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A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century (2018)

Chapter: 4 Current Status of Federal and State Programs and Cross-cutting Issues

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Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 50
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 52
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 53
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 54
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 55
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 56
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 57
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 58
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 59
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 60
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 61
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 62
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 63
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 64
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 65
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 66
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 67
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 68
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 69
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 70
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 71
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 72
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 73
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 74
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 75
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 76
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 77
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 78
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 79
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 80
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 81
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 82
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 83
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 84
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 85
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 86
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 87
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 88
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 89
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 90
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 91
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 92
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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.
×
Page 93
Suggested Citation:"4 Current Status of Federal and State Programs and Cross-cutting Issues." 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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Page 94

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4 Current Status of Federal and State Programs and Cross-cutting Issues INTRODUCTION A wide range of health outcomes—from fatal falls and amputations to chronic lung disease, muscu- loskeletal disorders, and cancer—are either caused or exacerbated by hazardous exposures in the work environment. Currently, there is no single, comprehensive occupational safety and health (OSH) surveil- lance system in the United States but rather an evolving set of systems using a variety of data sources that meet different surveillance objectives, each with strengths and weaknesses. As discussed, many federal and state agencies carry out this work. Figure 4-1 shows a Venn diagram representing major data sources for occupational injuries and illnesses (under the major categories of employers, medical records, and in- dividuals) and the overlap among the systems that collect these data for occupational injury and illness surveillance. The degree of overlap is a best guess estimate of how much overlap there is between sys- tems and illustrates that in the potential smart surveillance system of the future, there will be some over- lap between the sources and that there will be a need to collect data from multiple sources to obtain a comprehensive picture of OSH problems. In Figure 4-1, the sources of data from employers are BLS SOII, Workers’ Compensation, and Direct Reports by Employers to Regulatory Agencies. The sources of data from medical records are Ambulance Companies, Audiometry Providers, Birth Certificates, Cancer Registries, Death Certificates/Medical Examiners, Hospitals; Emergency Departments, Clinics, Clini- cians, Laboratories, Medicare Data Bases, and Poison Control Centers. The sources of data from individ- uals (Current Workers, Retirees, Disabled) are Health Surveys (BRFSS, NHIS, NHANES), and Proposed HSOII. The other sources of data are Newspaper Reports/Electronic Media. There are limited data to show overlap between different sources of studies showing the degree of overlap are: BLS SOII and workers’ compensation (Rosenman et al., 2006; Bodenand Ozonoff, 2008); or individual conditions such as acute traumatic fatalities (BLS), amputations (Largoand Rosenman, 2015), burns (Kicaand Rosenman, 2012) or skull fractures (Kicaand Rosenman, 2014). The successful model for a multisource occupational surveillance system is the Census for Fatal Occupational Injuries (CFOI). The major systems in place are largely focused on injury and disease outcomes. Hazard and expo- sure surveillance is important but currently very limited. In this chapter, we provide an overview of the major systems, organized by the health outcome under surveillance: fatal injuries, nonfatal injuries, and diseases. The current status of hazard surveillance is also discussed. The chapter concludes with a discus- sion of several crosscutting issues in OSH surveillance. A number of promising new developments in the field are described in Chapter 6. SURVEILLANCE OF FATAL OCCUPATIONAL INJURIES Substantial advances in the surveillance of fatal occupational injuries have been made over the past several decades with the development and implementation of several surveillance systems and programs (see Table 4-1). 48 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues FIGURE 4-1 Current Possible Overlaps in Data Sharing from the Major Sources of Data Used for Occupational Injury and Illness Surveillance. The size of inner circles do not represent relative importance of the source. CFOI is the only system to use data from multiple sources, and is illustrated by the overlaps. Other sources may overlap, but it is uncertain whether there is overlap because of confidentiality. In 1992, the Bureau of Labor Statistics (BLS, in the U.S. Department of Labor)—in response to rec- ommendations in the 1987 National Research Council (NRC) report—established the Census of Fatal Oc- cupational Injuries (CFOI), a nationwide surveillance system designed to produce a timely census of all fatal work injuries in the United States.1 A federal-state cooperative program implemented in all 50 states, CFOI uses multiple data sources, such as death certificates, police reports, federal agency administrative data, workers’ compensation claim records, and news media, to identify, verify, and describe fatal work injuries. For each death, information is collected about the deceased worker, including occupation and demographic characteristics, the establishment, the equipment involved, and the circumstances of the event. Two or more independent source documents are used to confirm that fatal injury cases are work related. National and state-level findings including both counts and rates2 by industry and occupation and other worker and establishment characteristics are issued annually, in the following calendar year. Sur- veillance findings are published through the media and made available on an interactive BLS website (BLS, 2017a). BLS has also published more extensive analyses of fatalities among workers in specific industries (e.g., road construction and landscaping), among specific worker groups (e.g., Hispanics, Asians), and due to specific events (e.g., machine-related deaths and suicides), as well as studies compar- ing analytic methods (Windau, 1998; Sincavage, 2005; Wiatrowski, 2005; Byler, 2013; Pegula, 2013; Harris, 2016). The National Institute for Occupational Safety and Health (NIOSH) also has access to the CFOI microlevel files to conduct more in-depth analysis and respond to public information requests, but limited resources to do this work. Given that BLS collects CFOI under CIPSEA, CFOI data can only be used for statistical purposes (OMB, 2007). 1 BLS notes that “to be included in CFOI: a death must have resulted from a traumatic injury; the incident that led to the death must have occurred in the United States, its territories, or its territorial waters or airspace; and it must be related to work. Defining work-relatedness is complex and BLS CFOI applies a standard definition” (BLS, 2016a). 2 Rates exclude persons younger than 16 years of age, volunteers, and resident military personnel. Prepublication Copy 49

TABLE 4-1 Examples of Surveillance Systems for Fatal Occupational Injuries in the United States Responsible Condition(s) under Population Time Frame for 50 Surveillance System Scopea Typeb Agency(ies) Surveillancec Data Source(s) Coveredd Approach Report Release Census of Fatal National P BLS* O: Fatal occupational Multiple: OSHA, All workers Census Annual Occupational 50 states States* injuries Coast Guard Injuries (CFOI) records, death certificates, police reports, media, etc. Fatality Assessment 7 states C NIOSH* O: Fatal occupational Field investigations All workers Case series Ongoing and Control States injuries—targeted and other data ( 2% all worker Evaluation (FACE) incidents sources deaths in U.S.) Program Firefighter Fatality National C NIOSH* O: Fatal occupational Field investigations All firefighters Case series Ongoing Investigation and State injuries and heart and other data ( 40% all firefighter Prevention Program attacks sources deaths in U.S.) in line of duty Commercial Fishing National P NIOSH* O: Fatal occupational Multiple: Coast All workers in Census Intermittent Incident Database Regional injuries and incident Guard records, death commercial fishing State survivors certificates, local industry media, etc. Fatalities in Oil and National C NIOSH* O: Fatal occupational Multiple: OSHA All oil and gas Census Intermittent Gas Extraction injuries and illnesses records, motor extraction workers vehicle crash reports, police reports, media and professional contacts NOTE: BLS, Bureau of Labor Statistics; NIOSH, National Institute for Occupational Safety and Health; OSHA, Occupational Safety and Health Administration; asterisk denotes funding agency. a Geographic levels at which findings are publicly available. b P, population based: data are collected on a census or representative sample of a defined population and allows for assessing extent of a health related event and monitoring trends with this population over time/locale ; C, case based: focus of data collection is on individual cases that require follow-up or immediate public health action. These approaches are not mutually exclusive. c O, outcome; H, hazard; E, exposure. d The population covered may include active and former workers, retirees, and others depending on the system.

Current Status of Federal and State Programs and Cross-cutting Issues BLS continues to make enhancements to CFOI and has, for example, expanded the number of varia- bles collected to include birthplace, contracted worker status, and, in the case of a contracted decedent, ownership of the contracting firm. Distinguishing fatal work-related motor vehicle from non-work-related incidents is particularly difficult, and BLS is currently working with NIOSH, the National Highway Traf- fic Safety Administration (NHTSA) and state agency partners to pilot new approaches to provide more comprehensive information about fatal occupational crashes. BLS has also improved the timeliness of releasing CFOI findings to the public. CFOI is well respected as an authoritative count of fatal work injuries at the national and state levels and a model for multisource surveillance of a health outcome. It provides robust information about the burden and distribution of fatal occupational injuries over time and serves as an important example of how surveillance findings can be used to monitor progress in meeting prevention goals, target interven- tion activities, and set research priorities. Findings have identified a decline in the fatal occupational inju- ry rate over time as well as continuing high risk among workers in certain industries, such as fishing, con- struction, transportation, and the self-employed (BLS, 2016b) (Figure 4-2). The data have also brought to light high-risk populations, including older workers and Hispanic workers (Byler, 2013; BLS, 2016b). Findings have also led to new federal outreach initiatives including, for example, a nationwide campaign to prevent falls in construction (OSHA, 2017a) and increased Spanish-language assistance for Hispanic employers and workers (OSHA, 2007). While CFOI provides essential statistical data on the approximately 5,000 fatal occupational injuries that occur each year (BLS, 2017a), the CFOI data lack sufficient detail about underlying causes of fatal incidents needed to develop specific prevention recommendations, and, as described above, BLS confi- dentiality practices restrict the use of the data for case-level public health intervention. For instance, the system does not allow for case-based follow-up to intervene in specific workplaces to protect others at risk or to learn more about specific factors (e.g., names of specific chemicals) contributing to workplace injuries. Since 1991, NIOSH has supported a collaborative endeavor with the states, the Fatality Assessment and Control Evaluation (FACE) program, to conduct in-depth investigations of targeted fatal occupational incidents with the objective of identifying factors contributing to these deaths. Currently seven states are funded by NIOSH to conduct approximately 100 investigations each year.3 NIOSH identifies national targets for investigation, which currently include falls from elevations and machine-related deaths, and the participating states have the option of identifying their own targets. FACE investigators use an approach developed by Haddon to identify underlying causes of the incidents (Haddon, 1970). This information is used to develop comprehensive recommendations for prevention. Each investigation results in a report with an incident description and prevention recommendations which is disseminated widely to industry, labor, equipment manufacturers, and other stakeholders. State FACE programs also work with local agency and private-sector partners to promote implementation of recom- mendations (NIOSH, 2017a). FACE provides valuable in-depth information about the circumstances leading to deaths that is either not collected or because of confidentiality not available in the CFOI statis- tics and exemplifies how data can be used to inform prevention. The investigation of sentinel fatalities through the FACE program has helped identify and increase public awareness of previously unrecognized hazards, and led to improvements in OSH practices at worksites, changes in public policy, and develop- ment of new safer technologies. For example, FACE investigations in Michigan led to a nationwide alert on hazards of methylene chloride exposures associated with bathtub refinishing (MI FACE, 2013; OSHA, 2013); FACE investigations of deaths among floor finishers in Massachusetts contributed to state law banning the use of highly flammable floor sealing products (MA COSH 2005; Azaroff et al., 2011); and a Kentucky FACE investigation of the death of an auto technician led to the redesign of a handicapped- accessible accelerator pedal (CSTE, 2015a). 3 Some additional state health agencies, such as in Wyoming, that do not participate in the FACE program also track work-related deaths for public health intervention purposes (WY DWS, 2016). Prepublication Copy 51

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Self-employed 13.6 13.1 12.7 12.6 12.8 11.0 10.6 4.2 4.0 All Workers 3.7 3.5 3.6 3.5 3.4 3.3 3.4 3.4 Wage and salary FIGURE 4-2 Rate of fatal work injuries per 100 full-time equivalents by employee status, 2006-2015. The 2015 rate of fatal work injuries for all workers was 3.4 fatal work injuries per 100,000 full-time equivalent workers (FTEs). The rate for self-employed workers has consistently been higher than that of all workers since the adoption of hours-based rates. NOTE: Rate = (Fatal work injuries/Total hours worked by all workers) x 200,000,000, where 200,000,000 = base for 100,000 FTEs working 40 hours per week, 50 weeks per year. The total-hours-worked fig- ures are annual average estimates of total at work multiplied by average hours for civilians, 16 years of age and over, from the Current Population Survey (CPS). In 2008, CFOI implemented a new methodology, using hours worked for fatal work injury rate calculations rather than employment. For additional information on the fatal work injury rate methodology, please see BLS, 2010. SOURCE: BLS 2016b. In 1998, Congress funded NIOSH to establish a Firefighter Fatality and Investigation Program mod- eled on FACE in which NIOSH staff conducts in-depth investigations of select firefighter deaths throughout the country (NIOSH, 2017b). Targets for this program go beyond fatal injuries to include out- comes such as heart attacks in the line of duty. NIOSH also supports more in-depth data collection on fa- tal incidents in several high-risk industries, including fishing and oil and gas extraction, and works with partners in these targeted industries to disseminate findings and promote use of the data for prevention (NIOSH, 2012, 2014a, 2017c). In recent years, there has been increased interest by state health agencies, unions, community organ- izations, and others for more timely and detailed information on specific workplace fatalities. In response, OSHA made additional timely information (including the victim’s name) on workplace fatalities investi- gated by the agency 4 available on its website until changing this practice mid-2017 (OSHA, 2017b). Ina- bility to access CFOI data for purposes of public health intervention has been a challenge. BLS has taken some steps to address this and make available to the public and state public health agencies timely data on fatal occupational injuries that are available through public sources including the web (Pegula and Meas- ure, 2016). Several nonprofit organizations have made data on work-related fatalities available through interactive mapping applications (CPWR, 2017; National COSH, 2017). 4 Only about a third of all fatal occupational injuries are investigated by OSHA (AFL-CIO, 2017; MA DPH, 2017); the remaining deaths are either outside of OSHA’s jurisdiction (e.g., self-employed, public sector in federal OSHA states), are due to causes such as on-the-road motor vehicle deaths or homicides at work not routinely inves- tigated by the agency, or came to OSHA’s attention more than 6 months after the incident. 52 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues SURVEILLANCE OF NON-FATAL OCCUPATIONAL INJURIES Nonfatal occupational injuries as discussed in this chapter encompass traumatic injuries due to sud- den events such as falls, motor vehicle crashes, violence, and being struck by machinery. Also included within this discussion are musculoskeletal disorders (MSDs), which are defined by NIOSH as “soft-tissue injuries that may be caused by either sudden or sustained exposure to repetitive motion, force, vibration, or awkward positions 5” (NIOSH, 2016g). Over the past several decades, federal agencies, in collaboration with states, have made improve- ments in surveillance of nonfatal occupational injuries. Major activities include the following: BLS enhancements to the Survey of Occupational Injuries and Illnesses (SOII) to collect addi- tional data on more severe injuries, add data on public employees, and expand data analysis; OSHA’s severe injury reporting system; NIOSH’s leveraging of other national public health surveillance systems and surveys; and State-based projects, funded largely by NIOSH, using state data sources to conduct surveillance of nonfatal occupational injuries at the state level. Survey of Occupational Injuries and Illnesses The SOII is the only source of uniform nationwide statistics on nonfatal work-related injuries in the United States, providing annual estimates of the number and rates of work-related injuries and illnesses for the nation and for the states that collaborate with BLS. This is available by industry, establishment employment size, and case severity as measured by work restriction or days of work lost (BLS, 2016c) (Figure 4-3). Conducted by BLS in collaboration with state agencies in 45 states and directly by BLS in the other 5 states, the SOII is an annual nationwide survey with a sample of approximately 250,000 pri- vate industry and state and local government establishments, selected to represent all industries and all sizes of establishments. Data from the railroad and mining industries included in the SOII published find- ings are obtained by BLS from the Federal Railroad Administration and the Mine Safety and Health Ad- ministration, which require reporting of all fatal and nonfatal work-related injuries and illnesses by rail- road and mine employers. The data collected by BLS for the SOII are based upon OSHA required records for occupational in- juries and illnesses—the OSHA Log of Work-Related Injuries and Illnesses (Form 300), the Injury and Illness Incident Report (Form 301), and the Summary of Work-Related Injuries and Illnesses (Form 300A). Establishments selected for the SOII are required by law to maintain records of all work-related injuries and illness that meet the OSHA requirements for recordkeeping for 1 year (even if otherwise ex- cluded from OSHA injury recordkeeping requirements) and report that information to BLS. Injuries and 5 The classification of MSDs in different surveillance systems is complicated. While in both the International Classification of Disease and the Occupational Injury and Illness Classification system used by BLS most MSDs are classified as injuries, there is a small set of conditions generally included in a broad definition of MSDs, such as carpal tunnel syndrome and Raynaud’s syndrome, that are classified as diseases. Since 2011, BLS and OSHA have applied a surveillance case definition for MSDs in employer-reported data aimed at identifying cases due to sus- tained exposure that takes into account information about both the nature of injury or illness and the event or expo- sure. Included are cases “where the nature of the injury or illness is pinched nerve; herniated disc; meniscus tear; sprains, strains, tears; hernia (traumatic and nontraumatic); pain, swelling, and numbness; carpal or tarsal tunnel syndrome; Raynaud’s syndrome or phenomenon; musculoskeletal system and connective tissue diseases and disor- ders, when the event or exposure leading to the injury or illness is overexertion and bodily reaction, unspecified; overexertion involving outside sources; repetitive motion involving micro tasks; other and multiple exertions or bod- ily reactions; and rubbed, abraded, or jarred by vibration” (NIOSH, 2016a). Prepublication Copy 53

54 Manufacturing Retail trade Accommodation and food services Construction Transportation and warehousing Wholesale trade Administrative and waste services Other services (except public administration) Professional and technical services Arts, entertainment, and recreation Real estate and rental and leasing Educational services Information Finance and insurance Management of companies and enterprises Mining, quarrying, and oil and gas extraction FIGURE 4-3 Distribution of nonfatal occupational injuries and illnesses by private industry sector, 2015. Injuries accounted for the majority of cases reported in 2015 among individual private industry sectors. Illnesses accounted for only a small fraction of cases reported in each industry sector. SOURCE: BLS, 2016d.

