Preface

This document provides evidence of the relevance and impact of the Health Hazard Evaluation (HHE) Program of the National Institute for Occupational Safety and Health (NIOSH). NIOSH produced the document as part of a review of its programs by the National Academies. NIOSH has asked the National Academies to assess its contributions to improving health and safety in the workplace.

The National Academies convened a Framework Committee to provide a common structure for NIOSH program reviews. In April 2006, HHE Program staff presented materials about the HHE Program to the Framework Committee. Subsequently, the Framework committee expressed the opinion that the HHE Program should be evaluated using a different approach than that in the framework developed for other NIOSH programs. In a report to NIOSH summarizing the issues raised by the Committee, the National Academies staff noted that the charge given to the National Academies is related specifically to evaluating research programs; the HHE Program primarily is a public health practice program driven by requests for services.

The NIOSH charge to the National Academies for the HHE Program is to conduct an evaluation based on the following elements:

• The impact of the program in reducing worker risk and preventing occupational illness in investigated workplaces.
  The impact of the program in transferring program-generated information to relevant employers and employees beyond the investigated workplaces.
  The impact of the program on the NIOSH research and policy-development programs.
  The impact of the program on the activities of regulatory agencies, occupational safety and health professionals and organizations, state and local health agencies, and others in the occupational health community, as achieved by transferring program-generated hazard and prevention information.
  
  
• The relevance of the program in addressing current and emerging workplace health hazards.

With this document, NIOSH is providing the National Academies' Committee to Review the NIOSH Health Hazards Evaluation Program information needed to begin the review process. We look forward to an ongoing dialogue with the committee to ensure that it has all the information needed to complete a thorough program review.

This document largely covers the period from 1996 to the present. For some of the materials presented, however, earlier information is included when it is necessary to provide a context for the later work. The first two chapters of this document provide an introduction to NIOSH and to the HHE Program and background descriptive and statistical information for putting the outcomes of the Program in perspective. These chapters address inputs, activities, outputs, outcomes, and external factors for the HHE Program as a whole. In the third chapter, the impact of the HHE Program is presented through narratives describing selected areas of investigation organized by HHE Program strategic goals. These narratives highlight areas where the activities and outputs of the HHE Program contributed to reducing exposure to hazardous agents and conditions and preventing occupational illness in the workplace. Many of the narratives exemplify how HHE Program actions in one or a small number of facilities affect not only the workers in these specific facilities, but also have broader impact by influencing activities of regulatory agencies, occupational safety and health professionals, and other organizations that play a role in occupational health. Supporting evidence for each investigation area is listed at the end of chapter 3. Websites are given for documents available on the Internet

Table of Contents

Appendices

Abbreviations

Executive Summary

Chapter 1: Introduction to NIOSH

Appendices

Abbreviations

Executive Summary

The National Institute for Occupational Safety and Health (NIOSH) is the federal agency responsible for conducting research and making recommendations to prevent occupational illness and injury. NIOSH is part of the Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (DHHS). The Health Hazard Evaluation (HHE) Program carries out the NIOSH mandate to respond to requests for field investigations to learn whether exposures or conditions in specific workplaces pose a health hazard to workers. These field investigations are termed health hazard evaluations, or HHEs.

The HHE Program has a unique role in NIOSH as an external sensor for current and emerging issues, helping the Institute stay relevant with regards to occupational health issues in today's workplaces. The HHE Program can be likened to a hospital emergency department, reflecting events happening in the community and serving as one of the first places people go for assistance in solving workplace problems. The HHE Program was designed to deal with problems whose causes, implications, and solutions are not well understood. Often, it has been in the center of controversy where scientific opinion and policy perspectives are at odds. This document provides evidence that in such situations the HHE Program has helped bring clarity to the issues, resolve uncertainties, and drive corrective actions. The HHE Program contributes to the NIOSH mission through a diverse set of activities and outputs. The Program's mission is to respond to requests for assistance, solve problems, communicate risk, and disseminate findings. To accomplish its mission the Program has identified the following three strategic goals: (1) prevent occupational illnesses through reduced exposure to workplace hazards, (2) promote occupational safety and health research on emerging issues, and (3) protect the health and safety of workers during public health emergencies. The activities and outputs of the Program directed towards these goals have achieved demonstrable outcomes in each of the areas the National Academies has been asked to evaluate.

This document provides evidence that decision-makers at workplaces throughout the U.S. have made changes to improve worker health in accordance with the recommendations made by HHE investigators. These changes have first occurred in workplaces investigated by the Program. Evidence for change can be seen in substitution of a toxic process chemical with a nontoxic chemical, installation of local exhaust ventilation to capture process emissions, implementation of a comprehensive program for providing respiratory protection, and enhancement of training programs to better inform workers about the nature of workplace hazards and the ways to ameliorate those hazards. This evidence comes from workplace partners via informal feedback and from data gathered directly by the HHE Program. The evidence points to impacts of the HHE Program on preventing silicosis among roofers, vision disturbances among workers exposed to certain amines, respiratory and skin irritation among poultry workers, exacerbation of asthma in school employees, musculoskeletal disorders among many occupations in the service and manufacturing sectors, and tuberculosis infection among hospital and correctional facility workers.

This document also offers evidence that the effects of individual HHE investigations extend to noninvestigated facilities with similar hazards and concerns, although the HHE Program has never had a formal mechanism to measure this impact. Effects, seen domestically and globally, occur as a direct result of HHE Program activities, such as posting of investigation reports on the NIOSH website and training of international partners, and through the work of intermediate customers. These include agencies and organizations that issue standards and guidelines. They have used data from HHE investigations to demonstrate need and formulate exposure criteria, and they have used recommendations from HHE investigators as models for corrective actions. HHE Program recommendations regarding infectious disease transmission have influenced CDC policy regarding respiratory protection for airborne infectious agents and helped frontline emergency responders do their jobs safely following hurricanes and floods. Other evidence in this document describes impacts on preventing lead poisoning among home renovators, latex allergies among healthcare workers, nonspecific symptoms among office workers exposed to volatile organic chemicals, flavoring-related lung disease among microwave popcorn workers; and impacts on the capacity of developing nations to prepare for emerging infectious diseases.

Historically, the HHE Program has led the way in documenting new, emerging, or previously unrecognized occupational hazards. Information derived from HHEs has helped open new areas of research at NIOSH and has contributed to a better understanding of practical means for hazard reduction. Among other examples, this document offers evidence for impacts on NIOSH research regarding the etiology of lung disease in workers exposed to flock, and engineering solutions to carbon monoxide exposure in the recreational boating industry.

The HHE Program is a unique resource within the federal government. To ensure its relevance, HHE Program services must be available in all economic sectors and to all segments of the U.S. working population within the bounds established by the enabling legislation. The Program is taking steps to promote public awareness of its services and its responsiveness to customer needs. It has adapted its activities to reflect social and economic changes affecting the American workplace, new areas of emphasis within NIOSH, and new mandates for all government programs. It will remain flexible by redirecting resources from areas where progress has been made in preventing occupational disease, such as tuberculosis in healthcare settings, to new hazards such as nanoparticles. Increasingly, the HHE Program is partnering with others in NIOSH to develop mutually beneficial working relationships.

By learning from program evaluation efforts, the HHE Program will further its efforts to reduce hazardous exposures and conditions and prevent occupational disease. Its mission of responding to requests for assistance, solving problems, communicating risk, and disseminating findings continues to be integral to the NIOSH mission.

Chapter 1 - Introduction to NIOSH

1.1  Overview

NIOSH is the federal agency responsible for conducting research and making recommendations for preventing occupational illness and injury. NIOSH is part of the Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (DHHS).

Surveillance data published by the U.S. Bureau of Labor Statistics (BLS) documents the burden of illness and injury associated with work [http://www.bls.gov/iif]. In 2005, 5,734 fatal work injuries occurred in the U.S., an average of 16 per day. In the private sector, 5,214 fatal work injuries and 4.2 million illnesses and non-fatal injuries were recorded. This human toll is accompanied by significant economic cost. The Liberty Mutual Workplace Safety Index estimated that direct costs for occupational injuries alone were $48.6 billion in 2004 [http://www.libertymutual.com/omapps/ContentServer?cid=11383 44114861&pagename=ResearchCenter%2FDocument%2FShowDoc&c=Document].

Changes in the workplace are creating new challenges for preventing occupational illness and injury. As the U.S. economy shifts from manufacturing to services and industries shift to newer technologies, the distribution of jobs and occupational hazards changes. Workforce demographics are also changing. By the year 2008, the U.S. workforce will grow to an estimated 155 million, with minorities constituting 28% of the workforce and women 48%. The workforce is also aging. By 2010, middle and older age workers will outnumber younger workers. Finally, there have been important changes in the conditions under which work is performed. Longer work hours, longer shifts, and compressed work weeks; part-time and temporary work; around the clock shift work telecommuting; and reduced job security are all realities of the modern workplace. NIOSH must work not only to prevent the occupational illnesses and injuries of today, but also to anticipate and prevent those of tomorrow.

