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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Suggested Citation:"1 Introduction." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

1 Introduction The workplace is where 156 million working adults in the United States spend many waking hours, and it has a profound influence on health and well-being. Work-related injuries and illnesses can impact quality of life (BLS, 2017a). Although some occupations and work-related activities are more hazardous than others and face higher rates of injuries, illness, disease, and fatalities, workers in all occupations face some form of work-related safety and health concerns (e.g., musculoskeletal disorders arising from repeti- tive motions, work-related stress, pulmonary symptoms or diseases caused by airborne exposures, and injuries resulting from falls or unstable work areas). Not only are such hazards a threat to worker well- being and hence to the nation’s health, but one study estimated the annual cost of occupational injuries, illnesses, and deaths in the United States at $250 billion, which is more than the $219 billion for all can- cer and approaching the $431.8 billion for all cardiovascular disease (Leigh, 2011). Reducing that health burden is the goal of occupational safety and health (OSH) surveillance. OSH surveillance provides the data and analyses needed to improve worker safety and health and to understand the relationships between work and injuries and illnesses. Today, OSH surveillance efforts are fragmented across multiple federal and state agencies that collect, store, analyze, and interpret data to meet their specific agency needs. Agency resources dedicated specifically to work-related safety and health surveillance are limited, partly because the responsibility for occupational health and safety issues is divided between labor and public health and there has never been core public health funding allocated specifically for OSH surveillance. Many factors point to a need to rethink and improve OSH surveillance in the United States including changes in the nature of work, the workforce, and employer-worker rela- tionships that have occurred over the past 40 years along with ever evolving methods and technologies for identifying, reducing, and eliminating work-related health and safety risks. A more cohesive and “smarter” OSH surveillance system is needed to address the demands and con- cerns of the current and future workforce. It needs to be “smarter” in the sense that the system needs to be one that demonstrates efficiencies, integrates strategies across multiple data sources, coordinates efforts across key surveillance agencies, and applies domain knowledge effectively to interpret data and to deliv- er insights to key stakeholders. Furthermore, there is an opportunity to think creatively about envisioning how that “smarter” system might build upon the current system and regulatory climate in the United States and take full advantage of new information technologies. Additionally, effective and comprehen- sive OSH surveillance models from other countries can be explored. This report aims to put forth a vision and pragmatic framework for a national OSH surveillance system in the United States with the goal of improving worker safety and health. BACKGROUND The topic of occupational safety and health surveillance across the United States was last examined comprehensively in a 1987 National Research Council (NRC) report Counting Injuries and Illnesses in the Workplace: Proposals for a Better System. In a more recent series of eight reports by the NRC and the Institute of Medicine that evaluated the National Institute for Occupational Safety and Health’s (NIOSH’s) research programs, all of the reports identified the need for improved OSH surveillance and for additional surveillance research (IOM and NRC, 2009). The Council of State and Territorial Epidemi- 10 Prepublication Copy

Introduction ologists has also issued calls for improvements to address surveillance gaps (Boulton et al., 2003; CSTE, 2010, 2014). There is recognition that surveillance could be conducted more innovatively and collabora- tively; for instance, by leveraging activities and resources regardless of whether they are drawn directly from various sectors of the workforce or other public health domains, or borrowed from unrelated fields. There is also the recognition that enhanced coordination of surveillance activities could enable individual state and federal agency responsibilities to better protect workers. New data sources and information technologies, such as those supporting health care reform (the Affordable Care Act), could also be used to support occupational safety and health needs. Changes in the Nature of Work and the Workforce and Implications for Occupational Safety and Health Since the 1987 report, there have been major changes in the nature of work, including em- ployee-employment arrangements, the distribution of employment among industry sectors, and the demographics of the workforce (see Figure 1-1; BLS, 2017a). Employment in manufactur- ing has declined, while significant growth in employment has occurred in the service sector, including health care. Individuals are likely to be working more than one job over their work- ing life, and may hold multiple jobs at the same time. Growth has occurred in nonstandard work arrangements, such as the use of independent contractors and the outsourcing of functions to other entities, and the development of “on-demand” or “gig” work, where employment is characterized by short-term contracts or freelance work (e.g., drivers who contract with ride- share companies)(Katz and Krueger, 2016). Furthermore, the workforce is more diverse and in- cludes more women (Figure 1-2), racial and ethnic minorities (Figure 1-3), and immigrants (Myers et al., 2013; BLS, 2017b). With these shifts in work and the workforce, employment is more precarious and many workers lack the protections and rights afforded by laws and regula- tions that make them more vulnerable and subject to abuse. FIGURE 1-1 Shifts in Employment by Selected Major Industry Sectors, United States, 2006-2026. Source: BLS, 2017a. Prepublication Copy 11