Current Status of Federal and State Programs and Cross-cutting Issues illnesses that are recordable for OSHA include those resulting in loss of consciousness, medical treatment beyond first aid, one or more missed days from work, restricted work activities, or transfer to another job (MI DCH, 2013). Since 1992, in addition to information from the OSHA Log, as recommended in the 1987 NRC report, the SOII has collected data on the nature and circumstances of the injury or illness (OSHA Form 301), as well as the characteristics of the affected workers for injuries resulting in one or more days away from work, which currently account for 32 percent of all reported cases (BLS, 2016e). Given the changes in case management that can shift injured workers from lost-workday cases to restrict- ed-work and job transfer cases, it is challenging to use these statistics as measures of injury severity. This more detailed information is referred to as the case and demographic data. BLS collects data elements that employers are required by OSHA to record, along with several optional case and demo- graphic variables including the race and ethnicity of the injured worker and the category that best de- scribes the regular type of job or work. These variables, however, are generally not analyzed due to the limited reporting of these optional data (Wiatrowski, 2014). As with CFOI, national and state-level esti- mates are issued annually, and are published and made available on the web (BLS, 2016c). BLS has continued to make improvements in the SOII. For example, in 2006, BLS began generating and publishing experimental rates by occupation, age, and gender, in addition to routinely published rates by industry, establishment, and case severity. 6 In addition, starting in 2008, BLS expanded the scope of the SOII by collecting and reporting data about work-related injuries and illnesses among state and local government workers, who were previously not included in the nationwide survey. 7 BLS has also piloted the collection of more detailed case and demographic data on a sample of injuries and illnesses that did not result in lost time but led to job transfer or restriction—which account for an increasing proportion of all cases reported over time—21 percent in 2015 (Wiatrowski, 2014; BLS, 2016f). Attention to enhanced information on all types of injuries is planned to be sought through a proposed household survey (see Chapter 6). BLS has also updated its injury and illness classification system to reflect current workplace hazards and has substantially reduced processing time to make the data more rapidly publicly available (Wiatrowski, 2014). The information derived from the analysis of SOII data is used by federal and state government agencies to set standards, target enforcement compliance assistance activities, develop and update educa- tional programs, and set research priorities. Industry and unions use the data for benchmarking their own injury and illness experience. In some industries, most notably construction, industry-specific rates are used as criteria in assessing qualifications of contractors and subcontractors. The SOII, however, has a number of significant limitations. Excluded from the SOII are the self- employed (e.g., independent contractors, including gig economy workers [on-demand contractors and freelance workers]), household workers, federal workers, U.S. Postal Service workers, and workers on farms with fewer than 11 employees. Altogether, these excluded populations represent about 9 percent of the workforce, the majority of whom are self-employed (Simpson, 2016). Also, the SOII does not collect case and demographic information for 70 percent of all reported injuries and illnesses (BLS, 2016e). While it has long been recognized that the SOII does not adequately capture chronic occupational illnesses for reasons discussed under disease surveillance below, there is increasing evidence that under- counting of injuries and acute illnesses is also a significant limitation, and there may be differential rates of reporting by establishment, injury and incident characteristics, as well as by state. In studies to quantify 6 Information on the number of employee hours provided by participating employers is used as the denominator in calculating rates by industry, establishment employment size, and case type. Since 2006, BLS has used external sources of denominator data (the BLS Current Population Survey and the Occupational Employment Statistics Pro- gram) to generate and publish experimental rates by occupation, age, and gender—as the employment data provided by participating employers are not broken down by these data elements. 7 Reporting by states and local agencies is voluntary for the 22 states without federally approved OSHA state plans covering state and local government workers. While the overall survey response rate for private-sector estab- lishments is about 95 percent, it is around 80 percent for state and local governments (Wiatrowski, 2014). Prepublication Copy 55

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century undercounting on OSHA Logs, estimates of the undercount range from 20 to 70 percent (Rosenman et al., 2006; Boden and Ozonoff, 2008; Wuellner et al., 2017). There is a consensus that the SOII substantially underestimates the true burden of work-related injuries among workers employed in establishments cov- ered by OSHA and that multiple factors contribute to underreporting (Azaroff et al., 2002; Ruser, 2008; Spieler and Wagner, 2014; Wiatrowski, 2014; Wuellner and Bonauto, 2014; Rappin et al., 2016; Wuell- ner and Phipps, 2016; Wuellner et al., 2016, 2017; Fagan and Hodgson, 2017) (see Box 4-1). Given concerns about the completeness of the injury and illness counts in the SOII, in recent years BLS has supported a program of research to better understand both the extent of the undercount and the contributing factors. Individual states have also compared findings from state systems combining data from multiple data sources (i.e., multisource surveillance systems) with SOII estimates (Kica and Rosen- man, 2014; Largo and Rosenman, 2015). Recently reported findings based on interviewers with a sample of recordkeepers at establishments participating in the SOII indicated that many recordkeepers possess a limited understanding of the recordkeeping requirements and identified many common recording errors. Recordkeeper characteristics (SOII experience, OSHA recordkeeping experience, and OSHA recordkeep- ing training) were found to be associated with better practices and knowledge (Wuellner and Phipps, 2016). Additionally, there is concern that some of the most vulnerable workers, which often include racial and ethnic minority and immigrant workers, may be those whose injuries are least likely to be captured in the SOII (Sabbath et al., 2017). Notably, since race and ethnicity are optional variables, data on race and ethnicity are incomplete and BLS does not include them in the annual data it releases on its website. A related challenge is the inability to characterize the injury experience of temporary agency workers, as under OSHA recordkeeping rules, most injuries to temporary agency workers are recorded under the su- pervisory employer, which is more commonly the host employer rather than the “staffing agency,” which is the employer of record (OSHA, 2014). OSHA records and in turn the SOII are also unable to provide information across multiple employers who may be working at a single site with shared work environ- ment responsibilities. This is an increasing concern as multiemployer workplaces, already common in the construction industry, are becoming more common in other industries (Weil, 2014, 2017). BOX 4-1 Underreporting of Injuries in the Workplace Multiple factors have been identified as contributing to the underreporting of work-related injuries in the workplace and consequently the SOII: Unawareness or confusion by recordkeepers about the OSHA recordkeeping requirements. Lack of effective systems in workplaces for documenting and recording injuries. Delays between initial injury and subsequent work absence that goes into the following calendar year. Potentially intentional nonreporting due to concerns about OSHA penalties, increases in workers’ compensation premiums, or failure to be considered for contracts due to poor safety records. Failure by workers to report their injuries to their employers or to file claims under the workers’ compensation system, particularly if the injury is less serious. Workers may fear reprisal by their employers (2016 OSHA regulations stipulate that employer policies for reporting workplace inju- ries and illnesses need to be reasonable and specifically prohibit retaliation against employees who report a workplace injury). Employer medical management policies that may contribute to undertreating and underrecord- ing. Failure of health care provider to recognize work-relatedness (especially true for musculoskeletal disorders and chronic illnesses). 56 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues In the last major revision to OSHA’s injury and illness recordkeeping regulations in 2001, the agen- cy had proposed that construction employers be required to maintain a site log for larger construction pro- jects of the injuries and illnesses of all subcontractors with 11 or more employees working at the site. The proposal was widely supported by unions, but opposed by employers, and thus was not included as a pro- vision; citing complexities for construction employers and questioning the utility of the data (OSHA, 2001). Similarly, neither OSHA injury and illness recordkeeping and reporting requirements nor the SOII capture the enterprise-wide injury and illness experience for employers who operate multiple establish- ments. Thus, there is no ability to track injuries and illnesses at the enterprise or corporate level. OSHA had considered requiring enterprise level reporting by some larger employers as part of the new electronic injury reporting requirements issued in 2016 (discussed in Chapters 3 and 6), but the agency decided not to include such a provision in the final rule, again citing complexities involved with such reporting (OSHA, 2016a). Another significant limitation of the SOII is the relatively small sample size at the state level. In all but the largest states, the sample is too small to provide sufficiently detailed data on different injury types in specific industries or occupations needed to target tailored intervention and prevention efforts (Davis et al., 2012). The SOII data are not routinely aggregated over years, although BLS is currently exploring methods for doing so. (On the other hand, in doing so trends in time would be less evident.) Finally, SOII, like CFOI, is a population-based surveillance system. BLS is required by CIPSEA to protect the confiden- tiality of SOII data and to ensure they are used only for statistical purposes. Establishment-level data are not made available to OSHA or other agencies for purposes of follow-up in specific workplaces to protect others at risk or to for further information gathering. The SOII data are available to researchers for BLS- approved projects. In the past, this research had to be carried out at BLS headquarters but the Census Bu- reau and the Bureau of Labor Statistics are in the process of making certain BLS restricted data sets, in- cluding SOII and CFOI data, available to qualified researchers for statistical research exclusively through the Federal Statistical Research Data Centers managed by the U.S. Census Bureau. 8 Potential improvements in the SOII. BLS’s pilot collection of case and demographic data on the ap- proximately 21% of recordable cases result resulting in job transfer or restriction has demonstrated this is feasible (BLS, 2015; BLS 2017b). Routine collection of these data in the SOII would provide important in- formation about how occupational injuries and illnesses are managed and a much more complete accounting of the full range of injuries and illnesses and the circumstances in which they occur (NRC, 2001). Because, this would involve utilization of data already recorded by employers under the OHSA record-keeping rules and the large majority of employers report their data to SOII electronically, it would add little to the em- ployer reporting burden. New natural language processing tools are being developed by BLS for auto- coding narrative information collected in the SOII (see Chapter 7), which can be anticipated to continue to improve over time and to help minimize the additional costs of processing these data at BLS. Eliminating health disparities is major goal of public health (CDC, 2016). Collection of information about race and ethnicity in public health surveillance systems is of high importance as it provides infor- mation to identify and disparities in health across population groups. While there are robust data on the differential risk of fatal occupational injury across racial and ethnic groups available through CFOI, there is a paucity of such information on nonfatal injuries and illnesses. Collection of race and ethnicity data as an optional variable in the SOII for approximately 40% of cases suggests it is feasible for employers to report this information (Ref). However, incomplete reporting of these data underscore the importance of OSHA’s making this a mandatory data element in OSHA record-keeping. As described elsewhere, the changing nature of employment arrangements is a 21st century reality and occupational health surveil- lance systems will need to address this change. The current inability of the SOII to characterize the OSH risks faced by workers employed in non-traditional employment arrangements is a significant gap that can 8 The SOII data set is now available at the Federal Statistical Research Data Centers and the CFOI data are planned to be made available at these Centers in fall 2017. Prepublication Copy 57

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century be addressed in part by collecting this information on OSHA logs and the SOII. It may benefit employers as well as providing information needed for accurate calculation of their establishment specific illness and injury rates. Engagement of employers and workers in developing guidance on how to collect these data elements will be important. An unheralded advantage of the SOII is its potential to foster use of data by employers and workers at the establishment level. Providing feedback to those who report data for surveillance purposes is a core component of an effective public health surveillance system. (Thacker et al., 2012). Advances in infor- mation technology provide new opportunities for BLS to provide employers with feedback on their data and data analysis tools that they can use to target efforts to prevent work-related injuries and illness among their employees and reduce associated economic costs. As described, private sector employer par- ticipation in the SOII is legally mandatory. According to a 2011 analysis, the response rates of private sector employers were over 90% between 2003-2010 (Huband and Bobbit, 2013). While response rates for the SOII leave room for improvement, they are certainly of a lesser concern than underreporting of injuries and illnesses. Making the data meaningful for employers so that it seen as useful rather than as simply a reporting exercise has potential to improve not only response rate but data quality. Periodic as- sessment of undercount will continue to be an important activity of BLS to improve the accuracy and rep- resentativeness of the SOII estimates. OSHA enforcement of injury and illness recordkeeping require- ments, including enforcement to protect workers who are retaliated against for reporting injuries, will remain critical to help ensure more complete and accurate recording and reporting. Conclusion: Although limited, the SOII remains the most extensive system for standardized information on nonfatal occupational injuries and acute illnesses across the nation today. Better and more efficient use of the SOII to meet surveillance objectives, including characterization of disparities in risk among vulnerable groups of workers, is possible. Recommendation A: BLS and OSHA should collaborate to enhance injury and illness record- ing and the SOII to achieve more complete, accurate, and robust information on the extent, distri- bution, and characteristics of work-related injuries and illnesses and affected workers for use at the worksite and at national and state levels. As part of this effort, BLS should routinely collect detailed case and demographic data for injuries and illnesses resulting in job transfer or restricted-duty work. Fur- thermore, OSHA should amend its injury and illness recording requirements to collect information on race and ethnicity as well as on employment arrangement to identify vulnerable worker populations and risks that may be associated with the changing nature of work. In the near term: OSHA should make type of employment arrangement (e.g., traditional, independent contractor, temporary agency worker, and on-call worker) and race and ethnicity mandatory data elements on the OSHA Form 301, and BLS should incorporate this information into the SOII case and demo- graphic data. OSHA should collaborate with BLS in determining the best approach to collecting this information (e.g., what questions should be included on Form 301). BLS should routinely collect detailed case and demographic data for injuries and illnesses result- ing in job transfer or restricted duty as well as those resulting in days away from work. BLS should implement methods to aggregate SOII data over time to generate more robust and de- tailed state-level estimates. OSHA and BLS should collaborate to enhance recordkeeping training for employers and BLS should evaluate approaches for providing initial information and ongoing feedback to data re- corders in establishments enlisted to participate in the SOII both to improve the data quality and to promote employer use of data for prevention. 58 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues In the longer term: BLS and OSHA should collaborate to determine the best way to collect injury and illness data across multiple employers working at single sites, and across enterprises with multiple establish- ments. BLS should assess the feasibility and usefulness of extending collection of case and demographic data to all reported cases as automated approaches to coding SOII narratives are improved. Op- tions for collecting such data should be evaluated in light of information that will be made availa- ble through the OSHA electronic reporting initiative. OSHA Severe Injury Reporting OSHA has undertaken many initiatives over the years to address the lack of access to establishment- specific injury and illness data in the SOII. Since OSHA was established in 1971, employers under OSHA jurisdiction have been required to promptly report workplace fatalities and incidents resulting in hospital- izations of three or more employees to the agency for evaluation and investigation. In 2014, OSHA ex- panded its reporting rules to require employers to report fatalities within 8 hours and all incidents result- ing in in-patient hospitalization, amputation, or loss of an eye within 24 hours (referred to by OSHA as severe injuries). These expanded reporting requirements have enabled OSHA to better target limited en- forcement and compliance assistance resources to the most dangerous workplaces and engage more high- hazard employers in eliminating serious hazards (Michaels, 2016). The data also have allowed the agency to gather information on the causes of incidents to identify serious hazards, prevent future incidents, and form the basis for revised standards. The severe injury reporting rule went into effect January 1, 2015. During its first year of operation, OSHA reported that employers notified the agency of 10,388 nonfatal incidents, including 7,636 hospital- izations and 2,644 amputations. These data represent only reports made to federal OSHA, not the OSHA state plans. 9 In addition, OSHA estimates that these reports may represent fewer than half of the severe injuries that were required to have been reported to federal OSHA (Michaels, 2016). Recent findings from Massachusetts, a federal OSHA state, indicate that fewer than half of work-related amputations were re- ported by employers covered by OSHA (Grattan et al, 2017). Since OSHA does not have the resources to conduct an onsite investigation or inspection for every severe injury report, the agency has developed a triage system for evaluating and responding to reports (OSHA, 2016b). Under its current procedures, all fatalities and reports of two or more hospitalizations are subject to an inspection as are reports involving a worker under 18 years of age, reports from employers with a history of similar incidents or multiple violations, or reports of incidents involving hazards covered by emphasis programs or any imminent danger. For other reports, OSHA gathers additional information from the employer about the incident, the injured employee, hazards involved, and history of the employ- er to determine whether to conduct an onsite inspection or an offsite rapid response investigation. Under a rapid response investigation, an employer is required to conduct its own investigation, abate any hazards found, report findings and abatement verification to OSHA in writing, and post the information in the workplace. To assist employers, OSHA is providing tools on conducting incident investigations, devel- oped jointly with the National Safety Council. OSHA is also collecting and compiling data from the severe injury reports. During the severe injury report intake process, the agency collects data on the employer, the employee (including employee’s age and employment arrangement [e.g., contract or temporary worker]), the injury, and the incident, and then enters it into the OSHA Information System (the agency’s primary program and regulatory database). 9 The 26 OSHA state plan states are required to adopt reporting requirements that are as effective as federal OSHA’s requirements. A number of states, including California and Washington, have required the reporting of all in-patient hospitalizations for many years. Other state plan states are in the process of adopting requirements similar to federal OSHA. Prepublication Copy 59