To meet the challenges of occupational safety and health, NIOSH is guided by its mission to provide national and world leadership to prevent work-related illnesses and injuries. In carrying out this mission, NIOSH adheres to a core set of values:

• Relevance - Our programs are responsive to the occupational safety and health problems that are found in today's workplaces and the workplaces of tomorrow.
  Diversity - Our employees reflect the full spectrum of diversity found in the U.S. workforce and our research and interventions reflect the diversity of solutions needed for the U.S. workplace.
  Quality - We utilize only the best science, the highest level of data quality, and the most transparent and independent peer-review.
  Partnership - We accomplish our mission in partnership with employers and workers as well as with academia, industry, government, and scientific and professional communities, both nationally and internationally. These partnerships are formed strategically to improve planning, execution, and review of NIOSH research. They also help translate and transfer research outputs to the workplace.
  Access - Our customers can obtain all NIOSH products and services through expanded traditional and electronic access.
  Performance - Our programs are results-oriented.
  
• Accountability - Our programs are evaluated by how well they solve the occupational safety and health problems found in today's workplaces and the workplaces of tomorrow.
  

1.2  Legislative Foundations

The main legislative underpinnings of NIOSH are the Federal Coal Mine Health and Safety Act of 1969 (amended in 1977) and the Occupational Safety and Health Act of 1970. The Mine Safety and Health Act recently was amended by the Mine Improvement and New Emergency Response Act of 2006, which gave new responsibilities to NIOSH.

The "Coal Act" was passed in the aftermath of a devastating coal mine explosion in West Virginia in 1968. It took the lives of 78 miners and crystallized public opinion that stronger measures were needed to protect coal miners at work. Responsibilities for the Coal Act were split between the Department of Health, Education and Welfare, which was charged with non-regulatory activities, and the Mine Enforcement and Safety Administration in the Department of the Interior (DOI), which was charged with developing and enforcing workplace safety and health regulations in the mining industry. NIOSH subsequently assumed the health screening and research responsibilities specified under the Coal Act. When the Coal Act was amended in 1977, the Mine Enforcement and Safety Administration was replaced by the Mine Safety and Health Administration (MSHA) in the Department of Labor.

The Occupational Safety and Health Act of 1970 (Appendix 1.1) followed closely after the Coal Act. It created NIOSH and the Occupational Safety and Health Administration (OSHA). OSHA, in the U.S. Department of Labor, is responsible for developing and enforcing workplace safety and health regulations. NIOSH, in DHHS, is responsible for providing occupational safety and health research, information, education, and training.

NIOSH responsibilities are described in Section 22 of the Occupational Safety and Health Act of 1970. The Institute is authorized to do the following activities:

• Develop recommendations for occupational safety and health standards. Perform all functions of the Secretary of Health, Education and Welfare (subsequently Health and Human Services) under Sections 20 and 21 of the Act. Conduct research on worker safety and health (Section 20). Conduct training and employee education (Section 21). Develop information on safe levels of exposure to toxic materials and harmful physical agents and substances. Conduct research on new safety and health problems. Conduct on-site investigations to determine the toxicity of materials used in workplaces (Health Hazard Evaluations - 42 CFR Part 85; and General Research Authority - 42 CFR Part 85a).
• Fund research in other agencies or private organizations through grants, contracts, and other arrangements.

Congress has set a clear division between the research function of NIOSH and the regulatory and enforcement functions of MSHA and OSHA. Although NIOSH works with MSHA and OSHA to achieve the common goal of protecting worker safety and health, NIOSH has a unique identity as the sole federal government organization primarily charged to conduct occupational safety and health research.

Through its legislated authorities, NIOSH provides national and world leadership to prevent work-related illness, injury, disability, and death by gathering information, conducting scientific research, and translating the knowledge gained into products and services. The NIOSH mission is critical to the health and safety of every American worker.

As a legislative authority granted in the Occupational Safety and Health Act, NIOSH responds to requests for workplace evaluations from employers, employees and their representatives, and other agencies. These evaluations have come to be known as HHEs. Through the HHE Program, NIOSH identifies current health hazards and recommends practical, scientifically sound solutions for reducing exposures and preventing disease and disability. The HHE Program has an interdisciplinary team (e.g., industrial hygienists, engineers, occupational physicians, epidemiologists, and psychologists) who assess the relationship between workplace exposures and employee health, and identify measures to ameliorate hazards. When no health hazards are found they provide credible and comprehensive information to concerned employers and employees. HHE activities take place in workplaces throughout the nation in response to acute and chronic problems, including public health emergencies.

Under the Energy Employees Occupational Illness Compensation Program Act of 2000, NIOSH also has responsibilities to assist with implementing a program that provides compensation and medical benefits for nuclear weapons workers who may have developed certain work-related illnesses. In this effort, NIOSH works closely with the Departments of Energy, Labor, and Justice.

1.3  Organizational Structure and Management

NIOSH is located within CDC, which is located within DHHS. The NIOSH Director is appointed by the DHHS Secretary and reports to the CDC Director. DHHS recently implemented performance-based management, in which management responsibilities cascade through the administrative structure. Thus, each manager's performance plan includes formal responsibilities specifically tailored to support the responsibilities of others higher in the management chain. Under this management system, responsibilities ultimately derive from priorities established by the Office of Management and Budget (OMB), in the Executive Office of the President.

The organizational components of NIOSH are shown in Figure 1-1 (page 7). The main organizational units are divisions and laboratories. These are a mixture of disease and injury-specific divisions (respiratory diseases, safety research), expertise-specific divisions (applied research and technology, laboratory research, surveillance and field studies, education and information dissemination, personal protective technology), and industry-specific units (mining). The divisions and laboratories are in Cincinnati, Ohio; Morgantown, West Virginia; Pittsburgh, Pennsylvania; and Spokane, Washington. NIOSH leadership is located in Washington, DC; and Atlanta, Georgia. To coordinate across these geographically dispersed units, NIOSH extensively uses modern information technology, including e-mail and audio and video conferencing.

NIOSH unveiled the National Occupational Research Agenda (NORA) in 1996. NORA is a partnership program to stimulate innovative research and improved workplace practices; it has become a research framework for NIOSH and the nation. Collaborations are fostered in eight sector-based Research Councils that include NIOSH and its partners; the Councils establish national goals and objectives for addressing the needs of their sector. The NIOSH Program Portfolio is comprised of eight NORA Sector Programs; fifteen cross-sector programs organized around adverse health outcomes; statutory programs and global efforts; and seven coordinated emphasis areas (Table 1-1). Each of these has an internal steering committee that helps plan NIOSH activities. The HHE Program is a cross-sector program.

NIOSH is committed to performance-based management, and has developed key performance indicators to track performance. For example, NIOSH tracks financial performance by monitoring discretionary funding (i.e., not personnel, salary, and benefits) allocated to divisions and laboratories. The NIOSH target is 25% discretionary by 2010. The FY 2006 ratio was 20%. NIOSH also optimizes the ratio of supervisory staff to non-supervisory staff. CDC established a FY 2006 goal of 1:10. In FY 2006, the NIOSH ratio was 1:13.

NIOSH management operates within the context of broader federal management requirements and initiatives. The 1993 Government Performance and Results Act mandated that federal agencies develop multiyear strategic plans, annual performance plans, and annual performance reports. Programs in the NIOSH Program Portfolio are following this mandate.

Another management requirement is responsiveness to the OMB's Program Assessment Rating Tool [http://www.whitehouse.gov/omb/part/], which is used by the Office to assess federal agency performance on a number of measures including strategic planning, program management, and program results. Program Assessment Rating Tool performance ratings are an important consideration in budget requests by the President. Current NIOSH key performance measures for the Program Assessment Rating Tool were established in 2004. They target the following safety and health-focused achievements by 2014:

• 50% reduction in the respirable coal dust overexposures of operators of longwall and continuous mining machines, roofbolters, and surface drills.
  40% reduction in the number of workers being struck by construction vehicles and equipment in the road construction industry.
  
• 75% of professional fire fighters and first responders have access to CBRN respirators.
  

NIOSH receives external guidance and advice from two Federal Advisory Committees. The Board of Scientific Counselors (BSC) is composed of external authorities from a variety of fields related to occupational safety and health. BSC members provide advice and guidance to NIOSH in developing and evaluating research hypotheses, documenting findings, and disseminating results that will improve the safety and health of workers. They also evaluate the degree to which NIOSH activities: 1) conform to standards of scientific excellence; 2) address currently relevant occupational safety and health needs, either alone or in collaboration with activities outside of NIOSH; and 3) produce their intended results. The Mine Safety and Health Research Advisory Committee performs a similar function, focusing on issues related to occupational safety and health in mining.