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century FIGURE 1-2 Shifts in Labor Population by Gender, United States, 1996-2026. Source: BLS, 2017b. FIGURE 1-3: Shifts in Labor Population by Race and Ethnicity, United States, 1996-2026. Source: BLS, 2017b. 12 Prepublication Copy

Introduction Approaches to occupational safety and health surveillance have yet to evolve to address effectively the changing nature of work. For example, some current data-collection approaches that use “establish- ments” as the basic employer unit typically rely on single employers and worksites, which are insufficient because those approaches are unable to capture gaps and emerging concerns created by the evolution of employment (Weil, 2014). Furthermore, data on hazards, protective safety, and health-management prac- tices in individual work settings have not routinely been collected in a systematic way. The ability to carry out rigorous workforce safety and health surveillance has other challenges as well. For example, in certain industry sectors (such as agriculture) or demographic groups (such as day laborers or teenagers), the total number of workers in an industry is necessarily a rough estimate due to temporal fluctuations or the nature of the work. The limitations of such denominator data make it difficult to determine baseline rates for injuries or illnesses in order to measure risks, track trends, and evaluate the effectiveness of efforts to reduce injury and disease. A major change has been in the evolution, effectiveness, and relative ubiquity of information and communications technology (both methods and tools) since the 1987 report. Major advances in data col- lection and storage, analytic methods, sensors, and mobile devices allow information to be gathered and connected with central collection resources. Although the revolution of Internet search methods has made it easier to search for information, the quality of such large amounts of data obtained is uneven depending on factors such as source and age. Social media have also become sources of insight regarding societal trends and offer one of many methods for information dissemination that new technologies can provide. Occupational safety and health surveillance efforts will need to leverage newer technologies and tools for identifying, organizing, analyzing, and interpreting data in more innovative, powerful, and cost-effective ways. Doing so could reveal problems, trends, and emerging issues within and across sectors, groups, and geographic regions of workers. Also, these technologies offer opportunities to improve the dissemina- tion of information to those that can use surveillance data to take preventive action, thereby improving worker safety and health and reducing associated human and economic costs of work-related injuries and illnesses. PURPOSE OF THIS STUDY The National Academies of Sciences, Engineering, and Medicine formed an ad hoc committee to undertake the current study requested and sponsored by three key federal agencies involved with occupa- tional safety and health: NIOSH, the Bureau of Labor Statistics (BLS), and the Occupational Safety and Health Administration (OSHA). The committee was tasked with developing a vision for “smarter” occu- pational safety and health surveillance in the United States (see Statement of Task, Box 1-1). To address the task statement, the collective expertise and experience of the committee includes individuals with ex- pertise in occupational epidemiology, occupational medicine, occupational safety and health, haz- ard/exposure surveillance, public health, statistics, survey methods, biomedical informatics, data mining and analytics, economics, cost-benefit analysis, and workplace organization and management (see Ap- pendix B). The committee held information-gathering meetings with invited experts to help it address its task, and members of the public were invited to attend and provide comments at these meetings (see Ap- pendix C). The committee intends the report to be useful to the study sponsors and to other federal and state agencies that have an interest in occupational safety and health. The report may also be of interest broadly to employers, labor unions and other worker advocacy organizations, the workers’ compensation insur- ance industry, as well as state epidemiologists, academic researchers, and the broader public health com- munity. The study was undertaken over an 18-month period during which there were major changes in the U.S. political scene and in government priorities. Because of uncertainties regarding those evolving pri- orities and resource availability, the committee has offered observations and recommendations that are intended to suggest useful efforts for both the short and long term. The report’s short-term recommenda- tions in most cases do not require new resources except in cases where new work is recommended, new resources may be required (e.g., see Recommendation D in Chapter 6). The recommendations are lettered Prepublication Copy 13

