3
Relevance of the Health Hazard Evaluation Program

EVALUATION OF RELEVANCE

As discussed in Chapter 1, a relevant program can be described as an integrated program involving interrelated surveillance, research, and transfer activities. The relevance of its activities can be determined by the severity or frequency of hazards addressed and the number of people at risk, the extent to which the program addresses gender-related issues and those of underserved populations (see Box 1-1 for definition), and the extent to which the health and safety needs of small businesses are addressed. Program structure and content must also increase program relevance.

The Health Hazard Evaluation (HHE) Program primarily serves a legislated, public health practice mission, and its relevance must be evaluated in that context. HHEs address issues that, by definition, are in the early stages of investigation and intervention. One important function of an HHE is to provide preliminary data that may lead to a more extensive research program. The mandate of the program, however, requires it to respond to requests, whether or not more in-depth research may follow. Within this constraint, the committee believes the program can elicit and prioritize requests to fit into an interrelated surveillance, research, and transfer matrix involving the rest of the National Institute for Occupational Safety and Health (NIOSH). One of the challenges faced by the HHE Program is weighing the need to be responsive to individual requests with the need to develop strategic approaches to identifying emerging health threats in the workplace. A careful balance serves both functions. Through response to requests the program may identify



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

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 4 emerging issues, and identifying emerging issues helps in priority-setting among investigations. To assess program relevance, the committee begins this chapter with a review of major inputs to the program, including the strategic planning and stakeholder processes, and considers whether resources have been appropriately allocated and used to meet strategic needs. The chapter continues with an evaluation of the HHE Program’s activities and outputs, a discussion of how the program handles emerging issues, and then a discussion of the relevance of the program’s emergency response activities. The committee’s findings related to each of these topics are highlighted in bold. Recommendations related to the improvement of program relevance are found within the body of the text throughout the chapter and are organized and summarized in Chapter 5. The final section of this chapter provides the committee’s rating for relevance. RELEvANCE OF INPuTS (PLANNINg AND RESOuRCES) Strategic Planning Finding 1: The HHE Program’s strategic plan is highly relevant to the program mission. The HHE Program’s strategic and intermediate goals are summarized in Ta- ble 3-1. These were developed by the HHE Program in response to a recommenda- tion by the NIOSH Board of Scientific Counselors (BSC) to “improve the efficiency of processes, prioritization of tasks and overall management of the program [in- cluding to … d]evelop annual goals and measurable objectives regarding the work products, priorities and work processes of the HHE Program that are practical, cost effective, and consistent with resources” (NIOSH BSC, 2006). The committee finds that the HHE Program has made a serious effort to respond to this recommenda- tion. The goals are well targeted and relevant, and can be measured by the number and types of HHE requests received, the number of reports and field investigations conducted related to each of these goals, and their effects as determined through followback surveys (described in Chapter 2). Appropriate performance measures for each intermediate goal have been chosen, given the limited resources of the program. The committee believes, however, that with additional resources, perfor- mance measures could be made more specific and ambitious. There is no indication that surveillance or workers’ compensation data were used to formulate the HHE Program’s strategic plan. Given more resources, onsite follow-up investigations to assess the impact of interventions would help the program assess and revise its goals and performance measures as necessary. The committee comments on individual performance goals and measures in Table 3-1.

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

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

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

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

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

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

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

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 5 600 500 400 Number 300 200 100 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Technical asstance/ Field investigation consultation Figure 3-1.eps FIguRE 3-1 Distribution of HHE requests by response category. NOTE: Category 1 and 2 requests are combined under technical assistance/consultation. Category 3 and 4 requests are combined under field investigation (see Box 2-2 for a description of the HHE request categories and responses). SOURCE: NIOSH (2007b). information and telephone communication rather than field investigations. These forms of follow-up were specifically developed in response to external reviews and indicate HHE Program success in redirecting resources to provide appropriate in- formation in response to routine questions. However, this increased proportion of routine requests may also suggest that the HHE Program now has the opportunity to conduct more outreach and encourage more requests (for example, those that meet strategic needs or represent new or emerging hazards) that would require site visits (if sufficient funding is available to conduct them). The committee asked the HHE Program to provide information regarding all HHE requests, including types of requestor, hazard and sector involved, and the types of responses. Tables 3-2 and 3-3 were derived by the HHE Program in response (NIOSH, 2007g). The data were drawn from the program’s management tracking system, which was developed primarily for record retrieval and not data analyses. Because most HHE requests are related to multiple hazards or hazard classes, the HHE Program developed the following strategy for tabulation of hazard class of requests: • Indoor environmental quality (IEQ)—any request that included an IEQ issue, regardless of other issues also present

