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. Frequently, preparation involves consulting with NIOSH analytical chemists, biologists, microbiologists, and other laboratory-based researchers to identify the best available assessment methods. These interactions often lead to partnerships to develop and test new methods.

Once the background information is obtained, an initial site visit is scheduled. During a typical initial visit, HHE investigators lead an opening conference to discuss concerns with managers, employees, worker representatives (such as unions), health personnel, and engineering or maintenance staff familiar with the workplace and the issues of concern. Typically, the investigators follow the opening conference with an observational evaluation (walk-through) of the facility. HHE investigators are accompanied by management, employees, and union representatives. The primary purpose of the walk-through is to gain an understanding of work processes and work practices and note the use of engineering controls and personal protective equipment. The walk-through often provides an opportunity for informal conversations with employees about specific aspects of their jobs and the potential health hazards. After the walk-through, HHE medical and industrial hygiene staff each focuses on activities relevant to their expertise. HHE medical staff conducts confidential employee health interviews to obtain information on the nature and scope of work-related illnesses. These are generally non-structured interviews with employees. Depending on the size of the work force in the areas of concerns, interviews often are done with a randomly selected sample of workers and with those known to have health problems. HHE industrial hygiene staff may measure environmental conditions or sample air, surfaces, or bulk materials to document exposure levels over a work shift or for specific tasks. Exposure assessments can be designed to represent the range of potential exposures or to focus on the jobs and tasks likely to have the highest exposures. Additionally, HHE investigators may examine exposure monitoring records, purchasing and production records, medical and first aid records, and health and safety-related policies and procedures. Several HHE investigators are fluent in Spanish and, when needed, use this expertise for communicating with employers and employees. Occasionally, other NIOSH staff with foreign language skills are asked to participate in an HHE.

Followback survey data reveal a high level of satisfaction with HHE activities during a field investigation site visit. For example, among HHE requestors (the number of respondents varies by question, ranging from 107 to 156), 96% reported that they had been kept informed of the HHE investigators' plans, 89% reported that the site visit was timely, 89% reported that the investigators were thorough, and 93% reported that the investigators were objective.

At the end of the initial site visit, HHE investigators meet with managers, employees, employee representatives, and others involved in the visit. In this closing conference, they discuss what was accomplished during the visit, orally provide preliminary recommendations, and discuss their initial thoughts about the need for further evaluation. Data collected after the initial site visit as part of the HHE Program's followback survey show that these verbal recommendations produce workplace changes. Of 212 respondents, 88% reported that recommendations made at the closing conference were implemented prior to receipt of the final report.

For some HHEs, the initial site visit is sufficient for gathering the information needed to address the issues of concern. For others, the initial visit is a prelude to a more in-depth investigation. HHE investigators, in consultation with their supervisors and managers, make the decision about the need for further investigation. The decision may be based on observations made during the initial visit, results of real-time measurements, or results of preliminary sampling. The decision depends primarily on the need for additional information to fully address the concerns raised in the HHE request; secondarily HHE investigators consider whether the situation provides an opportunity to gather information that would contribute to a broader understanding of a problem and could have impact beyond the investigated facility. In this way, an HHE opens the door for opportunistic research. If a more in-depth investigation is planned, this will be carried out over a period of weeks to months, depending on the characteristics of the situation.

Consultation and Technical Assistance

For HHE requests classified as Category 1 or 2, although a field investigation is not conducted, the HHE Program still provides Consultation/Technical Assistance services to HHE requestors. (In this document, the term is used for responses to HHE requests classified as Category 1 or 2). When the problem has been previously investigated by other parties and reports of those investigations are available, HHE staff review these reports and provide opinions regarding the methods, interpretation of the data, and appropriateness of the conclusions and recommendations based on the findings. HHE staff also may gather additional information from employer and employee representatives to aid in their assessment, consult with other NIOSH scientists, review the scientific literature, and prepare a written response summarizing their activities, including, when appropriate, recommendations on how to address the problem. This information is shared with employer and employee representatives. In some instances the HHE Program makes referrals to other agencies or to organizations that can help the requestor identify health and safety professionals in the private sector (e.g., the Association of Occupational and Environmental Clinics or the American Industrial Hygiene Association).

2.5  Outputs

HHE Reports

The final HHE report is the main vehicle by which the HHE Program communicates its findings. 42 CFR Part 85 stipulates that the HHE Program determine whether potentially toxic or hazardous effects have been found and share that information with the employer and employees. For field investigations, the HHE Program produces two types of reports, numbered reports (which are now available through the NIOSH website: www.cdc.gov/niosh/hhe) and letter reports (which are distributed to involved parties at a facility and made available to others upon request). Although reporting practices have changed over time, the HHE Program has emphasized numbered reports when the information is believed by the HHE investigators and managers to be of generalized interest beyond the facility involved. Between 1996 and 2006, the HHE Program produced 495 numbered reports (listed in Appendix 2.9), 503 letter reports for other field investigations (listed in Appendix 2.10), and 1999 technical assistance/consultation letter reports. Twelve examples of numbered reports are included in Appendix 2.11 and five examples of letter reports are included in Appendix 2.12. These examples were chosen to reflect the range of issues and the complexity of investigations with which the HHE Program has been involved.

Because HHE numbered reports are distributed to audiences with diverse technical backgrounds, and to individuals outside the investigated facility, efforts have been made to make their contents understandable to anyone who might read them. The content and format of the HHE report for field investigations has evolved over time. Changes have been made based on findings from various program evaluations including the current followback program. Major changes include using a standard report format and adding a plain language summary (termed the Highlights page). The HHE Program recently began a transition to a new report format (see the first example in Appendix 2.11). For the most part, changes were made to streamline the report preparation process, focus the report on the information most needed by the investigated workplace (e.g., findings and recommendations), and enhance the appearance of the report, taking advantage of new desktop publishing capabilities.

In HHEs for which Spanish is the primary language of the employees, HHE correspondence and reports have been translated. The HHE Program has the ability to use contractors for other translation needs.

The HHE Program internally manages technical and policy review of most HHE reports. Generally, reports and letters are prepared by HHE Program staff, reviewed by supervisors, and reviewed and cleared by managers within HETAB or FSB (or their respective Divisions), depending on which branch handled the evaluation. In accordance with NIOSH policy, HHE reports are reviewed by the NIOSH Office of the Director when they contain policy positions or raise national media interest. When a report is deemed to contain influential scientific information according to the OMB "Final Information Quality Bulletin for Peer Review," [http://www.whitehouse.gov/omb/ inforeg/peer2004/peer_bulletin.pdf] the report is sent to external peer reviewers. Influential scientific information has been defined as information that the agency expects to have a clear and substantial impact on important public policies or private sector decisions. Recently, an HHE field investigation concerning potential radiation exposures related to baggage screening by employees of the Department of Homeland Security has been determined to meet this criterion and is being prepared for external peer review.

The followback surveys gather information about the HHE report. Although employers are informed that they are required to post the HHE field investigation report in a place accessible to affected employees, 15% of 205 respondents reported that all affected employees did not have access to the report. The HHE Program has no authority to enforce the posting requirement, and employers are not subject to penalties for noncompliance.

As a step in promoting workplace actions to reduce hazards, parties in the workplace must understand the findings of the HHE and the rationale for the investigators' recommendations. When asked about the extent to which they agreed with the statement "I understood the technical information in the report," the average response among 223 respondents was 3.35 (1=strongly disagree, 4=strongly agree). Although the level of understanding varied somewhat among employees and employers, the differences were not significant. When asked a question about the utility of the plain language summary, the average response among 217 respondents was 3.59 (using the scale as in the prior question). Of 206 respondents, 63% said the plain language summary was very useful; 39% said it was somewhat useful.

While receiving, reading, and understanding are important aspects of the communication process, effectiveness of the communication can also be gauged by the extent to which the recipients accept the HHE investigators' conclusions. The followback surveys reveal room for improvement in this area. While the majority of respondents report agreeing with the HHE conclusions, the extent of agreement varies by the workplace role of the respondent, with 88% of 120 managers and 61% of 83 nonmanagers agreeing.

Other Outputs

In addition to HHE reports, the Program produces several other types of products, including website content; peer-reviewed publications; book chapters; and presentations at professional, trade, and agency conferences and meetings. A list of publications and presentations for the last 10 years is included in Appendix 2.13 and Appendix 2.14, respectively.

2.6  Transfer

Investigated Facilities

Informal transfer of information to involved parties at the worksite occurs throughout the process of HHE response as the HHE staff is in contact with the HHE requestor and others at the workplace. At the end of a field investigation or technical assistance/consultation effort, HHE investigators mail their report to the HHE requestor and other labor and management representatives at the involved facility. HHE Program regulations stipulate that the employer shall post the report so that it is accessible to affected employees. For lengthy field investigations, HHE investigators may prepare interim reports containing preliminary findings and recommendations.

… And Beyond

Once the HHE report is sent to the investigated facility, the HHE Program sends a copy to the appropriate OSHA regional office. The HHE Program posts numbered reports on the NIOSH website and announces their availability in eNews, a monthly electronic newsletter produced by NIOSH [http://www.cdc.gov/niosh/enews/default.html]. Currently, eNews has approximately 24,000 subscribers. HHE reports also are posted on Epi-X. All state epidemiologists receive notices about these reports automatically through Epi-X, as does any Epi-X participant who indicates interest in receiving notices about occupational health items. HHE reports are also sent to the National Technical Information Service, where they may be purchased in varying formats (microfiche, download, CD, or paper copy) for approximately $10-$30 depending on the length of the document.

The HHE Program maintains electronic and paper filing systems for HHE requests, information collected through HHE Program activities, and HHE Program letters and reports. These filing systems are a resource for documenting the history of the Program's activities, managing the Program, and planning research.

The electronic tracking system is maintained by HHE Program staff in Cincinnati. It is built on a Microsoft Access database that contains information about all HHE requests since the Program's inception. The database is used by HHE Program managers to efficiently retrieve information about specific HHE requests (e.g., date of request, nature of concerns, identity of requestor, identity of HHE investigators, dates of HHE activities) and to describe aspects of HHE Program management (e.g., trends in the number of requests, types of requestors, nature of HHE Program response). HHE Program staff also use the database to efficiently transfer information about emerging issues (e.g., trends in requests by industry sector, specific hazards) to researchers in other NIOSH programs. To further information sharing, the HHE Program maintains a user-friendly interface to the Access database on the NIOSH intranet. This program allows other NIOSH program managers and researchers to search the database for information about HHE Program activities relevant to their work.

Although the complete historical record for each HHE is maintained at the location of the investigators (Cincinnati or Morgantown), the HHE Program maintains a centralized repository in Cincinnati of HHE request forms and final reports. These files are kept in the HHE Program office for at least 7 years and then are sent to the Federal Records Center. When the HHE Program receives requests for information not presented in the HHE letter or numbered report, staff retrieve, review, and forward appropriate records. Frequently, current and former employees and employers involved in legal action related to the issues evaluated by the HHE Program request records of HHE activities under the Freedom of Information Act. From 1997 through 2006, the HHE Program provided findings from HHEs to 232 individuals requesting records through the Freedom of Information Act.

The HHE Program uses various mechanisms to transfer information beyond investigated workplaces. As noted in the Outputs section above, these mechanisms include preparing scientific manuscripts; developing other NIOSH-numbered documents; contributing to CDC reports; writing articles for trade publications; and presenting at conferences, meetings, and workshops.

2.7  Customers and Partners

The HHE Program works with its partners and intermediate customers to develop and transfer outputs, and relies on intermediate and final customers to take actions to achieve reductions in occupational exposures and illnesses. These relationships are summarized in this section, with the roles of specific partners and customers highlighted. In considering impact, the evidence shows that HHE customers make pivotal contributions towards accomplishing the HHE Program mission. Sixteen letters from customers and partners providing evidence of outcomes are included in Appendix 2.8.

The primary final customers of the HHE Program are the employers, employees, and their representatives (primarily labor unions) who submit requests for investigations. Characteristics of these customers and issues related to their interactions with the HHE Program were discussed as a planning input in Section 2.3. Ultimately, their actions determine whether outcomes are achieved in investigated workplaces. The HHE Program is responsible for responding to requests in a timely and scientifically rigorous and objective manner, making recommendations consistent with best professional practices, and clearly communicating those recommendations and their rationale. Customers are responsible for taking corrective actions, and the extent to which they do so is influenced by many factors, which are discussed in Section 2.8.

Employers, employees, and their representatives in noninvestigated facilities also are recipients of HHE Program outputs and, thus, are final customers. When health hazards in noninvestigated facilities are similar to those in investigated facilities, HHE Program recommendations can be used as guidelines for making changes to reduce exposures and occupational illnesses. Transfer pathways for information involve HHE Program dissemination efforts and dissemination efforts of intermediate customers. As in investigated facilities, the final customers are responsible for acting appropriately once they are given information generated by the HHE Program.

