www.cdc. fluids gov/niosh/98-102.html) Take-home HHE investigators and data supported NIOSH policy document (http://www.cdc. lead gov/niosh/contamin.html) Histoplasmosis HHE investigators and data supported NIOSH guidance document (http://www. cdc.gov/niosh/docs/2005-109/) Hexavalent HHE investigators and data supported NIOSH policy statement: NIOSH chromium Comments on the OSHA Request for Information on Occupational Exposure to Hexavalent Chromium (http://www.cdc.gov/niosh/topics/hexchrom/pdfs/Cr(VI)_ NIOSH_OSHA.pdf) Respirator HHE data supported NIOSH policy document (http://www.cdc.gov/niosh/ decision logic docs/2005-100/appendix.html) Hearing loss HHE investigators supported NIOSH guidance document (http://www.cdc.gov/ niosh/docs/96-110/pdfs/96-110.pdf) Body art HHE data supported NIOSH guidance (http://www.cdc.gov/niosh/topics/bbp/ bodyart/) Workers with HHE investigators and HHE data helped develop NIOSH website content (http:// disabilities www.cdc.gov/niosh/topics/wdd/default.html) Emergency HHE investigators, drawing on their HHE field experience, helped develop response NIOSH website content (http://www.cdc.gov/niosh/topics/emres/) Skin notation In progress SOURCE: NIOSH (2008e). 

104 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 scientific publication specifically. Overall, for a program that is characterized as a service program, the committee found the HHE Program to be quite actively engaged in the applied scientific enterprise. F  inding 3.4:  The HHE Program strongly influences research programs and the scientific body of knowledge. The HHE Program has both indirect and direct influence on the research direc- tions of NIOSH programs. For example, the various NORA committees develop research agendas for NIOSH programs they advise. According to a NORA sector committee member, some of the agendas are influenced by the work of the HHE Program (Barbara Silverstein, Research Director, Safety and Health Assessment and Research for Prevention, Washington State Department of Labor and Industries, personal communication, July 9, 2008). More directly, much of the research within, for example, the NIOSH Respiratory Diseases Research Program (RDRP), is based on unanticipated workplace hazards identified through the HHE Program. The HHE Program has stimulated research in areas such as the respiratory problems caused by flavorings, flock, waterproofing spray, and vaporized viruses. The output of this research is evidenced by the extensive publication list described in Section 4 of this chapter. Aside from impacts already highlighted in this report, the HHE Program, since the 1990s, has contributed to other research areas, including the engineering control of noise exposure in indoor firing ranges; the etiologic relationships and health effect mechanisms associated with various musculoskeletal disorders and with male repro- ductive function associated with bicycle seats; and exposure monitoring techniques related to environmental tobacco smoke, nanotechnology, anthrax, and abrasive blasting (NIOSH, 2008e). Though it was beyond the committee’s charge to review other NIOSH programs influenced by the HHE Program, the committee assumes, based on information received from the program, that it has influenced research within the NIOSH Cancer, Reproductive and Cardiovascular Diseases Program; the Engineering Controls Program; the Exposure Assessment Program; the Hearing Loss Prevention Program; the Musculoskeletal Disorders Program; the Nanotechnology Program; and the Personal Protective Technology Program, among others. The com- mittee was not able to determine the level of influence based on the information presented. It is evident that HHE Program input has led to major contributions of new information in the literature and has increased the scientific knowledge base about workplace hazards. One of the strengths of the HHE Program is its flexibility and responsiveness to a variety of occupational health problems. It maintains this strength with a very small budget and limited personnel, which requires the effective use of scientific 

