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NIOSH Respiratory Diseases Research Program

Evidence Package for the National Academies' Review 2006-2007

NIOSH Programs > Respiratory Diseases > Evidence Package > 8. Surveillance Activities

8.6 State-Based Surveillance Program

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 In the mid-1980s, with the exception of the Coal Workers’ X-Ray Surveillance Program, no ongoing national surveillance systems existed for occupational respiratory disease morbidity. Conventional data sources were often inadequate. For example, the BLS annual Survey of Occupational Injuries and Illnesses has long been widely criticized as inadequate for diseases with a long latency period, including many occupational respiratory diseases such as silicosis. While industry and occupation may be included in available data from other national surveys (e.g. the National Health and Nutrition Examination Survey and the NHIS), any occupational attribution (i.e., ‘work-relatedness’) of respiratory diseases for which data is available in these surveys is necessarily indirect.

The needs for integration of occupational health into the mainstream of public health activities at the state level and for use of state-based approaches to obtain surveillance data and information to identify research and intervention priorities have been recognized for at least two decades. In 2001, these needs were described in, “The Role of the States in a Nationwide, Comprehensive Surveillance System for Work-Related Diseases, Injuries, and Hazards: A Report from the NIOSH-Council of State and Territorial Epidemiologists (CSTE) Surveillance Planning Work Group” ( and [External links]) (A8-11).


 NIOSH, in association with state health departments, initiated targeted provider-reporting systems, called SENSOR in 1987. SENSOR addressed limitations of provider-reporting systems (e.g. lack of epidemiologic case definitions; lack of formal, defined networks of sentinel providers with specific responsibility for reporting selected conditions, or lack of guidance). As part of this initiative, NIOSH recommended that each participating state target a select list of work-related conditions that were important problems in the state and appropriate for surveillance under the SENSOR model. NIOSH also developed a list of work-related conditions of public health importance. Of the initial 10 states participating in the SENSOR program in 1987, six (Colorado, Massachusetts, Michigan, New Jersey, New York, Wisconsin) identified WRA and four (Michigan, New Jersey, Ohio, Wisconsin) identified silicosis as conditions targeted for surveillance. Three of the originally funded WRA states (Massachusetts, New Jersey, Michigan) and California continue surveillance for WRA under the SENSOR program or using the SENSOR model; two of the original silicosis states (MI and New Jersey) continue surveillance for silicosis.

Examples of specific approaches and activities collaboratively undertaken by RDRP, states, and other partners for the surveillance of WRA and silicosis include:

  • Collaboration on the development of standard state reporting guidelines, case definitions, and case classification schemes for surveillance of WRA (1999) and silicosis (1997 and 1999)
  • Development of standard consensus variables and formats collected across state programs with coding that conformed to existing CDC data standards (1997–1998)
  • Creation of software to facilitate data collection, coding, reporting, compilation and aggregate analysis, the Respiratory Disease Surveillance System (RDSS) (1998)

Outputs and Transfer

In general, the outputs of the state-based surveillance program are related to establishing surveillance capacity at the state level and providing states with support and guidance, as needed. For example, RDRP has supported states by assisting with publications such as “Guidelines: Minimum and Comprehensive state-based Activities in Occupational Safety and Health,” Stanbury M, Rosenman K, Anderson H. CSTE/DHHS (NIOSH) Publication No. 95-107 (

RDRP staff together with state and other partners have disseminated state-based surveillance data and outreach materials in various ways, including the following (for full list see A8-12):

  • Peer-reviewed journal publications (16 on WRA and 14 on silicosis)
  • MMWR (one on WRA and three on silicosis) These reports provided guidance and case definitions for the surveillance of these occupational lung diseases by state health departments
  • Three book chapters
  • Three NIOSH Alerts (on latex asthma, asthma associated with diisocyante-based spray-on truck-bed liners, and silicosis deaths in construction workers)
  • Four NIOSH numbered documents (1999 and 2002 “WoRLD Surveillance Reports” and 2000 and 2004 “Worker Health Chartbooks”)
  • Distribution of over 13,000 printed copies of a state-partner brochure “What Dental Technicians Need to Know about Silicosis” to dental laboratories nationwide. ( [External link]).
  • Posting of a state-based surveillance information on the “ORDS” topic page on the NIOSH Web site ( )
  • 138 other items of outreach materials (84 on WRA, 18 on silicosis, six on other occupational lung diseases [e.g. hypersensitivity pneumonitis, SARS, beryllium, flock-workers lung, tularemia], and 31 on general information or state surveillance annual reports)