Other government agencies request HHEs and also are HHE Program customers. At the national and local levels, OSHA is a unique and critical agency customer due to its role in occupational safety and health in the U.S. Nationally, OSHA uses data generated by the HHE Program to support rulemaking. Examples in the areas of ergonomics, musculoskeletal disorders, and tuberculosis are cited in Chapter 3. Local OSHA offices refer employees or employers to the HHE Program or request technical assistance from the HHE Program as an offshoot of their own investigations. For example, the state OSHA program in North Carolina asked the HHE Program to investigate bromopropane exposure in furniture manufacturing [NIOSH 2002; NIOSH 2003]. OSHA did not have a standard for bromopropane, their investigators did not have experience in measuring it, and they did not have the capacity to assess the health complaints. As part of the HHE field investigation, the HHE Program partnered with NIOSH researchers to assess the relationship between DNA damage and bromopropane exposure [Toraason et al. 2006]. And, by networking with other NIOSH researchers, the HHE Program helped initiate a research project to better characterize the bromopropane exposure hazard and to evaluate the utility of a biomarker for assessing exposure [Hanley et al. 2006].

Government agencies, professional organizations, and academic institutions, among other groups, that do not request HHEs are intermediate customers of the Program. When the HHE Program transfers its outputs to these agencies through publications and participation in meetings and conferences, they can use the information to inform their own work. Through this indirect mechanism, the HHE Program can influence its final customers in noninvestigated facilities. The Program, however, has no formal mechanism to assess its effectiveness along this path. The Program is aware, however, of interest in its products among stakeholders. In 2003, NIOSH conducted a stakeholder survey among four professional associations: the American Association of Occupational Health Nurses, the American College of Occupational and Environmental Medicine, the American Industrial Hygiene Association, and the American Society of Safety Engineers. The purpose of the survey was to determine stakeholders' experiences with NIOSH publications and information services and to solicit suggestions for improving them. Of the 1,200 anonymous and randomly selected participants solicited, 688 persons responded, yielding a 57% response rate. Of these, 65% placed a high value on publicizing and increasing circulation of HHE reports. Announcing HHE reports in the NIOSH eNews is responsive to this need.

Research programs in NIOSH are both partners and intermediate customers of the HHE Program, and the distinction can be difficult to make within the context of a specific area of investigation. For this review, the HHE Program has considered other NIOSH programs as partners when their activities and outputs were integral to solving a problem during an ongoing HHE investigation, and as intermediate customers when their activities and outputs were originally part of an HHE investigation but were expanded in scope and detail beyond the investigated facility. Examples are the relationships between the HHE Program, NIOSH analytical methods researchers, and NIOSH engineering controls researchers. HHE investigators have a long history of working closely with these researchers. Information is transferred through informal professional relationships, an annual in-house conference, and weekly or biweekly reports prepared by NIOSH divisions and transmitted by email and through a NIOSH wide intranet. Partnerships develop when new biological and chemical methods are needed to assess health hazards in workplaces being investigated by the HHE Program and when complex engineering solutions specific to the investigated workplace are an integral part of the HHE investigation. Often the researchers continue the line of research begun during the HHE. At this point, the activities and information are transferred out of the HHE Program and the researchers are considered customers. An example described in Chapter 3 concerns CO and houseboats.

A close partnership exists between the HHE Program and the NIOSH Emergency Preparedness and Response Office. Before 2001, responsibility for emergency planning was decentralized throughout the Institute. In 2001-2002, the HHE Program had a leadership role in the NIOSH response to the World Trade Center and anthrax crises. In 2003, the NIOSH Office of the Director created a focal point for emergency response, followed in 2004 by creation of the Emergency Preparedness and Response Office. Many staff in leadership and technical positions in this Office formerly worked in the HHE Program. Although no personnel funding is provided, the HHE Program contributes to the activities of this Office by assigning staff for field deployment, for technical and leadership roles in the CDC Directors' Emergency Operations Center (DEOC), and to serve as subject matter experts for developing guidelines, policies, and documents. Currently, the HHE Program, along with staff from other NIOSH Programs, has significant responsibilities for pandemic influenza planning as part of a CDC-wide activity.

Similarly, the HHE Program partners with other parts of CDC. In particular, partnerships have been developed with the Coordinating Center for Environmental Health and Injury and the Coordinating Center for Infectious Disease. These partnerships involve HHE Program staff contributing to epidemiologic investigations for diseases such as tuberculosis and histoplasmosis and laboratorians from these Centers providing support for HHE field investigations for exposures such as dioxins and pesticides. A new partnership has been initiated with the Coordinating Center for Health Information and Service to help carry out the HHE Program customer survey.

2.8  Outcomes

Investigated Facilities

Data from the HHE followback program provide insights into intermediate and end outcomes in investigated facilities. The last in the series of followback questionnaires focuses on the status of actions taken in response to the HHE investigators' specific recommendations. The information is self-reported by respondents and not validated by HHE investigators. These data are difficult to analyze and interpret due to the varying number of recommendations across HHEs, the varying numbers and types of respondents, the lack of respondent knowledge about what has happened, and disagreement among respondents about what has happened. Nevertheless, the data provide useful information that can be followed up with other types of investigations. The findings underscore the need for onsite followback evaluations to get a true picture of what is happening in the workplace after an HHE has ended.

Among 289 respondents who reported knowing something about the status of the recommended item, 62% reported that actions were taken to implement the recommendation and 12% reported that actions were planned. Figure 2-14 shows that outcomes vary according to the type of recommendation made. Fewer than 50% of respondents reported actions taken for medical surveillance (ms) recommendations; between 50% and 75% reported actions taken for personal protective equipment (pp), communication (cm), engineering controls (ec), administrative controls (ac), and exposure monitoring (em); and 85% reported actions taken for housekeeping (hk).

The followback surveys also provide a measure of HHE Program end outcomes in investigated facilities. Of 140 respondents, 81% reported that workplace conditions improved since the HHE visit and 88% of these reported that the HHE recommendations contributed to the improvements. Of 68 respondents, 62% reported that employee health had improved. Over the series of followback questionnaires for each HHE, respondents are asked about their perceptions of the hazard at different points in time. On a scale of 0 (no hazard) to 4 (severe hazard), the mean hazard rating showed a continuous and statistically significant decline from 2.09 after the initial site visit, to 1.84 about 1 month after the HHE report was issued, to 1.81 a year after the HHE report was issued.

… And Beyond

In contrast to the direct evidence available from the followback program, the HHE Program has never had a formal mechanism to measure outcomes in noninvestigated facilities. With a few exceptions, the evidence for impact on noninvestigated facilities is indirect. Where there is documented evidence of intermediate outcomes on organizations and agencies that develop policy and influence occupational health practice, we have assumed that noninvestigated facilities benefit. The evidence in Chapter 3 includes many examples of such outcome pathways. For example, outputs of the HHE Program in ergonomics and musculoskeletal disorders, tuberculosis, indoor environmental quality, and flavorings have provided unique information to OSHA to support regulatory action to control these occupational health hazards. In addition, the outputs of the HHE Program regarding lead were used by the EPA to develop policies that affect the entire lead abatement industry.

2.9  Challenges and External Factors

External factors affect the HHE Program in several ways. First, untold factors influence whether the Program receives requests for HHEs when health hazards are present in a workplace. These factors relate to awareness of the HHE Program, incentives for submitting requests (e.g., free services available to small business owners), disincentives to submitting requests (e.g., employees' fear of reprisals by their employers), acknowledgement in the workplace that a problem might exist, and legal limits on the authority of the Program. Second, numerous factors influence whether workplace changes are made in accordance with HHE Program recommendations. These factors relate to economic realities in individual workplaces, attitudes about health and safety in the workplace, labor-management relations, and regulatory requirements, among others. Some of these issues are discussed in more detail below.

Legal Factors

The laws and regulations underlying the HHE Program define the scope of its activities. The HHE Program has no authority to conduct investigations for state and local public sector employees unless the states have an OSHA-approved occupational safety and health program that covers these employees. In industries covered by the Occupational Safety and Health Act, the HHE Program does not have right of entry to address safety issues and physical hazards, including those related to ergonomic factors and musculoskeletal disorders. While the HHE Program has successfully carried out many investigations in workplaces where it does not have entry authority, numerous instances can be cited when employers denied entry to HHE investigators. This has occurred even when the HHE Program has good information indicating that a health hazard is likely to be present in the workplace. Also, the HHE regulations do not include physicians (who are not employees) as valid requestors even when they often know about the existence of workplace health hazards. When the HHE Program receives a request from a physician, it advises the physician to inform his/her patient about the Program. Anecdotally, physicians report that patients may not be willing to submit an HHE request due to concerns about reprisals by their employer. Similarly, when in the course of their work, other agencies, including state and local health departments, EPA, and the Agency for Toxic Substances and Disease Registry, learn of potential occupational health problems, these agencies contact the HHE Program. In these situations, the HHE Program can only carry out an HHE field investigation when the employer is willing to cooperate. Similarly, employer cooperation is required for followback visits. The mandate of the HHE Program pursuant to the Occupational Safety and Health Act and Mine Safety and Health Act is to make a determination about the existence of a health hazard; return visits following the determination are not addressed. Over a 2-year period, the HHE Program has been able to conduct return site visits for eight of 13 facilities contacted. The primary reason that a followback program investigation was not done in the remaining five facilities was management concerns that a return visit would be disruptive and possibly create new problems.

Because NIOSH has no enforcement authority relating to correcting health hazards in the workplace, the HHE Program has no way to compel employers to act on its recommendations. Although reports of HHE field investigations are sent to OSHA, historically these have not been used as the basis for compliance actions. The ability of the HHE Program to influence employers to act is a complex issue that the HHE Program is now trying to better understand through its followback program. In eight facilities for which we made followback visits, we noted varying levels of implementation of HHE investigators' recommendations. Because the number of followback visits was small and the characteristics of each facility were so different, the results cannot be generalized. We did, however, learn many lessons about the process of doing this type of followback investigation and are using these lessons to develop improved plans for moving forward with onsite followbacks in the future.

Social Factors

The changing importance of organized labor in the work force has been both a positive and negative influence on the HHE Program. When NIOSH was first established, approximately 25% of the U.S. labor force belonged to a union; today fewer than 12% of workers are union members, and there has been a concomitant decrease in the number of requests for HHEs from unions. Also, when unions were at the height of their enrollment many had their own health and safety departments that could address routine health and safety issues encountered by their members. As union membership has declined and union priorities have shifted, some health and safety departments have been eliminated. This change could decrease the number of HHE requests as the individuals most familiar with the HHE Program are no longer in the position to submit requests or it could increase the number of HHE requests as union resources to address concerns are no longer available. Also, in the past, in some industries union-management agreements led to occupational safety and health issues being addressed internally; these agreements may become less prevalent, possibly increasing demand for HHE services. The presence of a union may also be important in influencing whether HHE Program recommendations are implemented. The extent to which this plays a role, however, is not known.

Over the last decade and continuing into the future, the percentage of immigrant workers in the U.S. labor force has increased. The Hispanic workforce is increasing more than five times faster than the non-Hispanic workforce. Statistics show that immigrant workers are disproportionately employed in agriculture, construction, and other industries known to have high risks for work-related illnesses and injuries. HHE staff involved in outreach efforts in the Hispanic community have learned that these workers generally are not aware of the HHE Program and are reluctant to request assistance due to legal and social reasons. Outreach efforts of the HHE Program have yet to generate substantial numbers of HHE requests from the growing Hispanic workforce.

The BSC review teams in 1996 and 2005 recommended that the HHE Program increase the percentage of technical assistance/consultation responses to ensure that the highest priority problems resulted in a field investigation. While the HHE Program has considered this guidance in making triage decisions, external influences can divert resources. Examples include doing field investigations to address routine IEQ problems at federal facilities and requests from Congressional representatives to evaluate issues reported by constituents. While the total number of such requests is small, they shift resources and efforts away from other higher priority activities.

In recent years, disasters from natural and human causes have had a dramatic impact on the HHE Program. Devastating floods, hurricanes, and terrorist attacks have added new responsibilities to the Program. Responses to each of these events have shifted significant resources from the HHE Program's traditional activities. The HHE Program now considers emergency preparedness and response to prevent work-related injuries, illnesses, and deaths (as part of a NIOSH, CDC, or U.S. Public Health Service activity) to be a critical part of its mission, and has reflected that in its strategic goals.

Media attention to an issue influences the HHE Program in many ways. Media attention can be the factor that draws attention to an issue and plays a role in stimulating a request. HHE Program involvement is often cited in newspaper articles and television news broadcasts regarding issues of national and local interest. HHE Program involvement in evaluating the health effects of working with irradiated mail (described in Chapter 3) is one example [Hsu 2002]. Media coverage may also affect implementation of HHE Program recommendations by drawing public attention to the need for change in a workplace.

In some HHEs, overlapping interests between occupational health and other areas of public health help bring attention to an issue and facilitate change. For several of the issues discussed in Chapter 3, the convergence of occupational health and general public health concerns probably played a role in promoting change. For example, while carbon monoxide exposures associated with houseboats are an occupational concern for employees who work on or around houseboats, widespread media attention and actions by government agencies other than NIOSH focused by and large on potential exposures to the public in recreational boating. Similarly, while the hazards of lead exposure among home renovation contractors are of concern as an occupational health problem, much of the public health agency infrastructure that helps address this issue arose because of concerns about lead poisoning in children.

2.10  A Vision for the Future

Working on the scientific frontier as the HHE Program does is perhaps more important now than ever before given the social and economic changes affecting the American workplace. These changes, in addition to new areas of emphasis within NIOSH and new mandates for all government programs, demand flexibility and creativity. While remaining true to its legislative mandate, evolution of the HHE Program will enable it to make the most of opportunities and to overcome challenges created by external change. Historically, the Program has adapted its activities to respond to external change. Looking ahead, the spheres of inputs, transfers, and collaborations, as they relate to all three strategic goals, will be increasingly important as the HHE Program strives to strengthen its relevance and impact.