Another source of external input is the National Advisory Committee on Occupational Safety and Health (NACOSH), which was created by the Occupational Safety and Health Act of 1970 to advise NIOSH and OSHA on occupational safety and health programs and policies. Members of the 12-person advisory committee are chosen on the basis of their knowledge and experience in occupational safety and health. Two members represent management, two members represent labor, two members represent the occupational health professions, two members represent the occupational safety professions, and four members represent the public. Two of the health representatives and two of the public members are designated by the DHHS Secretary, although all members are appointed by the Secretary of Labor. The members serve 2-year terms. NIOSH and OSHA provide staff support for NACOSH. The Director of NIOSH and the Assistant Secretary of Labor for Occupational Safety and Health usually attend NACOSH meetings. NACOSH is a vehicle not only for external input for the agencies but also a body to whom the agencies must be responsive. NACOSH meetings are held twice annually and are open to the public.

1.4  Resources

The NIOSH budget is a direct appropriation from Congress, as a specific line item in the DHHS/CDC appropriation. The Congressional language accompanying the appropriation often contains specific directives about the intended use of some funds. For example, these "earmarked" directives instruct NIOSH to use specific portions of the funds to conduct research targeting certain industries such as agriculture or construction, or to support research or surveillance initiatives such as NORA and Emergency Preparedness. In addition, Congress or DHHS may charge NIOSH to lead or participate in evolving public health activities such as the World Trade Center health surveillance efforts. Funding is not always provided. Prior to FY 2006, the CDC took a portion of the NIOSH budget to offset the cost of administrative and infrastructure support provided by CDC and to fund the NIOSH portion of costs associated with business consolidations established under the President's Management Agenda. Beginning in 2006, Congress moved the charges associated with business support services from the NIOSH appropriation and appropriated the funding directly to the CDC (approximately $35 million). Escalating personnel costs, combined with projections of diminished appropriations and continuing "earmark" obligations, create significant challenges as NIOSH strives to fulfill its mission and optimize its impact on occupational safety and health.

In FY 2006, $255 million was appropriated for NIOSH. Table 1-2 (page 10) shows NIOSH funding for the years 1996 through 2006. After adjusting funding for the Biomedical Research and Development Price index (which adjusts not only for inflation but also for increased costs of conducting scientific investigation due to new technologies, among other factors), NIOSH has had only a modest increase in funding since 1996. Essentially all of the increase is the result of funding "earmarked" for NORA priorities.

The current NIOSH staffing level is approximately 1413 full-time equivalents (FTEs). This level has fluctuated over the past decade from a low of 1364 FTE in 1996 to a peak of 1521 FTE in 2003 and then a subsequent steady decline to the current level. The increases leading to the peak in 2003 can be attributed, in part, to NIOSH absorbing the research teams of the former Bureau of Mines and the establishment of a new Health Effects Laboratory Division in Morgantown, West Virginia, and the National Personal Protection Technology Laboratory in Pittsburgh, Pennsylvania.

1.5  Planning and Logic Model

NIOSH has a long history of organized planning to optimize its relevance and impact. During the 1980s, NIOSH conducted a series of national symposia on the leading causes of occupational-related illness and injury. Those meetings resulted in 10 written strategies for prevention that guided NIOSH research programs during the early 1990s. In 1996, NIOSH and its partners unveiled NORA, a framework to guide occupational safety and health research into the new millennium-not only for NIOSH but for the entire occupational safety and health community. Approximately 500 organizations and individuals outside NIOSH provided input into the development of NORA. The NORA process resulted in a list of 21 research priorities in occupational safety and health [http://www2a.cdc.gov/nora/]. Teams of researchers and other stakeholders were organized primarily according to types of health problems or disciplinary approaches for each of these priority research areas. Many of the teams published agendas for research. NIOSH researchers, including those from the HHE Program, were prominent in those efforts.

During the NORA process, NIOSH developed a strategic plan for the years 1997-2002 [http://www.cdc.gov/niosh/gpran1a.html]. A new plan was developed for the years 2004-2009 [http://www.cdc.gov/niosh/docs/strategic/]. The strategic goals of the current plan are to:

• Conduct research to reduce work-related illnesses and injuries.
  Promote safe and healthy workplaces through interventions, recommendations and capacity building.
  
• Enhance global workplace safety and health through international collaborations.

To address these strategic goals and the needs of the next decade, NORA has been modified [http://www.cdc.gov/niosh/NORA/]. The second decade of NORA is organized to prepare research agendas along the lines of major industrial sectors. These research agendas are being developed with broad involvement and input from all parties with an interest in occupational safety and health. This new NORA strategy will allow NIOSH to more effectively address the needs of U.S. industries and workers.

NIOSH has developed an operational logic model to assure that its strategic planning activities are logical and appropriate, and optimize its relevance and impact (Figure 1-2). The logic model moves from left to right across the chart, beginning with production and planning inputs. Those inputs lead to NIOSH activities. The outputs lead to customer activities. Some NIOSH customers are intermediaries who use or adapt NIOSH outputs before they reach the NIOSH final customers, including employers, employees, educators, and regulators. The actions of NIOSH customers contribute to workplace health and safety improvements. This process is affected by external factors including economic and social conditions and the regulatory environment. A brief discussion of the logic model elements follows.

Planning inputs are data that guide NIOSH to research action. Many sources, including HHEs, surveillance programs, and risk assessments, provide input. An essential planning activity for NIOSH is the collection, analysis, and interpretation of health and hazard data. NIOSH uses illness, injury, fatality, exposure, and hazard data for those purposes. NIOSH actively engages in surveillance to obtain data that can guide its efforts. The "NIOSH Worker Chartbook," now in its second edition, is an important source of occupational health surveillance data [http://www.cdc.gov/niosh/docs/chartbook/].

It is important to note that inputs can turn activities off as well as on. This occurs when activities have been completed, have become lesser priorities, or have otherwise outlived their usefulness.

NIOSH engages in a broad range of Activities. Key activities include many types of research, field investigations of workplaces (including HHEs), surveillance, policy development, and health communications.

Over 1,000 active research projects are underway at NIOSH. These projects encompass a large number of areas and disciplines, such as:

• Hazard control development and testing, exposure assessment, epidemiology, behavior, toxicology, biology, and risk assessment.
  Research, standards development, and evaluation of personal protective technologies.
  Developing environmental sampling and testing methods.
  Performing laboratory-based and field research: intramural, extramural, domestic, and international.
  
• Developing practical workplace interventions, testing them for effectiveness, and promoting their adoption in the workplace.

HHEs, a specific NIOSH activity, result in new research knowledge that can be broadly applied in the workplace. HHEs are a planning input to NIOSH research programs and provide a mechanism for translating research findings into practical recommendations for controlling workplace health hazards.

NIOSH operates two fatality investigation programs, one focused on line-of-duty deaths among fire fighters and one addressing fatalities for all other workers. In both programs, investigators assess the circumstances around each fatality to formulate prevention strategies. Information about prevention strategies is shared with stakeholders.

NIOSH supports training of occupational safety and health professionals, which helps transfer NIOSH research to the workplace. NIOSH developed university-based Education and Research Centers (originally named Educational Resource Centers) in 1977 to meet the need for well-trained safety and health professionals. NIOSH currently funds 16 Education and Research Centers at leading universities to provide graduate and continuing education programs in occupational medicine, occupational health nursing, industrial hygiene, safety, and related disciplines. These Centers serve as regional resources for occupational safety and health professionals in industry, labor, government, and academia; and for the public. The Centers are funded for 5 years at a time through a competitive peer-review process. NIOSH also supports approximately 40 smaller training project grants that are focused on providing qualified professionals for the field.

Outputs and Transfer: The result of research is new knowledge. New knowledge serves society by providing practical guidance on matters of importance to the population. NIOSH carries out the responsibility to disseminate results of its research with a variety of outputs such as reports, publications, recommendations, workshops, databases, tools and methods, training and education materials, demonstration projects, best practices, developmental technologies, and licenses and patents.

Efforts to maximize the impact of NIOSH outputs through effective transfer to customers are coordinated by the Office of Health Communications. This office works with each research program to plan and execute communications strategies designed to reach a variety of customers. Customers include employers and their representatives (such as trade associations), employees and their representatives (labor unions), standard-setting organizations, professional associations, academics, and the public. NIOSH researchers publish in peer-reviewed publications and present their work at conferences. They create NIOSH documents and other information products. The NIOSH publications office stocks more than 4,200 NIOSH document titles. It distributed nearly a million printed publications and CD-ROMs in 2003. In addition, NIOSH publications and products are accessible on the NIOSH website [http://www.cdc.gov/niosh/pubs.html]. A survey of four occupational safety and health professional organizations indicated that NIOSH is effectively reaching its customers with credible and useful information.

Other special types of NIOSH outputs include testimony on behalf of proposed regulations, and documents recommending criteria for health and safety hazards in the workplace. NIOSH-recommended criteria represent the formal link between NIOSH and OSHA or MSHA; and between research and rule-making. For example, NIOSH scientists recently testified to OSHA about the OSHA-proposed new rule on hexavalent chromium, a carcinogen and skin irritant.