RDRP staff also collaborated and provided technical support to the NCEH, Asthma Program staff and to their state asthma grantees (beginning 2000) by way of site visits to nine states (Connecticut, Maine, Missouri, Mississippi, Utah, Nebraska, Pennsylvania, Wisconsin, Virginia), teleconferences with two states (Georgia, Minnesota), and presentations at three state asthma summits(Pennsylvania, Maryland, West Virginia).

State-based surveillance has played an important role in identifying new diseases and emerging problems as well as previously recognized diseases. For example, state partners and RDRP researchers identified and documented in the scientific literature a new putative asthmagen used in herbicide production: 3-amino-5-mercapto-1,2,4,-triazole (AMT), a feed chemical used in the production of a systemic herbicide. ( In this case, the identification of a sentinel cluster of WRA by state-based surveillance resulted in a series of field and laboratory investigations. As a result, AMT is now listed as a known asthmagen in the AOEC Exposure Coding System.

In another example, state-based surveillance identified a well-known problem in a new setting. One death in Michigan from status asthmaticus and eight confirmed cases of WRA in the state of Washington were identified as due to isocyante-induced asthma caused by isocyanate exposure during spray-on truck-bed liner application. This finding resulted in the NIOSH Alert “Preventing Asthma and Death from MDI Exposure During Spray-on Truck-bed Liner and Related Applications” (A4-12, A4-13, A4-14).

Intermediate Outcomes

The state-based surveillance program has provided important opportunities to influence the actions of others outside of RDRP. For example, state partners of RDRP state-basedprojecthave submitted summary case data and exposure sampling data for use in proposed regulations and standards related to glutaraldehyde, wood dust, respiratory sensitizers, and silica. Some individual examples of how the state-based surveillance program has influenced others are noted below.

RDRP state-based surveillance staff worked with the AOEC to revise their Exposure Coding System to indicate asthmagens identified in the literature (1994). The AOEC Exposure Coding System is utilized by states and RDRP to code and summarize reported exposures ( [External link]). In 2002, RDRP staff, state partners and the AOEC developed a protocol for the systematic review of identified asthmagens in the AOEC Exposure Coding System for either removal or validation, as well as review of proposed asthmagens for addition to the system.

RDRP staff provided input to the CSTE on development of their 1996 CSTE Position Statement recommending that silicosis being placed under nationwide surveillance in1996 ( [External link]). RDRP staff also provided input to development of a 1999 CSTE position statement that provided specific silicosis surveillance guidance and a recommended case definition ( [External link]). CSTE Position Statements are influential and provide programmatic guidance and influence public health on national, state and local levels.

 Summary WRA data obtained via state-based surveillance was used to document a well-recognized cause of WRA, natural rubber latex (NRL) (MMWR CDC Surveill Summ 1999; 48:1–20). Case reports from a large cluster of cases in Massachusetts were used in the 1997 NIOSH Alert “Preventing Allergic Reactions to Natural Rubber Latex in the Workplace,” DHHS (NIOSH) Publication No.97-135) to illustrate NRL allergy (A4-4). The Alert was disseminated to over 3,000 health care facilities in Massachusetts. In part as a result of these findings of state-based surveillance, Massachusetts initiated a number of prevention activities. The Massachusetts Department of Public Health convened a Latex Work Group with representatives from nine different programs to foster policy initiatives and activities. Activities included a survey of latex policies in 88 acute care hospitals, the formation of an external Latex Committee, and a state-wide conference attended by 118 participants from 66 hospitals across the state. Intermediate outcomes include Massachusetts Office of Emergency Medical Services regulations requiring a latex-free kit in every ambulance (April 2000) and promotion of latex-safe policies in food preparation (105 Code of Massachusetts Regulations [CMR] 590.004 (E); March 2001).