The HHE Program welcomes a dynamic dialogue with the National Academies panel and looks forward to its recommendations. The Program is planning several activities to further the discussions generated by this review and to develop an action plan in response to the recommendations. The HHE Program will engage the HHE Cross-sector Program Steering Committee and is planning a stakeholder public meeting.

To ensure HHE Program relevance, the Program's services must be available in all economic sectors and to all segments of the U.S. working population, subject to the limits of its legal authority. HHE requests, which are the primary inputs to the Program, must reflect new occupational health hazards and hazards facing priority populations. The customer survey about to be launched by the HHE Program will create a better understanding of awareness about the HHE Program, barriers and motivators to making HHE requests, and desirable channels of communication for specific groups of customers. This information will be used by the Program to develop a targeted marketing campaign to generate HHE requests in priority areas. Collaboration of the HHE Program with NIOSH partners and stakeholders through NORA will also contribute to this effort. The HHE Program anticipates that these activities will increase its visibility among its customers, but recognizes that other innovative approaches may be needed.

The followback program is a valuable tool for the HHE Program whose full potential has yet to be realized. Results of the followback program will be especially useful for understanding, monitoring, and enhancing impact at investigated workplaces. Building on the initial data analysis efforts, the Program will conduct periodic analyses of followback survey data and use the findings to improve HHE Program processes and document impact. Through targeted onsite followback investigations, the Program will expand its efforts to better understand motivators and barriers to implementing HHE recommendations, including economic factors in individual facilities. This type of information historically has not been collected by the HHE Program, and it could be used by NIOSH programs involved in cost-benefit research.

The HHE Program recognizes the growing need to expand its transfer activities to ensure that its workplace investigations have impact beyond investigated facilities. Leveraging the work at specific facilities is a vital component of the overall impact of the HHE Program. A comprehensive and cohesive plan, including expanded and creative use of the Internet, is needed to reach larger and new customer and stakeholder communities. The HHE Program has hired a health communication specialist to augment its capabilities in this area. With new capacity in health communication and social marketing, the HHE Program will strengthen its dissemination efforts, looking for new ways to reach its customers in workplaces, government agencies, academia, and other organizations.

Collaborations with other NIOSH Programs and with stakeholders in other government agencies and in professional organizations are important in ensuring that the work of the HHE Program has an impact on occupational health policies, regulations, and guidelines. The HHE Program will benefit from NIOSH-wide efforts to strengthen existing and develop new collaborations. As the Institute creates opportunities for more effective partnerships across organizational lines through the NIOSH Program Portfolio, the HHE Program will be an active participant. Similarly, as the Institute formalizes partnerships through its expanding transfer activities, the HHE Program will seek opportunities to contribute.

The HHE Program is a unique resource within the federal government. It deals with problems whose causes, implications, and solutions are not well understood, and it regularly has been embroiled in areas of controversy where conflicting studies abound and policy stances are highly polarized. The HHE Program will continue to raise awareness of new health hazards, help bring scientific clarity to bear in resolving uncertainties, and drive corrective solutions that will reduce hazardous exposures and conditions and prevent occupational disease.

2.11  Supporting Evidence

HHE Reports

NIOSH [1998]. U.S. Department of Agriculture, U.S. Forest Service, Washington, DC. NIOSH HETA Report No. 93-1035-2686
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1993-1035-2686.pdf].

NIOSH [1999]. U.S. Department of Agriculture, U.S. Forest Service, Pacific Northwest Region, Portland, Oregon. NIOSH HETA Report No. 98-0111-2731
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0111-2731.pdf].

NIOSH [2002]. Custom Products, Mooresville, North Carolina. NIOSH HETA Report No. 98-0153-2883
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0153-2883.pdf].

NIOSH [2003]. Marx Industries, Inc., Sawmills, North Carolina. NIOSH HETA Report No. 99-0260-2906
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0260-2906.pdf].

Journal Articles

Hanley K, Petersen M, Curwin B, Sanderson W [2006]. Urinary bromide and breathing zone concentrations of 1-bromopropane from workers exposed to flexible foam spray adhesives. Ann Occup Hyg 50(6):599-607.

Mendell M, Fisk W, Kreiss K, Levin H, Alexander D, Cain WS, Girman JR, Hines CJ, Jensen PA, Milton DK, Rexroat LP, Wallingford KM [2002]. Improving the health of workers in indoor environments: priority research needs for a national occupational research agenda. Am J Pub Health 92(9):1430-1440.

Toraason M, Lynch DW, DeBord DG, Singh N, Krief E, Butler MA, Toennis CD, Nemhauser JB [2006]. DNA damage in leukocytes of workers occupationally exposed to 1-bromopropane. Mutat Res 603(1):1-14.

Weissman DN, Huy JM, eds. [2002]. Occupational infectious diseases. Clin Occup Environ Med 2:475-675.

NIOSH Numbered Documents

NIOSH [2004a]. Summary of health hazard evaluations: issues related to occupational exposure to isocyanates 1989 to 2002. DHHS (NIOSH) Publication No. 2004-116.
[http://www.cdc.gov/niosh/docs/2004-116/]

NIOSH [2004b]. Summary of health hazard evaluations: issues related to occupational exposures to fire fighters 1990 to 2001. DHHS (NIOSH) Publication No. 2004-115.
[http://www.cdc.gov/niosh/docs/2004-115/]

NIOSH [2003]. NIOSH alert: preventing lung disease in workers who use or make flavorings. DHHS (NIOSH) Publication No.2004-110.
[http://www.cdc.gov/niosh/docs/ 2004-110/pdfs/2004-110.pdf]

NIOSH [2002]. The changing organization of work and the safety and health of working people. DHHS (NIOSH) Publication No. 2002-116.
[http://www.cdc.gov/niosh/02-116pd.html]

NIOSH. [2001]. Research topics for the next decade:a report by the nora musculoskeletal disorders team. DHHS (NIOSH) Publication No. 2001-117.
[http://www.cdc.gov/niosh/2001-117.html]

Other Publications

Hsu S [2002]. Workers handling government mail report symptoms. Washington Post, February 9, 2002.
[http://pqasb.pqarchiver.com/washingtonpost/access/106328885.html?
dids=106328885:106328885&FMT=ABS&FMTS=ABS:FT&date=Feb+9%2C+2002&author=
Spencer+S.+Hsu&pub=The+Washington+Post&edition=&startpage=A.06&desc=Workers
+Handling+Government+Mail+Report+Symptoms]

Chapter 3 - Contributions of the HHE Program to Improving Worker Health

We have chosen to present the evidence for impact and relevance of the HHE Program by focusing on specific areas of investigation. These areas, however, do not represent all HHE activities, outputs, and outcomes during the last 10 years. From 1996 through May 2007, the HHE Program produced 1026 numbered or letter reports for field investigations. Of these, 50% fell within the selected areas. Many individual HHEs not described also could provide evidence of HHE Program contributions.

The HHE Program's impact on worker health begins by localized change in specific workplaces. The changes made at each worksite affect a few to hundreds or thousands of workers. The work of the HHE Program at a small number of facilities, however, has been leveraged to contribute to reductions in exposure and illness on a much larger scale.

Table 3-1 (page 55) is intended to orient the Evaluation Committee to the narratives describing the areas of investigation. Some of the investigation areas draw on experiences from one or a small number of HHEs within a short time frame; other represent many HHEs spanning many years. With the exception of the topic of Global Health, the selected investigation areas are hazard-focused. This approach is consistent with the intent of the Occupational Safety and Health Act's mandate to NIOSH to conduct workplace investigations and make a determination whether a health hazard exists in the investigated facility. As described in Chapter 2, the HHE Program has 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. Table 3-1 identifies the primary goal addressed by each investigation area. Due to the diverse activities carried out by the HHE Program, however, most of the investigation areas in this chapter address more than one of the HHE Program's strategic goals. As noted in the Preface, NIOSH has asked the National Academies to evaluate the HHE Program on relevance and on its impact in four areas: (1) reducing worker risk and preventing occupational illness in investigated workplaces, (2) transferring program-generated information to relevant employers and employees beyond the investigated workplaces, (3) influencing NIOSH research and policy-development programs, (4) influencing activities of regulatory agencies, occupational safety and health professionals and organizations, state and local health agencies, and others in the occupational health community. Table 3-1 identifies which of these areas are relevant to each investigation area. With a few exceptions, the evidence for impact on noninvestigated facilities is indirect. Where there is documented evidence of intermediate outcomes on organizations and agencies that develop policy and influence occupational health practice, we have assumed that noninvestigated facilities benefit.

For each of the investigation areas described in this chapter, the supporting evidence is referenced in the text. The complete citations are listed at the end of the chapter, by investigation area.

3.1 Strategic Goal 1: Prevent Occupational Illnesses through Reduced Exposure to Workplace Hazards

The evidence in this section is organized according to the nature of the health hazard addressed as follows: biological, chemical, physical, and mixed. The summaries of investigation areas provide evidence that decision-makers at specific facilities have changed their workplaces in accordance with the recommendations made by HHE investigators. In making recommendations, HHE investigators rely on the principle of a hierarchy of controls to reduce health hazards. Using this concept, controls fall into the following four broad areas: process, engineering, personal, and administrative. Thus, evidence for change can be seen in the substitution of a toxic process chemical for a nontoxic chemical, the installation of local exhaust ventilation to capture process emissions, the implementation of a comprehensive program for providing respiratory protection, or the enhancement of training programs to better inform workers about the nature of the health hazards and the ways to ameliorate those hazards. This chapter includes examples where HHE investigators have received informal feedback from parties in the workplace that changes have occurred and conditions have improved. The chapter also includes examples where the HHE investigators have returned to the workplace to document not only the improvement in workplace conditions, but also the impact on employee health. In addition, the chapter includes evidence about outcomes generated by the HHE Program's followback surveys.

Biological Hazards

Biosolids

Issue. Until the early 1990s, thousands of American cities were allowed to dump their raw and treated domestic sewage directly into the nation's rivers, lakes, and bays. By 1992, EPA enacted regulations to stop this practice, and municipalities began separating the domestic sewage into liquid and solid streams. The treated solid component, referred to as biosolids, was approved for use as an agricultural soil amendment and crop fertilizer, and in reclamation of strip mines. Shortly after the EPA regulations were enacted, questions were raised about potential health risks to workers involved in land application of biosolids and to people living in surrounding communities. In 1994, the death of a child from staphylococcal septicemia one week after riding a three-wheeler over biosolids sparked concern in the local community, extensive media coverage, and attention by several employee groups, including the United Mine Workers.

Based on data from 2002, an estimated 3.4 million dry tons of biosolids were used for agricultural purposes that year. Exposed occupational populations include wastewater treatment workers, haulers, applicators, and farmers. In 2004, the BLS estimated that there were 94,000 water and wastewater treatment plant and system operators in the U.S.

In February 1998, the HHE Program received a request from the safety manager at the Butler County Department of Environmental Services in Ohio for assistance in evaluating workers' exposures during the processing and land application of biosolids. The HHE request stated that some long-term employees had reported headaches, stomach cramps, and diarrhea after working with the biosolids. The HHE Program also received two subsequent HHE requests in 1999 and 2002 to evaluate worker exposures during the handling of biosolids as part of mine reclamation activities and spreading of biosolids at the working face of a landfill.

Approach. To determine the source of the illnesses, HHE investigators conducted monitoring to assess whether workers were exposed to aerosolized material from the waste stream or to the waste stream itself. The investigators examined whether the etiologic agent was suspended heavy metals, volatile organic compounds, or intestinal bacteria. To help understand the exposures and identify opportunities for prevention, the investigators interviewed affected employees to determine if work practices contributed to employee exposures.

Over several months, three site visits were made to the Butler County landfill. HHE investigators observed work activities, interviewed five employees who worked directly with the land application process, and performed exposure monitoring. HHE investigators collected area and personal breathing zone air samples for culturable bacteria, endotoxin from Gram-negative bacteria, volatile organic compounds, and trace metals. Bulk samples of sewage sludge were also collected and analyzed to determine the extent of contamination with coliform bacteria.

HHE investigators learned that the employees had each experienced at least one episode of gastrointestinal illness soon after working with the biosolids. Employees reported repeated intermittent episodes of gastrointestinal symptoms including diarrhea and abdominal cramping. The detection of enteric bacteria in the air and bulk samples collected during the evaluation indicated a potential for occupational exposure to disease-causing microorganisms. While the specific component(s) of the sewage sludge responsible for employees' symptoms were not determined, the nature and timing of the symptoms suggested occupational exposure by ingestion or inhalation of the sludge as a probable cause.

In response to the two other requests, HHE investigators conducted field investigations at two facilities to evaluate worker exposures to culturable bacteria, endotoxin, and volatile organic compounds. The investigation involving strip mine reclamation activities at Power Operating, Inc. in Pennsylvania was completed following an initial site visit and medical interviews. Symptoms of nausea and upper respiratory irritation had been reported after a biosolids application. No additional biosolids applications occurred after the HHE request was received, precluding opportunities to conduct additional assessments. The HHE at the Outer Loop Landfill in Kentucky involved area and personal breathing zone monitoring for culturable bacteria and endotoxin during dumping and spreading of biosolids at the working face of the landfill. Environmental monitoring data showed exposure to culturable enteric organisms and endotoxin.