I m pac t s 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 105 resources located elsewhere. For example, NIOSH has an interagency agreement with the HHS National Toxicology Program (NTP) to support research on complex industrial exposures (Bucher, 2008). NTP evaluates chemical agents of public heath concern for chronic toxicity, including carcinogenicity and reproductive toxicity, using modern methods in toxicology and molecular biology (NTP, 2008). Chemi- cals to be tested may be nominated by anyone with a concern. In 1998, the HHE Program conducted two HHEs related to bromopropane, a group of chemicals for which there are no OSHA standards, at the request of the North Carolina Depart- ment of Occupational Safety and Health (NIOSH, 2002b, 2003d). Comprehensive study of these chemicals would have required vast resources, and NIOSH subse- quently nominated bromopropane in two chemical forms for evaluation by NTP. NTP evaluated bromopropane based on documented evidence of worker exposures (citing HHEs in its final reports) and the published evidence of reproductive and developmental toxicity, and defined the critical needs for data to improve assess- ment of toxicity to humans (NTP, 2002a, b). HHE Program investigations led to two other published studies on bromopropane, one assessing the relationship be- tween DNA damage and bromopropane exposure, and the other to better charac- terize the bromopropane exposure hazard and to evaluate the utility of a biomarker for assessing exposure (NIOSH, 2007b). NTP sometimes calls on NIOSH for its expertise to help evaluate the urgency of testing chemicals nominated by others for review. For example, the HHE Program may conduct HHEs and report back summary findings to NTP. Infrequently, NTP supports HHE activities, for example, an HHE related to cellulose insulation (NIOSH, 2001d; Bucher, 2008). The HHE Program documented numerous productive arrangements with NIOSH laboratories for analytic purposes (NIOSH, 2007b). F  inding 3.5:  The HHE Program has a significant impact on the training, development, and placement of program alumni inside and outside the HHE Program in the occupational health community. A key output of the HHE Program is the occupational health professionals who have gone through training with the program. The HHE Program trains and places a large number of these professionals, constituting a significant transfer of ­human  Bromopropane is used in spray adhesives; as a precision cleaner and degreaser; in the synthesis of pharmaceuticals, insecticides, quaternary ammonium compounds, and flavors and fragrances; and as a solvent for fats, waxes, or resins (NTP, 2002a, b).  The NTP concluded that sufficient evidence existed to characterize 2-bromopropane as a repro- ductive hazard for humans (NTP, 2002b). 1-Bromopropane was determined to be a reproductive hazard for laboratory rodents, but insufficient evidence existed to conclusively show toxicity in humans (NTP, 2002a). 

106 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 capital to the occupational health community through hosting international visi- tors, providing one- to three-month rotations or joint residency programs for occupational medicine residents, offering “tag-along” opportunities to participate in HHEs, supporting positions for EIS officers, and supporting summer positions for minority students to learn about occupational health (NIOSH, 2008d). HHE- trained professionals bring the skills, methodologies, and habits developed by the HHE Program to a broad array of public and private agencies. The committee finds that the HHE Program plays a significant role in the training of the occupational health labor force through its participation in such programs as the Commissioned Officer Student Training and Extern Program (COSTEP) and EIS. The committee is impressed by the commitment to occupational health fostered by participation in HHE Programs over the decades, attested to by committee members themselves and reflected in numerous written and oral statements made to the committee. The occupational health community would benefit from continued HHE Program engagement in strategic recruitment of trainees, perhaps by partner- ing more extensively with ERCs and universities. Committee members conclude, based on their own experiences, that universities could and should be doing more to recruit the occupational health labor force of the future, and that the HHE Program could play a substantial role in the training and placement of that labor force. The funding of these programs is largely outside HHE Program control, which increases the need for the HHE Program to recruit actively from the CDC program training ranks. There is limited tracking of program alumni (NIOSH, 2008d), and the commit- tee finds little evidence that program alumni are used in any substantive capacity in advisory, case finding, or investigative roles (despite a high degree of enthusiasm and loyalty exhibited among program alumni encountered by the committee). The committee recommends the development of a program-level advisory board that would assist the HHE Program in leveraging its resources. In addition to program alumni, board members could include members of community groups and occu- pations not currently well served by the HHE Program. The advisory board could serve a recruiting and retention function, provide opportunities to use program alumni, assist with case finding, and provide expert advice about meeting some of the challenges facing the HHE Program given its limited resources and emerging challenges. R  ecommendation: Use the HHE Program to develop occupational health professional resources. This could be accomplished through a Increased recruitment of new investigators from universities, EIS,  .  COSTEP, occupational medicine residencies, Education and Re- search Centers for Occupational Safety and Health (ERCs), and state 