In 1993, the New Jersey Department of Health and Human Services (NJDHSS), Occupational Health Surveillance Program, identified a single, confirmed, sentinel case of silicosis in a worker employed for 35 years in the road construction industry. Road building materials such as concrete, asphalt, and masonry products contain silica sand, as well as other forms of crystalline silica. A total of 11 cases of confirmed or probable silicosis among workers in the road construction and elevated highway construction industries (Standard Industrial Classification codes 1611 and 1622) were subsequently identified in the New Jersey surveillance data. NJDHHS initiated a hazard surveillance project in partnership with the New Jersey Department of Transportation (NJDOT) to evaluate silica exposures on highway repair projects. In view of a concurrent Federal OSHA Special Emphasis Program for Silicosis, there was significant interest among contractors to demonstrate compliance. As a result, the NJDHSS and NJDOT joined with nine other agencies and groups (state and federal agencies, unions, state safety council, contractor trade association, and 10 New Jersey highway construction contractors) to form the New Jersey Silica Outreach and Research Alliance in 1999. This partnership, ultimately originating from state-based surveillance, resulted in a number of accomplishments:

  • Collection of air sampling data for seven different work tasks. (OSHA is using the aggregate data in its ongoing efforts to develop of a comprehensive standard for crystalline silica)
  • Provision of silica safety training, respirator fit-testing and medical qualification to ensure compliance with the OSHA respiratory protection standard by labor unions
  • Evaluation of existing and development of new off-the-shelf engineering controls for reducing exposure in collaboration with RDRP researchers
  • Incorporation of protective language into NJDOT road repair contracts which directs contractors to establish an approved Silica Safety and Health Program when airborne crystalline silica exceeds the OSHA PEL. The safety and health program includes engineering and work practice controls to reduce worker exposure to or below the PEL for silica dust. Contractors are required to provide a trained, competent person on site to implement the health and safety program when tasks generating crystalline silica dust are being performed ( [External link])

RDRP state-based surveillance staff worked with NCEH to include a nine question WRA module in an FY06 asthma call-back survey conducted through the Behavior Risk Factor Surveillance Survey (BRFSS). The BRFSS is an annual, nationwide telephone survey of adults 18 years of age and over that assess prevalence and trends of health-related behaviors, prevention practices, and selected health conditions administered in all 50 states, the District of Columbia, and three U.S. territories. This was the first time population-based state-level data was collected at this scale (from 25 states). Results are pending, but RDRP had previously assisted three state partners to pilot WRA questions in their BRFSS and findings from the pilot effort were published in a 2006 issue of the Journal of Asthma.

New York State re-vitalized its state Occupational Lung Disease Registry, increasing reporting to the Registry by 36percent over a two year period, October 2001 to 2003. New York State implemented a multi-faceted outreach campaign to increase case reports. The campaign targeted physicians and medical care facilities.

What’s Ahead

 Collaborate with NCEH/ATSDR to support collection of information on WRA through the BRFSS and increase the number of states funded for the Asthma Call-back Survey. In FY2006, RDRP will support the CY2007 NCEH/ATSDR Asthma Call-back Survey in 35 states, representing an increase of nine states from CY2006.

Update and modify the standard consensus variables and formats collected across state programs with coding that conformed to federal standards when these data are exchanged, stored, retrieved or analyzed in electronic form. The new coding structures and variables will conform to Public Health Information Network standards. The Public Health Information Network is a standards-based IT network that provides a means of exchanging comparable public health information at the local, state, and federal levels.

  • Transition from the 1987 Standard Industrial Classification to the 2002 North American Industry Classification System system
  • Transition from the 1990 Census Occupational Codes to the 2000 codes
  • Adjust coding to reflect new state data sources, such as Poison Control Center data and changes in state access to Emergency Department data

Support for NORA Sector Research Councils

  • With state partner assistance, present WRA and silicosis data by NORA Sectors
  • Provide state WRA and silicosis surveillance data to Research Sector Councils for problem identification, hypothesis generation, and evaluation