Outputs and Transfer. HHE investigators produced two numbered HHE reports [NIOSH 1999, 2003] and an HHE letter report. The reports included recommendations to improved personal hygiene, modify work practices, and use personal protective equipement to minimize exposure to biosolids, and enhance employee training regarding these issues. HHE investigators contributed to the development of a NIOSH guidance document on controlling potential occupational related to exposure to Class B biosolids (defined as those that are treated but still contain detectible levels of pathogens) [NIOSH 2000]. The document was revised in 2002, but the recommendations, many of which were derived from the initial HHE report, remained unchanged [NIOSH 2002]. The original NIOSH document was republished in the Journal of Applied Occupational and Environmental Hygiene [NIOSH 2001].

The principal HHE investigator was invited to make presentations at an EPA meeting, a meeting of the Kentucky-Tennessee Water Environment Association, and the American Industrial Hygiene Conference and Exposition. To ensure that worker safety and health issues were being adequately addressed, EPA also invited the principal HHE investigator to serve on the Pathogen Equivalency Committee, which reviews applications for new waste treatment processes.

Amidst growing concern and allegations of potential health hazards from biosolids applications, and following a hearing by the U.S. House of Representatives Science Committee on municipal waste disposal, EPA requested that the National Research Council (NRC) of the National Academy of Sciences review the science and epidemiology surrounding biosolids. Because of the paucity of information on worker exposures to biosolids, the principal HHE investigator was invited to an NRC meeting to summarize results of the NIOSH HHEs. In 2002, the NRC published a report on their assessment, citing the NIOSH HHE in a chapter on the epidemiologic evidence of health effects associated with biosolids production and application [NRC 2002].

Intermediate Outcomes. The Ohio waste treatment facility used results from the HHE to develop a new training program for employees, incorporating the hazard and hygiene recommendations from the HHE report.

Trade associations and other interested groups have disseminated information from these HHE reports to their members. Among the known organizations and media outlets that have disseminated this information are American City & County magazine; Occupational Hazards magazine; an occupational safety and health listserv hosted by Duke University; The Alliance For A Clean Environment, a non-profit environmental advocacy group; AGnet, a food safety network of the University of Guelph, Canada; and AgHealth News, a newsletter of the Agricultural Health and Safety Center of the University of California, Davis.

External Factors. The extensive media coverage surrounding allegations of health problems and a death related to biosolids application served to focus attention on this as both an important occupational and public health issue.

Brucellosis

Issue. Brucellosis is an infectious disease caused by the bacteria of the genus Brucella. Various Brucella species affect pigs, cattle, and other animals. Humans become infected by coming in contact with animals or animal products that are contaminated with these bacteria. The most common route of exposure is thought to be ingestion, although occupational exposures may occur among some of the more than 100,000 veterinarians and slaughterhouse workers in the U.S. In humans, brucellosis can cause a range of symptoms that are similar to the flu and may include fever, sweats, headaches, back pains, and physical weakness. Severe infections of the central nervous systems or lining of the heart may occur. Brucellosis can also cause long-lasting or chronic symptoms that include recurrent fevers, joint pain, and fatigue. Approximately 100 cases of brucellosis are reported each year in the U.S.; however, it is believed that only 4%-10% of cases are actually recognized and reported due to the variable and non-specific clinical manifestations of brucellosis. Reported cases of brucellosis are thought to reflect infection due primarily to non-occupational exposures (such as ingestion of contaminated foodstuffs). However, data concerning the source of reported infections are not collected.

The HHE Program received a request in March 1993 from employees at a 900-employee swine slaughterhouse and packaging plant in Sampson County, North Carolina to evaluate occupational transmission of brucellosis. Five cases of brucellosis had been reported at this facility in 1991 and 18 in 1992. Independent of the HHE investigation, the county health department reported nine cases of brucellosis in 1993. Sampson County was the top U.S. county for the number of reported cases (22) of brucellosis in 1991-1992.

Approach. HHE investigators conducted an investigation of brucellosis among employees at the North Carolina slaughterhouse using direct observation of work processes and practices, biological monitoring, health examinations, and questionnaires. The objective was to document the prevalence of brucellosis, identify risk factors, and identify opportunities for exposure and disease prevention among the approximately 190 workers on the kill floor. HHE investigators defined cases of brucellosis by a combination of the presence of positive antibody tests and the presence of symptoms consistent with infection. They identified 30 cases among 154 survey participants; 16 of the cases were newly recognized.

Specific risk factors were identified to be associated with higher rates of infection with Brucella, including experiencing cuts or scratches while working on the kill floor. Because the rates of seropositivity were high among employees of all kill floor departments, preventive measures were recommended for all employees who had potential for exposure to Brucella. However, the identification and eradication of brucellosis in animals is considered the primary means of preventing human infection in the occupational setting. As part of the HHE, HHE investigators worked with the U.S. Department of Agriculture (USDA) and the State of North Carolina to determine the source(s) of infection among swine processed at the plant.

Outputs and Transfers. HHE investigators recommended the following to plant management and employee representatives: processing only brucellosis-free swine, expansion of training programs for employees and supervisors to increase understanding concerning prevention and early recognition of brucellosis, improved personal protective equipment selection and use, ventilation system upgrades in the kill floor area, and instituting medical surveillance of employees at risk of exposure to Brucella.

Participants in the medical survey received individual notification of their test results. The HHE Program notified management officials and employee representatives of preliminary results and recommendations in a letter in August 1993. Correspondence with management and employee representatives occurred frequently until the HHE Program mailed the final report to those groups in March 1994 [NIOSH 1994]. HHE investigators presented study findings to public health audiences at four separate meetings across the country; these meetings included university (University of Cincinnati, Cincinnati, Ohio), state (Council of State and Territorial Epidemiologists, Denver, Colorado), and national audiences (Epidemic Intelligence Service Annual Conference and Centers for Disease Control and Prevention Grand Rounds, Atlanta, Georgia). The findings of this work were shared with the USDA via a liaison who worked directly with the HHE investigators. HHE investigators published the findings of this outbreak investigation in the Journal of Occupational and Environmental Medicine [Trout et al. 1995] and in the CDC Morbidity and Mortality Weekly Report (MMWR) [CDC 1994].

Intermediate Outcomes. Based on this investigation, the USDA changed its regulations (CFR Parts 51 and 78, March 1994) to provide for payment at fair market value for whole herds of swine depopulated (killed and buried) because of brucellosis. The justification of the regulation change included specific reference to the data produced by this HHE. The regulation was changed to eliminate human health risks associated with swine brucellosis (primarily due to elimination of exposure of workers to infected blood and tissues) and to hasten the elimination of brucellosis among swine herds. Later in 1994, the USDA made similar changes to the rules for cattle and bison (FR Vol 59, No. 199, 10-1994; FR Vol 60, No. 20, 01- 1995), extending the public health impact of this HHE to other U.S. abattoir and packaging plants.

Assessing the impact of the HHE and subsequent USDA regulation change is difficult because the number of occupational brucellosis infections is not tracked in the U.S. However, no similar outbreaks of swine brucellosis have been reported to the CDC or NIOSH since this work was completed. External Factors. The rule changes enacted by the USDA in 1994 provided for payment at fair market value to livestock producers for infected herds. Prior to this rule change by USDA, swine producers had incentive to dispose of their Brucella-infected swine by sending the swine to slaughter, leading to exposure of workers to infectious materials.

A union organization campaign was occurring at the facility during the time this HHE was conducted. The longstanding commitment of the HHE Program to dealing fairly and in a transparent manner with both management and labor enabled the HHE investigators to use this factor in a positive manner in this evaluation. As a result, the investigators gained nearly complete cooperation and participation from both management and workers in this HHE, a factor crucial to completion of the HHE.

Latex

Issue. Although the total number of exposed workers is not known, studies indicate that 8%-12% of healthcare workers regularly exposed to latex are sensitized, compared with 1%-6% of the general population. In the healthcare industry, workers at risk of latex allergy from ongoing exposure to latex (most commonly from gloves used for universal precautions) include physicians, nurses, aides, dentists, dental hygienists, operating room employees, laboratory technicians, and housekeeping personnel. Reports of work-related allergic reactions to latex increased during the 1980s and early 1990s due to the implementation of universal precautions among employees in the growing healthcare industry, where latex gloves are widely used to prevent exposure to infectious agents. At least 7.7 million people are employed in the healthcare industry in the U.S.

Latex allergy can result from repeated exposures to proteins in natural rubber latex through skin contact or inhalation. In some instances, sensitized employees experience reactions so severe that they impede workers' ability to continue working in their current job.

he HHE Program received 19 requests between 1990 and 2000 from various types of healthcare facilities for assistance with evaluating respiratory and allergy type symptoms experienced by their employees and thought to be due to latex. The number of employees identified in the HHE requests ranged from 24 to greater than 8,500. Six field investigations conducted between May 1995 and April 2000 involved assistance in evaluating a variety of symptoms including skin and respiratory irritation, congestion, asthma, hives, allergic symptoms, facial flushing, sneezing, and itchy and watery eyes. One request included two reports of anaphylaxis, two other requests identified concerns about latex allergy, and others raised concerns about IEQ. All requests involved facilities where natural latex rubber gloves were in use.

Approach. The HHE Program responded to requests with either field investigations (10) or by providing written technical guidance to the requestors (4); field investigations were more likely for those received earlier or those that posed issues not previously addressed. Some requests were not valid under our regulations and did not receive a detailed response. The field investigations all included some assessment of the potential for natural rubber latex exposure and skin, respiratory, and mucous membrane symptoms. HHE investigators conducted health assessments using questionnaires, pulmonary function tests, serum tests for latex-specific IgE and IgG, and skin patch testing. Exposure assessments included visual inspection of facilities, environmental sampling for airborne and surface latex contamination, characterization of other contaminants potentially present, observations of work practices and personal protective equipment use, and assessment of ventilation and engineering controls.

Some HHE investigations found that workers' symptoms were not related to latex exposure. For example, one found that the symptoms of many employees were associated with mold problems resulting from water incursions. In others, latex exposure was related to health problems including dermatologic conditions and rhinoconjunctivitis, and hand urticaria. HHE investigators found natural latex rubber protein on surfaces or in dust collected from air handling unit filters. In addition, HHE investigators documented airborne natural rubber latex in some hospital settings.

Outputs and Transfers. Recommendations for individual HHEs varied with the concerns expressed as well as the industrial hygiene and medical findings. In general, recommendations included: improving education and communication regarding allergies; improving preventive maintenance of mechanical systems (air handling, central vacuum systems), eliminating sources of moisture into the building envelope that contributed to mold growth, using non-latex or low-protein powder-free latex gloves, and instituting medical surveillance for early detection of work-related respiratory problems among workers.

For field investigations, the HHE Program delivered five numbered and five letter reports. In addition to these final reports and letters, HHE investigators worked with NIOSH researchers to produce a NIOSH Alert [NIOSH 1997] and a prevention guide [NIOSH 1998] addressing latex allergies and recommendations for their prevention. More than 360,000 copies of the Alert (between 1997 and 2006) and over 370,000 copies of the prevention guide (over 150,000 in the first year) were disseminated through the NIOSH toll-free number, at conferences, through personal contact with NIOSH personnel, and via download from the NIOSH website. As many as 250,000 of those copies were requested via telephone by interested individuals and organizations such as nursing directors, medical schools, infection control centers, fire departments, dentist's offices, veterinarians, nursing and convalescent homes, training programs, community health centers, and public health departments. HHE investigators wrote three scientific articles, two of which have been published and one submitted for publication in the peer reviewed literature [Pinkerton et al; Page et al. 2000a; Page et al. 2000b]. HHE investigators presented their findings at seven professional meetings and technical conferences to audiences that ranged from risk managers in the healthcare industry to health professionals in occupational and environmental medicine and scientists in the other CDC agencies. The DHHS issued a press release on June 23, 1997 upon publication of the Alert [http://0-www.cdc.gov.mill1.sjlibrary.org/niosh/updates/latexpr.html] and NIOSH established and maintains a topic page on its website addressing latex allergies [http://www.cdc.gov/niosh/topics/latex/].

HHE investigators provided input to the U.S. Food and Drug Administration regarding the labeling of latex gloves as low protein. Communications and Information Dissemination Program authors published two peer reviewed articles addressing the effects of the NIOSH latex Alert [Maxfield et al. 1999, 2000].

Intermediate Outcomes. A search of journals published between 1997 and 1999 indicated that at least 10 healthcare professional organizations cited the NIOSH Alert's recommendations in their publications. The publications included both national journals (e.g., American Family Physician, The Journal of Emergency Nursing, Occupational Health and Safety, and OR Manager) and state-based journals (e.g., Oregon Nurse and the New York State Dental Journal) [Anonymous 1997a,b,c,d,e,f; Anonymous 1998; Toland 1997; West 1998; Reddy 1998].

A Google search of "NIOSH Latex Alert" produced 40,100 hits revealing that dozens of agencies disseminated the information to healthcare providers and other interested parties by including it in their newsletters, posting it on their websites, and publishing excerpts or summaries in their publications. Examples included the New York State Department of Health and the Washington State Department of Labor and Industries. Trade journals such as Chemical Health and Safety published papers warning their members of potential health effects of latex glove use, citing the NIOSH Alert. The American Conference of Governmental Industrial Hygienists (ACGIH®) cites the NIOSH Alert in their proposed Threshold Limit Value for natural rubber latex [ACGIH® 2007].