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Employer reports of fatalities and severe nonfatal injuries stripped of personal identifiers are made availa- ble by OSHA in a publicly accessible database (OSHA, 2017c). OSHA’s summary analysis of severe in- jury reports is conducted on an ad hoc basis. From these reports, OSHA has identified industries with a higher number of severe injuries (e.g., construction, support activities for mining, and drilling and servicing for oil and gas). The reports have also helped OSHA identify patterns of severe injuries and take preventive action. For example, in 2015, OSHA’s Atlanta regional office noticed numerous reports of fingertip amputations among supermarket and restaurant workers using food slicers (Michaels, 2016). The agency took action to contact food ser- vice employers across the region and provide information about the hazards of food slicers and control measures to keep workers safe (OSHA, 2015). NIOSH Use of Existing Surveillance Systems and Surveys NIOSH conducts a number of surveillance activities aimed at filling gaps in information on nonfatal injuries. These include efforts using existing data sources in partnership with other federal agencies as well as support for injury surveillance in states, which will be discussed in the following section. Since the early 1990s, NIOSH has had an interagency agreement with the Consumer Product Safety Commission to collect data on nonfatal occupational injuries through an occupational supplement to the National Electronic Injury Surveillance System (NEISS). NEISS collects data on injuries associated with consumer products or work that are treated in emergency departments from a sample of U.S. hospitals. From this sample, the total number of occupational injuries treated in hospital emergency rooms nation- wide can be estimated. NIOSH publishes periodic reports based on these data and makes findings from 1998 forward publicly available through an interactive web-based application (CDC, 2017a) (Box 4-2). The data are also available to researchers for approved research projects. A significant advantage of this system, referred to as “NEISS-Work,” is that it captures information on all injured civilian workers who seek treatment in emergency departments, regardless of size of employer and nature of work or employ- ment arrangement, and therefore includes workers who are excluded from the SOII, such as the self- employed or volunteers. Another advantage is that it does not require an employer to report or even be aware of the injury or for an employee to file a workers’ compensation claim. Also, information is ab- stracted from medical records and thus can be assumed to be more clinically accurate than employer- reported data. It has been estimated that approximately one third of work-related injuries are treated in emergency departments (Jackson, 2001). While not all work-related injuries are captured in this NEISS- Work, this system provides useful national estimates of the trends in nonfatal occupational injuries overall and by nature of injury and event, and demographic characteristics (see, for example, Table 4-2). Notably, findings from NEISS-Work provide a different picture of the trend in occupational injuries than that pro- vided by the SOII. Whereas the SOII data indicate a downward trend in occupational injury rates since the early 1990s, NEISS rates have only more recently declined (Jackson, 2001; A. Richards, NIOSH, person- al communication, 2017). SOII and NEISS-Work injury rates by age also differ markedly. The findings from these two systems differ due to differences in the scope of the population covered and reporting by employers (Marsh et al., 2016; Rosenman, 2016; Tonozzi et al., 2016). A disadvantage of NEISS-Work is that information on occupation and industry has to be collected from the, often incomplete, medical rec- ord, making it less useful for targeting prevention measures. Other disadvantages of NEISS include a small sample size, lack of information about lost work time (other than limited information if the individ- ual is hospitalized), and limited information about race and ethnicity. NEISS-Work does provide an im- portant mechanism to conduct follow-back surveys of workers to obtain additional information, and NIOSH has conducted such surveys when additional resources have been available (Marsh et al., 2016). Recent follow-back studies by NIOSH found that the employers were aware of the injuries among their employees who were treated in the emergency departments and identified in the NEISS system. Accord- ingly, any difference between the increased number of injuries identified in NEISS, as compared to the 60 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues SOII, was not secondary to employers being unaware of the injury (Bhandari et al., 2016; Marsh et al., 2016; Tonozzi et al., 2016). NHTSA is currently funding NIOSH to conduct targeted surveillance, includ- ing a follow-back survey of emergency medical service workers using NEISS-Work. BOX 4-2 Searchable Work-Related Injury and Illness Data Systems and Resources Maintained By NIOSH According to the Centers for Disease Control and Prevention (CDC), the Work-Related Injury Statistics Query System (Work-RISQS) “is an interactive query tool to obtain estimates for the number of nonfatal occupational injuries treated in U.S. hospital emergency departments (EDs). The data are derived from the National Electronic Injury Surveillance System—Occupational Supplement (NEISS-Work). Work-RISQS users may interactively query on worker demographic characteristics, nature of injury, and incident circum- stances for ED-treated injuries from 1998 through the present to obtain national estimates” (CDC, 2017a). The CDC states that the “Employed Labor Force query system provides employed worker population estimates (workers >= 15 years) from 1980 through the present. Estimates may be derived for 0numerous demographics and work-related characteristics including industry sectors being targeted through the NIOSH National Occupational Research Agenda (NORA). Estimates are based on a subset of the BLS CPS public access data files maintained by the NIOSH Division of Safety Research (DSR), Surveillance and Field In- vestigation Branch, Injury Surveillance Team” (CDC, 2017b). Furthermore, CDC notes that “BLS developed the Occupational Injury and Illness Classification System (OIICS) to characterize occupational injury and illness incidents. OIICS was originally released in 1992. BLS redesigned OIICS in 2010 with subsequent revisions in 2012. The OIICS includes four hierarchical coding structures: nature of the injury or illness; part of body affected by the injury or illness; source and secondary source of the injury or illness; and event or exposure. NIOSH in collaboration with BLS has developed this website and the accompanying downloadable software application as a resource for occupational safety and health researchers, policy makers, employers, and others who may need to use the OIICS for uniformly characterizing occupational injuries and illnesses or better understanding the national occupational injury and illness data released by the BLS and NIOSH (CDC, 2017c). To code or use the OIICS coded data, one would need to properly understand the OIICS Coding Selection Rules” (BLS, 2012;CDC, 2017d). According to NIOSH, the “Coal Workers’ Health Surveillance Program (CWHSP) Data Query System is a federally mandated worker medical monitoring program for underground coal miners. Its intent is to pre- vent early coal workers’ pneumoconiosis (CWP) from progressing to disabling disease. Eligible miners can obtain periodic chest radiographs. Miners found to have radiographic evidence of CWP are advised of this and are provided, by law, the opportunity to work in a “low-dust” occupation in the mine. The program is operated by NIOSH, which has maintained data from this program since its inception in 1970. The data can be queried to produce tables and maps using the interactive system. The x rays included in this system en- compass x rays from the Coal Workers’ X-ray Surveillance Program (CWXSP) and the Enhanced Coal Workers’ Health Surveillance Program. The CWXSP also includes x rays from the National Coal Study (also known as the National Study of Coal Workers’ Pneumoconiosis) and the Miners’ Choice Health Screening Program” (NIOSH, 2016b). National Occupational Mortality Surveillance System (NOMS). NIOSH maintains a database (NOMS) that includes deaths by cause for most years between 1985 and 2010 where occupation and industry has been coded on death certificates from a convenience sample of states. The data are provided in a querya- ble form that prepares estimates of proportional mortality by industry and occupation to allow exploration of known or potential associations that could lead to research to test hypothesized associations and to exam- ine impact of prevention activities. The Work-Related Lung Disease Surveillance System (eWoRLD). This interactive website presents data on select work-related respiratory diseases. For many of these conditions, related exposure data are also presented. Data may presented in table, chart, or map format. Information is also available on tobacco use and smoking status by industry and occupation from the National Health Information Survey. Prepublication Copy 61

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century TABLE 4-2 Number, Percentage, and Rate of Nonfatal Occupational Ladder Fall Injuries, by Selected Characteristics and Data Source, United States, 2011 NEISS-Work (nonfatal injuries treated in EDs) Characteristic Number (95% CI) %a Rateb (95% CI) Total 34,000 (±6,800) 100 2.6 (±0.5) Men 30,100 (±6,300) 89 4 (±0.2) Women 3,900 (±1,300) 11 0.7 (±0.2) 20–34 11,000 (±2,500) 32 2.7 (±0.5) 35–44 9,900 (±2,500) 29 3.3 (±0.6) 45–54 7,100 (±2,500) 21 2.2 (±0.5) 55–64 4,400 (±1,500) 13 2.1 (±0.5) — — — White, non-Hispanic 19,900 (±6,100) 59 2.2 (±0.4) Other, non-Hispanic 2,000 (±1,000) 6 0.9 (±0.5) Hispanic 5,800 (±2,800) 17 3.1 (±1.3) Unknown — — — NOTE: CI, confidence interval; ED, emergency department. a Percentages might not sum to 100 because of exclusions and rounding. b Per 10,000 FTE workers. Each injury is only counted once, regardless of the number of ED visits. Rates were cal- culated by CDC based on the number of injuries and the number of primary employed FTE workers from the BLS Current Population Survey, 2011. Variances for NEISS-Work data and CPS data were pooled to estimate the vari- ance for injury rates. SOURCE: Socias et al., 2014. NIOSH supports additional focused activities to track nonfatal injuries in several industries. For ex- ample, as described, NIOSH funds the Center for Construction Research and Training, whose in-house data center uses a wide range of health, employment, and economic data sources to provide information about health and safety in the construction industry. Findings are routinely updated and published in an online chart book widely used by industry stakeholders (CPWR, 2013). Given the increasing recognition of the contribution of workplace violence to the burden of occupational injuries, NIOSH is also working with the Bureau of Justice, which conducts the National Crime Victimization Survey to improve and re- port on data on work-related violence. The agricultural sector poses unique challenges for surveillance given the range of work settings from large industrial farms relying on a migrant workforce to small family farms where family members are also at risk. Additionally, the agricultural industry is exempted from many labor protection laws in the United States. Data on all farm-related fatalities are collected in the multi-source CFOI, which shows agriculture to have one of highest fatality rates of any industry sector. Data on nonfatal injures among agriculture workers are collected in the SOII, however, as described, this survey excludes all farms with fewer than 11 employees. Also, the injury and illness experience of owner operator farms and family members who work on these farms is not captured as these farms do not meet the BLS criteria for an em- ployer. Despite limitations, the SOII indicates that the agriculture has one of the highest rates of nonfatal injuries and illnesses. 62 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues In the past, to provide information not available through the SOII, NIOSH conducted surveillance of injuries and illnesses among agricultural workers through a series of surveys carried out in collaboration with U.S. Departments of Agriculture and Labor, which were discontinued in 2015 due to fiscal con- straints. NIOSH is currently considering alternative approaches to conducting surveillance of health and safety of production agriculture workers, including the potential role that its extramural program, specifi- cally, the NIOSH funded regional Agricultural Centers, might play (NIOSH, 2016c). The new proposed BLS household survey will also need to be evaluated in its ability to identify agriculture related injuries and illnesses. Legislative changes that allowed BLS to survey employers with less than 11 employees would be useful but only partially effective to identify nonfatal cases missed in its employer survey, since it would not address the issue of the owner-operated farm that relies on family members. Conclusion: Agriculture is a high-risk industry sector where a legislative restriction and par- ticular work arrangements reduce the ability to obtain accurate counts of nonfatal injuries and ill- nesses. Future evaluations will need to be conducted to determine if recommended changes are suf- ficient to address the current limitations in OSH surveillance in agriculture. State-Based Surveillance of Nonfatal Occupational Injuries As described in Chapter 3, a small number of states, have established expanded case- and popula- tion-based surveillance systems for select occupational injuries and illnesses. While most of these ex- panded state programs focus on occupational illnesses, several states conduct injury surveillance and pre- vention activities addressing targeted injury types, populations at risk, or industries. State-based work- related injury surveillance makes use of records from a wide array of data sources—hospitals, emergency departments, poison control centers, and workers’ compensation systems—to identify and track injuries and to target intervention and prevention activities (see examples in Box 4-3). Several of these focused state systems combine data to get a more comprehensive picture of the condition under surveillance than would be possible with any single data source, and all include interven- tion and prevention activities. Half of the fundamental state surveillance programs, supported by NIOSH, use available state data sources to generate a standard set of over 20 occupational health indicators (Thomsen et al., 2007; CSTE, 2017a). These include several measures of work-related injury risk, such as the number and rate of work-related hospitalization for severe traumatic injuries (Appendix D). Some fundamental state programs include targeted efforts focused on specific types of injuries. As described, a significant advantage of these state-based programs is the ability to identify and address local concerns working with other government agencies, policy makers, trade associations, unions, and community part- ners. Workers’ compensation data have been used extensively for surveillance of work-related injuries, including musculoskeletal disorders, in several states, particularly where a state agency is the sole insurer for workers’ compensation, most notably, Washington State and Ohio. In 2015, NIOSH established a Center for Workers’ Compensation Studies to promote the use of these data to improve workplace safety and health in additional states (see Chapter 6). Additional Surveillance Systems Relevant to Nonfatal Occupational Injuries Some of the other surveys and data systems used by NIOSH to conduct surveillance of chronic dis- ease (described in Table 4-3) also provide information on nonfatal and fatal occupational injuries. An ad- vantage of such information that is collected within broader public health data systems is that, unlike em- ployer-based reporting, it allows for the assessment of the contribution of work-related injuries to the overall injury burden in the United States. For example, a question about activity at time of injury in the core module of the National Health Interview Survey (NHIS) allowed researchers to estimate that 29 per- cent of all injuries among the working-age population occurred at work. Among employed men age 55 to Prepublication Copy 63

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century 64 years of age, this figure was 49 percent (Smith et al., 2005). The National Center for Health Statistics (NCHS) is currently revising the NHIS and it is not clear whether this and other questions relevant to OSH surveillance will be retained in the core module (see further discussion of NHIS below). BOX 4-3 Data to Action Preventing Injuries in Michigan: The Michigan OSH surveillance program uses hospital data and workers’ compensation data to track amputations, burns, crushing injuries, acute hospitalized injuries, farm-related injuries, and skull fractures among workers. For example, a crushing injury occurred when a male worker in his late forties had his gloved hand caught in a hydraulic power press at a furni- ture manufacturer. The state surveillance program received the report and the incident was referred to Michigan OSHA. The company was inspected by Michigan OSHA about 3 months after the injury oc- curred and had not corrected the hazard at the time of the inspection. The company was cited for two serious violations (not utilizing any point-of-operation guard or device on the press and not establish- ing a die-setting procedure to ensure guards were properly installed and effective before the press was released for operation). Protecting Teens at Work: The Massachusetts Department of Public Health Young Workers Project (YWP) has used similar data to track injuries to working teens—a population at high risk of being in- jured on the job. When the surveillance data revealed high numbers of burns in a large franchised res- taurant chain, interviews with injured teens and follow-up worksite investigations by the YWP found teens were injured while brewing coffee. This primarily occurred during peak hours with high demand. Not aware brewing was ongoing, teens were pulling out brew baskets, causing hot coffee slurry to splash over their hands and wrists causing second and third degree burns. The YWP recommended that the company work with its equipment suppliers to find an engineering solution to the problem. The company designed a brewer which locks the coffee funnel until brewing is complete which is being used in many of the franchised establishments across the country. Other YWP findings have been used to promote increased protections for youths under Massachusetts’ child labor laws, requirements that youth job training programs provide health and safety training, and statewide outreach to teens, parents, teachers, and employers about protecting youth at work. Industry-Based Surveillance in the Trucking Industry—Washington State’s TIRES Project: In Washington State, the trucking industry has high workers’ compensation claim rates and costs. Past research by Washington’s state-based OSH surveillance program indicated that the most common and costly injuries were musculoskeletal disorders and falls. In response to this problem, Washington developed the Trucking Injury Reduction Emphasis through Surveillance (TIRES) project. TIRES part- nered with trucking industry stakeholders including employer associations and unions to further define the causes of work-related injuries and develop educational materials. Case-based surveillance that included interviews with injured workers led to the identification of loading and unloading freight, de- coupling trailers, strapping down loads, and ingress and egress from the cab and trailer as foci for inju- ry prevention. With the steering committee’s oversight and input, TIRES developed resources for pre- vention and education. The products focus on identifying workplace hazards and providing low-cost, simple solutions for injury prevention. During fiscal year 2016, more than 150,000 people accessed TIRES publications online via the project website (NIOSH, 2015a). TIRES training materials are used as a major component of the Washington Teamsters Training programs. TIRES researchers also de- veloped an online simulation training for young truck drivers, safety directors, and company leaders, in response to requests for more interactive education. These tools have been downloaded more than 30,000 times all over the world, including by TIRES partners in the Alabama Trucking Association Workers’ Compensation Fund, the Motor Carriers of Montana, and the Safety Driven-Trucking Safety Council of British Columbia (NIOSH, 2015a). 64 Prepublication Copy

TABLE 4-3 Examples of Surveillance Systems for Nonfatal Occupational Injuries in the United States Responsible Condition(s) under Population Time frame Surveillance System Scopea Typeb Agency(ies) Surveillancec Data Source(s) Coveredd Approach for report Release Survey of National, P BLS* O: Nonfatal work- Employer reports Most workerse Sample Annual Occupational Injuries 46 states States* related injuries and Illnesses (SOII) (95%) and acute illnesses (5%) National Electronic National P* NIOSH* O: Work-related Emergency All workers Sample of 67 Intermittent Injury Surveillance CPSC* injuries treated in department records emergency System—Occupational CDC emergency Special follow- departments Supplement departments back studies nationwide Targeted State-Based 3 states P, C, States* Of Multiple sources, Varies by Census and some Varies by system Injury Surveillance varies by NIOSH* vary by system system case series, varies Systems system by system Severe Injury National C OSHA* O: Severe injuries Employer reports All workers Case series Ad hoc Reporting State (hospitalizations, covered by amputations, eye federal or state loss) OSHA NOTE: Asterisk indicates funding agency. CDC, Centers for Disease Control and Prevention; CPSC, Consumer Product Safety Commission. a Geographic levels at which findings are publicly available. b P, population based: data are collected on a census or representative sample of a defined population and allows for assessing extent of a health related event and monitoring trends with this population over time/locale ; C, case based: focus of data collection is on individual cases that require follow-up or immediate public health action. These approaches are not mutually exclusive. c O, outcome; H, hazard; E, exposure. d The population covered may include active and former workers, retirees, and others depending on the system. e Excludes self-employed, workers on small farms, domestic, U.S. postal workers, and federal workers, approximately 9 percent of the U.S. workforce. f Massachusetts, young worker injuries and hospital worker injuries; Michigan, amputation, burns, crushing injuries, farm injuries, and skull fractures; Washing- ton, trucking industry worker injuries. 65

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Administrative databases originating in the health care system are yet another important source of information on work-related injuries but their use is currently limited by lack of information on work- relatedness in these records. Payment information in these data systems indicating workers’ compensation as payer can be used to identify some but not all work-related cases, as not all workers are covered under workers’ compensation, and some injured workers who are may not file claims or their claims may be denied (Spieler and Burton, 2012; Groenewold and Baron, 2013; Sears and Bowman, 2016). The Interna- tional Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) includes a supple- mental External Cause of Injury code—“External Cause Status”—that indicates if injury occurred while engaged in civilian activity for pay or income. ICD-10-CM was implemented in clinical settings in the fall of 2016 and the extent that these codes are being used in various health data sources remains to be evaluated. Conclusion: The use of the supplemental External Cause of Injury codes has substantial po- tential to enhance the utility of hospital inpatient, emergency department, and outpatient data sys- tems for OSH surveillance. Work-Related Musculoskeletal Disorders NIOSH’s prioritization of research and prevention resources based on burden, need, and impact di- rects attention towards the detrimental impact that work-related musculoskeletal disorders (WMSDs) have on workers and social insurance systems. Current estimates of the significant burden of WMSDs come from the BLS Survey of Occupational Injury and Illness – 31% of all occupational injuries (BLS, 2016g), state-based surveillance programs usually using workers’ compensation data - 43% of compensa- ble claims in Washington state (Marcum and Adams, 2017), and the National Health Interview Survey Occupational Health Supplement (CDC, 2017e). WMSDs likely strain the U.S. Social Security Disability Insurance (SSDI) System as the expiration of limited benefits provided for long-term disability under workers’ compensation are “taken-up” by benefits offered under SSDI (Reville and Schoeni, 2004; O’Leary et al., 2012). Throughout their history NIOSH and OSHA have recognized work as a risk to musculoskeletal health (NIOSH, 1997). A comprehensive review by the National Research Council and Institute of Medi- cine addressed the work-relatedness of musculoskeletal disorders (WMSDs) (NRC, 2001). This review gave recommendations to BLS to revise their data collection and reporting systems for more comprehen- sive surveillance of WMSDs and recommended for NIOSH a lead role in “developing uniform definitions of musculoskeletal disorders for use in clinical diagnosis, epidemiologic research, and data collection for surveillance systems.” Some of these recommendations to BLS and NIOSH are reiterated in this report, such as “including details on non-lost-workday injuries or illnesses (as currently provided on lost work- day injuries) to permit tracking of these events in terms of the variables now collected only for lost work- day injuries (age, gender, race, occupation, event, source, nature, body part, time on the job)” (NRC, 2001). The report also supported a broader surveillance approach recommending collection of additional information on the worker’s use of tools and technology, the organizational conditions under which work is performed and development of exposure assessment tools which could be used for hazard surveillance. Under current OSHA recordkeeping requirements, establishment level WMSD data are not easily available and OSHA’s efforts to improve establishment level recordkeeping requirements identifying WMSDs on OSHA logs have not been successful (GAO, 2016). The OSHA log prior to 2001 had includ- ed a column for “repeated trauma cases,” which was inclusive of some MSDs but not all (GAO, 2016). OSHA’s 2001 revised recordkeeping regulation included a column to identify MSD cases, but was delet- ed in a 2003 amendment to the standard. In 2010, OSHA proposed to modify the Log 300 form to include a specific column to identify which injuries are MSDs, which would provide more complete information on the extent of MSDs both in the workplace and in the SOII, but due to opposition and intervention by Congress, this proposed addition has not been finalized. 66 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues In the second decade of the National Occupational Research Agenda (from 2006-2016), industry sector councils included WMSD surveillance and prevention as part of their research agendas. In both the second and the third upcoming decade of NORA, NIOSH has included a Musculoskeletal Disorders Cross Sector Council, which reinforces the ubiquitous, pervasive nature of risk factors for WMSDs in all sectors of the U.S. economy. Conclusion: Work-related musculoskeletal disorders represent a large physical and economic burden on the U.S. workforce demanding a continued emphasis on surveillance of these disorders. OCCUPATIONAL DISEASE SURVEILLANCE Surveillance of diseases in which an occupational hazard or hazards were the cause or contributing factor is especially challenging because the illnesses of interest (e.g., coronary artery disease, chronic ob- structive pulmonary disease [COPD], lung cancer, and renal failure) can often have many potential risk factors, including work, that can contribute to disease development, and there is often substantial lag time between initial exposure and disease onset. Limited emphasis on occupational health in medical school curricula leaves most physicians ill equipped to assess work-relatedness of multifactorial conditions, which adds to the challenge (Michas and Iacono, 2008). The importance of work among the causes for these multifactorial conditions is underappreciated. Estimates of the preventable causes of these condi- tions generally ignores the impact of work resulting in incidence, prevalence, and mortality estimates that fail to identify primary prevention opportunities in the workplace. While the fraction of multifactorial ill- nesses that can be attributed to work may be small for common conditions such as lung cancer, workplace exposures may still account for a substantial human and economic burden. For example, consensus state- ments from the American Thoracic Society (ATS) based on the review of the medical literature have con- cluded that 15 percent of new-onset asthma among adults is caused by workplace exposures and that an- other 25 percent of adult asthma is work aggravated (Balmes et al., 2003; Torén and Blanc, 2009; Henneberger et al., 2011; Blanc, 2012). Similarly, the ATS and others have estimated that work exposures contribute to at least 15 percent of COPD cases (Hnizdo et al., 2002; Balmes et al., 2003; Raherison and Girodet, 2009). Other estimates of the attributable risk of work have been developed: 6.3 to 18 percent of coronary artery disease deaths, and 8.2 to 14.5 percent of chronic renal failure deaths (Steenland et al., 2003). A recent systematic review that covered 46 years and 8,000 published studies found good evidence for the role of a variety of chemical exposures in heart disease, pulmonary heart disease, stroke, and high blood pressure (SBU, 2017). In considering surveillance of long-latency conditions, it is useful to distinguish between diseases (such as silicosis and coal workers’ pneumoconiosis) that are almost invariably work related, and the di- agnosis itself as an indicator for work-relatedness (pathognomonic occupational diseases) and multifacto- rial diseases for which occupational causes are only one of a number of contributing factors. Approaches to surveillance of the long-latency work-related pathognomonic diseases and common multifactorial dis- eases differ markedly. For pathognomonic diseases, data sources such as hospital discharge records that include diagnostic information can be used for surveillance to assess extent of the condition. Surveillance of multifactorial diseases is much more challenging. For conditions with known occupational etiology and a relatively high fraction attributed to work such as asthma or COPD, case-based approaches that in- volve follow-up with individuals or their providers to ascertain work-relatedness and sources of exposure are feasible. Also, surveillance of exposures can be a useful adjunct (see discussion of hazard and expo- sure surveillance below). Surveillance of common multifactorial conditions, where the occupational contributions are less well studied but where the conditions are prevalent in the adult population (e.g., coronary artery disease, mental disorders) has generally been restricted to monitoring patterns of disease in relation to basic em- ployment information (e.g., usual industry and occupation). Results from these efforts have been used to generate hypotheses about potential occupational associations that inform research priorities, and the ap- proach may identify statistical aberrations (hot spots) that warrant follow-up. Research on cardiovascular Prepublication Copy 67