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

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 7 Reasons for the delay were not apparent to the committee. Timeliness, however, was an issue only for the final numbered report. This particular investigation was highly relevant and productive. The hazard was identified and reported to workers and management in a series of timely letter reports. The investigation resulted in new research activities, peer-reviewed publications, and policy efforts. The final report included all results in tabular form and an exhaustive set of appendixes that captured relevant correspondence and other materials, comprising nearly 200 pages of clear information. Many other reports delivered more quickly also contained clear information, tables of exposure and outcome data, and relevant references. Public accessibility to more complete data is extremely important for program relevance and impact. It would be useful to determine whether the traditional HHE numbered report is the appropriate venue to provide this access, given the time taken to produce some of these reports, or whether more rapid access to ap- propriately vetted data and reports might provide a more effective and efficient alternative. Providing comprehensive, accessible data is now a requirement for large-scale National Institutes of Health-sponsored extramural research, and the online provision of questionnaires, methods descriptions, and workplace diagrams allows accessibility of a more complete data set than that available through peer- reviewed published sources. Peer-reviewed publication, however, is also a criti- cally important feature of all scientific discovery including HHEs, and the HHE Program has been successful in producing such outcomes as a result of some of its investigations. The HHE Program could potentially increase the relevance (and impact) of its activities by determining whether data and information collected, or recommendations made, during the course of an HHE should be publicly released prior to the publication of its numbered reports. The numbered and letter reports in the committee’s sample demonstrate the depth of expertise available to the HHE Program. Expertise from other parts of NIOSH was included in the investigation of hazards such as noise and electro- magnetic field exposures. A high level of interagency cooperation and interaction with a variety of stakeholders in developing outreach materials was displayed, and these interactions were often relevant for policy development within NIOSH and beyond. The quality and depth of interaction between HHE Program staff and stakeholders is evident in major examples described in Boxes 3-2 through 3-5, as well as for information developed by the HHE Program concerning latex exposure (NIOSH, 1997c, 1998d), publications related to carbon monoxide as a prevalent and lethal hazard in outdoor settings (NIOSH, 1996b; U.S. Coast Guard, 2001, 2008; U.S. National Park Service, 2005); and the enhancement of understanding of indoor air quality issues (EPA and NIOSH, 1998; Mendell et al., 2002; Kreiss, 2005), among other topics.

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

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 7 knowledgeable and that the HHEs were conducted in a professional manner. Nearly all stakeholders who provided information to this committee were impressed with the level and breadth of expertise demonstrated by HHE staff. Based on reports reviewed by this committee, HHE Program staff members are well aware of the literature regarding different hazards or potential hazards associated with the requests they are receiving. Improvements could be made to avoid selection bias in followback program results by identifying similar facilities for which HHEs were not requested and by comparing health hazards before and after investigations. Follow-up health ques- tionnaires, examinations, or exposure monitoring could show significant improve- ment. These exercises, however, require resources the HHE Program may not have. Nonetheless, the committee believes the followback program is an important tool for program process improvement and could be made more valuable with input from program evaluation expertise. Current strategic goals include performance measures that would expand the current followback questionnaire feedback loop to address program impact and improve customer satisfaction. Continued efforts to improve the timeliness of reports, improve written and telephone communication, and enhance dissemination efforts were listed by the HHE Program as measurable objectives to improve customer response (see Table 3-1). No information was re- layed regarding the resources required to accomplish the objectives. Quality of Recommendations The committee assessed the quality of recommendations contained in HHE reports, and many were excellent. As one example, in response to an employee- generated request for an HHE, the HHE Program conducted an evaluation of a government-owned, contractor-operated hazardous waste “tank farm.” A great deal of negotiation with workplace management was required to conduct this investigation, but the result was a rapidly produced, thoughtful, and thoroughly referenced report that provided an overarching recommendation embedded with very specific recommendations (NIOSH, 2004b). This approach created a frame- work for managing specific problems across a complex worksite with multiple layers of responsibility. It provided a model that synthesized both the problems and the approaches to solving them. The committee found several reports and recommendations that do not exhibit the same level of quality. For example, in one reviewed report that was focused on musculoskeletal issues and recommendations, a variety of other potential safety hazards were identified, such as inadequately plumbed eyewashes and slippery surfaces. Only superficial recommendations to control these hazards were provided and did not include references for more detailed information (NIOSH, 2005a).