Surveys conducted of directors of infection control or directors of nursing at 323 randomly selected hospitals showed that hospitals receiving the NIOSH Alert were more likely to have progressed from a position of "inaction" to "advocacy" on the issue of latex use [Maxfield et al. 1999, 2000]. Directors who had seen the NIOSH Alert were more likely to report that they intended to have a relevant employee education program, had replaced powdered latex gloves, and had restricted latex glove use compared to directors who had not seen the Alert.

The Department of Veterans Affairs cites the NIOSH Alert repeatedly in the VA Directive on latex sensitivity/allergy [http://www1.va.gov/vasafety/page.cfm?pg=499]. Dozens of universities use the Alert as the basis for their own policies. Examples include the University of Rochester [http://www.safety.rochester.edu/ih/latex.html], the University of Pennsylvania [http://www.ehrs.upenn.edu/programs/occupat/latex_ allergy.html], and the University of Utah [http://uuhsc.utah.edu/pated/handouts/handout.cfm?id=1673].

Since 2000, the HHE Program has received only one request from a healthcare facility concerning latex exposure, suggesting that the information disseminated has been helpful in addressing the hazard.

End Outcomes. Facilities evaluated by HHE investigators made changes based upon HHE recommendations. A Colorado hospital cleaned up latent latex-containing dust and changed to low-protein powder-free gloves following an HHE. The Great Falls Tribune noted in an article published March 19, 2002, that a facility providing healthcare services to about 200,000 people in north central Montana implemented all changes recommended by the HHE Program.

NIOSH was one of the first organizations to recommend avoiding powdered latex gloves in its 1997 Alert. A shift from powdered to non-powdered latex gloves and to other non-natural rubber gloves was documented in healthcare trade journals in 1998. An article in the October 1998 edition of Health Industry Today noted sales of exam gloves that year were characterized by a "strong boost in the powder-free latex segment."

External Factors. Concerns by the healthcare industry about the adverse health risks to both patients and employees associated with the use of natural rubber latex products influence which products they select for use in their facility (i.e., latex gloves vs. non-latex). Thus, there were strong incentives to adopting HHE Program recommendations in investigated and noninvestigated facilities.

It is easy to remove latex gloves from routine use because they are disposable and a variety of acceptable substitutes is available.

Tuberculosis

Issue. In 1953, 84,000 new cases of tuberculosis (TB) were reported in the U.S. Over the next 30 years the number of new TB cases decreased an average of 6% each year. However, between 1985 and 1992, there was a resurgence of the disease with the number of new cases increasing 20%. In addition to the increasing number of cases, concerns were heightened by the emergence of multiple drug resistant strains of TB.

In 1990 the HHE Program began receiving requests addressing workplace risks for TB. Since that time, more than 100 such requests have been received concerning workers in healthcare facilities, drug treatment centers, homeless shelters, social services agencies, laboratories, coroners' offices, correctional institutions, animal inspection facilities, and medical waste treatment facilities, among others. In addition to requests from employers and employees at these facilities, requests came from partners in other CDC Centers and from state and local health departments to support epidemiologic investigations.

Approach. The HHE Program responded to requests with either field investigations or by providing written technical guidance to the requestors. Some requests were not valid under our regulations and did not receive a detailed response. Although the approach varied across the evaluations, many involved reviewing TB control-related policies and procedures, including medical screening and respiratory protection, and evaluating ventilation systems. Several investigations included air sampling for Mycobacterium tuberculosis or related airborne hazards such as aerosolized medications. Some involved thorough epidemiologic analysis of skin test data; others included investigation of specialized engineering controls such as ultraviolet germicidal irradiation (UVGI). Each evaluation led to recommendations to prevent TB infection and disease among workers.

The HHE Program's response to these requests provided opportunities to: (1) obtain information on occupational exposures to M. tuberculosis, for which no standard exists, (2) evaluate TB prevention and control strategies in a variety of workplaces, and (3) develop recommendations for strengthening TB prevention efforts.

Specific examples of activities and work environments evaluated through the HHE Program include the following:

• Evaluation of aerosol exposures generated by reciprocating saws during autopsy.


• Characterization of exposures to M. tuberculosis aerosols during medical waste processing.


• Evaluation of zoonotic TB transmission to animal care inspectors.


• Effectiveness of a supplemental filtration unit in an ambulance used to transport TB patients.


• Adequacy of engineering controls intended to reduce TB transmission at TB clinics and homeless shelters.


• Effectiveness of environmental controls at a prison following a large TB outbreak among human immunodeficiency-virus-infected inmates.


• Comparison of employee tuberculin skin test reactions with new serum assays specific for M. tuberculosis infection.

In undertaking these activities, HHE investigators partnered with colleagues in other NIOSH program areas, including the Engineering Control Emphasis Area, the Exposure Assessment Area, and respiratory disease research, and with state and local health departments and colleagues in other CDC Centers.

HHE investigators, largely as a result of their experience and expertise derived from conducting field investigations, have been directly involved in the development of NIOSH, CDC, and OSHA policy on TB in the workplace. They have participated in working groups and committees, contributed data to support recommendations, and written and reviewed chapters on environmental controls for CDC guidance documents that have been widely adopted in the U.S. [CDC 1994, 2005, 2006].

Outputs and Transfers. The HHE Program delivered 38 numbered HHE reports and 30 letter reports according to standard HHE protocols (see Section 3.4, Supporting Evidence). While some of these workplaces had previously been identified as being at increased risk for TB transmission (e.g., healthcare, corrections), HHEs helped to identify the magnitude of the problem in other workplaces such as laboratories [NIOSH 1999; Miller et al. 2002] and coroner's offices or morgues [NIOSH 1992a; Ussery et al. 1995; NIOSH 1997a; Martinez et al. 2001], and documented a new health hazard in the medical waste processing industry [NIOSH 1998a; Weber et al. 2000; Johnson et al. 2000].

Additionally, the HHE Program developed a NIOSH document summarizing the information from a decade of TB HHEs [NIOSH 2001]. Another important formal output included published proceedings of a NIOSH-sponsored workshop on engineering controls for preventing airborne infections [NIOSH 1994k]. This workshop brought together occupational health and infection control professionals as well as employer and employee representatives to discuss the current state of TB prevention, identify knowledge gaps, and recommend areas for further study.

Through a variety of venues, HHE investigators provided information to groups outside of the establishments that were evaluated. These included 17 peer-reviewed publications, two workshops and workshop proceedings, 25 invited and professional conference presentations, a book chapter [Boudreau 2005], and intra- and interagency information exchange activities (see Section 3.4, Supporting Evidence).

In response to controversy in the public health and healthcare communities over the use of respiratory protection and respirator fit testing for workers at risk of TB, HHE investigators made presentations to infection control and occupational safety and health professionals on this topic and developed a peer-reviewed publication on selection and use of respirators for workers exposed to infectious aerosols [Lenhart et al. 2004]. In addition, an HHE investigator gave a plenary presentation and participated in panel discussions at the CDC Workshop on Respiratory Protection for Airborne Infectious Agents in December 2004 [CDC 2004]. The goal of the workshop was to discuss the current state of scientific knowledge regarding transmission of TB and other infectious agents through the air, focusing on the scientific basis for respiratory protection of workers and identifying research needs to fill current knowledge gaps.

In addition to TB, the HHE investigators identified other potential occupational health hazards in these investigated facilities including exposure to ultraviolet radiation from UVGI systems used to disinfect air containing TB, and administration of aerosolized drugs such as pentamidine. HHE investigators disseminated results of the evaluations through HHE reports and presentations that highlighted the lack of data on efficacy of UVGI as a control measure and safety concerns.

HHE investigators have participated in many TB-related technical meetings, CDC document development committees, and a NIOSH testimony development team. The NIOSH team provided written comments on three occasions supporting the proposed OSHA rule on occupational TB and provided oral testimony at a public hearing with stakeholders [NIOSH 1998b]. HHE investigators also provided reviews of NIOSH TB-related publications.

Intermediate Outcomes. Development of National Guidelines and Standards. Intermediate customers for the HHE Program's work related to TB include standard and guideline setting government agencies and organizations including CDC, OSHA, and the Joint Commission on Accreditation of Healthcare Organizations. These customers have used information generated by the HHE Program to update TB control recommendations. CDC produced three major guidelines for the prevention of tuberculosis transmission [CDC 1994, 2005, 2006]. The Joint Commission on Accreditation of Healthcare Organizations used the CDC guidelines as a basis for their standards, which are followed by many hospitals in the U.S. OSHA uses the CDC documents in their enforcement procedures and in citing employers under the general duty clause of the Occupational Safety and Health Act. At the request of OSHA, HHE Program staff developed written guidance on the safe use of UVGI to disinfect air containing M. tuberculosis. This guidance was included as an appendix to the proposed OSHA TB standard [OSHA 1997]. OSHA used data from an HHE at a large urban hospital [NIOSH 1995a; Boudreau et al. 1997] in its risk assessment model to establish the need for a standard, and results from an HHE at a medical waste treatment facility [NIOSH 1998a] to recommend pre-treatment of TB-containing wastes prior to transport and to support the inclusion of medical waste workers in its proposed standard.

NIOSH Analytical Methods Development. Researchers inside and outside NIOSH are intermediate customers for the HHE Program's work related to TB. HHE activity spurred chemists and biologists in the NIOSH Exposure Assessment Emphasis Area to develop two NIOSH analytical methods, Method 0900 for M. tuberculosis, airborne, and Method 5032 for pentamidine isethionate [NIOSH 2007; Schafer et al. 1998; Tucker and Seitz 1991; Tucker et al. 1993]. These methods were later used in the field by HHE investigators.

Stimulating Additional Research. TB HHE reports and HHE investigators' participation in a NIOSH workshop on engineering controls for preventing airborne infections contributed to NIOSH contracts to assess the effectiveness of UVGI in a waiting room [Macher 1992] and simulated hospital room [Xu et al. 2005]. For the simulated hospital room study, HHE Program staff helped develop the request for proposal, select the awardees, and review the study protocol. An HHE investigator also provided technical assistance with UVGI measurement. Because of the difficulties in measuring ultraviolet irradiance levels from germicidal lamps, an HHE investigator suggested a new approach using a device that measures the heating power of radiation; this suggestion was acted on by a researcher from the University of Alabama who developed a method for this application [Rahn et al. 1999]. Additionally, NIOSH researchers (including HHE investigators) developed a guidance document using HHE Program-generated information and results of the contract work titled, Engineering Controls for Tuberculosis: Upper-Room Ultraviolet Germicidal Irradiation Guidelines for Healthcare Settings (now undergoing final clearance prior to publication).

Implementation of Recommendations at HHE Sites. The HHE Program is aware of several instances in which implementation of recommendations made in HHEs has led to a reduction in work-related TB infection risk as noted below.

El Dorado County health officials in California requested an HHE to address concerns about work-related TB risk at two of its clinics [NIOSH 2005a]. Acting on recommendations provided in the HHE report, plans are in place to make changes to their facilities' design and operation and to their infection control policy. These changes in facility design and policy will allow the facility to be able to care for patients with TB and other suspected airborne infections such as measles and severe acute respiratory syndrome (SARS), a capability that they previously did not have. The Hawaii State Department of Health made interim changes at its TB Clinic and later secured funding to do a complete renovation of its clinic to include a 10,000 square foot state-of-the-art facility using recommendations made by the HHE Program [NIOSH 2000a]. The Director of Health for the Hawaii State Department of Health invited the NIOSH Director to join the Governor of Hawaii and senior health department staff in the grand reopening of the clinic in appreciation of the "valuable technical assistance" provided by HHE investigators.

In 1995, in response to recommendations made in two prior HHEs, the U.S. Marshals Service requested additional assistance from the HHE Program in developing a nationwide database for collecting and analyzing TB skin test data. An HHE investigator made multiple visits to the U.S. Marshals Service headquarters office in Washington, DC over the course of about 5 years to provide direct assistance with the development of a database that allowed them to more readily recognize and monitor TB infection trends in employees stationed throughout the U.S.

Managers of the largest homeless shelter in St. Louis, Missouri, followed recommendations made by HHE investigators to install UVGI, improve ventilation system filtration, increase fresh air, and improve facility maintenance [NIOSH 2005b]. The request for an HHE and implementation of these recommendations followed an outbreak involving 19 cases of active TB between February 2001 and August 2003. Since then, no new cases of TB have been identified at the shelter.

Following-up on recommendations made in an HHE report, the South Carolina Department of Corrections implemented the HHE investigators' recommendations that included conducting air quality evaluations, establishing a multi-disciplinary task force to address TB control issues, and instituting an education and training program [Jensen 2001].

HHE investigators determined that errors in placement and interpretation of TB skin tests resulted in unnecessary treatment of fire fighters in Mississippi for presumed latent TB infections [NIOSH 2007]. HHE results and recommendations were used to stop the prophylactic treatment of firefighters, eliminating the potential for serious side effects from the TB medications. The HHE also quelled concerns about possible TB transmission in the workplace.