I m pac t s 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 107 and local health departments into HHE Program training rotations. This will require ongoing development of more attractive training, mentoring, and rotations. b Tracking and mobilizing the extensive talent and commitment rep-  .  resented in the HHE Program-trained occupational health work- force. A network of HHE Program alumni could be fostered to help develop HHE opportunities. A program-level advisory board could assist the program in leveraging resources, serve a recruiting and retention function, assist in identifying emerging issues, and pro- vide expert advice during normal program operations and when normal program operations are interrupted by emergency response activities. c Engagement and use of ERCs and other university-based training  .  programs to involve trainees in HHE field investigations. d  . More formal collaborations with ERC faculty and other extramural researchers to assist with field investigation, dissemination, and training opportunities. 4.  TRANSFER OF PROGRAM-GENERATED HAZARD AND PREVENTION INFORMATION TO THE OCCUPATIONAL HEALTH COMMUNITY The committee is charged with examining how the HHE Program transfers program-generated information to the occupational health community, with a particular focus on whether the information is presented appropriately. In this section, the committee begins by defining the occupational health community as a heterogeneous group of people requiring different strategies for effective transfer. The committee then turns to an evaluation of the specific knowledge transfer and exchange mechanisms used by the HHE Program to reach target audiences in the occupational health community. The occupational health community is heterogeneous and includes scientists, occupational public health professionals, the public health labor force as a whole, companies, managers, members of the labor force, and institutions that represent individuals and groups. A comprehensive and appropriate technology transfer program would be targeted to the needs of this heterogeneous community. In order to assess this aspect of the HHE Program, the committee collected numer- ous examples of HHE communication strategies, solicited written comments from stakeholders, heard testimony from employers and employees affected by the HHE Program, and received detailed responses to related questions from HHE Program staff. Furthermore, a majority of the HHE Program performance measures (listed in Table 3-1) are directly related to transfer activities, including increased targeted 

108 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 marketing; increased number of links to the HHE Program website from external websites; greater use of eNews and Epi-X; publishing of compendia of findings, annual reports, and peer-reviewed publications; participation in interagency ac- tivities; and participation at trade meetings. Finally, recommendations related to transfer activities in prior evaluations of the HHE Program (NIOSH BSC, 1997, 2006; RTI, 1997) have been addressed by the program staff and are now represented in its current portfolio of knowledge transfer and exchange activities. Examples of Transfer to the Occupational Health Community Transfer Material Type: Numbered HHE reports F  inding 4.1:  Numbered HHE reports are generally of high quality, of direct immediate benefit to investigated sites, and of benefit to the larger occupational health community. As discussed in earlier chapters, the numbered HHE report is the primary output of the HHE Program, emanating directly from the enabling legislation and regulation. The committee reviewed numerous examples of numbered HHE reports, received input from report recipients, and solicited comments from the occupational health community about HHE reports. The committee also examined response patterns from the HHE followback survey program designed to assess satisfaction before, during, and after the conduct of an HHE investigation. HHE reports are generally of very high quality and useful to the specific site investigated and to the larger community of educated and informed occupational health profes- sionals. The plain-language summary “Highlights” page included at the beginning of every numbered HHE report was specifically mentioned by stakeholders as being of particular use to workers. Ongoing efforts in the development of the format of numbered HHE reports seem to increase both efficiency and effectiveness. When necessary, given the composition of the labor force, HHE reports are translated into other languages. The HHE Program is at heart an applied research program; however, the fact that some HHE reports have been translated to the peer-reviewed scientific literature is testimony to their high quality. In its request for input, the committee heard very positive feedback about the quality, efficiency, and usability of the HHE report process and products. Transfer Material Type: Technical Assistance Letters F  inding 4.2:  Technical assistance letters appear to be an efficient use of HHE Program resources when problems are well understood. Because 