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century alphabetically in the order that they appear in the report and do not correlate with their order of priority; however, actions to carry out the recommendations along with the timing and methods for addressing them will be dependent on the creation of the coordinating entity recommended in the meta- recommendation (Recommendation Q; see Appendix A for the full recommendations). The committee views the report as serving as a reference that will serve the long-term planning needs of the OSH com- munity and other stakeholders, independent of the availability of new OSH resources or opportunities for organizational change in the short term. BOX 1-1 Statement of Task A more coordinated, cost-effective set of approaches for occupational safety and health surveil- lance is needed in the United States. A committee of the National Academies of Sciences, Engineer- ing, and Medicine will study opportunities and provide recommendations for developing a “smarter” system. In the course of its study, the committee will gather information about the strengths and limitations of existing national and state approaches and also review different methodologies and approaches for occupational safety and health surveillance, particularly with respect to usefulness and cost effective- ness. Based on information gathered during the study, the committee will develop a vision for a “smart- er” cost-effective occupational safety and health surveillance system; describe system components and their attributes; and recommend key steps for developing such a system. As part of its vision, the committee will Define essential requirements and goals for a modern occupational safety and health surveil- lance system; identify critical gaps to fill; reflect on how the methods, tools, and goals of surveil- lance may have changed since the 1987 NRC surveillance report was issued; and draw also upon other subsequent reports (for example, CDC’s Vision for Public Health Surveillance in the 21st Century, the Council of State and Territorial Epidemiologists meeting summaries from 2009 and 2013, and other NRC reports); Conceptualize ways that some surveillance data might be collected, analyzed, interpreted, and disseminated more cost-effectively or innovatively (including identifying novel or underutilized means of collecting data, collecting data at different scales or different interfaces, and creating collaborations across public health and other domains), and, where possible, identify new data opportunities given current and emerging technological advancements in information technology (such as electronic health records and electronic submission of OSHA 300 logs); Explore the respective current and potential roles of various federal and state agencies and pri- vate partners (such as employers and labor unions) in collecting and leveraging occupational safety and health surveillance information. The committee will identify cost, data quality and management, and other trade-offs inherent in differ- ent aspects of or different approaches to conducting surveillance (including the implications of using existing data systems versus collecting additional original data. It may also draw from surveillance ap- proaches that offer insights relevant to the United States that are represented in the experience of other nations or from other fields. The committee’s recommendations will include the strengths and weaknesses of the envisioned system relative to the status quo and identify key actors (i.e., NIOSH, BLS, OSHA, etc.) and both short- and long-term actions and strategies needed to bring about a progressive evolution of the cur- rent system. 14 Prepublication Copy

Introduction KEY TERMS AND DEFINITIONS Occupational Safety and Health Surveillance Surveillance is not unique to occupational safety and health. The Centers for Disease Control and Prevention (CDC) identified surveillance as the first of the ten core public health functions: “[To] monitor environmental and health status to identify and solve community environmental health problems” (CDC, 2011). Surveillance is defined by CDC as “the ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know” (Thacker et al., 2012). Many argue that surveillance is the cornerstone of public health practice, because successful prevention pro- grams inevitably build on an effective system for monitoring and responding to what happens in the community. Quality public health surveillance efforts rely on consistent and systematic application of methods over time. Gathering data is of little value if those data are not analyzed and interpreted to pro- duce information and understanding that is promptly disseminated to those in a position to take action. There is a useful distinction between case- and population-based surveillance. In case-based ap- proaches, the focus is on early identification of individual cases that require follow-up or immediate ac- tion by those who are typically legally mandated to do so (for example, the efforts of public health work- ers who identify and rapidly isolate or treat those with communicable diseases and of public health scientists who control or isolate an identified hazardous exposure). In population-based surveillance the focus is on a wider group and on collecting data to assess the extent of a health-related event and to moni- tor trends within a defined population over time and locale. Case- and population-based surveillance ac- tivities are complementary approaches. A specific circumstance may require immediate attention or inter- vention, even while the information about that case contributes to the ongoing collection of data about a population of similar individuals. OSH surveillance is a subset of the broader public health surveillance field. In OSH surveillance, da- ta are collected on work-related health outcomes (e.g., injuries, diseases, or fatalities) and on the presence of health and safety hazards (e.g., hazardous exposures or conditions). To date, the major focus has been on gathering data about health outcomes and analyzing these data to identify both sentinel cases and trends to inform the targeting and evaluation of efforts to control hazards and prevent occupational inju- ries and illnesses. The information produced by surveillance has also been used to inform policy devel- opment, to guide educational and regulatory activities, to develop safer technologies, and to enable re- search. The issue of hazard surveillance has not been emphasized in the U.S. approach to OSH surveillance, although it is a topic that may be addressed internally by some larger employers and is an area of ongoing investigation. Research on OSH surveillance is valuable, both for deriving new insights and recommending new interventions (i.e., research “using” data collected through surveillance) and for addressing the needs of the surveillance community to develop new approaches or technologies to address shortcomings in cur- rent surveillance practices (i.e., research “in support of” surveillance processes and methods). Both sur- veillance activities and surveillance research are driven by the actual practice of occupational safety and health. In that applied context, information produced by the analysis and interpretation of data collected through surveillance is used to address a problem in a specific workplace, industry, or region, often work- ing with employers, workers’ organizations, and health care providers. In understanding OSH surveil- lance, it is useful to consider three key elements: processes that constitute a surveillance system, compo- nents that enable these processes, and methods that are applied to accomplish surveillance processes. Chapter 6 of this report focuses on the processes, and Chapter 7 identifies and discusses enabling compo- nents and associated methods (see Box 1-2 for definitions). Prepublication Copy 15