End Outcomes. HHE Program activities and intermediate outcomes described in the previous section provide evidence of the Program's contributions to establishing and updating national policies and guidelines. Collectively, these prevention efforts led to a 46% decline in the total number of TB cases in the U.S. from 1992 to 2004, and a 17% decline in the incidence of infectious TB cases among healthcare workers from 1994 to 1998.

External Factors. HHE investigators participated on the NIOSH testimony team, preparing written testimony that was submitted to OSHA in support of a proposed TB standard and provided oral responses to questions received during public hearings. However, in 2003, OSHA withdrew the proposed standard, noting that existing TB control efforts, in particular the CDC guidelines (which incorporated information derived from the HHE Program) had led to a dramatic decline in TB in the general population, greatly reducing the risk of occupational exposure. OSHA also noted that an OSHA standard was unlikely to be more effective than the CDC guidelines in eliminating the risk of occupational transmission.

As the number of TB cases rose in the early 1990s, so did the number of HHE requests concerning TB. With the adoption of TB prevention measures recommended by CDC and others, the number of new TB cases declined. Along with that came a decrease in the number of new HHE requests in this area. The HHE Program adapted to this by redirecting efforts and resources and using experience gained through the TB HHEs to address new respiratory hazards facing U.S. workers such as biological agents of terrorism (e.g., anthrax) and emerging infectious diseases (e.g., SARS).

Chemical Hazards

Tertiary Amines

Issue. Exposure to tertiary amine compounds in the workplace has been linked to visual disturbances among workers. Tertiary amines are commonly used in the printing industry, where workers are exposed to these compounds through various inks and cleaning solutions.

The HHE Program received a request in January 2001 from Superior Label Systems management because many of their production line workers were experiencing blurred vision while at work. The workers described this phenomenon as though they were looking through "a fog "or "a mist." Although industrial hygienists from the State of Ohio's Bureau of Workers' Compensation and a private contractor had investigated the concerns and an ophthalmologist had examined some employees, none of them had been able to determine the cause of the ocular effects. While the visual and ocular changes experienced by the workers appeared to be reversible phenomena, the changes posed a safety hazard both on the job and when driving home.

Superior Label Systems is one of the largest flexographic printing operations for consumer product labeling in the United States. Superior Label Systems has about 360 employees in four facilities located in Ohio, Texas, and Arizona. The HHE involved the Ohio label production plant with 100 production workers.

Approach. HHE investigators postulated that amines could be causing the ocular effects and developed a protocol to evaluate this possibility. Full-shift personal breathing-zone air samples were collected daily for the two tertiary amines used, dimethylisopropanolamine and dimethylaminoethanol, during a week-long field investigation. HHE investigators administered a questionnaire inquiring about work practices and symptoms. Eye examinations were conducted at the beginning and end of both work shifts by a contract ophthalmologist.

HHE investigators found a significant association between symptoms of blurry, halo, and blue-gray vision, corneal opacity, decrements in visual acuity and contrast sensitivity at 2.5% contrast, and exposure to the tertiary amines. The mechanism of action of the corneal opacity was found to be direct deposition of dimethylisopropanolamine into the corneal epithelium without significant cellular dysfunction or toxicity. This chemical was the main ingredient of a product used to adjust the pH of the ink.

Outputs and Transfer. HHE investigators delivered a numbered final report [NIOSH 2001] including recommendations for diluting or eliminating the amine-containing pH adjuster, covering ink containers to reduce the amount of chemicals vaporizing into the work environment, and improving the local exhaust ventilation at the printing presses. A second numbered report issued in May 2003 [NIOSH 2003] documented the changes at Superior Label Systems since the 2001 investigation. These reports were distributed via standard HHE Program protocols.

HHE Program efforts to convey the study findings included a peer reviewed journal article [Page et al. 2003]; contacts with the National Association of Printing Ink Manufacturers, Inc., the Flexographic Technical Association, and the Graphic Arts Technical Forum; a press release from the NIOSH Office of the Director; and additional contacts with the American Academy of Ophthalmology, the American College of Occupational and Environmental Medicine, OSHA, and EPA. The HHE Program received more than 50 phone calls and website inquiries following the release of the final report in October 2001. HHE investigators also received more than 10 inquiries from concerned physicians applying this information directly to their own occupational medicine and ophthalmology practices.

Intermediate Outcomes. Chemists in the NIOSH Exposure Assessment Emphasis Area modified the NIOSH method for air sampling of amines in the workplace for this HHE investigation [NIOSH 2001].

As a result of this HHE investigation, OSHA worked with the manufacturer of the tertiary amine pH adjuster to change the Material Safety Data Sheet for the tertiary amine. The updated Material Safety Data Sheet allows workers to be aware of the potential health effects from exposures to these amines and methods of reducing exposure. Because of this study, tertiary amine compounds have been selected for inclusion in the NIOSH/BLS Disease Agent Survey, which is designed to assess nationwide exposure to important disease-causing chemicals.

EPA included the findings from this project in their report titled "Flexographic Ink Options: A Cleaner Technologies Substitutes Assessment" [EPA 2002]. EPA recommendations to industry now include awareness of the hazards associated with tertiary amine compounds.

The Standard Register Company contacted the HHE Program for advice on eliminating this amine-associated hazard from their facilities. Standard Register Company is a leading document services provider and employs about 3,800 workers.

End Outcomes. Superior Label Systems requested a return visit by HHE investigators in August 2002 to conduct a follow-up field investigation. This involved follow-up interviews and additional air sampling, documenting changes from the April 2001 site visit. HHE investigators documented the absence of visual disturbances and a significant decline in total tertiary amine levels. HHE investigators confirmed the immediate elimination of visual complaints among workers following management's implementation of HHE investigator recommendations.

Followback surveys for this HHE investigation included the comments that "pH adjuster has been diluted ever since the recommendation was made" and in response to the question of whether workplace conditions improved since the NIOSH visit indicated that the "[problem] has not been reported since!" Management reported that a new make-up air system was being worked on and plans were to have the work completed by November 2003. Superior Label Systems also reported renewed efforts to keep inks not in use in covered containers.

Asphalt

Issue. In 1991, Congress enacted the Intermodal Surface Transportation Efficiency Act which required each state to use a minimum quantity of "crumb-rubber modified" hot-mix asphalt paving material [http://ntl.bts.gov/DOCS/istea.html]. Because of industry (the Asphalt Institute) and labor (the Laborers' International Union of North America) concerns over the lack of available information on the human health effects resulting from the use of "crumb-rubber modified" hot-mix asphalt, a temporary legislative moratorium was passed. Congress directed EPA and the U.S. Department of Transportation, Federal Highway Administration to evaluate the potential environmental and human health effects associated with the use of crumb-rubber modified asphalt. Because part of the focus of this Congressional directive concerned potential occupational health and safety effects of crumb-rubber modified asphalt, EPA recommended that the Federal Highway Administration request technical assistance from NIOSH. In 1994, the HHE Program entered into an Interagency Agreement with the Federal Highway Administration to evaluate occupational exposures among asphalt road workers. The Department of Labor's North American Industry Classification System estimated employment in the paving, surfacing, and tamping equipment operators category (NAICS 237310, Highway, Street, and Bridge Construction) to be 21,340 workers as of May 2005.

Approach. To evaluate this potential health hazard, HHE investigators completed seven site evaluations between 1994 and 1997 (Michigan, California [2], Florida, Indiana, Arizona, and Massachusetts). The number of asphalt-exposed workers at these sites was approximately 80.

The HHE Program evaluated new air sampling methods for total and benzene soluble particulate; polycyclic aromatic compounds; sulfur compounds; and benzothiazole. Exposures were higher during crumb-rubber modified asphalt paving compared to conventional asphalt paving. Except for carbon monoxide, all concentrations were below applicable OELs. However, some chemical constituents in asphalt fume do not have an OEL. The unique medical study included serial acute symptom questionnaires and serial peak expiratory flow rate testing throughout the workday to evaluate acute changes in lung function of asphalt paving workers. This investigation demonstrated a relationship between health effects and personal exposures to total and benzene-soluble particulate. Eye, nose, or throat symptoms reported by paving workers occurred below the OEL for benzene-soluble particulate.

Outputs and Transfers. HHE investigators produced seven individual reports, which were delivered to the seven paving companies and their workers [NIOSH 1996a,b,c,d,e,f; NIOSH 1998]. HHE investigators also prepared a composite report which collectively analyzed the results of all seven site investigations [NIOSH 2001]. The HHE Program distributed 200 copies of this composite report according to standard program protocols.

The HHE Program recognized the need for further evaluation of engineering controls (ventilation) on asphalt paving vehicles, and shifted the task of continued research and study of asphalt control measures to the NIOSH Engineering Controls Emphasis Area.

HHE investigators contributed to a hazard review addressing the health effects of occupational exposure to asphalt [NIOSH 2000]; engineering control guidelines for hot mix asphalt pavers [NIOSH 1997]; and a peer-reviewed journal article on acute symptoms associated with asphalt fume among road pavers [Tepper et al. 2006]. HHE investigators presented at professional symposiums and to government agencies, trade associations, universities, and advocacy groups.

The HHE Program final composite report [NIOSH 2001] provided the Federal Highway Administration with data characterizing and comparing occupational exposures to crumb rubber modified asphalt and conventional asphalt, potential health effects associated with both types of asphalt, and new field testing methods to assess exposures. This report fulfilled the Federal Highway Administration's Congressional mandate to evaluate crumb rubber modified asphalt.

The HHE Program provided field sampling results for use by NIOSH researchers in the Exposure Assessment Emphasis Area in validation of the new environmental sampling and analytical methods for total and benzene-soluble particulate, polycyclic aromatic compounds, sulfur compounds, and benzothiazole.

Researchers from the NIOSH Engineering Controls Emphasis Area participated in the HHE program field investigations to assist in their evaluation of engineering controls on paving vehicles to control worker exposure to asphalt fume components.

Intermediate Outcomes. Three new NIOSH personal breathing zone and general air sampling methods were validated as a result of the HHE field investigations. These were Method 5042 for benzene-soluble fraction and total particulate, Method 5800 for polycyclic aromatic compounds, and Method 2550 for benzothiazole [NIOSH 2007; Jaycox and Olsen 2000].

The NIOSH Engineering Controls Emphasis Area produced site specific evaluation reports and five peer-reviewed publications regarding the use of local exhaust ventilation to reduce exposure to asphalt fume during road paving [Mickelsen et al. 1999; Mead et al.1997; Mead et al. 1999; Mickelsen et al. 2006; Moran et al. 1997]. Through a unique partnership effort involving the Engineering Controls Emphasis Area [http://www.cdc.gov/niosh/nora9906.html], since July 1997, all new highway class pavers have been manufactured with ventilation controls to reduce exposure to asphalt fumes. With a service life of 10 years, more than 80% of all current highway-class pavers now have these controls installed [CSA 2007]. This change reduced exposures to asphalt fume for approximately 300,000 highway paving workers across the nation.

The Occupational Health Clinics of Ontario Workers, Inc. used the exposure and health data obtained from the HHE Program asphalt paving investigations to develop proposed OELs which were submitted to the Ontario Ministry of Labour on Occupational Exposure Limits [OHCOW 2004].

Chlorinated Compounds

Issue. Chlorine is a broad spectrum, inexpensive disinfectant that is active against most microorganisms, including bacterial spores. Eye and upper respiratory tract irritation, common symptoms of chlorine exposure, are generally intermittent and vary in severity. In addition to chlorine, airborne chlorine-related compounds called chloramines have been suspected as a primary cause of the reported symptoms because of the interaction between the chlorinated water and nitrogenous material.

Exposure of poultry processing workers and USDA inspectors to chlorinated water is considered a widespread problem in the poultry processing industry. The BLS estimates national employment levels in 2005 for slaughterers and meat packers at 132,000; and for meat, poultry, and fish cutters and trimmers at 136,690. In addition to poultry processing, exposures to chlorinated compounds may also occur in indoor water parks, an industry which has grown in popularity in the U.S. and Canada since 2000. In 1994, there were five indoor water park resorts operating in the U.S. and Canada with approximately 300,000 square feet of indoor water park space. By the end of 2004, 63 indoor water park resorts were operating with approximately 1.8 million square feet of indoor water park space. Because these large indoor aquatic facilities heat large volumes of water and large expanses of air, some facilities recirculate previously heated air to reduce energy costs. This recirculated air may contain irritating concentrations of chlorine and chloramines.

Approach. In 2000, HHE investigators evaluated the complaints of aquatic animal trainers complaining of respiratory and eye irritation. These trainers reported increased symptoms when working in or near the water. Air sampling for trihalomethane (formed by the interaction of chlorine and organic matter) was conducted, and bulk water samples from the oceanarium tanks were analyzed for chloramines (at the time of this investigation there was no sampling method to measure airborne chloramine). Employee interviews were conducted and the oceanarium ventilation system was evaluated. HHE investigators concluded that aquatic animal trainers did experience symptoms of respiratory, eye, nose, and throat irritation. Air concentrations of trihalomethane were low, but chloramine levels in the oceanarium tanks remained constant throughout the day. Since chloramines have low solubility in water, HHE investigators concluded that chloramines could easily be released into the air when the aquatic mammals agitated the water.