I m pac t s 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 109 they are not disseminated widely, they are of little benefit to the larger occupational health community. As discussed in Chapter 3, the committee reviewed 10 examples of technical assistance letters written by the HHE Program staff to individual requestors in response to valid HHE requests. HHE Program staff indicated that technical as- sistance letters were generated when a considerable amount of expertise on a topic already exists, enabling staff to provide detailed information to the requestors. For example, a letter response to a request concerning ventilation conditions in a health facility used the findings of a site-specific building inspection, a health inspection by the state authority, findings of a site safety committee, a report by the Institute of Medicine, a referral to relevant guidelines generated by a different state agency, national engineering standards, and a peer-reviewed publication (NIOSH, 2007d). This four-page letter provided very detailed guidance for remedying the problem, with appropriate resources provided as enclosures. Additional examples of techni- cal assistance letters reviewed by the committee were on the topics of ventilation, exposures to well-defined chemical hazards, and exposure to biological hazards. In general, the letters were well documented. One of the letter reports pertaining to biological hazards included seven references to the peer-reviewed and regulatory literature (NIOSH, 2006f). Inclusion of such references in these reports effectively transfers knowledge of sources of relevant information. These letters do not ap- pear to be disseminated widely, limiting the potential impact of the transfer of knowledge. Transfer Material Type: Peer-Reviewed Publications F  inding 4.3:  The HHE Program engages in a great deal of formal scien- tific publication related to its research. The HHE Program provided the committee with 58 pages of titles of various papers disseminating program results dated from the early 1990s to the present. The titles include numbered HHE reports, journal articles, book chapters, NIOSH numbered documents, and other items appearing in trade journals. From 1996 to 2007, the HHE Program issued well over 100 peer-reviewed publications, including those in major medical journals, such as the Journal of the American Medical Association, the New England Journal of Medicine, the American Journal of Industrial Medicine, the Journal of Occupational and Environmental Medi- cine, and the American Journal of Surgical Pathology. HHE Program scientists have also authored peer-reviewed articles in the leading general journal of public health, the American Journal of Public Health. Articles are similarly well placed in toxicol- ogy (Neurological Toxicology, Toxicologist, Journal of Toxicology and Environmental 

110 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 Health, Critical Reviews in Toxicology); occupational health (American Industrial Hygiene Association Journal, Applied Occupational Environmental Hygiene, Journal of Occupational and Environmental Hygiene); and environmental health (Journal of Environmental Monitoring, Environmental Health Perspectives), 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 F  inding 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 

I m pac t s 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 111 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 F  inding 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 •  manufacturing: the American Automobile Manufacturers Association, in the National Cotton Council of America, and the International Roofing Exposition; •  professional associations: the National Hearing Conservation ­Association; at and •  regional meetings: the Kentucky-Tennessee Water Environment at A ­ ssociation, 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. 

112 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 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 Activity Type: Interagency Cooperation F  inding 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 

I m pac t s 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 113 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 F  inding 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. R  ecommendation:  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. 

114 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 Dissemination Strategies F  inding 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 

I m pac t s 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 115 i ­ nconsistencies 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 

116 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 initiative10 may be promising, but depends greatly on the adequacy of funding and support for that effort, about which the committee collected no information. R  ecommendation:  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). F  inding 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). 

I m pac t s 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 117 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. 

118 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 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 Environments 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 

I m pac t s 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 119 NIOSH should remain diligent to avoid negative impact on the protection of hu- man health in more routine occupational settings. R  ecommendation: 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. 

120 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 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.