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century BOX 1-2 Key Elements of Occupational Safety and Health Surveillance Processes: These include collecting data (from employers, medical facilities, state agencies, insur- ance companies, and even from patients); rationalizing those data by organizing and properly curating them; sharing and merging them as appropriate; interpreting them; informing federal or other public policy; educating employers and other interested parties regarding the lessons learned; and imple- menting solutions, guided by policy, regulation, or naturally occurring responses to the information made available. Enabling Components: The preceding listing of processes makes it clear that their implementation may be far from straightforward. The components that enable such work are both organizational and technological. They include the employers themselves, who are asked to participate actively in the collection and submission of data relevant to their company and their industry. They include health care providers who diagnose and treat health conditions and are required to report select conditions to state health agencies. They include the agencies that collect and coordinate data collection. Also rele- vant are other interested parties who contribute, such as employees themselves (who may experience adverse consequences by reporting on injury or illness), the trained individuals who manage the data systems, the educational programs that produce individuals (surveillance workers, employers, work- ers, clinicians, and others) with the necessary expertise to implement the various surveillance pro- cesses, and government oversight that seeks to enhance coordination while addressing the fiscal and organizational needs of the activity. Increasingly, however, it is the technology that enables effective and efficient implementation of surveillance processes. The devices themselves play an important role (e.g., sensors, tablet computers, electronic health records, web-based information-delivery mecha- nisms, smartphones, and the like), as do the developing conventions for standardizing terminology, integrating data securely in the cloud, using social media or crowd sourcing, or applying analytical software that supports the needs of the community when interpreting large amounts of collated data (Thacker et al., 2012). Methods: Methods drawn from many disciplines support OSH surveillance processes and are often embedded within technological components. As noted, surveillance research has often focused on the development of such methods, whether they involve new approaches to collecting data (or new kinds of data) in the workplace, new solutions to terminology standardization and to the related encoding processes, or new analytical techniques that enhance our ability to draw conclusions from available data. Issues of data completeness and data quality underlie all OSH surveillance. Throughout this report attention is directed to overcoming some of the known limitations in collecting data on the wide range of working populations. For example, one limitation in the Bureau of Labor Statistics annual Survey of Oc- cupational Injuries and Illnesses (SOII) is that it does not include self-employed individuals, contract workers, or those in on-demand jobs. As a core public health function, surveillance provides timely information to control or prevent ex- posure to hazards with the goal of reducing morbidity and mortality and improving population health. Thus, surveillance is generally viewed in a positive light and as a public good. Surveillance activities need to be sensitive to the privacy rights of individuals, and transparency is needed to ensure that all rele- vant stakeholders are informed about the steps that are taken to appropriately protect data collected about individual workers and the workplace. Thus, in public health and occupational health settings, the term surveillance is generally free of the negative connotations associated with government intrusion into the private lives of individuals. Concerns about privacy and confidentiality in occupational health surveil- lance are perhaps most pertinent if the information about an employee’s health could be used by an em- ployer against the employee. Ensuring that an ethical framework continues to undergird OSH surveillance is critical to providing necessary information to protecting workers and achieving safer and healthier workplaces. 16 Prepublication Copy