Since its inception, NIOSH has been strongly committed to transferring its outputs to customers. In recent years, use of newer electronic media has enhanced this effort. NIOSH has a website that supports approximately 500,000 user sessions (and about 2.8 million page views) per month. NIOSH also operates a technical information inquiry service that includes an 800 number and an Internet inquiry response service. In FY 2003, NIOSH responded to more than 100,000 inquiries by phone and almost 3,800 by Internet.

In 2004, NIOSH created an Office of Research and Technology Transfer to provide formal administrative support for the concurrently developing NIOSH Research to Practice (r2p) Initiative. The Office and r2p policies help ensure that NIOSH researchers consider translating their research findings into best practices, products, and technologies and disseminating those products from the very beginning of their research projects.

Outcomes:  As NIOSH research is transferred, the Institute often moves into more dependent partnerships with others, and has less control over what happens. The resources required to have an effect are less predictable, the outcomes are less sure, and the results harder to verify. NIOSH partners include employers, labor and industry groups, and regulatory bodies. In addition, manufacturers help develop and adopt new NIOSH-developed technologies as products for the marketplace. These customer activities and outputs are crucial to NIOSH having real-world impact. Influencing and motivating the actions of others is considered an intermediate outcome.

An end outcome is a NIOSH contribution to reducing morbidity or mortality from occupational injuries or diseases. Especially for diseases of long latency, such as induction of cancer by carcinogens, objective evidence of reduction in causative exposures may be considered a surrogate end outcome, as in the NIOSH Program Assessment and Rating Tool goal specifying reduction in coal mine dust exposure.

Chapter 2 - Overview of the HHE Program

2.1  Introduction

As noted above, as a legislative authority granted in the Occupational Safety and Health Act, NIOSH responds to requests for workplace evaluations from employers, employees and their representatives, and other agencies. These evaluations have come to be known as HHEs. Details regarding the nature and extent of the NIOSH response to these requests are given in subsequent sections. In accordance with the legislative mandate, an HHE is an investigation of a workplace to assess whether workers are exposed to hazardous materials or harmful conditions. This involves documenting levels of exposure, relevant health effects, and factors affecting exposure, and determining whether health effects are related to workplace hazards. This information is used to recommend measures to ameliorate hazards.

The contribution of the HHE Program to the NIOSH mission is evident throughout the NIOSH logic model. The HHE Program is a planning input to the Institute's research agenda, is responsible for numerous activities and outputs, and provides an essential means of transferring NIOSH outputs directly to workplaces. The HHE Program has a unique role as an external sensor for current and emerging issues, helping NIOSH stay relevant with regards to real issues in the workplace. The HHE Program can be likened to a hospital emergency department, reflecting events happening in the community and serving as one of the first places people go for assistance when concerned about their workplace.

A 13-minute video about the HHE Program, made in the mid-1990s, provides an excellent introduction to the Program (on DVD located at the back of this document). Through the words of HHE staff and employees and managers at five facilities investigated by the HHE Program, the video describes activities and outcomes of five field investigations, providing examples of evidence for outcomes at the investigated facilities and beyond. Two examples are given below.

From the owner of a small radiator repair business:

"I didn't know where to go or what to do, so I called NIOSH. I don't remember who told me to call them - because NIOSH is supposed to be, what I understand, a government agency to help small people before they get into big trouble…The guy I worked with was absolutely terrific to work with. I mean, he came out and he helped us, and that's what I was after, was help…I think a lot of people in our industry, there's just a, whatever you might say, I think they're scared of government people. I mean they don't want to be exposed to it. Well, with NIOSH, what I found was just the opposite - that they're there to help you, not hurt you."

From a manager at a research laboratory:

"One of the benefits of the study was that we got the attention of manufacturers of biological safety cabinets and pipette design. They began to work with us and try to design in some ergonomic changes into their equipment. This probably would not have happened had we just done our own evaluations within the facility."

As discussed in Chapter 1, one of the charges to NIOSH explicit in the Occupational Safety and Health Act is to "conduct workplace investigations." Section 20(a)(6) of the Act describes the core of the HHE Program as follows:

"…following a written request by any employer or authorized representative of employees, specifying with reasonable particularity the grounds on which the request is made, whether any substance normally found in the place of employment has potentially toxic effects in such concentrations as used or found; and shall submit such determination both to employers and affected employees as soon as possible."

Similar language is found in the 1977 Federal Mine Safety and Health Act and Amendments.

While the language of these two Acts establishes broad guidelines for a transparent investigation process, Congress also instructed NIOSH to develop regulations to govern when and how its investigations are conducted. Those regulations are found in 42 CFR Part 85 Requests for Health Hazard Evaluations (Appendix 2.1).

The mission of the HHE Program is defined as follows:

"To protect worker health through problem solving, research, risk communication, and dissemination of findings and recommendations by responding to external requests for hazard evaluations and technical assistance."

The HHE Program logic model (Figure 2-1), page 17) illustrates how the Program accomplishes its mission. The remainder of this chapter describes the logic model components.

2.3  Production Inputs

Personnel

For the most part, NIOSH employees in two Branches and Divisions carry out the HHE Program mission (Figure 2-2, page 19), with considerable support from and collaboration with staff throughout the Institute on specific investigations. These branches are the Hazard Evaluations and Technical Assistance Branch (HETAB) in the Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS) in Cincinnati and the Field Studies Branch (FSB) in the Division of Respiratory Disease Studies (DRDS) in Morgantown. The Manager of the HHE Program is the DSHEFS Director. The Coordinator of the HHE Program is the HETAB Branch Chief. Biographical sketches for the managers and supervisors in the HHE Program and a list of credentials and areas of expertise of the HHE Program staff in these two organizational units are included in Appendix 2.2.

When expertise beyond that available in the HHE Program is needed, the Program partners with researchers throughout the Institute. Strong collaborations have been formed with researchers in the Services; Manufacturing; Healthcare and Social Assistance; and Construction sectors and in the Respiratory Diseases; Hearing Loss Prevention; Immune and Dermal Disease; Musculoskeletal Disease; Work Organization and Stress-related Disorders; Cancer, Reproductive, and Cardiovascular Disease; and Personal Protective Technology cross-sector programs. In addition, the HHE Program partners regularly with researchers from the coordinated emphasis areas of Exposure Assessment and Engineering Controls. In a small number of instances, these researchers have primary responsibility for carrying out an HHE. When needed technical expertise is not available in NIOSH, the HHE Program works with experts in other government agencies or contracts with individuals in the private sector.

Inter-branch coordination occurs through joint participation by conference call in regular meetings to discuss and assign incoming HHE requests and by informal exchanges about procedural, policy, and scientific issues. In 2006, when NIOSH formally implemented the Program Portfolio concept as part of the second generation of NORA, the HHE Program was identified as a Cross-Sector Program and established a Steering Committee. The Steering Committee includes the HHE Program Manager (the DSHEFS Division Director), the HHE Program Coordinator (the HETAB Branch Chief), the HETAB Deputy Branch Chief, the Chief and Deputy Branch Chief of FSB; and representatives from the Division of Applied Research and Technology; Health Effects Laboratory Division; and the Emergency Preparedness and Response Office. To date, members of this group have played a role in creating or reviewing the HHE Program strategic plan. They will be a resource for the Program in updating the strategic plan in the future and moving the Program forward in response to this National Academies review.

HETAB is considered the administrative home of the HHE Program. It logs and tracks all HHE requests, maintains a central file of HHE requests and reports, and carries out routine communication functions such as notifying OSHA and state and local health departments of HHE requests. It also prepares supporting documentation for OMB approval pursuant to the Paperwork Reduction Act.

The HHE Program draws on staff trained as generalists in occupational medicine and other medical areas (e.g., family practice, internal medicine), epidemiology, and industrial hygiene, and specialists in ergonomics, engineering, behavioral science, pulmonary medicine, toxicology, occupational health nursing, and statistics (Figure 2-3). Because of the breadth of training in occupational health, HHE Program professionals are able to respond to a wide variety of current and emerging health concerns.

In the last few years, NIOSH divisions established targets for the ratio of personnel to discretionary funding as part of a Good Organizational Health Plan. HHE Program staffing decisions reflect the divisions' targets and the goals of maintaining an adequate number of staff in core science areas, retaining talented junior professionals as experienced senior scientists retire, and, when recruiting is feasible, attracting a diverse group of occupational health professionals in the core disciplines.

Currently, the number of FTEs in the HHE Program is 61, representing a 20% decline since 2001 (Figure 2-4). In the HHE Program, as throughout NIOSH, the total number of FTEs has declined since a peak in 2001, although the number increased somewhat in 2007. Some of this decline is attributed to CDC reorganization, including reassignment of clerical FTEs from NIOSH (three in HETAB and one in FSB) to CDC.