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century disease (Fang et al., 2010; Costello et al., 2016; Du et al., 2016) and mental disorders (LaMontagne et al., 2008; Cohidon et al., 2012; Niedhammer et al., 2014; Theorell et al., 2015) has identified work-related risk factors that could be incorporated into surveillance efforts. For example, increased risk of cardiovas- cular disease among those exposed to fine particulates and of mental health problems among those work- ing in stressful environments. In such efforts, disease and exposure information would need to be linked (see Chapter 6). There are opportunities to advance knowledge about the importance of occupation as a contributor to many health conditions that have multifactor etiology with more extensive information about the em- ployment history of individuals. The occupational medicine community has long advocated the collection of a more extensive occupational history in the individual patient’s medical record. These efforts have focused primarily on physician education but with little success. The potential of obtaining occupational information systematically through the electronic health record (EHR; see Chapter 6) offers a new oppor- tunity to expand understanding of the relationship of work to chronic health conditions. Once in the EHR, current occupational information and, more importantly, the development of full occupational histories will permit examination of specific common conditions to seek important signals of occupational factors. Once noted, these can be tracked, hot spots can be identified, and formal etiologic studies can be planned. It has been long recognized that the SOII is not an adequate source of information on occupational illnesses. The SOII captures only a limited percentage of acute illnesses such as dermatitis and few of the long-latency occupational illnesses with some relationship to work (Windau et al., 1991; Luckhaupt et al., 2013a; Alarcon, 2016). Although the 1987 NRC report recommended that NIOSH take the lead in occu- pational disease surveillance and develop a comprehensive national surveillance system using a wide va- riety of data, this funding to do so has not been provided to NIOSH. Rather, over the past several decades, NIOSH has taken more limited steps to advance surveillance of occupational disease. The major strategies used by NIOSH have been to leverage use of existing health data sources and surveys and to support state health agencies in building case- and population-based surveillance systems for select occupational health conditions. Key systems and approaches currently in place are listed in Ta- ble 4-4 and described briefly below. Death Certificate Data Since 1980, NIOSH has partnered with up to 30 states and the NCHS to obtain death certificate data and to code the narratives in these records on usual industry and occupation according to the Census Bu- reau’s Industry and Occupation classification system. The death certificate data from these states (includ- ing underlying and contributory causes of death, demographic data, and usual industry and occupation information) serve as the basis for the NOMS system which is used by NIOSH to monitor trends in chronic disease and other causes of mortality by occupation and industry. Occupational diseases such as asbestosis or silicosis that are almost always work related can also be characterized. NIOSH and other researchers have published studies based on analyses of these data that have both confirmed previous risks and pointed to new associations that require further research (Dubrow et al., 1987; Blair et al., 1993; CDC, 1995; Burnett et al., 1997; Savitz et al., 1998; Colt et al., 2001; Luckhaupt and Calvert, 2008; Rob- inson et al., 2015). Findings are periodically updated and made available on an interactive NIOSH web- site (Box 4-2). Electronic death registration systems, now implemented in most states, provide NIOSH with the op- portunity to include more states and provide more timely coded industry and occupation data (PHII, 2016) NIOSH is planning to conduct a pilot effort with NCHS in 2018 to apply computer-assisted coding tools to code all industry and occupation data collected in real time from the 17 states now participating in NOMS. If successful, this partnership will provide the opportunity to analyze mortality patterns by indus- try and occupation in all 50 states. 68 Prepublication Copy

TABLE 4-4 Examples of Surveillance Systems for Occupational Illnesses in the United States Responsible Condition(s) under Time Frame for Surveillance System Scopea Typeb Agency(ies) Surveillancec Data Source(s) Population Coveredd Approach Report Release National Health National P NCHS* O, H In-person household Adult civilian Sample Intermittent Interview Survey NIOSH* survey population living in Periodic (5-year) Multiple outcomes and U.S.e Occupational Health hazards that vary with Supplement NIOSH supplement Adult Blood Lead 26 states (and P, C NIOSH* E: Elevated blood levels Clinical laboratory All adults age 16 Census Annual Evaluation and aggregated) States* reports Surveillance Program SENSOR Pesticide 12 states (and C, P NIOSH*, O: Occupational pesticide- Multiple data All workers Case series Intermittent Surveillance aggregated) EPA* related injury and illness sources States Work-related asthma 5 states (and C, P NIOSH* O: Asthma caused or Multiple data All workers Case series Annual surveillance aggregated) States exacerbated by work sources: provider case reports, hospital, workers’ compensation records, etc. Multisource silicosis Michigan C,P NIOSH* O: Silicosis morbidity and Multiple data All workers Census Varies by state surveillance State mortality sources: provider case reports, hospital and workers’ compensation records death certificates Sharps injuries (blood- Massachusetts P NIOSH* E: Injuries due to Mandated sharps All workers in Census Annual borne pathogen State* contaminated needles and injury logs hospitals including exposure) among other sharp devices maintained by acute students in training hospital workers and chronic care hospitals National Occupational Aggregated P NIOSH* O: Chronic disease deaths Death certificates All workers Census Intermittent Mortality Surveillance data from 17 NCHS* by industry and occupation (NOMS) statesf (Continued) 69

TABLE 4-4 Continued 70 Responsible Condition(s) under Time Frame for Surveillance System Scopea Typeb Agency(ies) Surveillancec Data Source(s) Population Coveredd Approach Report Release National Occupational National and P NIOSH* O: Pneumoconiosis, Death certificates All workers Census Intermittent Respiratory Mortality state, some NCHS* hypersensitivity Surveillance county level pneumonitis and (NORMS) data mesothelioma deaths; other respiratory disease deaths by industry and occupation Occupational Cancer 5 states P NIOSH* O: Cancer incidence by State cancer All workers Census Intermittent Surveillance aggregatedg NIOSH* industry and occupation registries Hearing loss National P NIOSH* O: Hearing loss Sample of All workers Case series Peer-reviewed surveillance audiometric service papers providers and U.S. Air Force NOTE: Asterisk indicates funding agency. a Geographic levels at which findings are publicly available. b P, population based: data are collected on a census or representative sample of a defined population and allows for assessing extent of a health related event and monitoring trends with this population over time/locale ; C, case based: focus of data collection is on individual cases that require follow-up or immediate public health action. These approaches are not mutually exclusive. c O, outcome; H, hazard; E, exposure. d The population covered may include active and former workers, retirees, and others depending on the system. e Noninstitutionalized population. f Number of participating states has varied over time. g Previously one state; pilot under way expanding to five states.

Current Status of Federal and State Programs and Cross-cutting Issues The National Occupational Respiratory Mortality System (NORMS) is an interactive data system that is based on mortality data from death certificates provided to NIOSH annually by the NCHS (see Box 4-2). This national database contains information about deaths from 1968 forward with underlying or con- tributory causes of death from select respiratory conditions known to be associated with work: pneumo- coniosis, hypersensitivity pneumonitis (since 1979), and mesothelioma (since 1999) (Figure 4-4). Counts, age-adjusted rates, and potential years of life lost for all U.S. residents and some states and counties by age, gender, and race are generated from the database for various time periods and included in NIOSH’s electronic Work and Occupational Lung Disease (eWoRLD) system, an interactive web-based application that presents data on both occupational morbidity and mortality due to respiratory disease (NIOSH, 2017d; see Box 4-2). The national database does not include information about the usual industry and oc- cupation of the decedent. To address this, data from states participating in NOMS (see above) are incor- porated in the NORMS system and used to monitor mortality patterns of a broader range of respiratory diseases by industry and occupation. This “industry and occupation database” includes information on deaths due to chronic obstructive lung disease, asthma, influenza, lung cancer, mycobacterial infection, pleural plaques, and tuberculosis in addition to the work-related respiratory diseases named above. Sur- veillance findings from this database, including proportionate mortality ratios for respiratory diseases by industry and occupation for several time periods, are likewise included in the eWoRLD. NORMS also includes tools for data users including crosswalks for comparing changes in the Census Bureau’s Industry and Occupation Classification System codes over time (1990 and 2000 revisions) and Census population estimates used by the system in calculating mortality rates. FIGURE 4-4. Malignant mesothelioma annualized age-adjusted death rate* per 1 million population, † by state, United States, 1999-2015. *Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. standard population age distribution (CDC, 2017f). In two states (Maine and Washington), the age-adjusted death rate exceeded 20 per million per year. † , codes C45.0 (mes- othelioma of pleura), C45.1 (mesothelioma of peritoneum), C45.2 (mesothelioma of pericardium), C45.7 (mesothe- lioma of other sites), or C45.9 (mesothelioma, unspecified) were listed on death certificates were identified using CDC multiple cause-of-death data for 1999-2015. SOURCE: Mazurek et al., 2017. Prepublication Copy 71

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Health Survey Data The NHIS has been used by NIOSH and others to assess workers’ health. The NHIS is an ongoing annual household survey of approximately 35,000 households and 87,500 individuals conducted by the NCHS (NCHS, 2016). The survey is designed to represent the civilian noninstitutionalized population residing in the United States at the time of the interview. Its primary objective is to obtain national esti- mates of health care utilization, health conditions, health status, insurance coverage, and access, as well as to monitor trends in illness and disability in the nation. The NHIS consists of a core set of questions that have remained relatively unchanged along with supplemental questions that vary. Historically the core questions have collected basic employment information (employment status, current occupation, and in- dustry) so that NHIS data from every year could be used to study general trends in chronic disease and other health conditions by industry and occupation. NIOSH has periodically analyzed data from this gen- eral health section to provide baseline information on the health status of the workforce in major industry sectors (Table 4-5). As mentioned above, the NHIS is currently undergoing revision and the most recent proposal is to collect industry and occupation information on a rotating basis (NCHS, 2017). This would substantially reduce the utility of the data for examining not only health outcomes and disability but health care access and utilization as well as work-related health behaviors. TABLE 4-5 Prevalence of Selected Health Conditions, Work Organization and Psychosocial Factors, and Physical and Chemical Exposures Among U.S. Workers (health care sector versus all U.S. workers, 2010) All U.S. Workers Health Care Sector Prevalence (%) Prevalence (%) In the past 12 Monthsa Dermatitis 9.8 11. Health Conditions Carpal tunnel syndrome 3.1 3.3 Current asthma 7.2 8.7 Injury or poisoning at work 2.8 3.6* weekb 7.2 5.3 b week 18.7 14.4 Work Organization Factors Nonstandard work arrangementsa 18.7 10.7 a Temporary employment 7.2 3.9 Nonstandard shiftsa 28.7 29.0 Job insecurityc 31.7 22.8 c Psychosocial Exposures Work-family imbalance 16.3 16.9 Hostile work environmentsa 7.8 9.1 Exposure to potential skin hazards at worka 20.6 25.7 Exposure to secondhand smoke at workd 10.0 8.3 Physical/Chemical Exposures Exposure to outdoor worka 24.7 6.9 Exposure to vapors, gas, dust, or fumese 25.0 14.2 a Among U.S. adults who have worked in the past 12 months. b Among U.S. adults who have worked in the past 12 months, who only held one job. c Among U.S. adults who were employed in the week prior to interview. d Among nonsmoking U.S. adults who have worked in the past 12 months. e Exposure during longest-held job (all other exposures refer to current or most recent job). *These estimates have a relative standard error >30% and <50% and should be used with caution as they do not meet NCHS reliability/precision standards. SOURCE: NIOSH, 2013. 72 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues Periodically NIOSH funds occupational health supplements (NHIS-OSH) to collect national-level data on various occupational health outcomes and exposures, focusing on information not available in the SOII (NIOSH, 2016d). An advantage of collecting supplemental OSH data through the NHIS is that the data can be used to provide current national estimates on the prevalence of common work-related health conditions and expo- sures by industry and occupation (CSTE, 2013a). NIOSH also uses such data to assess progress in meet- ing the Healthy People 2020 objective concerning patient-physician communication regarding asthma and work (HHS, 2017). Additionally, NIOSH researchers have used the data for topical research, including, for example, the congruence between current and usual occupation, and links between workplace mis- treatment and sickness absenteeism (Luckhaupt et al., 2013b; Asfaw et al., 2014). The implementation of the OSH supplement on an ad hoc basis has been identified as problematic (CSTE, 2013a). There is a need for an ongoing NIOSH commitment to periodically incorporate the OSH supplement in the NHIS if this approach is to provide information about trends over time. With this recognition, NIOSH plans to support the supplement every 5 years; however, there is concern about funding as the survey costs are substantially increasing (Schnorr, 2016). Also, the wide range of potential questions related to occupa- tional safety and health in light of the need to limit survey length raises challenges in consistently collect- ing data over time. Conclusion: Pending the outcome of the proposed BLS pilot household survey, the periodic administration of the OHS supplement would need to be reevaluated. NIOSH is engaged in a number of additional activities to incorporate occupational information in existing health surveys and data systems. These are described in Chapter 6. Medical Monitoring Program Data Several ongoing programs that routinely monitor worker health in specific industries provide data useful for occupational health and safety surveillance. The NIOSH Coal Workers’ Health Surveillance Program is a medical monitoring program established by the Federal Coal Mine Health and Safety Act of 1969 (P.L. 91-173; NIOSH, 2017e). The intent is to prevent early coal workers’ pneumoconiosis from progressing to a disabling disease. Up to 2014, the program was based on voluntary participation of min- ers in medical examinations that included chest radiographs interpreted by physicians with special train- ing and certification by NIOSH (B readers 10), spirometry, and medical histories. Since 2014, new miners are required to participate in the program when first employed (preplacement) and at 3 years after hire. NIOSH compiles the data to describe the prevalence of coal workers’ pneumoconiosis and disseminates findings through a data query system (see Box 4-2). Despite the success in using these B-reader reports to conduct surveillance for coal workers’ pneumoconiosis, no similar program has been set up for other common pneumoconiosis such as asbestosis or silicosis. NIOSH has also encouraged large audiometry-testing firms to participate in a surveillance system for noise-induced hearing loss. These firms voluntarily submit audiometric hearing tests. The results have been published in peer-reviewed publications (Masterson et al., 2014). Results are analyzed by geograph- ic regions and industry sector. NIOSH has used data from the National Health and Nutrition Examination Survey to examine the prevalence of hearing loss by occupation and industry (Tak et al., 2009); individual states have used the BRFSS data (Stanbury et al., 2008) and case-based reporting by audiologists (MSU and MI DELEG, 2009). OSHA requires medical monitoring of workers exposed to a number of hazards, including asbestos, noise and silica. The asbestos and silica regulations require both chest radiographs and spirometry. The 10 A “B reader” is a licensed physician who has passed a test of interpreting 125 chest films for pneumoconiosis. The B reader maintains their certification by passing a test interpreting 75 chest films for pneumoconioses every 4 years. The testing/certification is part of regulations administered by NIOSH. Prepublication Copy 73