Introduction Employers can find OSH surveillance requirements challenging. Employers understand that they have the primary responsibility for safety in their workplace—as part of their ethical duty to their em- ployees, as mandated by statute, and to maintain a sustainable workforce in today’s economy. While em- ployers often seek useful and timely information to improve safety in their workplaces, they may become concerned if they feel that their time and efforts are spent primarily for the sake of regulatory compliance. The OSH surveillance community is well aware of potential tensions and the need to ensure that comply- ing with reporting requirements provide results that are valued by employers and workers. Workplace Hazard and Exposure Surveillance In the United States, OSH surveillance has focused primarily on health outcomes (lagging indica- tors) while hazard surveillance (a leading indicator) has received less attention. Hazard refers to the po- tential of a substance or condition to cause harm, while risk considers the probability that the hazard will cause harm. Thus, the health risk of a working condition is a function of both the presence of a hazard associated with the health condition and the extent of the exposure of an individual or population to that hazard. 1 In the context of surveillance, a hazard surveillance system (e.g. a chemical use inventory or reg- istry) identifies potential workplace hazards and can provide information on the distribution and location of a hazard where there is potential for exposure. An exposure surveillance system, monitors actual con- tact that workers have with the substance or condition (potentially including data on who the workers are who were exposed, the duration of the exposure, and the level or intensity of the exposure). Although the discussion above is most easily understood in terms of airborne chemical hazards or physical agents, it is equally relevant to acute injury risks. For instance, work at height may be consid- ered a hazard, whereas the exposure would be the proximity of the work to an unguarded leading edge. Similarly, moving heavy objects to an elevated position may constitute a hazard, the exposure would be related to the weight, the frequency and the biomechanical load determined by the lifting task and pres- ence of mechanical lifting aids. The relationships among hazard, exposure, and the “work-relatedness” of an illness or injury can be highly complex and subject to interpretation (Oppliger and Seixas, 2017). An injury or illness is work related if it was sustained in the workplace. However, only a small proportion of illnesses where work is a component in the mix of causes are currently ascribed to work exposures. For example, an individual’s lung disease (e.g., chronic obstructive pulmonary disease or asthma) or chronic back strain can be due to work-related exposures along with other factors in the worker’s life or genetic makeup (see Chapter 4). Oppliger and Seixas (2017) note that “Even ascribing acute injury to work is not as obvious as identifying the location at which the injury occurs; an injury at work may be partially due to non-work-related stress- ors (e.g., personal stressors affecting attention or vigilance) while injuries off the job may commonly have work-related contributions (e.g., neurologic toxins, long hours, shift work, or other stressors causing fa- tigue, etc.)”. Thus, for both acute and chronic injuries and illnesses, agreed-upon surveillance case defini- tions are necessary to manage the uncertainty of the contribution of work to a wide range of health condi- tions. In addition to physical, chemical, and biological agents, musculoskeletal strain is increasingly rec- ognized in many jobs associated with a wide range of both acute and chronic injury and a significant de- gree of disability. Even so, the assessment of various elements of exposure for musculoskeletal risks— including force, posture, repetition, work pace, work-rest cycles, and sedentary work—continues to pre- sent significant challenges. The assessment of hazardous psychosocial exposures in the workplace is also challenging, with the potential for health impacts related to work organization (e.g., numbers of coworkers, social support, re- porting relationships, and supervisory responsibilities), job demands (e.g., hours, shift work, unpredicta- 1 Risk=f(Hazard, Exposure). Where risk is the probability of an adverse outcome in a defined population; hazard is the inherent damaging potential of agent or condition; and exposure is the probability, frequency, and intensity of the agent interacting with an individual. Prepublication Copy 17