In 2000, the HHE Program received a management request to evaluate a turkey processing plant in Virginia where processing department employees were experiencing health problems possibly related to the use of "superchlorinated" water. HHE investigators observed work practices, collected air samples for chlorine and chloramines in the packaging department using an experimental sampling and analytical method developed by researchers in the NIOSH Exposure Assessment Emphasis Area, and administered a symptom questionnaire to 65 employees. Air flow patterns were visually evaluated in processing areas using theatrical fog. HHE investigators concluded that employee complaints of intermittent eye and upper respiratory irritation of varying severity were associated with superchlorination of the bird washing and chiller water, were greater for workers located near the water chillers, and were most common after returning from the morning break. Air sampling found measurable concentrations of chloramine in the areas where workers experienced symptoms, and chloramine was not detected in the non-complaint area. Air flow measurements found that stagnant conditions were present [NIOSH 2000].

In 2002, the Occupational Safety and Health Bureau of the Iowa Division of Labor requested the HHE Program to evaluate eye and respiratory irritation among some of the 600 workers at an Iowa poultry slaughtering and processing facility [NIOSH 2003]. The goals of this HHE were to determine if employees exposed to chlorinated water had more upper and/or lower respiratory symptoms than workers whose tasks involved less exposure to chlorinated water and whether exposure to chloramines was associated with respiratory symptoms and declines in lung function among workers. HHE investigators collected air samples for chlorine and chloramines using the experimental method (previously described) in the evisceration line and, for comparison purposes, the dark meat area. HHE investigators also made measurements for carbon dioxide, relative humidity, and temperature in both areas of the facility. HHE investigators found that chloramine (trichloramine and soluble chlorine) concentrations were significantly higher in the evisceration area than the dark meat area. Additionally, upper respiratory irritation symptoms were significantly more prevalent among the evisceration line workers than among the dark meat workers. Concentrations of soluble chlorine compounds were also significantly higher for employees who reported upper respiratory symptoms than for employees who did not. Finally, mean personal-breathing-zone concentrations of trichloramine and soluble chlorine were higher for workers with significant cross-shift declines in lung function.

In 2006, HHE investigators conducted a follow-up survey at the Iowa poultry slaughtering and processing facility to determine whether engineering and ventilation controls implemented by the company since the previous HHE had reduced work-related symptoms. Air sampling and employee interviews were conducted and engineering controls implemented since the previous survey were evaluated. HHE investigators concluded that the lower rates of all symptoms reported by processing workers, paired with reduced soluble chlorine compounds, demonstrated the effectiveness of the new engineering controls implemented at this facility [NIOSH 2006].

In 2007, the Warren County (Ohio) Health Department requested assistance from the HHE Program to investigate respiratory symptoms, skin rash, and eye irritation reported by employees at a large indoor water park. This ongoing survey includes air sampling for chloramines (trichloramines and soluble chloramines), bulk water sampling for water conditions, microbials and sulfates/sulfites, administering health surveys to water park employees, and evaluating the ventilation and water systems.

Outputs and Transfers. HHE investigators issued a report [NIOSH 2000] recommending improvements to the integrity and efficiency of the superchlorination system and the ventilation system in the processing areas of the Virginia facility.

HHE investigators issued a report [NIOSH 2003] recommending further exposure assessment and modifications to the Iowa facility's ventilation system. The HHE Program collaborated with the NIOSH Engineering Control Emphasis Area, whose researchers visited the facility and provided the facility's management with extensive engineering recommendations. In the follow-up HHE report [NIOSH 2006], HHE investigators recommended that plant management continue to monitor health problems reported by the workers and perform routine maintenance on the new engineering controls to ensure proper operation.

HHE investigators made presentations at three national occupational safety and health conferences and published a peer-reviewed journal article [King et al. 2006] to further disseminate findings and recommendations regarding poultry processing.

Intermediate Outcomes. The NIOSH Exposure Assessment Program developed a new method for the evaluation of airborne chloramines [NIOSH 1994].

Based on the NIOSH research, the USDA approached NIOSH to discuss new collaborations. The goal will be to increase dissemination of information about worker exposure to chlorinated compounds more widely in the poultry industry.

End Outcomes. During the follow-up evaluation of the Iowa facility, HHE investigators documented reduction in the number of poultry processing workers reporting eye and respiratory symptoms (specific symptoms declined from 13% to 44%). HHE investigators also found reduced levels of soluble chlorine compounds in the processing area following implementation of HHE Program engineering control recommendations [NIOSH 2003, 2006].

Followback surveys from management at one facility [NIOSH 2003] conveyed satisfaction with the HHE Program, reporting that all three HHE recommendations had been implemented and that workers' health had improved as documented during the follow-up evaluation.

External Factors. The draft NIOSH sampling and analytical method has shown promise in quantifying chloramine exposures but is still being evaluated to ensure that minimum detection levels can be consistently achieved. Active company participation and willingness to implement control measures at great cost were instrumental in the success of the HHE Program investigation at the Iowa poultry processing plant.

What's Ahead. The HHE Program is continuing to investigate respiratory symptoms, skin rash, and eye irritation among indoor water park employees at the Ohio facility, and is assisting the NIOSH Exposure Assessment Emphasis Area in field testing modifications to the new air sampling method for chloramines.

Lead in the Abatement and Construction Industries

Issue. Lead exposure is one of the oldest known occupational health hazards. Hippocrates first documented the toxicity of this metal among workers in 370 B.C.E. Despite its longstanding status as a known health hazard, lead continues to pose a hazard today, particularly from its use in paint and allied coatings.

The HHE Program received a request from the Housing and Urban Development (HUD) Office for Policy Development and Research to evaluate occupational health and safety hazards during the HUD Lead-Based Paint Abatement Demonstration. Because of its extensive use in paint and allied coatings over the last two centuries, a significant number of buildings and other structures in the U.S. still have extensive amounts of lead based paint. HUD was mandated to implement a lead-based paint abatement demonstration project by 1987 and 1988 amendments to the Lead-Based Paint Poisoning Prevention Act (Public Law 91-695). The goal was to compare costs and efficacy of various alternative methods of lead-based paint abatement.

In 1992, Congress passed the Housing and Community Development Act (Public Law 102-550) which included, as Title X, the "Residential Lead-Based Paint Hazard Reduction Act of 1992." Title X, by amending the Toxic Substances Control Act, directed federal agencies to respond to the national problem of childhood lead poisoning caused by lead hazards in housing and establish a program to administer and control lead abatement in housing. Congress directed NIOSH to "…conduct a comprehensive study of means to reduce hazardous occupational lead abatement exposures."

Between 1991 and 2000, the HHE Program received 10 additional requests from state health departments, universities, contractors, and a non-profit organization to conduct investigations evaluating lead exposures associated with lead paint abatement hazards in the construction industry. One request sought an evaluation of exposures encountered by custodial workers engaging in duties that included painting and plumbing repairs.

Approach. HHE investigators conducted field investigations for all of these requests. The number of site visits conducted per investigation ranged from one to nine. Lead-paint coated structures included bridges, water towers, and interior and exterior surfaces of single and multi-family residences. Airborne and surface sampling for lead was conducted at the various facilities for an array of abatement and surface preparation techniques. The use of engineering and ventilation controls as well as personal protective equipment and work practices was observed and evaluated by HHE investigators. Blood lead determinations were an additional evaluation component for five of the HHE Program investigations.

Restoration and renovation activities included abrasive removal (wet and dry), paint removal with heat guns, chemical removal, encapsulation, enclosure, and replacement. Airborne lead concentrations across the HHE Program investigations for both breathing zone and area samples spanned three orders of magnitude from non-detectable to thousands of micrograms per cubic meter of air. The highest exposures were more than 10 times the OSHA Permissible Exposure Limit. The activities produced surface lead contamination up to several thousand milligrams of lead per square meter, which represented a hazard to occupants. Lead content of paints were documented up to 37% by weight. Lead was determined to be present on the driver's side floor of 27 privately owned vehicles from one HHE investigation where abrasive blasting was performed, indicating that take-home exposure was a concern. HHE investigators addressed inappropriate work practices and lack of personal protective equipment during the investigations.

Outputs and Transfer Activities. Because of the magnitude of the problem of lead hazards in U.S. housing described by Congress, the HHE Program developed a network of partners from other federal agencies, state agencies, trade and industry associations, and labor groups, all of whom had an interest in reducing lead exposures. In addition, HHE investigators led a project and worked with research staff from other NIOSH programs to prepare a report for Congress on protecting workers exposed to lead-based paint hazards [NIOSH 1997]. HHE investigators participated in, and provided technical review and data for development of educational information, new regulations, and best practice guidelines by federal regulatory agencies [OSHA 1993a, EPA 1994, HUD 1995, HUD 1999]. HHE investigators provided technical review and consultation for lead-related research done by federal regulatory agencies in response to mandates from Congress [EPA 1998, HUD 1991].

Eleven final reports from these HHE Program investigations addressed a variety of work situations in which lead exposure was anticipated to be significant including: lead abatement with HUD, restoration and renovations of buildings known to have a significant amount of lead based paint, abrasive blasting of a steel bridge and a water storage tank and tower in preparation for repainting, and lead contamination that was carried home on workers' clothing and vehicles. Recommendations applicable to the work environments evaluated included training needs, proper work practices and effective engineering controls, prevention of safety hazards, initial risk assessment of the lead abatement tasks to be performed, personal hygiene facilities, respiratory protection programs, medical monitoring, and surveillance (see Section 3.4, Supporting Evidence).

HHE Program staff served as expert advisors to the EPA and HUD during the development of guidelines, regulations, and training courses. Over the course of 8 years, HHE Program staff gave presentations to more than 20 different audiences including the Steel Structures Painting Council, the University of Washington, the National Lead-Safe Housing Conference & Exposition, and the National Lead Abatement Council National Conference.

In addition to the HHE final reports, HHE investigators published technical reports in scientific and trade journals, a NIOSH Alert, a chapter in HUD national guidelines controlling lead in housing, and a NIOSH report for Congress on the evaluation and control of worker lead-based paint hazards. Six peer-reviewed articles were published between 1992 and 2002 from the HHE Program investigations [Sussell et al. 1992; Sussell et al. 1995; Sussell et al. 1996; Sussell et al. 1999; Sussell and Ashley 2002; Drake et al. 2003].

The primary HHE Program investigator for evaluating lead hazards in the construction industry also served as a technical advisor to the EPA, HUD, the Alliance to End Childhood Lead Poisoning, and the National Center for Lead-Safe Housing. The primary HHE investigator also participated in the review of EPA's Proposed Rule on Lead-Based Paint Activities (40 CFR Part 745) and the State of Washington Department of Labor's draft lead standard.

All together, the information gathered during this effort was disseminated through more than 50 different outlets. The various venues included HHE Program distribution and posting requirements for final reports, the NIOSH Authoritative Recommendations Program, HUD guidelines, EPA training materials, professional and trade conferences, scientific and trade publications, the NIOSH Surveillance Program's Adult Lead Exposure Surveillance Program (42 states), and a report to Congress.

Data from HHEs was used to develop two NIOSH field-portable methods for lead [NIOSH 2007].

Intermediate Outcomes. In the preamble to its 1993 Lead Exposure in Construction, Interim Final Rule (codified as 29 CFR 1926.62), OSHA used HHE Program data [OSHA 1993a]. OSHA cited findings from the HHE investigation of the HUD Lead-Based Paint Abatement Demonstration to support its decision in Section 2 - Key Issues, Medical Surveillance, to not require medical surveillance for all workers with any exposure to lead. Additionally, OSHA indicated in the preamble that in order to analyze the feasibility of the standard, it examined "exposure data ...believed to be representative and reliable" from several sources, including HHE Program final reports [OSHA 1993b].

In 1993, OSHA provided uniform inspection and compliance guidance to its compliance officers for Lead Exposure in Construction, 29 CFR 1926.62, Interim Final Rule. The guidance was based on its recently promulgated standard and, in part, on the HHE Program data cited in the preamble [OSHA 1993a,b]. HUD and EPA updated and produced work practice guidelines for construction workers and homeowners using HHE Program technical input and reports [EPA 1994]. The American Society for Testing and Materials published a paper based on the final report of an HHE investigation at Ohio University [Sussell et al. 1995].

The University of California Berkeley and Ohio University selected and used work practices to reduce worker lead exposures based upon HHE Program evaluations of lead abatement demonstration projects.

Based in part on the NIOSH field-portable methods for lead developed using field testing in HHEs, the American Society for Testing and Materials developed and published two standards for assessing lead in paint, settled dust, soil and air particulate samples by field-portable methods [ASTM 2007a,b].

External Factors. The intense regulatory focus created great interest in worker lead hazards in residential renovation, abatement, and other construction activities. The HHE Program responded by doing HHEs to assess worker and occupant exposures during lead abatement and renovation in cooperation with local, state and federal agencies, and with universities. The regulatory activity may have inhibited HHE requests from small and medium enterprises in the construction industry. Due to concerns that high exposures found during an HHE might trigger enforcement action or additional regulation targeted at their activities. The HHE Program responded by contacting construction trade associations and providing advice and assistance. Gradually the HHE Program built trust with industry representatives, and as a result, several contractors later requested HHEs related to lead hazards during residential or steel structures renovation work.