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

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m 75 EMERgINg ISSuES Finding 8: The HHE Program is an effective tool for uncovering emerg- ing issues. Emerging issues in occupational health include newly created hazards such as those arising from nanotechnology;6 newly discovered hazards such as diacetyl flavoring; and known hazards in new or previously overlooked populations, such as silica exposure among roofers. Nanoparticles7 are recognized as a potential health hazard and have been identified as an emerging issue by the National Academies Committee to Review the NIOSH Mining Safety and Health Research Program (NRC and IOM, 2007). As described in Chapter 2, OSHA has the lead in control- ling well-understood hazards through legally enforceable standards. NIOSH has the responsibility to investigate new and emerging hazards for which standards do not exist or may be inadequate. The HHE Program is an important mechanism within NIOSH for identifying and investigating emerging issues. The results of HHEs are similar to case reports in the medical literature; they are not always as definitive or as easily generalized to other workplaces as are the results of epidemiological research. But the HHE Program can take action on emerging issues in much less time, for much less money, and with much more flexibility to modify investigations in response to changing circumstances. One of the difficulties NIOSH and the HHE Program face in adapting the program to address emerging issues is that HHEs are done in response to requests, rather than being self-initiated. Nevertheless, NIOSH and the HHE Program could do more to track emerging issues and promote appropriate requests to address emerging issues. A resource for stimulating HHE requests related to emerging hazards is the 26 state OSHA programs, all of which have enforcement and consultation resources, and all of which are members of the Occupational Safety and Health State Plan Association. To date, however, there is no evidence of interaction with this orga- nization. The program could establish a stakeholder group or groups to assist in identifying exposure circumstances or types of workplaces that could be the object 6 Nanotechnology, sometimes called molecular manufacturing, is a branch of engineering that deals with the design and manufacture of extremely small electronic circuits and mechanical devices built at the molecular scale. Nanotechnology is often discussed together with microelectromechanical systems (MEMS), a subject that usually includes nanotechnology but may also include technologies higher than the molecular level (http://whatis.techtarget.com/definition/0,,sid9_gci213444,00.html, accessed March 28, 2008). 7 Nanoparticles are microscopic particles with an aerodynamic diameter of less than 100 nm. They are sometimes referred to as ultrafine particles (http://sis.nlm.nih.gov/enviro/iupacglossary/ glossaryn.html, accessed August 6, 2008).

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 7 of HHE requests likely to have high relevance or impact. The NORA sector councils may serve this function. Newly Identified Hazards Work Organization Issues Work organization describes how work is managed and organized. Issues include long or irregular hours, awkward or repetitive motion, job changes due to new technologies, and excessive or conflicting job demands. Twenty years ago, work organization issues were all but ignored; today, there is a growing recogni- tion that work organization can have a major impact on worker health. Two of the most common problems are musculoskeletal disorders and stress-related condi- tions. Work organization issues can arise in any working population, but they are especially important in the healthcare and other service industries and in disaster response. A number of HHEs have addressed work organization and its impact on health. They include HHEs of musculoskeletal disorders at the Los Angeles Times (NIOSH, 1990); of electronic headset noise exposure among transcribers at Kai- ser-Permanente in California (NIOSH, 2005b); of respiratory, gastrointestinal, dermal, and stress-related disorders among members of the New Orleans Police Department after Hurricane Katrina (NIOSH, 2006e); and of respiratory disease and mental disorders among New York transit workers exposed in the 9/11 attack on the World Trade Center (NIOSH, 2005c). NIOSH has recognized that work organization issues are doubly relevant to its mission: even if they themselves do not cause death and disability, they may increase an afflicted worker’s vul- nerability to more traditional health and safety hazards. The HHE Program is instrumental in identifying and responding to emerging issues associated with work organization. Chemical Hazards To be more proactive, the HHE Program and NIOSH might consider certain classes of chemical compounds as emerging issues. For example, organic aldehydes such as acrolein are highly reactive compounds and widely used in certain indus- trial processes. Acrolein, used in the production of acrylic acid, has known toxic properties and may be carcinogenic (ATSDR, 2007). Quinones are another group of chemicals of potential concern. Occupational exposure to quinones may occur in the dye, textile, chemical, tanning, photographic processing, and cosmetic indus- tries (OSHA, 2007). NIOSH and the HHE Program could determine the industries

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

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 7 NIOSH and the HHE Program to maintain and systematically review a tickler file of odd and unexplained findings to be reviewed periodically for follow-up and further investigation. Previous sections of this chapter have addressed the need for the HHE Program to better communicate with non-union workers and underserved populations. Emerging issues are particularly difficult to identify among these workers, specifi- cally because of lack of communication with them. Novel means of outreach to these populations might include community organization and worker centers, as well as publicly funded health clinics. Recommendation: Initiate formal periodic assessment of new and emerging hazards. The committee recommends the following steps: a. Evolve from a program that passively receives requests to a proactive program that seeks opportunities for field investigations. b. Develop systematic approaches to identify hazards where OSHA permissible exposure limits are inadequate or nonexistent, to iden- tify unknown hazards, and to identify known hazards encountered under new circumstances. c. Establish and periodically review a tickler file of inconclusive or unexpected evaluation results to determine whether new trends or problems may be emerging. d. Periodically meet with intramural and extramural research scien- tists and stakeholders in government, academe, labor, and industry to discuss specific unresolved evaluations, to review aggregate find- ings, and to solicit input about new or emerging hazards or interven- tions. The HHE Program could establish one or more stakeholder groups to assist in identifying exposure circumstances or types of workplaces that could be the object of HHE requests likely to have high relevance and impact. The NORA sector councils may serve this function. EMERgENCY RESPONSE Finding 9: The HHE Program is uniquely qualified to formulate in- formation needed to safeguard the workforce responding during and following a disaster. The program is well prepared to deploy during emergencies. Emergency preparedness is one of the most relevant aspects of the HHE Pro- gram. The strength of the HHE Program in emergency response comes from the