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century noise regulation requires audiometric testing. There is, however, no provision in these regulations to col- lect the results of the medical testing and use the data for surveillance of these conditions. In addition to mandatory medical monitoring programs, NIOSH, medical specialties and industry trade groups have de- veloped recommended medical monitoring for individuals working with multiple substances, for example diacetyl and isocyanates. Conclusion: NIOSH has effectively used the results from a mandatory medical monitoring program for coal miners and a voluntary program for noise exposed workers for occupational ill- ness surveillance. Use of the results of mandatory medical monitoring required by OSHA and the recommended medical monitoring conducted by employers has the potential to improve surveil- lance data for selected occupational illnesses. Infectious Disease Surveillance Infectious diseases can be an important public health problem in many different work settings (Mo- linari et al., 2007; Keech and Beardsworth, 2008; Edwards et al., 2016). Some work environments present increased risk of select infectious diseases. For example, livestock workers have been shown to be at risk of methicillin-resistant Staphylococcus aureus infections, hepatitis, Q fever, leptospirosis, and antibiotic- resistant Escherichia coli (Klous et al., 2016). Child care workers are at risk of several infectious diseas- es: cytomegalovirus through contact with toys or diaper changes, hepatitis B and C, and human immuno- deficiency virus (HIV) transmitted through blood, and a variety of enteric pathogens such as hepatitis A, cryptosporidium, giardia, shigella, campylobacter, enteroviruses, and rotavirus transmitted by fecal-oral contamination through diaper changes or via sink faucets and the hands of child care workers or children (Reves and Pickering, 1992; Churchill and Pickering, 1997; Cordell et al., 2004). Health care workers can be exposed to several infectious agents through sharp injuries (e.g., HIV, hepatitis B virus, and hepatitis C virus; NIOSH, 2017f) as well as through direct patient care (e.g., pertussis and meningococcus) and the contaminated environment (e.g., Clostridium difficile) (Weber and Rutala, 2016). And both health care workers and corrections officers are at increased risk for tuberculosis (IOM, 2001; NIOSH, 2016e). The workplace can also be a critical locus for transmission of infectious disease, regardless of initial causation. For example, the annual epidemics of influenza A that are tracked around the world impact workplaces of many types. Influenza can lead to pneumonia and dehydration and can worsen long-term medical conditions, such as congestive heart failure, asthma, or diabetes. Timely information about work- related transmission of infectious diseases can be strategically important to facilitate rapid assessment and intervention to control the spread of disease to other workers and the public, particularly workers in criti- cal and public-related services such as health care, medical waste treatment, emergency response, postal and package delivery, utilities, and transportation. In the United States, state, local, and territorial public health agencies take the lead on receiving cas- es of specified infectious conditions. The Council of State and Territorial Epidemiologists (CSTE) is re- sponsible for defining and recommending which diseases and conditions are nationally notifiable and re- ported to CDC. All but five of the nationally notifiable diseases are infectious diseases. States voluntarily report these conditions to disease-specific CDC programs through the Nationally Notifiable Disease Sur- veillance Systems (NNDSS). Of the 90 conditions included in the NNDSS, approximately 36 include some information on work largely because of one or more specific work relationships. As noted, information about work is important not only in identifying the exposure source for reported cases but to address the workplace as a locus of potential disease transmission. However, the occupational data collected currently are not harmonized across conditions nor coded using a standard coding system. CDC is undergoing an agency-wide effort both to harmonize the variables collected in its surveillance systems and to improve the NNDSS techno- logical infrastructure by basing it on interoperable, standardized data and exchange mechanisms. CSTE has recommended that CDC incorporate industry and occupation and other work information as appropri- ate in CDC surveillance systems as feasible (CSTE, 2014). This ongoing work provides an important op- portunity for NIOSH and its state partners to influence collection and harmonization of industry and oc- 74 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues cupation information for conditions within the NNDSS. There appears to be increasing recognition that standardized collection and coding of industry and occupation information could substantially enhance surveillance of infectious diseases in relation to work, a significant gap in OSH surveillance. NIOSH and CSTE are currently engaged with colleagues at CDC to identify next steps to be taken to move this for- ward. In a related effort, they are also collaborating in the development of a Reportable Condition Knowledge Management System, a system designed by CSTE as a web portal for public health agencies to manage reporting criteria to facilitate automatic electronic case reporting of reportable and notifiable conditions documented in electronic health records (CSTE, 2017b). On another front, given the multiple hazards, including exposure to infectious disease, faced by heath care workers, NIOSH has developed the Occupational Health Safety Network (OHSN). OHSN is a web-based application to collect standardized data from employers on common work-related injuries and illnesses among hospital workers, which includes a module to collect information on injuries from con- taminated needles and other sharp devices (sharps injuries). A convenience sample of 114 hospital sys- tems (2014 data) is currently reporting data through OHSN. As part of its state funded activity, NIOSH also contributes to the support of the Sharps Injury Surveillance System in Massachusetts. State law in Massachusetts requires hospitals to report case-level data on all sharps injuries to the state health depart- ment annually. Sharps injury surveillance is essentially an exposure surveillance system, as the focus is not on the injury or the development of an infection but the sharp injury as an indicator of potential expo- sure to blood-borne pathogens. OSH surveillance programs in state health agencies may also collaborate with their infectious dis- ease programs to investigate and address clusters of infectious disease in the workplace. For example, occupational safety and health staff worked with infectious disease colleagues in California to identify, investigate, and prevent coccidiomycoses among construction workers in the solar industry (Wilken et al., 2015). Conclusion: Further work is needed to increase collaboration between infectious and occupa- tional public health programs at the state and federal levels to ensure that information on work is regularly collected and considered as part of infectious disease surveillance activity, including in- vestigations. State-Based Surveillance Systems for Occupational Disease Surveillance Approximately 10 states have built on mandatory state disease reporting requirements to implement case-based surveillance of selected occupational disease using a model initially developed by NIOSH— the Sentinel Event Notification System for Occupational Risks (SENSOR) (Rutstein et al., 1983; Baker, 1989). This model is based on the concept of a sentinel health event in which a single event is considered a sentinel or warning sign that the prevention system has failed and follow-up with the worker and/or the worksite may be warranted to prevent additional cases (Baker, 1989). Initially based primarily on case reporting by healthcare providers, the model has evolved over time to include use of multiple sources such as death certificates, administrative data sources such as statewide hospital data sets and worker’s compensation records, laboratory reports, and other sources such as calls to poison control centers and agricultural extension programs, for case ascertainment, e.g., silicosis (Schleiff et al., 2016). NIOSH iden- tifies national priorities for targeted funding and states have the option of proposing their own targets. Case definitions for surveillance, which have been developed by NIOSH and the states, are used to con- firm cases. Case follow-up may include public health investigations of the worksite, referrals to OSHA or other agencies to control exposures and protect other workers at risk, and steps to ensure the affected in- dividual has appropriate medical treatment. Follow-up also allows for collection of additional data to bet- ter understand the epidemiology of the disease. Summary data are used by states to target broader-based prevention efforts and have included, for example, dissemination of prevention recommendations; chang- es in state policies; and educational outreach to employers, workers, and health care providers. While data from case-based surveillance may or may not be complete or representative, summary findings can identi- Prepublication Copy 75

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century fy new hazards and provide important otherwise unavailable information to inform prevention efforts (Rosenman et al., 2003). Currently state-based surveillance systems are in place for surveillance of work-related lung disease, with a focus on asthma and silicosis, and pesticide-related injury and illnesses. All use multiple data sources for case ascertainment and data to inform prevention efforts. Participating states also submit their data to NIOSH for aggregation and analysis to gain a broader understanding of the problems, fill gaps in national level surveillance, and foster prevention activities such as those described in the following exam- ples. Findings of work-related asthma associated with cleaning products in multiple states have led to changes in national policies regarding certification of products as “green cleaners” only if they contain no known asthma-causing chemicals (Green Seal Institutional Cleaning Products, 2017). Data from multiple states on illness associated with the use of pesticide-releasing foggers led the Environmental Protection Agency to issue new requirements for product labeling to improve user understanding of risks and safe use (CDC, 2008). Additionally, 28 states participate in the NIOSH Adult Blood Lead Epidemiology and Surveillance (ABLES) program (2015 data). These states require clinical laboratories to submit reports of blood lead tests in both adults (and children) to a state health agency. Blood lead levels (BLLs) at or above the refer- ence level of 5 μg/dL are considered an indicator of exposure (CSTE, 2015b). Laboratory reports general- ly do not contain information about the industry or occupation of the affected worker. States conduct fol- low-up of individual cases based on blood lead levels to ensure adequate medical treatment and removal from exposure and to identify the source of exposure, including industry of the affected worker, and to control exposures. Many state health agencies work with OSHA to conduct follow-up in workplaces where cases were exposed to lead. Summary data are used to monitor trends and to identify high-risk in- dustries and communities for outreach. States participating in ABLES submit their data to NIOSH and summary findings are published annually (Alarcon, 2016). The NIOSH ABLES program, which provides resources for adult blood lead surveillance in most of the participating states, reports that the program has contributed to a greater than 60 percent decline in the prevalence g/dL among adults in the United States from 1994 through 2013 (NIOSH, 2016f) (Figure 4-5) A limited number of states have de- veloped similar laboratory-based surveillance systems for other metals such as cadmium and mercury (e.g., New York and Michigan; New York State Department of Health, 2016; MI DHHS, 2015). The occupational health indicators generated by NIOSH funded OSH programs in about half the states include measures of several diseases almost always caused by work such as mesothelioma and as- bestosis as well as elevated blood lead levels in adults and occupationally related calls to poison control centers (Appendix D). Summary In echoing the conclusions of the 1987 NRC committee, there are no modifications of the BLS em- ployer survey that would enable it to measure the occurrence of occupational illnesses. Studies have doc- umented that the SOII only captures a limited percentage of acute illnesses is even less useful in counting long-latency occupational illnesses. Individual states and NIOSH collect occupational illness surveillance data but the data are not compiled and findings regularly released. Individual research publications, sur- veillance reports, and web applications are used to disseminate findings but not with all occupational ill- nesses combined, not in conjunction with the release of the BLS SOII data, and not on a regularly sched- uled basis. Recommendation B: NIOSH, working with the state occupational safety and health surveil- lance programs and across divisions within the agency, should develop a methodology and coordi- nated system for surveillance of both fatal and nonfatal occupational disease using multiple data sources. The data should be analyzed, interpreted, and presented regularly in a comprehensive public re- port. 76 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues The data sources to be considered should include reporting by audiometric providers, disease regis- tries (such as cancer and chronic renal failure), hospitals, laboratories, physicians, poison control centers, and health surveys as well as appropriate exposure databases. It is important that illness data collected by the states and NIOSH be analyzed and released in a timely manner. The data should be released in con- junction with BLS illness data in a manner that does not delay data released by BLS. In the near term, NIOSH should combine information from the existing focused occupational disease surveillance systems (e.g., ABLES, pesticide illness, silicosis surveillance, and NORMS) and mesothelioma from cancer registries and other relevant occupational health indicators to provide a more com- prehensive annual report on the extent of occupational illness morbidity and mortality that can be released in conjunction with information from the SOII. Methods for extrapolating from available data to generate national estimates should be explored. To enhance surveillance of occupational lung disease, NIOSH should require all B readers to re- port all chest radiographs interpreted to be positive for all types of pneumoconiosis. Increased collaboration between NIOSH and CDC infectious disease surveillance programs, with improved collection of occupational information, will be important to improve documentation of endemic and epidemic infectious disease related to work. FIGURE 4-5 National prevalence rate* of reported cases of elevated blood lead levels (BLLs),† by year (Alarcon, 2016). * Bureau of Labor Statistics Local Area Unemployment Statistics (LAUS) program (http://www.bls.gov/lau/staa data.txt). †Since 2009, the case definition NOTE: A total of 30 states submitted data in 2013 (down from 41 states in 2012): Alabama, Alaska, Arizona, Cali- fornia, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachu- setts, Michigan, Minnesota, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Vermont, Washington, Wisconsin, and the second number is the number of states reporting Prepublication Copy 77

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century In the longer term, Gaps identified in the occupational illness surveillance system will need to be addressed through future developments that may involve o New or modified state regulations, requiring close coordination with the states, many of which have already promulgated reporting regulations. o Inference of occupational disease burden and trends that result from enhanced exposure as- sessment (Recommendation H, see Chapter 6). o Updating the list of occupational sentinel health events, establishing additional criteria for es- tablishing a link between workplace exposures and common diseases. Action on recommendations that address the inclusion of occupational information in medical records (see Recommendation J, see Chapter 7), federal health surveys and public health surveil- lance systems (Recommendation M, see Chapter 7), and automated coding of the industry and occupation information (see Recommendation L, see Chapter 7) will be important for ensuring the optimal implementation over time of this recommendation. OCCUPATIONAL HAZARD AND EXPOSURE SURVEILLANCE Occupational hazard surveillance is the systematic assessment of the occurrence of workplace risks with potential to contribute to health, disease, and injury among working populations, Exposure surveil- lance measures actual risk by including distribution of, and the secular trends in exposure to workplace risks. In a public health context, hazard or exposure surveillance identifies settings or individuals ex- posed to hazardous levels of specific agents allowing for intervention to reduce risk. While there is no comprehensive occupational exposure surveillance system in the United States, the concept has been dis- cussed over the past several decades and was included in the 1987 NRC report. Risk is defined as the combination of hazard and exposure. A hazard is a substance or condition with an inherent ability to harm; for example, in the case of chemicals, the material’s toxicity is the point of reference, while for radiant energy, the wavelength determines the hazard. Harm results when individ- uals or populations come into contact with, and are exposed to, the hazard. Both the intensity and the du- ration of exposure are important to determine. For some hazardous exposures the harm can just be acute (e.g., acute poisoning by carbon monoxide), for others the harms are cumulative or latent and cause or contribute to chronic disease (e.g., asbestos), and for others the harm may be both acute and chronic (e.g., lead). The 1987 NRC report identified hazard and exposure surveillance as a priority and presented four recommendations: OSHA should include quantitative exposure information in its publicly available database. OSHA should require submission of all exposure measurements required by industry in comply- ing with OSHA standards. NIOSH should compile and publish exposure data collected during health hazard evaluations as well as analyze these data to characterize the evaluated industries. NIOSH should include quantitative exposures in any future occupational hazard surveys. Opportunities for creating systems to address these recommendations have been challenging; never- theless, significant advances have been made. OSHA responded positively to the recommendations by including quantitative industrial hygiene measurements in their publicly available Integrated Management Information System (IMIS), and these data are now being explored by researchers for quality and poten- tial intervention research approaches. In addition, the NIOSH divisions focused on respiratory health and on surveillance utilize IMIS data for surveillance purposes. However, the specific goals and procedures for use of these data for ongoing surveillance have not been defined. In addition, NIOSH has compiled 78 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues and created exposure-specific databases derived from the health hazard evaluation (HHE) investigations and to date have posted data for lead and noise (NIOSH, 2015b). Data on formaldehyde exposures are expected to be posted soon. Large-scale hazard surveys, such as the National Occupational Hazards Survey (NOHS) and the Na- tional Occupational Exposure Survey (NOES) (see also Chapter 6), have not been conducted since the 1980s and those data, which were widely used, are now considered out of date and of limited utility (NIOSH, 1974; NIOSH, 2017g). In 2011, NIOSH conducted a web-based survey of health care work- ers—the Health and Safety Practices Survey of Healthcare Workers—to evaluate the extent of the use of well-known precautionary practices to minimize exposure to chemical hazards (NIOSH, 2017h). The primary lessons learned were that recommended exposure controls are not always implemented by the employer or employees; barriers to use of personal protective equipment (PPE) include that PPE is not provided or the perceived risk of exposure is underestimated, even for highly toxic chemicals such as chemother- apeutic drugs; and research is needed to evaluate factors preventing the use of safe handling practices. Problems with a web-based survey were characterized and difficulty in reaching some of the health care worker component groups (housekeeping and environmental services) was noted. OSHA’s publicly available IMIS and Chemical Exposure Health Data (CEHD) include quantitative industrial hygiene measurements from a variety of sources.11 Assessment of IMIS data from the 1980s found that, despite the limitations in using exposure data from a compliance database, some surveillance objectives are met when examining exposures to airborne lead and airborne silica. An analysis of the airborne concentrations of lead collected during OSHA compliance inspections from 1979 to 1985 identified 52 industries which had more than one-third of the median air lead levels measured that were greater than the permissible ex- posure limit (Froines et al., 1990). The data developed in this analysis also indicated the need to investi- gate certain industries with high exposures but few inspections. Methods were also developed that permit ranking of potentially hazardous industries in a geographic area using IMIS data. Researchers have continued to explore the effective use of IMIS data for risk characterization. A systematic review of studies using or analyzing IMIS data identified 29 such studies, most of which fo- cused on single analytes such as lead or silica (Lavoue et al., 2013a). These authors also identified poten- tial biases due to underreporting of values under the limit of detection. However, despite the limitations of these data, their potential for ongoing hazard characterization was highlighted. Additional modeling of the IMIS data using ancillary information about the workplace and its history of inspection demonstrated ad- ditional utility of the IMIS data in understanding some workplace characteristics associated with higher exposure levels (Sarazin et al., 2016). A number of other studies examining specific issues, for instance isocyanate asthma, have used IMIS data to identify and characterize high-risk conditions (Lefkowitz et al., 2015). Despite the above examples using IMIS data, the limitations of using compliance data for surveil- lance are well recognized. The data are not comprehensive or balanced with respect to the exposures characterized, the workplaces or jobs selected for monitoring, or the complete reporting of results. In ad- dition, although making these data available to the public is a big step forward, they are not routinely dis- seminated in a simple way for use by the public or health agencies. Promising developments in the sur- veillance of occupational hazards and exposures is further discussed in Chapter 6. 11 The CEHD, available since 2010 as part of the OSHA Information System, also contains quantitative industrial hygiene measurements but these are limited to those that are processed by the OSHA Salt Lake Technical Center. The CEHD and IMIS have a significant degree of overlap (about 50 percent) but each data set contains a substantial amount of unique data (Lavoue et al., 2013a,b). Prepublication Copy 79