As shown in Figure 2-5 and 2-6, between 1996 and 2006, the decline in HETAB staffing generally was continuous, with new sources of funding shifting FTEs among projects but not adding to the overall total. In HETAB, FTEs largely have been supported by HHE funds not tied to a specific topic area (termed base funds); additionally, the program has received a small portion of NIOSH funds earmarked for activities in areas such as tuberculosis and human immunodeficiency virus. [Not shown in Figure 2-6 are 0.2, 0.4, and 0.4 FTEs funded by NORA in 2005, 2006, 2007, respectively]. In FSB, the number of FTEs rose when research funding for NORA (asthma) and emerging issues flavorings) was provided, and fell when these projects ended.

Funding

For FY 2007, the HHE Program was allocated $7.7 million, or 3% of the total $250 million NIOSH budget. This figure includes $5.9 million (77%) for personnel costs and $1.7 million (23%) for discretionary spending. Funding has been fairly level since 2000.

As is true for most other NIOSH programs, the NIOSH Office of the Director allocates funds to each of the two Divisions responsible for the HHE Program and they, in turn, determine funding levels for their branches. HHE funding has largely come from the NIOSH base budget (Figures 2-7 and 2-8). The HHE Program, however, has received targeted funding to partially offset its expenses arising from emergency response activities. These funds mostly have been used to enhance facilities and equipment inventories. For example, after the attack on the World Trade Center, the HHE Program received funds to purchase a truck and trailer for onsite deployment during emergency response ($115,000) and to construct a staging/storage bay ($389,000) in Cincinnati. After the discovery of anthrax in the U.S. mail, the Program received $77,000 to purchase a unit to decontaminate sampling and other equipment used during HHE field investigations.

Over the last 10 years, limited NORA research funding has been provided to the HHE Program for its core activities. FSB received NORA and Institute funding to support expanded research initiatives. Funding for research initiatives are shown in Figure 2-8, along with base HHE Program funding. This funding supported activities of the Respiratory Disease Research Program, which were done in conjunction with HHE investigations.

Facilities and Equipment

To accomplish its mission, the HHE Program maintains facilities for the storage and maintenance of scientific equipment needed for field investigations. HETAB and FSB each have inventories of sampling and monitoring equipment for assessing exposures, personal protective equipment for HHE investigators, and an array of logistical support equipment and supplies. Good working relationships with equipment vendors help ensure that needed supplies and equipment can be ordered quickly during public health emergencies. The HHE Program maintains an emergency response trailer in Cincinnati, which is designed as a staging facility for field investigations. It also is used to support large-scale non-emergency field investigations. The Program also supports a medical trailer, based in Morgantown, equipped to assess pulmonary effects of workplace exposures. The HHE Program relies on analytical chemistry and biological monitoring capabilities within NIOSH and NIOSH-funded contract laboratories for sample analysis. In certain instances, sample analysis also is done by other CDC laboratories.

2.3  Planning Inputs

Prior HHE Program Reviews

Since the beginning of the HHE Program, NIOSH has taken steps to assess and enhance its effectiveness. Between 1972 and 2006, the HHE Program engaged in 12 program evaluations of itself, some done internally, others externally. Each stimulated Program improvements. Evaluation methods included expert review panels, key informant interviews, and customer satisfaction surveys. Highlights of the most recent evaluations are presented below. The reports from these evaluations are provided in the Appendices as noted below.

Research Triangle Institute Evaluation. In 1996, HHE Program managers successfully competed for CDC funding to support evaluation projects, and awarded a contract to the Research Triangle Institute, a contractor with expertise and experience in evaluating federal agency programs. The focus of this effort was to develop recommendations for a system of ongoing assessment of the HHE Program. The study team met with HHE Program staff, reviewed reports and prior evaluation studies, and conducted stakeholder interviews with NIOSH staff outside of the HHE Program and with representatives of management, labor, state health departments, and regulatory agencies. Their report noted that the "stakeholders we spoke with were uniform in their endorsement of the value and accomplishments of the HHE Program. They characterized the HHE Program as important in generating new knowledge to protect worker health and safety and in providing a valuable service to groups that needed the expertise and credibility that NIOSH could provide." In their final report (Appendix 2.3), the Research Triangle Institute recommended that the HHE Program systematically survey employers and employees in workplaces where it conducts investigations and provides technical assistance/consultation to learn whether HHEs satisfy customer needs, result in improved workplace health and safety, and identify emerging problems. The HHE Program adopted the broad concepts outlined by the Research Triangle Institute and developed and implemented an ongoing evaluation program, referred to as the followback program.

The followback program implemented by the HHE Program was based on the following principles:

• The process of conducting an evaluation is useful only if managers and staff are committed to using the feedback provided to improve the program.


• The evaluation program will be integrated into the HHE process and become a routine Program activity.


• The evaluation program will focus on the HHE Program's response to requests for assistance at specific worksites.


• The evaluation program will not be used to evaluate the work of individual employees and will not be used in the formal performance evaluation process.

The goals of the followback program are twofold: (1) provide feedback to improve the process by which HHEs are conducted and improve the worksite-specific outputs of the HHE Program, and (2) assess the effectiveness of HHEs in effecting change in the workplace and in improving the health of workers. These goals are accomplished through questionnaire surveys and field visits. Questionnaires are distributed for all HHEs involving a field investigation and 50% of those involving technical assistance/ consultation. (Note: All followback questionnaires are included in Appendix 2.4). Field visits are conducted for six to eight HHEs per year, resources permitting.

One HHE Program staff person is responsible for day-to-day administration of the followback surveys, including obtaining information from HHE investigators regarding potential survey participants, mailing questionnaires, following up nonrespondents, and quality assurance of the returned surveys prior to data entry. Survey forms are mailed to key participants identified by the HHE investigators. These same individuals are asked to respond throughout the followback process for each HHE. For field investigations, one questionnaire is mailed within weeks of the initial site visit. This questionnaire focuses on establishing a baseline regarding perceptions of the health hazard and on the customers' satisfaction with procedural aspects of the HHE. For all HHEs included in the followbacks, a questionnaire is mailed approximately 1 month after the HHE investigators deliver their final report. This questionnaire focuses on assessing the value of the report, current conditions in the workplace and, in the case of a field investigation, actions taken since the initial site visit. Another questionnaire is mailed approximately 1 year after the HHE investigators deliver their final report. This questionnaire focuses on current conditions in the workplace and on actions taken in response to the HHE investigators' recommendations. HHE investigators are also surveyed about their perceptions regarding various workplace factors, perceptions about the potential for new information to come from the investigation, and procedural issues related to completing the investigation.

The followback program was fully implemented in October 1999. In July 2006 the HHE Program funded a $34,400 Interagency Agreement with the United States Office of Personnel Management, Center for Talent Services. Center for Talent Services scientists with experience in program evaluation, customer service, and statistics analyzed followback survey data for fiscal years 2000-2005. Table 2-1 provides information about response rates for each of the surveys.

Over all surveys, the response rate was 63%. Response rates by year are not shown, but for the initial site visit survey, the response rate was 69% in the first four years and 44% in the last 2 years; the HHE Program modified its procedures and the response rate for 2006 has improved (51%). Response rates were higher 1 month after release of the HHE report than 1 year after release. The analysis results presented in the remainder of this chapter represent individual respondents' opinions about HHEs; the number of respondents per HHE varies. The data reveal variability among respondents, reflecting random differences among individuals and systematic differences by the respondent's workplace role. While these variations can be examined individually for each HHE, the statistical issues involved in summarizing the data over all HHEs have been challenging. The HHE Program is working with its statisticians and with its interagency partners to revise the survey forms and develop new statistical approaches to summarizing the data to facilitate analysis in the future.

1996 Board of Scientific Counselors Evaluation. In 1996, the NIOSH Director commissioned a team to review the HHE Program and report its findings to the NIOSH BSC. Members of the four-person review team were affiliated with a university, a state health department, a large corporation, and organized labor. The recommendations made by the reviewers in their report to NIOSH (Appendix 2.5) and subsequent actions by the HHE Program are summarized below.

Enhance the responsiveness of the Program to the needs of the requestors (customers) of HHEs. The review team specifically recommended restructuring the communications process to ensure that HHE investigators understood the agenda of the requestor and that all parties involved understood the investigators' plans, improving the clarity of the risk communication messages delivered by the investigators, and developing new easy-to-read reporting formats. The HHE Program responded by developing a Procedures Manual for staff conducting HHEs. In addition to providing detailed explanations of standard operating procedures, the Manual addresses the need to understand requestors' expectations; this information is reinforced by supervisors during the training and mentoring of HHE investigators. Supervisors and managers in the HHE Program increased their diligence when reviewing investigation reports to ensure the creation of clear messages about health hazards and their solutions. The HHE Program began including a one-page plain language summary (titled Highlights of the NIOSH Health Hazard Evaluation) in the standard report and also provides this summary as a separate, legal-sized document designed to be posted on a workplace bulletin board.