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century bility, and exposure to demanding customers), job control (e.g., ability to control rate or order of work components), and fair treatment (e.g., perceptions that both the individual and workers in general are be- ing treated fairly by the employer). Health effects generally associated with these include cardiovascular disease, depression and anxiety, suicide, effects related to sleep deprivation including injury risk, and even workplace violence. Costs, Effectiveness, Efficiency, and Cost Effectiveness One important goal of a 21st-century OSH surveillance system is to collect the most relevant data at the lowest cost feasible. A surveillance system would meet the definition of being cost effective if it iden- tifies data with the biggest impact on improving worker safety and health while minimizing the cost of collecting those data (Gold et al., 1996; Haddix et al., 1996). A cost-effective surveillance system would also recognize trade-offs between the importance of individual data elements in identifying factors that can be modified to improve worker safety and health and the costs of collecting each of those data ele- ments. As a result, a cost-effective surveillance system might be less comprehensive than an ideal system because the costs of collecting the ideal set of surveillance data might be judged to be prohibitively ex- pensive from a societal perspective. Finally, an efficient system for collecting OSH data may not be effec- tive or cost effective if it targets the collection of data that have only minimal impact on improving work- er safety and health outcomes. A fundamental concept in conducting a cost-effectiveness analysis of any intervention, including an OSH surveillance system, is that costs and benefits are always measured and compared from a societal perspective (Gold et al., 1996; Haddix et al., 1996; Muennig, 2008). A societal perspective is preferred when considering the value of public investments and policy because comparing costs and benefits solely from the perspective of individual stakeholders can lead to erroneous conclusions and recommendations. Thus, this report adopts a societal perspective of cost effectiveness. The costs of a surveillance system include not only the costs of data collection, but also the costs as- sociated with the health and productivity consequences of occupational exposures, injuries, illnesses, and mortality on workers, their families, and society. As previously noted, the most recent estimate of the total economic burden of occupational illness, injury, and death is $250 billion annually in the United States (Leigh, 2011). Therefore, an improved OSH data surveillance system can be used by policy makers and stakeholders to prioritize interventions for reducing the economic costs of occupational illness, injury, and death to society. Identifying areas of greatest need for OSH interventions through use of an improved sur- veillance system and then targeting effective interventions based on previous research and evidence is likely to produce significant and substantial savings to employers, employees, and society (Schulte et al., 2017). The importance of assessing costs and benefits of an improved OSH surveillance system is dis- cussed further in Chapter 7. ORGANIZATION OF THE REPORT This report covers the breadth of the committee’s statement of task. Chapter 2 sets forth the guiding principles and objectives developed by the committee and used as a basis for the report’s recommenda- tions. The chapter also provides an overview of the committee’s vision of a future “smarter” surveillance system. In Chapter 3 the committee examines the federal and state agencies and stakeholders engaged in occupational safety and health surveillance in the United States. It also summarizes the major recommen- dations of the 1987 NRC report and the response to that report’s recommendations. Chapter 4 provides a more detailed summary of the current status of OSH surveillance in the United States. It summarizes the current approaches to surveillance of fatal and nonfatal occupational injuries and of occupational illness- es. The chapter also discusses the current, albeit limited, state of hazard surveillance and addresses the crosscutting issues of state-based surveillance, surveillance research, and data on populations at risk. OSH surveillance activities outside the United States are summarized in Chapter 5, emphasizing activities that may offer lessons for ongoing work in this country. To address the gaps identified in Chapter 4, Chapter 6 18 Prepublication Copy