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century CROSS-CUTTING ISSUES This section provides a brief overview of several topics relevant across the different end points un- der surveillance: the role of state programs, surveillance research, and sources of information on popula- tions at risk. State-Based OSH Surveillance Programs The 1987 NRC panel recognized the importance of the state-federal partnership and recommended that NIOSH continue and expand its efforts to develop the occupational health surveillance capability of state health departments through technical assistance and financial support. NIOSH responded positively to these recommendations and, even in the absence of additional dedicated federal funding for surveil- lance, now supports some level of OSH surveillance activity in 27 of the states. 12 Initially, in the late 1980s, state activities focused largely on exploring use of death certificate and cancer registry data to ex- amine patterns of disease in relation to employment characteristics. Today, states are exploring many dif- ferent data sources, in some instances as part of multisource surveillance systems, to meet state surveil- lance objectives and to inform action to improve worker safety and health, while helping to fill gaps in national surveillance. There are many recognized benefits: the state programs have access to unique state data sources; they are in a position to conduct case- as well as population-based surveillance with the attendant respon- sibility to follow up in individual workplaces; and, because the states have legal access to key identifiers, they are able to link data sources to develop a more comprehensive understanding of the magnitude and distribution of the conditions under surveillance. The states have also demonstrated the critical position they are in to use the surveillance findings to promote practical actions to improve worker safety and health. While important advances have been made in OSH surveillance at the state level, there are signifi- cant obstacles to building effective programs across the nation. As described in Chapter 3, worker safety and health is seen largely as a responsibility of the Department of Labor. As a result, occupational health and safety and OSH surveillance have remained relatively low priorities in the general public health community at both national and state levels. Occupational safety and health has not received strong sup- port from HHS or CDC and OSH surveillance has not been funded by CDC as a core public health func- tion. Consequently, whereas in some public health domains, such as infectious disease and cancer preven- tion, surveillance programs are in most if not all states, close to half of the states report having little or no OSH surveillance capacity. In a nationwide assessment of state health agencies regarding epidemiologic and surveillance capacity in eight public health domains, only 20% of states reported having substantial epidemiologic and surveillance capacity in occupational health, the lowest percentage of all domains as- sessed (CSTE, 2013b). This results not only in lack of attention to occupational safety and health but missed opportunities for collaboration across public health domains to address to convergent public health concerns that effect workers as well as the general public. Given limited resources for OSH surveillance, states with OSH programs rely on transient federal funding allocated through a highly competitive application process. While this is not unique to occupa- tional health, it substantially hinders continuity and strategic consistency (Burkom, 2017). State pro- grams come and go over funding cycles leaving gaps in nation’s OSH surveillance capacity. This problem is compounded by lack of a comprehensive national strategic plan for state-based surveillance identifying critical national priorities for expanded state-based surveillance. An additional “operational” barrier faced by states is the funding mechanism used by NIOSH to award funds for state OSH surveillance pro- 12 Twenty-six states have funding from NIOSH for fundamental or expanded surveillance (detailed later in the chapter). Additionally, five states have NIOSH funding for work with workers’ compensation data (of these one state is not part of the 26 states with fundamental or expanded surveillance). 80 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues grams. In other public health domains, state based surveillance activities are funded through applied pub- lic health practice mechanisms. However, NIOSH supports state surveillance activities through a competi- tive research application process (research cooperative agreements). This research application process introduces practical challenges for states. These include, for example, the inability of inexperienced states who wish to initiate OSH surveillance programs to meet research grant eligibility requirements such as innovation and the need for principle investigators with published research articles. For even experienced states, this has created hurdles—such as evaluation for ongoing funding based on innovation and the number of peer-reviewed publications—rather than success in collecting and using surveillance data to inform policy and practice. Additionally, these research applications require human-subjects review, which state institutional review boards are reluctant to conduct for ongoing surveillance programs, con- sidered as applied public health practice. Conclusion: State OSH programs play an essential role in a national OSH surveillance system and are especially well positioned to disseminate surveillance findings to those in positions to take action to protect worker safety and health. It is not necessary to conduct in-depth expanded programs for all conditions in all states in order to have an effective national surveillance system. However, contri- bution of such programs would be increased if implemented within the context of a comprehensive strate- gic surveillance plan developed by NIOSH in conjunction with the states as well as BLS and OSHA. Al- so, enhanced coordination among federally funded OSH and other public health programs at the state level have the potential to increase the effectiveness and efficiency of these state-based programs. Recommendation C: NIOSH should lead a collaborative effort with BLS, OSHA, the states, and other relevant federal agencies to establish and strengthen state-based OSH surveillance pro- grams. This should be carried out as part of a national coordinated effort to monitor priority conditions, hazards, and exposures; to identify emerging workplace risks; and to facilitate prevention programs that address these concerns. Furthermore, this should be carried out with the full support of and assistance from other parts of HHS-CDC. In the near term: OSH Agency Collaboration Within States: NIOSH, BLS, and OSHA should actively encourage and promote collaboration among their programs in the states to reflect the national commitment to interagency effectiveness for OSH surveillance and leverage surveillance and prevention ex- pertise across agencies. This should include sharing data and taking advantage of unique state- level data sets and case-based surveillance capacities to identify and respond to emerging occupa- tional safety and health hazards and conditions. Public Health Agency Collaboration Within States: NIOSH and other CDC centers that support state-based surveillance and prevention activities should promote collaboration among their state- level programs to monitor and address public health problems of shared concern, such as vio- lence, asthma, infectious disease, traffic safety, and health inequities among vulnerable popula- tion groups. NIOSH should also o Explore and implement, as appropriate, alternative approaches to funding ongoing surveillance in the states as applied public health programs rather than research programs. o Foster increased coordination and communication between its intramural and extramural sur- veillance programs. o Encourage NIOSH-funded Education Research and Training Centers and Agricultural Health and Safety Centers to provide technical and research support to state surveillance programs in their regions as part of their required outreach and education core activity. Prepublication Copy 81

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Surveillance Research Research is the process of systematic investigation to generate new facts, and it is important for all types of surveillance, including OSH surveillance. There are important distinctions, however, between research and surveillance (CDC, 2010). The most obvious distinction is that the primary goal of surveil- lance is to inform public health action, not necessarily to generate new knowledge. The dissemination of information produced by a surveillance system to guide action would be a central consideration in devel- oping and evaluating surveillance systems. In contrast, in research, findings are usually disseminated through a process called knowledge translation, tending to be less well-structured and often ad hoc. Another important distinction is that surveillance is an ongoing process, whereas research is not necessarily so. Accordingly, surveillance is usually funded through the core operating funds of a public health organization, while research is usually funded through competitions, which may be targeted (i.e., strategic) or investigator initiated. Despite these differences, it can be difficult to make the distinction be- tween surveillance and surveillance research. This can happen, for example, when states conduct surveil- lance to protect the health of the state population, but also analyze the state data together with a national data set to generate new knowledge. Surveillance research can generally be divided into two broad categories. The first is research that uses data collected through surveillance to generate new knowledge. Generating data for research is a well-accepted objective for a surveillance system, although not the primary objective for most systems. The second type is research to develop or adapt methods for surveillance. This type of applied research is less common, although increasingly recognized as being important for improving the efficiency and effec- tiveness of all types of public health surveillance. Applied surveillance research will play an important role in developing new approaches and adapting new technologies to build a smart OSH surveillance sys- tem for the 21st century. Research Using Surveillance Data to Generate New Knowledge About Occupational Health Within a surveillance system, the data collected are usually limited to the minimum data necessary to accomplish the objectives. This limitation is imposed for multiple reasons, including cost, protection of privacy, and acceptability of the system by those who provide data. When supporting research is an objec- tive of a surveillance system, then the scope of data collection may be greater than it otherwise would be (i.e., if supporting research were not an objective). In any event, even if supporting research is not an ex- plicit objective of a surveillance system, the data collected by the system can usually support research. Examples range from descriptive analyses, hypothesis-driven research, and research to assess the impact of interventions, including more general policies both as natural experiments and as simulated scenario analysis (“what if”). Given that research occurs under a different legal and ethical framework than public health surveil- lance, an important consideration in this type of research is to ensure that the researcher has the legal au- thority to use the data, that the necessary ethical approvals have been obtained, and that the necessary mechanisms are in place to ensure the protection of privacy. In practice, the same people conducting sur- veillance may also be conducting research, but this does not diminish, and may even augment, the need to clearly distinguish between the use of surveillance data for public health practice and research. Research to Develop and Evaluate Methods for Occupational Health Surveillance Applied research aims to develop, implement, and evaluate methods and tools for conducting sur- veillance. It is considered applied because the focus is to improve aspects of the surveillance process. The following are examples of applied research in occupational safety and health: Development of novel technologies for measurement of exposure (e.g., accelerometers in helmets, clothing to measure repetitive movements) and collection of outcomes (e.g., social media, crowd sourcing); 82 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues Development of data-coding technologies (e.g., natural language processing and statistical meth- ods) to be shared; Application of or development of new statistical methods in occupational health for detection of events, clusters, or other outliers; Linking in data sets to join variables, to assess reporting, to get denominator for rates, and to tri- angulate; Assessment of data quality and new data sources for case ascertainment; Estimation of attributable fraction of COPD caused by exposures at work, and Evaluation of whether traditional approaches to capturing and coding occupation and industry cover new work arrangements and development of new approaches to capturing this information. To be research, the results or methods need to be generalizable. Thus, periodic evaluation of surveillance data may be research if the findings are generalizable while periodic evaluation of a surveillance system would be part of ongoing surveillance programming. Current Surveillance Research BLS intramural researchers conduct surveillance research both using CFOI and SOII data and are developing new methods. These include, for example, development of coding software for assigning standard codes for occupation and event based on free text, and web-sweeping approaches for ascertain- ing fatal occupational injuries in publicly available data sets. As described above, the agency has process- es in place for researchers to apply to use CFOI and SOII data for research purposes and is in the process of making these data available at their Federal Statistical Research Data Centers (in a manner that pre- serves data confidentiality). In recent years, BLS has also supported a program of intramural and extra- mural research specifically aimed at better understanding the undercounting of injuries and acute illnesses in the SOII and factors that contribute to it. As will be described in Chapter 6, they are also supporting research to explore the feasibility of a worker survey. NIOSH likewise conducts and supports surveillance research using surveillance data as well as ap- plied research to develop new surveillance methods. Within NIOSH, investigators periodically compete with other researchers for funds to support investigator-initiated surveillance research projects using exist- ing data sets. NIOSH also funds investigator-initiated research activities carried out by extramural re- searchers in universities and the states and other nonprofit organizations (for examples, see NIOSH, 2014b). With the exception of an extramural funding stream specifically designated for surveillance re- search in 2000, extramural applications for surveillance research are submitted to the general NIOSH ex- tramural research funding competition. NIOSH does not appear to have a current research agenda for sur- veillance, although many of the NORA industry sectors have identified surveillance activities among their research goals. Sources of Information on Populations at Risk This chapter thus far has focused primarily on approaches used to collect data on health outcomes or hazards (numerator data). As mentioned in the 2009 Institute of Medicine (IOM) report Traumatic Injury Research at NIOSH, information about the “population at risk (denominator data) is also critical for sur- veillance and necessary to calculate injury and illness rates that allow for identification of disproportion- ate risks among segments of the population and subsequent priority setting” (IOM, 2009). The SOII and some state workers’ compensation insurance programs collect data on numbers of workers and hours of work as part of ongoing data collection which allows for calculating injury and ill- ness rates by industry (but not occupation and demographic characteristics such as age, gender, and race and ethnicity.) Other systems, such as ABLES, CFOI, and NEISS-Work, rely on external sources of de- nominator data to use in calculating incidence rates by employment and demographic characteristics. A Prepublication Copy 83

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century number of different sources of employment data are collected by federal statistical agencies, each with strengths and limitations, and the choice depends upon the availability of robust data at the geographic level of interest and intended purpose. An important distinction is that between employee count and hours-based incidence rates. The denominator for hours-based incidence rates, which takes into account time persons are at risk, is generally expressed as a full-time equivalent (FTE).13 As reported by BLS, count-based incidence rates underestimate risk among part-time workers, an important consideration in addressing the need to understand the injury and illness experience of the increasing numbers of workers in contingent employment situations (Ruser, 1998). One of the most widely used sources of employment information in generating injury or illness rates at the national and state levels is the Current Population Survey (CPS) conducted by BLS. BLS maintains a public use access file and NIOSH has developed a user-friendly query system—the Employed Labor Force query system—based on these data that provides employed worker population estimates of both counts of workers and FTEs (workers age 15 years or older) from 1980 through the present. A significant advantage of the CPS employment data is that this is a panel survey and data on employment and hours of work are collected from the same individual over time and aggregated to generate annual employment estimates. A disadvantage is that the sample size is often too small to generate robust rates for detailed segments of the population at the state or local level. The American Community Survey (ACS), conduct- ed by the U.S. Census Bureau, is another important source of employment estimates with the advantage of a larger sample size. A disadvantage is that information about weeks and hours of employment is col- lected from individuals at a single point in time and thus subject to recall bias or error due to changes in work and work schedules over the course of the year. Also, the ACS reports employment data as a cate- gorical rather than a continuous variable and offers no recommended method for computing FTEs. The Quarterly Census of Employment and Wages is yet another source of employment information. Unlike both the CPS and ACS, which are household surveys, the Quarterly Census of Employment and Wages Program at BLS provides data on the numbers of employed workers by industry provided by employers as part of the unemployment insurance system. This source may be expected to provide the most accurate count of workers but information about occupation hours of work or demographic characteristics is not provided. The BLS’s Current Employment Survey is another source of employment data based on data provided by a smaller sample of employers on a more frequent basis. BLS also generates monthly Local Area Unemployment (and employment) statistics for census areas and metropolitan regions combining data from employer-reported and household survey sources. Unemployment Insurance (UI) wage files maintained by states for purposes of determining eligibility of claimants for UI benefits are another source of employment data for potential use in OSH surveillance. NIOSH is currently working in collaboration with state and academic partners to explore the use of alternative data sources alone and in combination for generating employment denominators for use in OSH surveillance. This important research needs to be conducted. Practical guidance tools for selecting appropriate denominators for state OSH surveillance programs and other researchers are also needed. With changes in the health care delivery system there is increasing emphasis on documenting health needs at the community level. For example, under the Patient Protection and Affordable Care Act (P.L. 111-148) all nonprofit hospitals are required to conduct community health needs assessments to qualify for Medicare and Medicaid reimbursement (IRS, 2016). Local health departments also prepare a commu- nity health assessment as part of the public health department accreditation process (PHAB, 2015). Alter- natives for generating community-level OSH surveillance information need to be explored. Accurate documentation of employment among the contingent workforce in light of the changing nature of work and work relationships is a significant challenge and has potentially important implications for generating estimates of health and safety risk. Between 1995 and 2005, BLS collected data on contin- 13 An FTE is the number of hours worked by one employee on a full-time basis. The concept is used to convert the hours worked by several employees into hours worked by full-time employees. A full-time employee in generally considered to work 40 hours per week and 50 weeks per year, or 2,000 hours per year. 84 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues gent and alternative employment arrangements in periodic supplements to the CPS (GAO, 2015). These supplements were discontinued due to insufficient funds. While BLS has often requested funding to re- peat this survey every two years, congress has not allocated funding to do so. BLS did field a contingent worker supplement again in 2017 with one-time DOL funding, but it is unclear when the survey will be repeated. These surveys are needed to provide critical information about the workforce. Additional re- search is also needed to assess the validity of information on alternative work arrangements collected in population surveys that has implications for OSH surveillance. Research on how to generate authoritative labor statistics in light of the many changes in the structure of work including the emergence of the on- demand economy is a critical area of research with relevance far beyond OSH surveillance (NASEM, 2017). Another concern expressed by OSHA to the committee is the lack of comprehensive data on estab- lishments in the United States by industry that could be used to inform outreach and dissemination efforts. Although this information is collected through the unemployment insurance system overseen by BLS, it is not available to OSHA. Public health access to unemployment insurance listings of establishments by North American Industry Classification System code is also limited and varies by state. SUMMARY While substantially improved since 1987, the current state of OSH surveillance continues to have gaps and lacks maturity across the end points under surveillance. A robust system for fatal injuries is in place. Advances have been made in surveillance of nonfatal injuries with some critical omissions or shortcomings remaining. There continues to be limited surveillance of most chronic occupational diseas- es. There is very limited surveillance of hazards and exposures necessary for informing effective ap- proaches to prevention for long latency health outcomes. There is not a clear delineation of specific objec- tives for each component of the current surveillance system, and a comprehensive synthesis of findings across these systems is lacking. Although there is some coordination across the multiple entities engaged in surveillance, the current “system” operates more as a collection of separate and sometimes fragmented data systems, rather than a coordinated national OSH surveillance system that effectively promotes use of the data for prevention. Using the framework of the objectives of an ideal surveillance system outlined in Chapter 2 the committee identified the major gaps in surveillance (see Box 4-3). Agencies are well aware of current limitations and are engaged in a number on ongoing activities with potential to address many of these gaps. These are presented in Chapters 6 and 7. REFERENCES AFL-CIO. 2017. Death on the Job: The Toll of Neglect. Available online at https://aflcio.org/sites/default/files/2017- 04/2017Death-on-the-Job.pdf (accessed June 15, 2017). Alarcon, W. A. 2016. Elevated blood lead levels among employed adults—United States, 1994–2013. Morbidity and Mortality Weekly Report 63(55):59-65. Asfaw, A. G., C. C. Change, and T. K. Ray. 2014. Workplace mistreatment and sickness absenteeism from work: Results from the 2010 National Health Interview Survey. American Journal of Industrial Medicine 57(2):202- 213. Azaroff, L., C. Levenstein, and D. H. Wegman. 2002. Occupational injury and illness surveillance: Conceptual fil- ters explain underreporting. American Journal of Public Health 92(9):1421-1429. Azaroff, L., H. M. Nguyen, T. Do, R. Gore, and M. Goldstein-Gelb. 2011. Results of a community-university part- nership to reduce deadly hazards in hardwood floor finishing. Journal of Community Health 36(4):358-368. Baker, E. L. 1989. Sentinel Event Notification System for Occupational Risks (SENSOR): The concept. American Journal of Public Health 79(Suppl):18-20. Balmes, J., M. Becklake, P. Blanc, P. Hennenberger, K. Kreiss, C. Mapp, D. Milton, D. Schwartz, K. Toren, and G. Viegi. 2003. American Thoracic Society statement: Occupational contribution to the burden of airway disease. American Journal of Respiratory Critical Care Medicine 167:787-797. Prepublication Copy 85