Identify emerging occupational health problems and find workable solutions to these problems. The review team recommended that the HHE Program triage more requests for technical assistance/consultation in lieu of a field investigation, to say "no" more often to requests that are unlikely to expand current scientific knowledge, and to expand the referral net for HHE requests. Since that time, the HHE Program has increased the proportion of requests handled by referrals or technical assistance/consultation; this change, however, resulted by and large from the increased number of requests concerning indoor environmental quality (IEQ). The HHE Program uses the term IEQ to refer to problems with the indoor built environment that result in adverse health and comfort symptoms among building occupants that improve when occupants are away from the building. For certain topics, the HHE Program has developed standard response letters that help the program respond more efficiently. In addition to general issues regarding IEQ, other examples where standard response letters commonly are used include diesel exposure in fire stations, dust in postal facilities, and cancer clusters in non-industrial settings. To expand the referral net, the HHE Program initiated several activities, but has not formally tracked the impact of these activities on the number and type of HHE requests. Apart from continuing to make presentations about the HHE Program at various trade and labor conferences, the following activities were undertaken:

• Making presentations about the HHE Program to OSHA Compliance Assistance staff and OSHA Regional Administrators.


• Adding links to the HHE Program from the websites of the OSHA Consultation and Compliance Assistance Programs and the OSHA worker home page.


• Adding a link to the HHE Program from the website of the United Steelworkers Union.
• Developing and distributing an information sheet about the HHE Program to selected state health departments.


• Organizing an annual two-day workshop for state-based Epidemic Intelligence Officers with an interest in occupational health.


• Translating HHE Program brochures into Spanish and distributing these at appropriate meetings, workshops, and conferences.


• Meeting with Hispanic community organizations in the Cincinnati area to increase awareness of the HHE Program.


• Publishing an article about the HHE Program in a Spanish language newspaper in Indianapolis.


• Distributing HHE Program brochures to OSHA Alliance participants working on problems with which the HHE Program has expertise.


• Increasing HHE report dissemination by website postings and using various electronic resources (described below) to alert partners, customers, and stakeholders to the postings.

The issue of increasing awareness about the HHE Program was identified again in a later program evaluation (described below) and continues to be an active area for the Program. Recently, HHE Program staff initiated a pilot project in the Cincinnati area to assess awareness about the HHE Program among occupational physicians in the community and to disseminate HHE Program brochures to their patients. Additionally, the HHE Program is embarking on a systematic customer survey. The survey will be the first step in the development of a targeted marketing strategy that ensures the HHE Program is responsive to the needs of its primary customers. Through the survey, the HHE Program will gather information about awareness of the Program, customers' needs regarding content and preferred channels for communication, and occupational health hazard issues important to customers.

Document the impact of HHEs on the requestors, including evaluation of the effectiveness of solutions which have been recommended. The review team recommended a "… formal, rigorous, ongoing program to evaluate the impact of HHEs." The team indicated support for an effort along the lines of that suggested by the Research Triangle Institute evaluation contractor, which provided the foundation for the on-going followback program.

Disseminate the results of HHEs in a variety of forms to other employers, worker organizations, health and safety professionals and public health officials to maximally impact health and safety practice. The HHE Program has enhanced the dissemination of its reports. Current dissemination efforts are described in full later in this chapter. New activities and products since this program evaluation include posting of reports on the NIOSH website; announcing the reports in NIOSH eNews; announcing reports to all state epidemiologists and Epidemic Intelligence Officers through the Epi-X, a secure electronics communication network maintained by CDC for public health agencies nationwide; preparing a NIOSH Alert on Flavorings [NIOSH 2003]; developing a summary document on HHE investigations of isocyanates [NIOSH 2004a] and another on HHE investigations of fire fighters [NIOSH 2004b]; and developing plans for a new summary document on HHEs in the healthcare and social assistance sector.

Maximize the ability to accomplish the ppreceding recommendations within the constraints of limited resources. The review team recommended organizational changes and staffing augmentation. While the HHE Program did not institute changes in its organizational structure and responsibilities, staff in HETAB and FSB increased their efforts to coordinate activities through more regular face-to-face and telephone meetings.

2005 Board of Scientific Counselors Evaluation. In 2005, the NIOSH Director charged the BSC to assemble a subgroup of its members to review the HHE Program. Members of the four-person subgroup were affiliated with two universities, a private sector consultant, and a large corporation. In their report to the full BSC (Appendix 2.6), the reviewers noted that "… the HHE Program is an innovative customer-oriented, field research approach to evaluating and problem-solving emerging occupational health risks. This program has been a significant component of NIOSH over the years and needs to be maintained or enhanced." Their recommendations and subsequent actions taken by the HHE Program are summarized below. While some actions have been initiated, the HHE Program has not yet addressed many of the points due to the timing of this evaluation in conjunction with preparation for this National Academies review. In fact, the reviewers expressed the opinion that their review would help prepare the HHE Program for the National Academies review.

Restate the mission of the programs in DSHEFS and DRDS. The review team recommended redefining and clarifying the missions of HETAB and FSB. They also recommended doing fewer field investigations and increasing referrals to other agencies and the private sector for requests regarding IEQ.

Improve efficiency, prioritization, and management. The reviewers recommended developing strategic goals and performance measures. Shortly after receiving their report, the HHE Program began a strategic planning process resulting in the development of the strategic plan described on page 1.

Ensure adequate staffing and budget. The review team recommended that the HHE Program identify the critical mass of staff and specific disciplines needed to perform essential functions at each location. This continues to be an ongoing management priority. Two examples can be seen regarding recently retired staff with expertise in noise/hearing loss and ergonomics. HHE Program managers began to plan for the departure of these two key staff members about 1 year prior to their retirement date. In the area of noise/hearing loss, managers identified existing staff with interest in this area, sent them for short-term training and fostered mentoring opportunities with the senior departing staff and other NIOSH subject matter experts. In the area of ergonomics, managers recruited an individual with industrial hygiene and ergonomic expertise and partnered her with the senior departing staff for several months.

Enhance promotion of the program among stakeholders and customers. The review team recommended several general measures to enhance familiarity with the Program. One specific recommendation was to omit the name of the investigated facility from the HHE report. The review team expressed the opinion that the HHE practice of including the name of the facility in its reports was a disincentive for employers who might otherwise make an HHE request. Neither the legislative mandate nor regulatory framework governing the HHE Program addresses this issue. The HHE Program has had internal discussions about the advantages and disadvantages of this recommendation, and has begun to seek input from its partners, customers, and stakeholders. The HHE Program is looking forward to the National Academies Evaluation Committee perspectives on this issue.

Strategic Planning Processes

HHE Program Planning

In the mid-1990s, the HHE Program embarked on a strategic planning process that focused largely on internal process issues. Over the past 12-18 months, in response to the recent BSC recommendation and guidelines from the NIOSH Office of the Director for NORA sector and NIOSH cross-sector programs, the HHE Program has developed an outcome-oriented strategic plan to guide its activities.

The HHE Program's strategic and intermediate goals are listed below. For each of the intermediate goals listed below, annual goals and performance measures were developed for fiscal year 2007 (Appendix 2.7). These will be reviewed and revised annually and progress monitored towards meeting the intermediate goals. As priorities, inputs, and external factors change, the intermediate goals and strategic goals will be updated as needed.

Strategic goal 1: Prevent occupational illnesses through reduced exposure to workplace hazards.

• Intermediate goal: HHE Program customers request assistance for high priority occupational health problems.


• Intermediate goal: Workplaces investigated by the HHE Program implement HHE Program recommendations to ameliorate health hazards.


• Intermediate goal: Employers and employees at workplaces where the HHE Program provided technical assistance/consultation have information about health hazards that is helpful in addressing workplace concerns.


• Intermediate goal: Professional practices, guidelines, policies, standards, and regulations are influenced by information generated from the HHE Program.

Strategic goal 2: Promote occupational safety and health research on emerging issues.

• Intermediate goal: NIOSH and other researchers will have information about emerging issues identified in HHE investigations.

Strategic goal 3: Protect the health and safety of workers during public health emergencies.

• Intermediate goal: NIOSH and other researchers will have information about emerging issues identified in HHE investigations.
• Intermediate goal: HHE Program partners and customers have essential information to address high priority occupational health issues during public health emergencies.


• Intermediate goal: HHE Program personnel respond appropriately to requests for assistance.


• Intermediate goal: The HHE Program is ready to respond to requests for assistance.

Participation of the HHE Program in NORA

Throughout the history of NORA, HHE Program staff has been involved in NORA activities, principally because of their expertise in the NORA topic areas. As a whole, however, the HHE Program had only a minimal role in the NORA process before 2006, when public health practice activities became a larger part of NORA activities.