Introduction then discusses the promising developments, processes, and technologies that can be used to improve OSH surveillance, including electronic reporting initiatives, electronic health records, the mobilization of workers’ compensation systems, and new directions for hazard surveillance. This is followed by a focus in Chapter 7 on key actions essential for moving forward with an improved national OSH surveillance system, emphasizing (1) quantification of the economic and health burden of occupational illness and in- jury, (2) coordination of surveillance efforts, (3) use of information technology, and (4) enhanced training and support for surveillance practitioners. The report’s concluding chapter offers a final overarching me- ta-recommendation and summarizes the report’s conclusions and recommendations for achieving a smart- er OSH surveillance system. REFERENCES BLS (Bureau of Labor Statistics). 2017a. Employment by major industry sector. Available online at https://www.bls.gov/emp/ep_table_201.htm (accessed November 21, 2017). BLS. 2017b. Civilian labor force participation rate, by age, sex, race, and ethnicity. Available online at https://www. bls.gov/emp/ep_table_303.htm (accessed November 21, 2017). Boulton, M. L., R. A. Malouin, K. Hodge, and L. Robinson. 2003. Assessment of the epidemiologic capacity in state and territorial health departments – United States, 2001. MMWR 52(43):1049-1051. CDC (Centers for Disease Control and Prevention). 2011. Core functions of public health and how they relate to the 10 essential services. Available online at https://www.cdc.gov/nceh/ehs/ephli/core_ess.htm (accessed April 10, 2017). CSTE (Council of State and Territorial Epidemiologists). 2010. 2009 National Assessment of Epidemiology Capaci- ty: Finding and Recommendation. Available online at http://www.cste2.org/webpdfs/ecabrieffinal2010.pdf (accessed August 22, 2017). CSTE. 2014. 2013 National Assessment of Epidemiology Capacity: Finding and recommendation. Available online at http://www.cste2.org/2013eca/CSTEEpidemiologyCapacityAssessment2014-final2.pdf. Accessed August 22, 2017. Gold, M. R., J. E. Siegel, L. B. Russell, and M. C. Weinstein. 1996. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press. Haddix, A. C., S. M. Teutsch, P. A. Shaffer, and D. O. Dunet. 1996. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York: Oxford University Press. IOM and NRC (Institute of Medicine and National Research Council). 2009. Evaluating Occupational Health and Safety Research Programs: Framework and Next Steps. Washington, DC: The National Academies Press. Katz, L. F., and A. B. Krueger. 2016. The rise and nature of alternative work arrangements in the United States, 1995-2015. National Bureau of Economic Research: NBER Working Paper No. 22667. Available online at http://www.nber.org/papers/w22667 (accessed November 29, 2017). Leigh, J. P. 2011. Economic burden of occupational injury and illness in the United States. Milbank Quarterly 89(4):728-772. Muennig, P. 2008. Cost-Effectiveness Analyses in Health: A Practical Approach, 2nd ed. San Francisco, CA: Jossey-Bass. Myers, D., S. Levy, and J. Pitkin. 2013. The Contributions of Immigrants and Their Children to the American Work- force and Jobs of the Future. Washington, DC: Center for American Progress. Available online at: https://www.americanprogress.org/issues/immigration/report/2013/06/19/66891/the-contributions-of-immigrant s-and-their-children-to-theamerican-workforce-and-jobs-of-the-future/ (accessed November 22, 2017). NRC (National Research Council). 1987. Counting Injuries and Illnesses in the Workplace: Proposals for a Better System. Washington, DC: National Academy Press. Oppliger, A., and N. Seixas. 2017. What makes a disease ‘occupational’? Annals of Work Exposures and Health 61(2):135-136. Schulte, P. A., R. Pana-Cryan, T. Schnorr, A. L. Schill, R. Guerin, S. Felknor, and G. R. Wagner. 2017. An ap- proach to assess the burden of work-related injury, disease, and distress. American Journal of Public Health 107(7):1051-1057. Thacker, S. B., J. R. Qualters, and L. M. Lee. 2012. Public health surveillance in the United States: Evolution and challenges. Morbidity and Mortality Weekly Report 61(3):3-9. Weil, D. 2014. The Fissured Workplace: Why Work Became So Bad for So Many and What Can Be Done to Im- prove It. Cambridge, MA: Harvard University Press. Prepublication Copy 19

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The workplace is where 156 million working adults in the United States spend many waking hours, and it has a profound influence on health and well-being. Although some occupations and work-related activities are more hazardous than others and face higher rates of injuries, illness, disease, and fatalities, workers in all occupations face some form of work-related safety and health concerns. Understanding those risks to prevent injury, illness, or even fatal incidents is an important function of society.

Occupational safety and health (OSH) surveillance provides the data and analyses needed to understand the relationships between work and injuries and illnesses in order to improve worker safety and health and prevent work-related injuries and illnesses. Information about the circumstances in which workers are injured or made ill on the job and how these patterns change over time is essential to develop effective prevention programs and target future research. The nation needs a robust OSH surveillance system to provide this critical information for informing policy development, guiding educational and regulatory activities, developing safer technologies, and enabling research and prevention strategies that serves and protects all workers.

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century provides a comprehensive assessment of the state of OSH surveillance. This report is intended to be useful to federal and state agencies that have an interest in occupational safety and health, but may also be of interest broadly to employers, labor unions and other worker advocacy organizations, the workers’ compensation insurance industry, as well as state epidemiologists, academic researchers, and the broader public health community. The recommendations address the strengths and weaknesses of the envisioned system relative to the status quo and both short- and long-term actions and strategies needed to bring about a progressive evolution of the current system.

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