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century BOX 4-3 Key Gaps in Occupational Safety and Health Surveillance Objective: Guide immediate action to address urgent health events Gap: Lack of a national approach for information sharing and collaboration among agencies to allow for timely identification and response to serious new and emerging health conditions and haz- ards Objective: Measure the burden Gaps Lack of nonfatal injury data on some major working populations including, the self-employed, workers on small farms, domestic workers, and contingent worker populations (e.g. temporary, GIG, immigrant workers) Limited data on nonfatal injuries in populations under surveillance due to underreporting, insuf- ficient collection of detailed information for majority of cases reported, limited indictors of injury severity Insufficient data on chronic occupational disease and limited synthesis of available information No approach for systematic collection of information about hazards and exposures Lack of data on economic and social impact of occupational injuries and illnesses Objective: Detect new or emerging hazards Gap: Limited capacity in federal agencies to analyze available injury, illness, fatality and exposure data to identify workplaces or populations at high risk, emerging trends, and actively promote use of data for prevention Objective: Identify high risk industries, occupations, worksites and populations Gaps: Ready access to establishment level data by government agencies for targeting preventive out- reach and enforcement Lack of data on nonfatal injuries and acute illnesses at the firm level and on multi-employer worksites Limited data on socio-demographic characteristics and work arrangements needed to identify potential vulnerable populations Lack of occupational information in data sources originating in the healthcare delivery system that are a crucial complement to employer based reporting Insufficient employment data on the contingent workforce needed to generate estimates of risk Objective: Guide planning, implementation and evaluation of prevention programs at establishment and state levels Gaps: No systematic means to foster use of data by employers and workers at the establishment level or to provide feedback on injury and illness experience to assist with hazard identification and prevention efforts Limited or no OSH surveillance capacity in many states and missed opportunities for collabora- tion across public health domains Objective: Generate hypothesis and make data available for research Gap: No surveillance research agenda 86 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues Bhandari, R., S. M. Marsh, A. A. Reichard, and T. R. Tonozzi. 2016. Characterizing emergency department patients who reported work-related injuries and illnesses. American Journal of Industrial Medicine 59(8):611-621. Blair, A., M. Dosemeci, and E. F. Heineman. 1993. Cancer and other causes of death among male and female farm- ers from twenty-three states. American Journal of Industrial Medicine 23:729-742. Blanc, P. D. 2012. Occupation and COPD: A brief review. Journal of Asthma 49(1):2-4. BLS (Bureau of Labor Statistics). 2010. Census of Fatal Occupational Injuries-Hours-Based Rates. Available online at https://www.bls.gov/iif/oshnotice10.htm (accessed November 8, 2017). BLS. 2012. Occupational Injury and Illness Classification Manual Version 2.01. Available online at https://www. bls.gov/iif/oiics_manual_2010.pdf (accessed November 8, 2017). BLS. 2015. Occupational Injuries and Illnesses: a Pilot Study of Job-transfer or Work-restricted Cases, 2011-2015. Report 1056. Available online at https://www.bls.gov/iif/oshwc/osh/case/djtr2012.pdf (accessed November 8, 2017). BLS. 2016a. Scope of the Census of Fatal Occupational Injuries. Available online at https://www.bls.gov/iif/ cfoiscope.htm (accessed June 12, 2017). BLS. 2016b. Fatal occupational injuries in 2015, charts. Available online at https://www.bls.gov/iif/oshwc/cfoi/ cfch0014.pdf (accessed May 1, 2017). BLS. 2016c. Survey of Occupational Injuries and Illnesses (SOII)—Information for Respondents. Available online at https://www.bls.gov/respondents/iif (accessed April 4, 2017). BLS. 2016d. 2015 Survey of Occupational Injuries & Illnesses Summary Estimates Charts Package. October 27, 2016. Available online at https://www.bls.gov/iif/oshwc/osh/os/osch0057.pdf (accessed September 18, 2017) BLS. 2016e. Employer-reported Workplace Injury and Illness Summary. Available online at https://www.bls.gov/ news.release/osh.nr0.htm (accessed June 15, 2017). BLS. 2016f. Table 2. Numbers of nonfatal occupational injuries and illnesses by case type and ownership, selected industries, 2015. Economic News Release Available online at https://www.bls.gov/news.release/osh.t02.htm (accessed June 13, 2017). BLS. 2016g. Nonfatal occupational injuries and illnesses requiring days away from work, 2015. Economic News Release. USDL-16-2130. Available online at https://www.bls.gov/news.release/osh2.nr0.htm (accessed No- vember 8, 2017). BLS. 2017a. Census of Fatal Occupational Injuries (CFOI)—Current and Revised Data. Available online at https://www.bls.gov/iif/oshcfoi1.htm (accessed April 4, 2017). BLS. 2017b. Non-fatal Occupational Injuries and Illnesses with Days of Job Transfer or Restriction, Survey of Oc- cupational Injuries and Illnesses. Available online at https://www.bls.gov/iif/oshwc/osh/case/osch0059.pdf (accessed November 8, 2017). Boden, L. I., and A. Ozonoff. 2008. Capture-recapture estimates of nonfatal workplace injuries and illnesses. Annals of Epidemiology 18(6):500-506. Burkom, H. S. 2017. Evolution of public health surveillance: Status and recommendations. American Journal of Public Health 107(6):848-850. Burnett, C., J. Maurer, H. M. Rosenberg, and M. Dosemeci. 1997. Mortality by occupation, industry, and cause of death, 24 reporting states (1984–1988). Cincinnati, OH: NIOSH. DHHS (NIOSH) Document No. 97-114. Available online at https://www.cdc.gov/niosh/docs/97-114/pdfs/97-114.pdf (accessed May 5, 2017). Byler, C. 2013. Hispanic/Latino fatal occupational injury rates. Monthly Labor Review February:14-23. Available online at https://www.bls.gov/opub/mlr/2013/02/art2full.pdf (accessed April 4, 2017). Cal/OSHA. 2010. California becomes first state to set safety guidelines for flavoring chemical. News December 2, 2010 Available online at https://www.dir.ca.gov/DIRNews/2010/IR2010-35.html (accessed June 14, 2017). CDC (Centers for Disease Control and Prevention). 1995. Proportionate mortality from pulmonary tuberculosis as- sociated with occupations—28 states, 1979–1990. Morbidity and Mortality Weekly Report 44:14-19. CDC. 2008. Illnesses and injuries related to total release foggers: Eight states, 2001-2006. Morbidity and Mortality Weekly Report 57(41):1125-1129. CDC. 2010. Distinguishing public health research and public health nonresearch. Available online at https://www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf (accessed June 15, 2017). CDC. 2016. Strategies for reducing health disparities; selected CDC sponsored intervention, US, 2016. Morbidity and Mortality Weekly Report Supplement 65(1). Available online at www.cdc.gov/mmwr/volumes/65/su/pdfs/ su6501.pdf (accessed November 8, 2017). CDC. 2017a. The Work-Related Injury Statistics Query System. Available online at https://wwwn.cdc.gov/ wisards/workrisqs/ (accessed April 5, 2017). Prepublication Copy 87

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century CDC. 2017b. Employed Labor Force (ELF) Query System. Available online at https://wwwn.cdc.gov/wisards/cps/ (accessed December 1, 2017). CDC. 2017c. Occupational Injury and Illness Classification System. Available online at https://wwwn.cdc. gov/wisards/oiics/ (accessed December 1, 2017). CDC. 2017d. Occupational Injury and Illness Classification System: Coding Selection Rules. Available online at https://wwwn.cdc.gov/wisards/oiics/ (accessed December 1, 2017). CDC. 2017e. NIOSH Worker Health Charts: NHIS Occupational Health Supplement. 2017. Available online at https://wwwn.cdc.gov/Niosh-whc/source/ohs (accessed November 8, 2017). CDC. 2017f. Multiple Cause of Death 1999-2005. Available online at https://wonder.cdc.gov/wonder/help/mcd. html#Age-Adjusted Rates (accessed December 1, 2017). Churchill, R. B., and L. K. Pickering. 1997. Infection control challenges in child-care centers. Infectious Disease Clinics of North America 11(2):347-365. Cohidon C., G. Santin, J. Chastang, E. Imbernon, and I. Niedhammer. 2012. Psychosocial exposures at work and mental health potential utility of a job-exposure matrix. Journal of Occupational and Environmental Medicine 54:184-191. Colt, J. S., L. Stallones, L. L. Cameron, M. Dosemeci, and S. H. Zahm. 2001. Proportionate mortality among U.S. migrant and seasonal farmworkers in twenty-four states. American Journal of Industrial Medicine 40:604-611. Cordell, R., L. Pickering, F. W. Henderson, and J. Murph. 2004. Infectious diseases in childcare settings. Emerging Infectious Diseases 10(11):e9. Costello, S., A. M. Neophytou, D. M. Brown, E. M. Noth, S. K.Hammond, M. R. Cullen, and E. A. Eisen. 2016. Incident ischemic heart disease after long-term occupational exposure to fine particulate matter: Accounting for 2 Forms of Survivor Bias. American Journal of Epidemiology 183(9): 861–868. CPWR (Center for Construction Research and Training). 2013. The Construction Chart Book. Available online at http://www.cpwr.com/publications/construction-chart-book (accessed April 5, 2017). CPWR. 2017. Fatality map. Available online at http://stopconstructionfalls.com/fatality-map/ (accessed April 4, 2017). CSTE (Council of State and Territorial Epidemiologists). 2013a. Counting work-related injuries and illnesses: Tak- ing steps to close the gaps. Available online at http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Occu pationalHealth/SummaryRecClosGapsMtg2013.pdf (accessed June 22, 2017). CSTE, 2013b. National Assessment of Epidemiologic Capacity, Findings and Recommendations. Available online at http://www.cste2.org/2013eca/CSTEEpidemiologyCapacityAssessment2014-final2.pdf (accessed September 4, 2017). CSTE. 2014. Position Statement 14-OH-02. Inclusion of work information as data elements in CDC sur- veillance systems. Available online at www.cste.org/?page=Position Statements (accessed November 28, 2017). CSTE. 2015a. Handicapped-Accessible Accelerator Pedal Redesigned Based on Fatality. Available online at http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/Occupational_Health_Success_Stories/KY_success_stor y-_handicappe.pdf (accessed July 18, 2017). CSTE. 2015b. Public Health Reporting and National Notification for Elevated Blood Lead Levels. Available online at http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2015PS/2015PSFinal/15-EH-01.pdf (accessed June 14, 2017). CSTE. 2017a. Occupational Health Indicators. Available online at http://www.cste.org/members/group.aspx?id= 106668 (accessed June 10, 2017). CSTE. 2017b. Surveillance/informatics: Reportable Condition Knowledge Management System. Available online at http://www.cste.org/group/RCKMS (accessed May 8, 2017). Davis, L., M. Standbury, B. Materna, and E. Simms. 2012. Putting Data to Work for Worker Safety and health, suc- cess stories in the states. Available online at https://c.ymcdn.com/sites/cste.site-ym.com/resource/resmgr/ OccupationalHealth/OC_Health_Book_FINAL.pdf (accessed May 1, 2017). Du Y., X. Xu, M. Chu, Y. Guo, and J. Wang. 2016. Air particulate matter and cardiovascular disease: The epidemio- logical, biomedical and clinical evidence. Journal of Thoracic Disease 8(1): E8–E19. Dubrow, R., J. Sestito, N. Lalich, C. Burnett, and J. Salg. 1987. Death certificate-based occupational mortality sur- veillance in the United States. American Journal of Industrial Medicine 11:329-342. Edwards, C. H., G. S. Tomba, and B. F. de Blasio. 2016. Influenza in workplaces: Transmission, workers’ adherence to sick leave advice and European sick leave recommendations. European Journal of Public Health 26(3):478-485. Fagan, K. M., and M. J. Hodgson. 2017. Under-recording of work-related injuries and illnesses: An OSHA priority. Journal of Safety Research 60:79-83. 88 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues Fang, S. C., A. Cassidy, and D. C. Christiani. 2010. A systematic review of occupational exposure to particulate matter and cardiovascular disease. International Journal of Environmental Research and Public Health 7(4): 1773–1806. Froines, J. R., S. Baron, D. H. Wegman, and S. O’Rourke. 1990. Characterization of the airborne concentrations of lead in U.S. industry. American Journal of Industrial Medicine 18(1):1-17. GAO (U.S. Government Accountability Office). 2015. Contingent Workforce: Size, Characteristics, Earnings, and Benefits. Available online at http://www.gao.gov/assets/670/669766.pdf (accessed June 14, 2017). GAO. 2016. Workplace Safety and Health: Additional Data Needed to Address Continued Hazards in the Meat and Poultry Industry. GAO-16-337. Washington, D.C.: U.S. Government Printing Office. Grattan K., L. K. Davis, M. Fiore, E. Pechter, J. Laing. 2017. Employer Compliance with OSHA Requirement to Re- port Amputations, Updated Findings from a Massachusetts Study. CSTE Annual Conference, June 2017 Boise ID. Green Seal Institutional Cleaning Products. 2017. Green Seal. Available online at www.greenseal.org/FindGreenSeal ProductsandServices.aspx?vid=ViewProductDetail&cid=16 (accessed June 15, 2017). Groenewold, M. R., and S. L. Baron. 2013. The proportion of work-related emergency department visits not ex- pected to be paid by workers’ compensation: Implications for occupational health surveillance, research, poli- cy, and health equity. Health Services Research 48(6 Pt 1):1939-1959. Haddon, W. 1970. On the escape of tigers: An ecologic note. American Journal of Public Health 60(2):2229–2234. Harris, R. 2016. Suicide in the workplace. Monthly Labor Review. Available online at https://www.bls.gov/opub/ mlr/2016/article/suicide-in-the-workplace.htm (accessed May 5, 2017). Henneberger, P. K., C. A. Redlich, D. B. Callahan, P. Harber, C. Lemiere, J. Martin, S. M. Tarlo, and O. Vandenplas. 2011. An official American Thoracic Society statement: Work-exacerbated asthma. American Journal of Respir- atory Critical Care Medicine 184(3):368-378. HHS (U.S. Department of Health and Human Services). 2017. Asthma. Available online at https://www.healthy people.gov/2020/topics-objectives/topic/respiratory-diseases/objectives (accessed April 5, 2017). Hnizdo, E., P. A. Sullivan, K. M. Bang, and G. Wagner. 2002. Association between chronic obstructive pulmonary disease and employment by industry and occupation in the U.S. population: A study of data from the Third National Health and Nutrition Examination Survey. American Journal of Epidemiology 156:738-746. Huband, E. M. and P. Bobbit. 2013. Nonresponse Bias in the Survey of Occupational Injuries and Illnesses. BLS.Statistical Survey Papers. Available online at https://www.bls.gov/osmr/pdf/st130170.pdf (accessed No- vember 8, 2017). IOM (Institute of Medicine). 2001. Tuberculosis in the Workplace. Washington, DC: National Academy Press. IOM. 2009. Traumatic Injury Research at NIOSH: Reviews of Research Programs of the National Institute for Oc- cupational Safety and Health. Washington, DC: The National Academies Press. IRS (Internal Revenue Service). 2016. New Requirements for 501(c)(3) Hospitals under the Affordable Care Act. Available online at https://www.irs.gov/charities-non-profits/charitable-organizations/new-requirements-for- 501c3-hospitals-under-the-affordable-care-act (accessed June 14, 2017). Jackson L. 2001. Non-fatal occupational injuries and illnesses treated in hospital emergency departments in the United States. Injury Prevention 7(Suppl I):i21-i26. Keech, M., and P. Beardsworth. 2008. The impact of influenza on working days lost: A review of the literature. Pharmacoeconomics 26(11):911-924. Kica, J., and K. D. Rosenman. 2012. Multi-source surveillance system for work-related burns. Journal of Occupa- tional and Environmental Medicine 54(5):642-647. Kica, J., and K. D. Rosenman. 2014. Multi-source surveillance system for work-related skull fractures in Michigan. Journal of Safety Research 51:49-56. Klous, G., A. Huss, D. J. Heederik, and R. A. Coutinho. 2016. Human-livestock contacts and their relationship to transmission of zoonotic pathogens, a systematic review of literature. One Health 2:65-76. Largo, T. W., and K. D. Rosenman. 2015. Surveillance of work-related amputations in Michigan using multiple data sources: Results for 2006-2012. Occupational and Environmental Medicine 72(3):171-176. LaMontagne A.D., T. Keegel, D.A. Vallance, A. Ostry, and R. Wolfe. 2008. Job strain—Attributable depression in a sample of working Australians: Assessing the contribution to health inequalities BMC Public Health 8(181). Lavoue, J., M. Friesen, and I. Burstyn. 2013a. Workplace measurements by the U.S. Occupational Safety and Health Administration since 1979: Descriptive analysis and potential uses for exposure assessment. Annals of Occu- pational Hygiene 57(5):661-683. Prepublication Copy 89

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Lavoue, J., M. Friesen, and I. Burstyn. 2013b. Workplace measurements by the U.S. Occupational Safety and Health Administration since 1979: Descriptive analysis and potential uses for exposure assessment. Annals of Occu- pational Hygiene 57(1):77-97. Lefkowitz, D., E. Pechter, M. Lumia, A. Stephens, K. Fitzsimmons, L. Davis, J. Flattery, J. Weinberg, R. J. Harri- son, M. J. Reilly, M. S. Filios, G. E. White, and K. D. Rosenman. 2015. Isocyanates and work-related asthma: Findings from California, Massachusetts, Michigan, and New Jersey, 1993-2008. American Journal of Indus- trial Medicine 58(11):1138-1149. Luckhaupt, S., and G. M. Calvert. 2008. Deaths due to blood-borne infections and their sequelae among health care workers. American Journal of Industrial Medicine 51(11):812-824. Luckhaupt, S. E., J. M. Dahlhamer, B. W. Ward, A. L. Sussell, M. H. Sweeney, J. P. Sestito, and G. M. Calvert. 2013a. Prevalence of dermatitis in the working population, United States, 2010 National Health Interview Survey. American Journal of Industrial Medicine 56(6):625-634. Luckhaupt, S. E., M. A. Cohen, and G. M. Calvert. 2013b. Concordance between current job and usual job in occu- pational and industry groupings: Assessment of the 2010 National Health Interview Survey. Journal of Occu- pational and Environmental Medicine 55(9):1074-1090. MA COSH (Massachusetts Coalition for Occupational Safety and Health). 2005. Protecting Workers and Home- owners from Wood Floor-finishing Hazards in Massachusetts. Available online at http://www.masscosh. org/files/ProtectingFromFloorFinishingHazards.pdf (accessed April 4, 2017). MA DPH (Massachusetts Department of Public Health). 2017. Fatal Occupational Injuries in Massachusetts: 2008- 2013. Available online at http://www.mass.gov/eohhs/docs/dph/occupational-health/fatal-reports/work-related- fatalities-2008-2013.pdf (accessed June 15, 2017). Marcum J. L., and D. Adams. 2017. Work-related musculoskeletal disorder surveillance using the Washington State workers’ compensation system: Recent declines and patterns by industry, 1999-2013. American Journal of In- dustrial Medicine 60(5):457-471. Marsh, S. M., A. A. Reichard, R. Bhandari, and T. R. Tonozzi. 2016. Using emergency department surveillance data to assess occupational injury and illness reporting by workers. American Journal of Industrial Medicine 59(8):600-610. Masterson, E. A., M. H. Sweeney, J. A. Deddens, C. L. Themann, and D. K. Wall. 2014. Prevalence of workers with shifts in hearing by industry: A comparison of OSHA and NIOSH hearing shift criteria. Journal of Occupa- tional and Environmental Medicine 56(4):446-455. Mazurek, J. M., G. Syamial, J. M. Wood, S. A. Hendricks, and A. Weston. 2017. Malignant mesothelioma mortali- ty—United States, 1999-2015. Morbidity and Mortality Weekly Report 66:214-218. Michaels, D. 2016. Year one of OSHA’s Severe Injury Reporting Program: An Impact Evaluation. Available online at https://www.osha.gov/injuryreport/2015.pdf (accessed April 4, 2017). Michas, M. G., and C. U. Iacono. 2008. Overview of occupational medicine training among US family medicine residency programs Family Medicine 40(2):102-106. MI DCH (Michigan Department of Community Health). 2013. Thirteen indicators of the health of Michigan’s work- force. Available online at http://www.michigan.gov/documents/Michigan_Indicator_Report_revised_412 06_156036_7.pdf (accessed July 18, 2017). MI DHHS (Michigan Department of Health and Human Services). 2015. Heavy Metals Surveillance in Michigan: Eighth Annual Report. Available online at http://www.oem.msu.edu/userfiles/file/Annual%20Reports/Heavy Metals/2014HeavyMetalsAnnualReport.pdf (accessed June 14, 2015). MI FACE (Michigan Fatality Assessment and Control Evaluation). 2013. Methylene chloride causes death of three Michigan bathtub refinishers. Hazard Alert. Available online at http://www.oem.msu.edu/userfiles/Bathtub RefinishingHA14.pdf (accessed April 4, 2017). Molinari, N. A., I. R. Ortega-Sanchez, M. L. Messonnier, W. W. Thompson, P. M. Wortley, E. Weintraub, and C. B. Bridges. 2007. The annual impact of seasonal influenza in the U.S.: Measuring disease burden and costs. Vac- cine 25(27):5086-5096. MSU and MI DELEG (Michigan State University and the Michigan Department of Energy, Labor, and Economic Growth). 2009. Annual Report on Work-related Noise-induced Hearing Loss in Michigan. Available online at http://www.oem.msu.edu/userfiles/file/Annual%20Reports/Hearing/08NIHL_Report.pdf (accessed June 12, 2017). NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Information Technology and the U.S. Workforce: Where Are We and Where Do We Go from Here? Washington, DC: The National Academies Press. 90 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues National COSH (Council for Occupational Safety and Health). 2017. U.S. Worker Fatality Maps. Available online at http://www.coshnetwork.org/fatality-database-maps (accessed April 4, 2017). NCHS (National Center for Health Statistics). 2016. About the National Health Interview Survey. Available online at https://www.cdc.gov/nchs/nhis/about_nhis.htm (accessed June 14, 2017). NCHS. 2017. National Health Interview Survey 2018 Questionnaire Redesign: Proposed Design. Available online at https://www.cdc.gov/nchs/nhis/2018_quest_redesign.htm (accessed November 27, 2017). New York State Department of Health. 2016. Heavy metals surveillance: New York State Heavy Metals Registry. Available online at https://www.health.ny.gov/environmental/workplace/heavy_metals_registry (accessed June 14, 2017). Niedhammer I., H. Sultan-Taieb, J.F. Chastang, G. Vermeylen, and A. Parent-Thirion. 2014. Fractions of cardiovas- cular diseases and mental disorders attributable to psychosocial work factors in 31 countries in Europe. Inter- national Archives of Occupational and Environmental Health 87(4):403-11. NIOSH (National Institute for Occupational Safety and Health). 1974. National Occupational Hazard Survey. Vol- ume I: Survey Manual. Cincinnati, OH: NIOSH. NIOSH. 1997. Musculoskeletal Disorders and Workplace Factors - A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. Cincinnati, OH: NIOSH. Available online at https://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf (accessed November 8, 2017). NIOSH. 2012. A Story of Impact: NIOSH esearch Cited in Recommendations for Improving Commercial Fishing. NIOSH Publication No. 2012-129 March 2012. Available online at https://www.cdc.gov/niosh/docs/2012- 129/pdfs/2012-129.pdf (accessed May 5, 2017). NIOSH. 2013. 2010 Occupational Health Supplement. Available online at https://www.cdc.gov/niosh/topics/nhis/ healthcareocc/hcocctables.html (accessed December 1, 2017). NIOSH. 2014a. Impact: PFD Manufacturer Adopts NIOSH Research Into Product Development Process. Available online at https://www.cdc.gov/niosh/docs/2015-119/pdfs/2015-119.pdf (accessed May 6, 2017). NIOSH. 2014b. NIOSH research projects. Available online at https://www.cdc.gov/niosh/programs/surv/projects 2.html#ohd (accessed June 14, 2017). NIOSH. 2015a. Washington Occupational Injury and Illness Surveillance Program—Annual Report. Available online at https://www.cdc.gov/niosh/oep/pdfs/annualreports/washington-occupational-injury-and-illness surveillance- program.pdf (accessed November 17, 2017). NIOSH. 2015b. Health Hazard Evaluations. Available online at https://www.cdc.gov/niosh/hhe/resources.html (ac- cessed May 8, 2017). NIOSH. 2016a. Definitions of Traumatic Injuries and MSDs. Available online at https://www.cdc.gov/niosh/ programs/msd/risks.html (accessed June 13, 2017). NIOSH. 2016b. Coal Workers’ Health Surveillance Program (CWHSP) Data Query System. Available online at https://webappa.cdc.gov/ords/cwhsp-database.html (accessed December 1, 2017). NIOSH. 2016c. National Agriculture, Forestry and Fishing Agenda. Available online at https://www.cdc.gov/niosh/ nora/comment/agendas/agforfish/default.html (accessed June 13, 2017). NIOSH. 2016d. National Health Interview Survey: Occupational Health Supplement. Available online at https://www.cdc.gov/niosh/topics/nhis/ (accessed April 5, 2017). NIOSH. 2016e. Tuberculosis. Available online at https://www.cdc.gov/niosh/topics/tb/ (accessed May 8, 2017). NIOSH. 2016f. Adult blood lead epidemiology and surveillance. Available online at http://www.cdc.gov/niosh/ topics/ables/description.html (accessed November 21, 2016). NIOSH. 2016g. NIOSH Musculoskeletal Disorders Prevention Programs. May 2016. Available online at https://stacks.cdc.gov/view/cdc/39919 (accessed December 21, 2017). NIOSH. 2017a. Fatality Assessment and Control Evaluation (FACE) Program. Available online at https://www.cdc. gov/niosh/face/default.html (accessed April 4, 2017). NIOSH. 2017b. Firefighter Fatality Investigation and Prevention. Available online at https://www.cdc. gov/niosh/fire/default.html (accessed January 29, 2017). NIOSH. 2017c. NIOSH and partners work to prevent worker deaths from exposures to hydrocarbon gases and va- pors at oil and gas wellsites. Available online at https://www.cdc.gov/niosh/docs/2017-110 (accessed May 8, 2017). NIOSH. 2017d. Welcome to eWORLD. Available online at https://wwwn.cdc.gov/eworld (accessed June 14, 2017). NIOSH. 2017e. Coal Workers’ Health Surveillance Program. Available online at https://www.cdc.gov/niosh/ topics/cwhsp/ (accessed April 5, 2017). Prepublication Copy 91