Beginning in 1996, HHE Program staff participated on most of the 21 NORA priority research teams and had active roles in the occupational infectious disease, allergic and contact dermatitis, hearing loss, musculoskeletal disorders, indoor environment, asthma and chronic obstructive pulmonary disease, and special populations at risk teams. They transferred the knowledge gained from their HHE experiences to internal and external partners by participating in team-sponsored workshops and contributing written materials for the teams' products including journal articles and reports. For example, HHE Program staff played a significant role in preparing publications on occupational infectious diseases [Weissman and Huy 2002], musculoskeletal disorders [NIOSH 2001], IEQ [Mendell et al. 2002], and work organization [NIOSH et al. 2002].

Beginning in 2006, the HHE Program is assisting four of the eight NORA sector programs from which the majority of HHE requests have historically come: (1) construction, (2) healthcare and social assistance, (3) manufacturing, and (4) services. An HHE Program staff person is a member of each of these sector research councils and steering committees. Participating in NORA research councils and steering committees provides the HHE Program with a means for direct involvement in establishing occupational safety and health research priorities. Moreover, it opens up new opportunities for the HHE Program, helping the HHE Program give increasing emphasis to areas where new information is needed to address high priority occupational health research and prevention issues. Input from NORA councils and committees will be used by HHE Program managers to make decisions about the nature and extent of its response to incoming HHE requests. The HHE Program anticipates that increased awareness about its capabilities and services will lead to new HHE requests in areas important to NORA sectors. Additionally, participating in NORA research councils and steering committees will help foster collaborations between the HHE Program and other NIOSH programs. One partnership already developed from these new efforts is addressing the emerging use of orthopthalaldehyde, a replacement for glutaraldehyde as a sterilant, in the healthcare sector. HHE Program staff will be documenting usage patterns, exposure levels, presence and effectiveness of controls, and symptom prevalence to help focus further research.

As needs are articulated, the HHE Program plans to add a representative to one or more of the other NORA sector programs (mining, transportation, wholesale and retail trade, agriculture). In the meantime, the HHE Program communicates less formally with these programs by providing information from past HHEs, identifying trends in new HHE requests, and providing important findings as they occur.

Participation of the HHE Program in NIOSH Cross-Sector Programs and Emphasis Areas

The HHE Program has representatives on the steering committees of several Cross-sector Programs (Respiratory Diseases; Emergency Preparedness/Response; Hearing Loss Prevention; Immune, Dermal & Infectious Diseases; Personal Protective Technology; Work Organization & Stress-Related Disorders) and Emphasis Areas (Exposure Assessment, and Small Business Assistance and Outreach). Their participation provides an avenue to transfer findings, particularly regarding emerging issues, to NIOSH researchers and to learn about research priorities for which the HHE Program could gather information.

HHE Requests

The following persons can request an HHE and are the Program's primary customers:

• An employer.


• A union (defined as an organization that represents employees in collective bargaining).


• An employee representing at least two other employees at the workplace in question.


• A single employee, if the work area of concern has three or fewer employees.


• A federal agency safety and health committee (at least half of the members must be in agreement).


• Federal agency employees not covered by a certified safety and health committee.


• The Secretary of Labor, in the case of a federal agency.

Requests for HHEs can be made by sending in the HHE request form, writing a letter, or completing (electronically) the form available on the NIOSH website. Any HHE requestor can ask that the HHE Program not reveal their identity to the employer. Over the past 10 years, the proportion of requestors asking for confidentiality has increased from about 36% to about 60%.

NIOSH has the authority to conduct health hazard evaluations in response to requests concerning the following types of workplaces:

• An employer.


• A union (defined as an organization that represents employees in collective bargaining).


• An employee representing at least two other employees at the workplace in question.


• A single employee, if the work area of concern has three or fewer employees.


• A federal agency safety and health committee (at least half of the members must be in agreement).


• Federal agency employees not covered by a certified safety and health committee.


• The Secretary of Labor, in the case of a federal agency.
• Workplaces covered by the Occupational Safety and Health Act of 1970. This includes private sector workplaces, unless occupational safety and health issues fall under the jurisdiction of another agency (e.g., railroads, airlines).


• Workplaces covered by the Federal Mine Safety and Health Act of 1977.


• Federal agencies including military services with civilian employees.

Requests for technical assistance from requestors and workplaces not included in the Occupational Safety and Health Act (such as most public employees), are conducted in the same manner as an HHE except that the HHE Program has no legal recourse should the employer decline to permit all or part of the evaluation.

For statistical purposes, the HHE Program classifies its customers as employees, unions, management, government, and other (which includes physicians and family members of employees). Figure 2-9 shows how the distribution of customers has changed historically. For example, from 1985-1989, 23% of HHE requests were from union representatives and only 14% were from individual employees. In 2002-2006, this trend reversed, with 60% of HHE requests from individual employees and 12% from union representatives. As home computers have become more prevalent and the HHE Program put its request form online, the number of electronic requests has increased. Since the HHE Program began tracking this information in 2005, the percentage of electronic requests has increased from 49% to 68%. The ease of submitting requests via the Internet is likely a contributing factor to the number of requests that are invalid according to the HHE Program regulations (e.g., requests from fewer than three employees or from a family member of a worker). This has increased from 16% in 1997 to 46% in 2006.

Managers at federal, state, and local government agencies request assistance from the HHE Program. In some cases agency managers ask the HHE Program to address problems in their own facilities. For recordkeeping purposes, these are now classified as management requests. In other cases, agencies ask the HHE Program to help them carry out their mandate. These requests are now classified as government requests. In many cases, other agencies seek assistance from the HHE Program because it has unique technical expertise and resources not readily available elsewhere or there is a need for an objective, scientifically credible evaluation from a government entity.

An example of a management request from a government agency regarding their own employees was that received in 1993 from the U.S. Forest Service. This request concerned possible reproductive and other health effects related to exposure of their employees to tree-marking paint. Based on environmental sampling and assessment of health effects, HHE investigators concluded that chronic low-level exposures to mixed solvents might be related to acute symptoms. They recommended that the Forest Service use a high solid, low solvent, waterborne paint [NIOSH 1998]. After implementing this recommendation, in 1998 the Forest Service asked the HHE Program to evaluate exposures associated with use of the newly-formulated paint. HHE investigators found that hydrocarbon exposures were either below the limit of detection or were at trace concentrations [NIOSH 1999]. Based on their findings, the HHE investigators assisted the Forest Service in developing a formulation list for waterborne paint, and the Forest Service used that information to develop bid specifications for future paint purchases. Not only were the technical contributions of the HHE helpful in lowering exposure levels, but involvement of the HHE Program also contributed to improved labor-management relations (a letter from the National Federation of Federal Employees acknowledging this aspect of the HHE is included in Appendix 2.8).

An example of a government agency request concerning a private sector facility was one received in 2004 from a state health agency. This request concerned possible health effects of solvent exposures at a manufacturing facility in their jurisdiction. Interim results and individual medical findings have been reported. The final numbered report will be released soon, and HHE investigators plan to share the findings with policy makers involved in setting occupational exposure limits and guidelines.

Data from the followback surveys show that HHEs often are requested when other problem-solving resources have been exhausted, lines of communication have broken down, or parties differ about the nature and severity of problems. When asked about their perception of the hazard in the followback questionnaires, respondents with different workplace roles vary in their answers. Generally, employers are less likely to report that a hazard exists and when they do, they believe that it is less severe than employees believe it is.

HHE customers at investigated facilities have a good impression of the HHE Program. Sixty respondents completed all followback questionnaires in the series. On a scale of 1 (poor) to 4 (excellent), impressions of the HHE field investigation were in the good to excellent range. The average response was 3.47 after the initial site visit, 3.25 about 1 month after the report was issued, and 3.14 about 1 year after the report was issued. For technical assistance/consultations, 63% of 70 respondents report that the final report of the HHE investigations was helpful to them. Of 52 respondents, 72% reported that they shared information in the report with others at the worksite.

HHE Triage Process

Although HHE Program managers have always made decisions about the best way to respond to each incoming HHE request, a formal process for specifying the type of response (area of expertise needed, field investigation versus technical assistance/consultation) was not implemented until 1993. Development of the current triage process was prompted by a surge in requests regarding IEQ concerns. In October 1992, the CBS evening news aired a segment about IEQ problems in buildings; they highlighted the NIOSH toll-free phone number and encouraged viewers to contact NIOSH for assistance with IEQ problems. As a direct result of that broadcast, the number of IEQ HHE requests mushroomed to 814 in 1993 (more than five times the number of IEQ HHE requests expected). The HHE Program could not respond with a field investigation for most of these requests and the reality of dealing with such an overwhelming number of requests led to the development of a triage process to determine which HHE requests would receive a field investigation. The triage process quickly became and continues to be used as an important management tool for directing Program resources towards the highest priority issues and those for which the HHE Program's activities are likely to reduce hazardous exposures and improve workers' health. In triage meetings held twice weekly to discuss new requests, decisions are made based on the information included on the HHE request form, but may be modified when additional information is obtained by the investigators assigned.