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

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t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m at n i o s h 0 RELEvANCE SCORE The program’s strategic goals are appropriate, although some intermediate goals and performance measures could be made more ambitious if resources were available. The committee finds that the HHE Program responds well to HHE requests, and that HHEs play a key role in addressing widespread occupational health issues, such as musculoskeletal disorders, and emerging issues, such as lung disease from diacetyl-based flavorings. However, the committee believes the pro- gram could do a better job of eliciting a broader array of requests, especially from underserved populations and those exposed to new or newly recognized hazards. Rapid changes in the economy and workforce have affected the nature of HHE requests. The HHE Program has generally met these challenges with a judicious use of its resources, while remaining true to its mission. The program could do even better by making greater use of available surveillance data and by sharpening its focus on emerging issues. The HHE Program has established a triage process to determine how to best meet the needs of each requestor within the limits of available resources. The triage process leads to improved efficiency, but it would benefit from increased trans- parency and more sophisticated site visit selection. Reports sent to the requestors and other interested parties and published on the NIOSH website are well written and relevant, reflecting a high level of expertise, and are supported by appropriate documentation. However, the quality and utility of some of the recommendations in the reports have not always met the same high standards. This could be cor- rected through a better quality assurance program. The timeliness of the reports has consistently been an issue in the past, but the HHE Program has shown some improvement in this area. The 9/11 attacks and Hurricanes Katrina and Rita put needed emphasis on emergency response. The HHE Program has responded well to these emergen- cies and is uniquely qualified to develop better ways to protect the U.S. workforce during such disasters. NIOSH and the HHE Program are well prepared to deploy during emergencies. After consideration of the criteria provided in the Framework Document (see Box 1-2), the committee assigns the HHE Program a score of 4 for relevance. The committee was asked to evaluate whether program activities are in priority areas and whether the program is engaged in relevant transfer activities. Although the committee makes multiple recommendations for improvement, it finds that pro- gram activities are in priority subject areas and that the program is engaged in ap- propriate transfer activities. A lower score, according to the scoring criteria, would indicate either a focus on lesser priorities or a lack of information dissemination.

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r e l e va n c e o f t h e h e a lt h h a z a r d e va l u at i o n P r o g r a m  Had the committee not been required to give an integer score, it might have rated the program between 4 and 5. In another example, an HHE was performed for an employer who managed home care services through a California county office (10,000 home care workers, primarily representing workers from underserved populations) (NIOSH, 2004a). Representatives from the county office reported a successful partnering of the HHE Program with the Labor Occupational Health Program (LOHP) of the University of California, Berkeley (Ayala, 2008). LOHP developed follow-up training to as- sist in implementation of HHE recommendations, which also contributed to the creation of a Labor Management Committee that discussed health and safety, as well as other issues. In this example, the HHE Program took advantage of local resources to maximize the effectiveness of HHE recommendations. A third example of HHE Program-state occupational health collaboration was provided in comments by an industrial hygienist working at the Massachu- setts Department of Public Health Occupational Health Surveillance Program (OHSP), which receives NIOSH funding for its occupational asthma surveillance activities (Pechter, 2008).8 Over time, three referrals for investigation of potentially hazardous exposures associated with work-related asthma were identified, and the industrial hygienist contacted the HHE Program to conduct investigations at these worksites. New-onset asthma associated with exposure to a particular compound (3-amino-5-mercapto-1,2,4-triazole) was identified (NIOSH, 2003b; Hnizdo et al., 2004). As noted by the stakeholder: “The identification of a new asthmagen is important, not only for the protection of workers currently exposed, but also to the process of scientific inquiry about respiratory sensitizers and asthma preven- tion” (Pechter, 2008). The HHE Program had previously identified asthma in flock workers at one company site (NIOSH, 1998a), while the OHSP request led to the identification of hazards in a second plant (NIOSH, 2006a; see Box 3-3 for a more detailed description of flock and related HHE Program activities). 8 These comments reflect personal opinions and are not necessarily those of the Massachusetts Department of Public Health.