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century NIOSH. 2017f. Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C. Available online at https://www. cdc.gov/niosh/topics/bbp/ (accessed May 8, 2017). NIOSH. 2017g. Health and Safety Practices Survey of Healthcare Workers. Available online at https://www.cdc. gov/niosh/topics/healthcarehsps/aboutstudy.html (accessed June 14, 2017). NIOSH. 2017h. National Occupational Exposure Survey (NOES). Webpage. Available online at https://www.cdc. gov/noes/default.html (accessed November 8, 2017). NIOSH. 2017i. Unpublished data. Correspondence between Audrey Richards, NIOSH Division of Safety Research to Dr. Letitia K. Davis, Massachusetts Department of Public Health. NRC (National Research Council). 1987. Counting injuries and illnesses in the workplace: Proposals for a better system. Washington, DC: National Academy Press. NRC. 2001. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, D.C. National Academies Press. O’Leary P., Boden L.I., Seabury S.A., Ozonoff A., and E. Scherer. 2012. Workplace Injuries and the Take-Up of Social Security Benefits. Social Security Bulletin 72(3). OMB (Office of Management and Budget). 2007. Implementation Guidance for Title V of the E-Government Act, Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA).Notice of Decision. 72 Federal Register 33362-33377, June 15, 2007. OSHA (Occupational Safety and Health Administration). 2001. Occupational Injury and Illness Recording and Re- porting Requirements. Final Rule. 66 Federal Register 5921-5923, January 19, 2001. OSHA. 2007. Hispanic outreach. Available online at www.osha.gov/OshDoc/data_Hispanic/hispanic_outreach.pdf (accessed June 12, 2017). OSHA. 2013. Methylene chloride hazards for bathtub refinishers. Available online at https://www.osha.gov/dts/ hazardalerts/methylene_chloride_hazard_alert.pdf (accessed May 8, 2017). OSHA. 2014. Temporary Worker Initiative. TWI Bulletin 1. Available online at https://www.osha.gov/temp_ workers/OSHA_TWI_Bulletin.pdf (accessed April 4, 2017). OSHA. 2015. OSHA fact sheet: Preventing cuts and amputations from food slicers and meat grinders. Available online at https://www.osha.gov/Publications/OSHA3794.pdf (accessed June 13, 2017). OSHA, 2016a. Improve Tracking of Workplace Injuries and Illnesses. Final Rule.81 Federal Register 29637-29639, May 12, 2016. OSHA. 2016b. Memorandum for Regional Administrators and State Designees from Thomas Galassi, Director, Directorate of Enforcement Programs, “Revised Interim Enforcement Procedures for Reporting Requirements under 29 CFR 1904.39,” March 4, 2016. Available online at https://www.osha.gov/dep/enforcement/Interm _Enforcement_Procedures.html (accessed April 5, 2017). OSHA. 2017a. National safety stand-down to prevent falls in construction. Available online at https://www.osha. gov/StopFallsStandDown (accessed April 4, 2017). OSHA. 2017b. Fatality and catastrophe investigation summaries. Available online at www.osha.gov/pls/imis/ accidentsearch.html (accessed April 4, 2017). OSHA. 2017c. Severe injury reports. Available online at https://www.osha.gov/severeinjury/index.html (accessed May 8, 2017). Pegula, S. M. 2013. An analysis of fatal occupational injuries at road construction sites, 2003–2010. Monthly Labor Review November. Available online at https://www.bls.gov/opub/mlr/2013/article/an-analysis-of-fatal-occupa tional-injuries-at-road-construction-sites-2003-2010.htm (accessed April 4, 2017). Pegula, S. M., and A. Measure. 2016. Web scraping and a timely repository for fatality data. Presentation to the Data Users Advisory Committee, Bureau of Labor Statistics. November 10, 2016. PHAB (Public Health Accreditation Board. 2015. Guide to national public health department initial accreditation. Available online at http://www.phaboard.org/wp-content/uploads/Guide-to-Accreditation-final_LR2.pdf (ac- cessed June 15, 2017). PHII (Public Health Informatics Institute). 2016. Next generation electronic death registration system: Supporting improved quality and timeliness of vital records data. Available online at https://www.phii.org/sites/www. phii.org/files/resource/pdfs/20160316%20Next%20Generation%20EDRS%20Report%20FINAL%20WEBSIT E.pdf (accessed June 13, 2017). Raherison, C., and P. O. Girodet. 2009. Epidemiology of COPD. European Respiratory Review 18:213-221. Rappin, C. L., S. E. Wuellner., and D. K. Bonauto. 2016. Employer reasons for failing to report eligible workers compensation claims in the BLS Survey of Occupational Injuries and Illnesses. American Journal of Industri- al Medicine 59(5):343-356. 92 Prepublication Copy

Current Status of Federal and State Programs and Cross-cutting Issues Reves, R. R., and L. K. Pickering. 1992. Impact of child day care on infectious diseases in adults. Infectious Disease Clinics of North America 6(1):239-250. Reville R. T. and R. F. Schoeni. 2004. The Fraction of Disability Caused at Work. Social Security Bulletin 65(4). Available at https://www.ssa.gov/policy/docs/ssb/v65n4/v65n4p31.html (accessed November 8, 2017). Robinson, C. F., J. T. Walker, M. H. Sweeney, R. Shen, G. M. Calvert, P. K. Schumacher, J. Ju, and S. Nowlin. 2015. Overview of the National Occupational Mortality Surveillance (NOMS) system: Leukemia and acute myocardial infarction risk by industry and occupation in 30 U.S. states 1985-1999, 2003-2004, and 2007. American Journal of Industrial Medicine 58(2):123-137. Rosenman, K. D. 2016. OSHA, well past its infancy, but still learning how to count injuries and illnesses. American Journal of Industrial Medicine 59(8):595-599. Rosenman, K. D., M. J. Reilly, D. P. Schill, D. Valiante, J. Flattery, R. Harrison, F. Reinisch, E. Pechter, L. Davis, C. M. Tumpowsky, and M. Fillios. 2003. Cleaning products and work-related asthma. Journal of Occupation- al and Environmental Medicine 45(5):556-563. Rosenman, K. D., A. Kalush, M. J. Reilly, J. C. Gardiner, M. Reeves, and Z. Luo. 2006. How much work-related injury and illness is missed by the current national surveillance system? Journal of Occupational and Envi- ronmental Medicine 48(4):357-365. Ruser, J. W. 1998. Denominator choice in the calculation of workplace fatality rates. American Journal of Industrial Medicine 33(2):151-156. Ruser, J. W. 2008. Examining evidence on whether BLS undercounts workplace injuries and illnesses, Monthly Labor Review, August 2008, https://www.bls.gov/opub/mlr/2008/08/art2full.pdf. (Accessed November 17, 2017). Rutstein, D. D., R. J. Mullan, T. M. Frazier, W. E. Halperin, J. M. Melius, and J. P. Sestito. 1983. Sentinel Health Events (occupational): A basis for physician recognition and public health surveillance. American Journal of Public Health 73(9):1054-1062. Sabbath, E. L., L. I. Boden, J. A. Williams, D. Hashimoto, K. Hopcia, and G. Sorensen. 2017. Obscured by adminis- trative data? Racial disparities in occupational injury. Scandinavian Journal of Work, Environment, and Health 43(2):155-162. Sarazin, P., I. Burstyn, L. Kincl, and J. Laboue. 2016. Trends in OSHA compliance monitoring data 1979-2011: Statistical modeling of ancillary information across 77 chemicals. Annals of Occupational Hygiene 60:432- 452. Savitz, D. A., D. P. Loomis, and C. K. Tse. 1998. Electrical occupations and neurodegenerative disease: Analysis of U.S. mortality data. Archives of Environmental Health 53:71-74. SBU (Swedish Agency for Health Technology Assessment and Assessment of Social Services). 2017. Occupational health and safety–Chemical exposure. Available online at http://www.sbu.se/261e (accessed May 17, 2017). Schleiff, P. L., J. M. Mazurek, M. J. Reilly, K. D. Rosenman, M. B. Yoder, M. E. Lumia, and K. Worthington. 2016. Surveillance for silicosis—Michigan and New Jersey, 2003–2011. Morbidity and Mortality Weekly Report 63(55):73-78. Sears, J. M., and S. M. Bowman. 2016. State trauma registries as a resource for occupational injury surveillance and research: Lessons from Washington State, 1998-2009. Public Health Reports 131(6):791-799. Sincavage, J. R. 2005. Fatal occupational injuries among Asian workers. Monthly Labor Review October:49-55. Available online at https://www.bls.gov/opub/mlr/2005/10/art6full.pdf (accessed April 4, 2017). Smith, G. S., H. M. Wellman, G. S. Sorock, M. Warner, T. K. Courtney, G. S. Pransky, and L. A. Fingerhut. 2005. Injuries at work in the U.S. adult population: Contributions to the total injury burden. American Journal of Public Health 95(7):1213-1219. Socias, C. M., C. K. Chaumont Menendez, J. W. Collins, and P. Simeonov. 2014. Occupational ladder fall inju- ries—United States, 2011. Morbidity and Mortality Weekly Report 63(16):341-346. Spieler, E. A., and J. F. Burton, Jr. 2012. The lack of correspondence between work-related disability and receipt of workers’ compensation benefits. American Journal of Industrial Medicine 55(6):487-505. Spieler, E. A., and G. R. Wagner. 2014. Counting matters: Implications of undercounting in the BLS survey of oc- cupational injuries and illnesses. American Journal of Industrial Medicine 57(10):1077-1084. Stanbury, M., A. P. Rafferty, and K. D. Rosenman. 2008. Prevalence of hearing loss and work-related noise induced hearing loss in Michigan. Journal of Occupational and Environmental Medicine 50(1):72-79. Steenland, K., C. Burnett, N. Lalich, E. Ward, and J. Hurrell. 2003. Dying for work: The magnitude of U.S. mortali- ty from selected causes of deaths associated with occupation. American Journal of Industrial Medicine 43(5):461-482. Prepublication Copy 93

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century Tak, S., R. R. Davis, and G. M. Calvert. 2009. Exposure to hazardous workplace noise and use of hearing protection devices among U.S. workers—NHANES, 1999-2004. American Journal of Industrial Medicine 52(5):358- 371. 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. Theorell T., A. Hammarström, G. Aronsson, L. T. Bendz, T. Grape, C. Hogstedt, I. Marteinsdottir, I. Skoog, and C. Hall. 2015. A systematic review including meta-analysis of work environment and depressive symptoms. BMC Public Health 15:738. Thomsen, C., J. McClain, K. Rosenman, and L. Davis. 2007. Indicators for occupational health surveillance. Mor- bidity and Mortality Weekly Report 56(RR-1):1-7. Tonozzi, T. R., S. M. Marsh, A. A. Reichard, and R. Bhandari. 2016. Reported work-related injuries and illnesses among Hispanic workers: Results from an emergency department surveillance system follow-back survey. American Journal of Industrial Medicine 59(8):622-630. Torén, K., and P. D. Blanc. 2009. Asthma caused by occupational exposures is common—a systematic analysis of estimates of the population-attributable fraction. BMC Pulmonary Medicine 9:7, doi: 10.1186/1471-2466-9-7. Weber, D. J., and W. A. Rutala. 2016. Occupational health update: Focus on preventing the acquisition of infections with pre-exposure prophylaxis and postexposure prophylaxis. Infectious Disease Clinics of North America 30(3):729-757. 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. Weil, D. 2017. How to make employment fair in an age of contracting and temp work. Harvard Business Review, March 24. Available online at https://hbr.org/2017/03/making-employment-a-fair-deal-in-the-age-of-contract ing-subcontracting-and-temp-work (accessed June 15, 2017). Wiatrowski, W. J. 2005. Fatalities in the ornamental shrub and tree services industry. Compensation and Working Condition, July 25. Available online at https://www.bls.gov/opub/mlr/cwc/fatalities-in-the-ornamental-shrub- and-tree-services-industry.pdf (accessed April 4, 2017). Wiatrowski, W. J. 2014. The BLS survey of occupational injuries and illnesses: A primer. American Journal of In- dustrial Medicine 57(10):1085-1089. Wilken, J. A., G. Sondermeyer, D. Shusterman, J. McNary, D. J. Vugia, A. McDowell, P. Borenstein, D. Gilliss, B. Ancock, J. Prudhomme, D. Gold, G. C. Windham, L. Lee, and B. L. Materna. 2015. Coccidioidomycosis among workers constructing solar power farms, California, USA, 2011-2014. Emerging Infectious Diseases 21(11):1997-2005. Windau, J. A. 1998. Worker fatalities from being caught in machinery. Compensation and Working Condition Win- ter:35-38. Available online at https://www.bls.gov/opub/mlr/cwc/worker-fatalities-from-being-caught-in- machinery.pdf. (accessed June 12, 2017). Windau, J., K. D. Rosenman, H. Anderson, L. Hanrahan, L. Rudolph, M. Stanbury, and A. Stark. 1991. The identifi- cation of occupational lung disease from hospital discharge data. Journal of Occupational Medicine 33(10):1061-1066. Wuellner, S. E., and D. K. Bonauto. 2014. Exploring the relationship between employer recordkeeping and underre- porting in the BLS Survey of Occupational Injury and Illness. American Journal of Industrial Medicine 57(10):1133-1143. Wuellner, S., and P. Phipps. 2016. Identifying patterns in employer reporting errors in the BLS Survey of Occupa- tional Injuries and Illnesses. Pp. 3322-3335 in JSM Proceedings, Statistical Computing Section. Alexandria, VA: American Statistical Association. Available online at https://www.bls.gov/osmr/pdf/st160200.pdf (ac- cessed April 4, 2017). Wuellner, S. E., D. A. Adams, and D. K. Bonauto. 2016. Unreported workers’ compensation claims to the BLS Sur- vey of Occupational Injuries and Illnesses: Establishment factors. American Journal of Industrial Medicine 59(4):274-279. Wuellner, S. E., D. A. Adams, and D. K. Bonauto. 2017. Workers’ compensation claims not reported in the Survey of Occupational Injury and Illnesses; Injury and claim characteristics. American Journal of Industrial Medi- cine 60(3):264-275. WY DWS (Wyoming Department of Workforce Services). 2016. Wyoming state occupational epidemiologist re- leases most comprehensive report on workplace fatalities since program’s inception. Available online at http://www.wyomingworkforce.org/news/2016-10-25a (accessed May 8, 2017). 94 Prepublication Copy

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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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