Who will respond? During the triage process, assignments are made to one of the two branches, although occasionally staff from both branches work together on an HHE. Generally, requests are assigned to HETAB when they concern mixed exposures and nonspecific health effects, specific diseases apart from respiratory disease, and specific exposures for which HETAB has unique expertise (e.g., ergonomics, heat, noise, radiation). HHE requests are handled by FSB when the issues in the request address an area of active FSB research (e.g., bronchiolitis obliterans and flavorings, beryllium) and when specific pulmonary diseases are the primary concern. For some issues, primarily IEQ, but also tuberculosis and metalworking fluids, among others, interest and expertise reside in both branches. HHE Program managers decide these on a case-by-case basis, considering the details of the request and the availability of resources within the branches at the time of the request. Once an HHE is assigned, the assigned branch assumes responsibility for all aspects of the HHE, including devising an approach; reviewing study protocols; and preparing, reviewing, and releasing reports.

How to respond? When a request is received, HHE Program managers and supervisors review the request and assign it to one of the four response categories listed below. The assignments are made using selection criteria that consider the nature and severity of reported adverse health effects, reported occupational exposures, similarity to previous evaluations, presence of a unique workforce, potential for successful intervention, and available resources.

Category 1. These requests do not meet the criteria for a valid request (as described earlier) and concern issues outside the scope of the HHE Program (e.g., safety or the outdoor environment) and are therefore administratively invalid. The HHE Program notifies the requestor and refers the requestor to another agency such as OSHA or a state or local health department.

Category 2. These are valid or invalid requests for which technical information is supplied to the requestor without conducting a field investigation. Examples include health problems that are not likely to be related to a particular work setting, well-recognized problems with readily apparent solutions, problems that have already been adequately evaluated by NIOSH or others, problems for which NIOSH has standard recommendations, and problems that call for enforcement (by others) of existing laws. Potential responses include providing relevant information, including self-help materials to the requestor and, in some circumstances, the employer; referring the requestor to another agency; and conducting a limited investigation from the office (e.g., by reviewing reports of prior evaluations, medical records, or exposure monitoring data). When the request is invalid but the HHE Program believes that a field investigation might be warranted, the requestor is contacted quickly and provided information about what constitutes a valid request.

Category 3. These are valid requests for which a field investigation is necessary to adequately evaluate the occupational safety and health problem described.

Category 4. These are valid requests that present a complex problem or an opportunity for research. These may take longer than Category 3 requests to complete due to required method development or other technical issues.

For Category 3 and 4 requests, a standard letter of acknowledgment is sent to the requestor, informing him/her that the NIOSH project officer will be in contact. Also, e-mail notifications are sent to the appropriate OSHA Regional Office or MSHA District Office, and the appropriate State Epidemiologist to notify them of the request and the HHE Program's intent to conduct a field investigation. Once a project officer has been assigned, a notice is generated by the HHE Program and posted on Epi-X, a secure electronics communication network maintained by CDC for public health agencies nationwide.

Figure 2-10 shows the distribution of HHE requests by response category over the last 10 years, collapsing the four categories into two: technical assistance/ consultation (categories 1 and 2) and field investigations (categories 3 and 4). This figure shows that the number of field investigations has declined during the past 10 years from 126 in 1997 to 58 in 2006. This decrease is due in large part to the increase in the proportion of requests concerning IEQ issues and the HHE Program's ability to respond to these requests by phone calls and letters. Comparing the most recent 5-year period (2002-2006) to the 5-year period one decade earlier (1992-1996), the data reveal that during both periods, the HHE Program was less likely to respond with a field investigation for IEQ requests (27% in 1992-1996 and 8% in 2002-2006) than for requests concerning other health hazards (32% in 1992-1996 and 33% in 2002-2006). Other factors contributing to the changing response pattern include the decreased number of HHE Program staff, decreased discretionary funding for the Program, increased complexity of field investigations, and increased demands for staff involvement in activities other than traditional HHEs (including emergency response and preparedness, participation on agency and expert committees, document development and review, international technical assistance, and mentoring and training non-NIOSH occupational health and safety professionals). Figure 2-11 shows that the likelihood of a field investigation varied by industrial sector (classified according to the current NORA definitions), reflecting, in part, variation in IEQ requests by sector. Comparing the two sectors with the largest number of requests, those from the manufacturing sector were more likely to result in a field investigation than those from the service sector. Although the proportion of field requests was highest for the agriculture and mining sectors, the total number of requests in these sectors was very small.

The HHE Program received 3,716 requests for investigations from 1997 through 2006, averaging 372 each year. This average is lower than the historic Program average in all prior years (498), excluding 1993, the year of the significant influx of IEQ requests.

The distribution of HHE requests by industry sector (by Standard Industrial Classification) has also changed over time, reflecting the changing U.S. economy (Figure 2-12). The manufacturing sector, which accounted for 30%-40% of HHE requests in the 1970s through 1990s, now accounts for less than 20%.

The distribution of HHE requests by nature of the problem has also changed over time. The most significant change has been an increasing concern about IEQ. HHE requests for IEQ problems typically involve nonindustrial buildings such as government buildings, private sector offices, schools, healthcare facilities, and hotels and resorts.

The number of HHE requests for IEQ problems received annually increased from an average of four per year in the 1970s to more than 230 per year in the 2000s. Figure 2-13 shows the increase in number and percent of IEQ requests by decade since inception of the HHE Program. As noted above, requests for IEQ problems are much less likely to result in a field investigation than requests for other potential health hazards.

When triaging HHE requests for IEQ, HHE Program managers are particularly attuned to opportunities where a field investigation will likely develop new knowledge. For example, field investigations have been carried out to explore the relationship between dampness and asthma, test new sampling equipment for mold, and evaluate the utility of biomarkers for mold exposure. Field investigations, however, may also be carried out when practical, objective technical assistance is needed, particularly from federal government agencies. Recent examples include problems related to renovations in historic buildings by the DOI and moving employees into offices directly adjacent to a construction site on the CDC Atlanta campus.

Typically, field investigations are not performed for IEQ HHE requests where occupant symptoms are nonspecific, an environmental cause is not likely to be identified, or, conversely, the cause of the problem is obvious (e.g., dampness due to water incursion through a leaking roof), or building operation strategies to improve the indoor environment exist. For these requests, the requestor may or may not be contacted by telephone. Telephone contact is usually made when specific, serious symptoms are reported, environmental factors may be causal, or previous IEQ evaluations have been performed. Information gathered in the telephone call is used to determine the most appropriate response. For requests that do not result in a field investigation, a standard informational letter is sent to the requestor and, if desired by the requestor, to facility management. Enclosed information includes peer-reviewed scientific literature and IEQ documents produced by CDC/NIOSH, OSHA, the Environmental Protection Agency (EPA), and the HHE Program. The requestor is also provided websites for additional IEQ information as appropriate to address specific concerns. In some instances, a consultation process continues by telephone until HHE Program staff determines that the requestor's needs have been met.

HHE Procedures Manual

In 1999, following the recommendation of the 1996 BSC review team, the HHE Program compiled the first comprehensive Procedures Manual for internal use. The Procedures Manual is used as a guide for training new staff and as a reference for all staff. Its contents are based on regulation, policy, and experience gained over the 35-year history of the HHE Program. The Procedures Manual covers the following topics:

• The legal basis for HHEs and related activities.


• Procedures for processing HHE requests and assigning investigators.


• Guidelines for conducting HHEs.


• Review of HHE-related correspondence and reports.


• Protection of participants in HHEs.


• Potential concerns related to the conduct of HHEs.


• HHE records and requests for information.


• Distribution of HHE correspondence and reports.

The Procedures Manual is a living document. It has been updated twice since its inception and will continue to be updated as needed. One outcome of the HHE Program's efforts to develop the Manual was a request from the Occupational Health Branch in the California Department of Health Services to help develop their Field Investigations Policies and Procedures Manual (a letter from California Department of Health Services acknowledging the assistance of the HHE Program is included in Appendix 2.8).

2.4  Activities

Field Investigations

Field investigations are carried out for HHE requests classified as Category 3 and 4. In a field investigation at a facility specified in an HHE request, the HHE Program uses state of the art scientific methods to assess whether workplace exposures and conditions pose a health hazard and, if so, recommends technically sound, practical methods of hazard control. When no health hazards are found, HHE reports play a useful role in explaining the issues to concerned managers and employees. For example, the HHE Program received a management request for assistance in evaluating concerns at an electric power generator station about cancer among their employees. An HHE investigator reviewed available medical records and exposure reports and met with parties at the worksite to understand their concerns. After concluding that the cancers were unlikely to be work-related, the HHE investigator held an informational meeting with employees and managers to explain the findings.

The investigative team usually consists of an industrial hygienist and an occupational medicine physician or epidemiologist. The team prepares for their initial site visit by contacting employer and employee representatives (including the requestors of the HHE) to identify exposures and health issues of concern, reviewing the scientific literature on relevant issues, and consulting, as needed, with scientists inside and outside NIOSH. Frequent