Physical Hazards

Ergonomics and Musculoskeletal Disorders

Issue. Musculoskeletal disorders (MSDs) account for 30% to 40% of workplace injuries. Work-related musculoskeletal disorders (WRMSDs) are soft tissue injuries that may involve muscles, tendons, ligaments, nerves, and supporting structures such as intervertebral discs. Examples include carpal tunnel syndrome, tenosynovitis, tension neck syndrome, and low back pain. WRMSDs vary in severity from mild periodic symptoms to severe chronic and debilitating conditions. Risk factors that contribute to WRMSDs include repetitive, forceful, or prolonged exertion; frequent or heavy lifting, pushing, pulling, or carrying of heavy objects; prolonged awkward postures; and exposure to vibration. Jobs or working conditions that combine risk factors increase the risk for musculoskeletal problems.

MSD cases tend to involve higher percentages of long-term work loss compared with other occupational illnesses. The Bureau of Labor Statistics reported that a median of 9 days away from work was reported for MSD cases in 2005, slightly greater than the median of 7 days for all nonfatal injuries and illnesses.

In the late 1980s OSHA announced that it would target workplaces to insure that WRMSDs were being addressed and recorded on OSHA's illness and injury logs. This led to an upsurge in reporting of WRMSDs across all types of industries and occupations. During this period the HHE Program began to receive an increased number of HHE requests to address WRMSDs. Much of the increase in MSDs was thought to be due to changes in work processes and technology that exposed employees to increased repetitive motion, increased forceful movements, and increased use of extreme, constrained postures in their work. Some of the reporting was also attributed to increased awareness. Most of the HHE requests focused on identifying the scope of injuries and specific workplace risk factors for MSDs, and asked for recommendations to address ergonomic hazards.

Approach. Because this was emerging research, HHE investigators had to develop and refine their approaches and tools over time to evaluate WRMSDs. They developed tools to evaluate physical work factors for the upper extremity (forceful exertions, extreme or awkward postures, repetitive movement, contact stress) using observational methods and questionnaire surveys in each workplace. For evaluating risk of back injury, HHE investigators focused on methods to evaluate lifting/forceful movements, awkward postures, heavy physical work, whole body vibration, and static work postures. These methods used the revised NIOSH lifting equation [NIOSH 1994] or more advanced techniques, such as a lumbar motion monitor [NIOSH 1995]. A variety of tools for obtaining worker input were designed and improved over time, including worker diaries, standard interviews, and standardized questionnaires. HHE investigators also used standard observational methods for assessing postural variation in workers who demonstrated highly dynamic activities, recording data on videotape, and then analyzing the tapes using dedicated software. For certain HHEs, HHE investigators collaborated with university researchers (such as the Ohio State University and the University of Michigan) or state agencies (such as Washington Labor and Industry) to take measurements with instruments that relied on sensors attached directly to the workers for the measurement of exposure variables at work. HHE investigators also evaluated ergonomic prevention and control activities in a variety of workplaces. They provided recommendations for strengthening ergonomic activities, and implementing or improving ergonomic programs to reduce musculoskeletal disorders. HHE investigators assisted site managers in their selection of appropriate equipment for reducing risk of injury based on limiting known risk factors, and helped with procedures for analyzing workplaces. Almost all of the 100 HHE projects resulted in on-site evaluations by ergonomists, industrial hygienists, engineers, physicians, nurses, and epidemiologists.

Meat Packing and Poultry. Some of the HHE Program's earliest work was in the red meat industry [NIOSH 1989]. At Morrell Meatpacking [NIOSH 1989], we were asked to assist OSHA because of suspected high rates of upper extremity WRMSDs. By questionnaire and physical examination, NIOSH investigators determined that 50% of the 200 selected workers had current upper extremity WRMSDs. Observations and measurements of line speed and line height were also used, as well as documentation of frequency of repetitive motion (captured and analyzed on videotape) and observed forceful motions.

Video Display Terminals. The HHE Program advanced the science for assessing the ergonomics of video display terminal (VDT) use in non-data entry users. The findings from two large HHEs, involving over 1800 workers, documented a dose response relationship between hours of VDT use and upper extremity WRMSDs. This was accomplished through use of both questionnaire data and observational work sampling, provided the rationale for recommendations regarding work stations, rest breaks, and medical management [NIOSH 1990a, NIOSH 1993a].

Outputs and Transfers. The HHE Program has completed 67 final reports over the last decade according to standard HHE Program protocols. During this same period, HHE investigators have also contributed to more than 25 peer-reviewed publications and book chapters (see Section 3.4, Supporting Evidence).

The HHEs documenting WRMSDs among VDT users generated much press and attention from ergonomists and scientists around the world [NIOSH 1992, 1993a]. HHE investigators were invited to present their findings in a special session at the prestigious 4th Worldwide Display Unit Council in Berlin, Germany (1994), the largest consortium of academics, government, and non-government organizations researching VDTs in the world.

Two HHE physicians provided over 100 presentations to a broad cross section of industry, professional (occupational safety, health, and medicine), academic, government, and individual company audiences, at national and international meetings. These included presentations at the International Ergonomic Association Meetings in 1997 and 1998, where HHE investigators gave invited lead session presentations to an international audience of experts.

An HHE investigator developed and presented a 4-day course on methods for assessing and controlling musculoskeletal hazards to students in the occupational and environmental health bachelor's degree program at the University of West Indies, Kingston, Jamaica in 2007. The arrangements for the training were made by a Jamaican scientist who had completed an internship in the HHE Program.

The NIOSH document Elements of Ergonomics Programs: A Primer Based on Workplace Evaluations of Musculoskeletal Disorders, published in 1997, drew extensively upon 96 HHE Program ergonomic investigations [NIOSH 1997c]. The primer offers practical ways to identify, evaluate, and ameliorate ergonomic hazards. As Surgeon General and Assistant Health and Human Services Secretary Dr. David Satcher stated, "The NIOSH Primer is a unique resource for anyone who seeks information about practical and cost-effective ways to prevent these injuries and illnesses." It received the 1998 Alice Hamilton Award for Excellence in Occupational Safety and Health (Educational Materials Category). It has been mailed to over 40,000 health and safety professionals and referenced over 10,000 times on the Internet, and by professional safety and health groups, such as Occupational Hazards (Does Your Ergonomics Program Need a Tune-up?) [Mansdorf 1999]; universities such as Wayne State University [http://www.oehs. wayne.edu/anicon/ergo%20survey%20OEHS-1-24-02.pdf] and University of Minnesota, Duluth [http://www.d.umn.edu/ehso/ergonomics/esurvey.pdf]; and government agencies such as NASA [http://ohp.nasa.gov/topics/ergo/index.html].

HHE investigators led the writing of the NIOSH statement to OSHA's advanced notification of promulgation of rulemaking, as well as the testimony and comments to OSHA during Congressional hearings on the proposed OSHA ergonomics standard. Data from HHEs were used to document the seriousness and disability of WRMSDs, and document underreporting of MSDs on OSHA illness and injury logs [NIOSH 2001a].

HHE investigators conducted HHEs in ship building, ship repair, and ship dismantling to develop ergonomic intervention strategies, which led to surveys that identified processes with effective and potentially transferable control techniques. These were in participation with such partners as the Maritime Advisory Committee on Occupational Safety and Health, OSHA, and the Maritech Advanced Shipbuilding Enterprise. This work, including the proposed strategies and recommended solutions, was transferred to the NIOSH Engineering Control Emphasis Area, which worked with HHE investigators to formulate specific engineering recommendations to reduce ergonomic risk factors.

In August 1998, the National Academies was asked by the U.S. Congress to conduct a review of NIOSH's Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back [NIOSH 1997b]. The final conclusion of the National Academies Review Panel stated that, "the NIOSH critical review provided substantial sound scientific evidence linking back injuries, carpal tunnel syndrome and other MSDs to work." The National Academies noted "compelling evidence" in the document that reducing biomechanical stress on the job reduces the risk of injuries.

Intermediate Outcomes. As a result of the Morrell Meatpacking HHE [NIOSH 1989], investigators became involved in OSHA's efforts to develop an ergonomic standard. HHE investigators were asked by OSHA to develop the 1993 OSHA Ergonomic Meatpacking Guidelines [http://www.osha.gov/Publications/osha3123.pdf)] [OSHA 1993a]. These guidelines became the prototype for all other OSHA ergonomic guidelines and ergonomic standards, which currently appear on the OSHA website [http://www.osha.gov/SLTC/ergonomics/guidelines.html].

The recommendations from the VDT HHEs [NIOSH 1990a, 1993a] regarding work stations, rest breaks, and medical management were adapted by several large corporations, such as Times Mirror newspapers, the Wall Street Journal, and other national newspapers.

The HHEs studying upper extremity MSDs developed an epidemiologic case definition for field studies that was based upon symptom frequency, duration, and severity. Prior to these HHEs, most studies used a case definition only based on the presence or absence of symptoms [Dickinson et al. 1992], which was considered by many scientists as too broad a case definition to be useful when assessing WRMSDs. An HHE investigator published an article documenting the validity of the questionnaire for identifying WRMSD cases [Baron et al. 1996]. This HHE-derived case definition subsequently became one of the most frequently used definitions in peer-reviewed publications [Fogleman and Lewis 2002; Smith et al. 2003; Morse et al. 2001].

The HHEs addressing VDT issues [NIOSH 1990a, 1992, 1993b, 1995] brought attention to psychosocial factors and their relationship to upper extremity and neck MSDs. The NIOSH occupational psychosocial questionnaire developed for these HHEs has been used by other researchers [Gerr et al. 2002; Hannan et al. 2005] to study MSDs in computer users.

The HHE Program investigated musculoskeletal problems and the use of scanning check stand systems among grocery store checkers. HHEs were conducted at Kroger Company [NIOSH 1990b], Shoprite [NIOSH 1991] and Schnuck's and Dierberg's [NIOSH 1993c]. These investigations resulted in recommendations for check stand design, including lowering the scales, reducing the reach across conveyors, moving the keyboard in front of the cashier, and relocating the bag stand to the side of the cashier. HHE investigators found that check stand scanners where the cashier faces the customer and scans groceries in a front-facing direction place the least stress on the worker when compared to other check stand designs. On August 18, 2003, the American Industrial Hygiene Association asked that OSHA use these HHE recommendations in their proposed ergonomic guidelines for grocery store designs. They stated that, "Check stand manufacturers today incorporate these recommendations into their designs. OSHA should echo the results of the NIOSH HHE that looked at checker unload check stands and development of WRMSDs. NIOSH found that this type of workstation increased the risk factors associated with scanning and recommended that both the work practice and the check stand be eliminated" [www.aiha.org/1documents/GovernmentAffairs/ga-ergonomics-retail-grocery-comments-08-18-03.pdf].

The NIOSH recommendations for check stand manufacturers led the Food Marketing Institute and its industry engineers to develop and install front facing cashier stands throughout the grocery industry. Postural and lifting analysis performed by HHE ergonomists led several St. Louis, Missouri grocery stores [NIOSH 1993c] to change the handling of customer grocery items to decrease postural load and risk for WRMSDs.

In 1994, HHE reports [NIOSH 1992, 1993b] became the foundation for the document NIOSH Publications on Video Display Terminals [NIOSH 1999], and VDT Safety and Health Programs for OSHA in 1995. The National Institute for Environmental Health Sciences (NIEHS) based its Health and Safety manual guidelines [NIEHS 2004] for VDT users largely on the recommendations from these HHEs and NIOSH's compilation from Publication 99-135 [NIOSH 1999].

An HHE investigator was editor of the 400-page document Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for WRMSD of the Neck, Upper Extremity, and Low Back [NIOSH 1997b]. This document identified and reviewed over 2000 scientific articles about workplace factors and MSDs (including 96 HHEs from 1990-2000), summarized methods and results for more than 600 studies, and interpreted their significance. The OSHA Compliance Program and Office of Technical Support used the document as evidence for regulating ergonomic problems in the U.S. in its 2000 Ergonomics Standard. The NIOSH document has been used in Congress to provide evidence of work-relatedness of disease. Dr. Linda Rosenstock, NIOSH Director at the time, stated, "By providing compelling evidence that these types of disorders are a significant problem in U.S. workplaces, the science document will serve as a fundamental technical resource for research." The document received the 1998 Alice Hamilton Award for Excellence in Occupational Safety and Health (Human Studies Category).

In 1998, HHE investigators, because of their experience in dealing with hand and wrist musculoskeletal disorders, were on an expert panel that developed Consensus Criteria for the Classification of Carpal Tunnel Syndrome in epidemiologic studies. This panel published needed guidance [Rempel et al. 1998] that has been used to resolve questions of carpal tunnel syndrome case definition from researchers in the field of ergonomics.

HHE investigators led a project with the University of California Agricultural Safety and Health Center at Davis, California; the College of Agricultural and Life Sciences, University of Wisconsin, Madison, Wisconsin; the Washington State Department of Labor and Industries, Olympia, Washington; the National Center for Farmworker Health in Austin, Texas, Farm Workers Union; and OSHA to evaluate occupational hazards and exposures for agricultural workers, and produced the document Simple Solutions: Ergonomics for Farm Workers [NIOSH 2001], based partially on several HHEs in the agricultural sector. This document shows cost effective ways to prevent MSDs and how to make inexpensive new tools or modify existing ones to reduce the risk of pain. It is posted on several agricultural websites, including that of the National Center for Farmworker Health (NCFH), which provides information to a network of more than 500 migrant health center service sites in the U.S.

NIOSH provided comments to OSHA on its 2000 proposed ergonomics standard; many of the comments were based on input and experience from HHEs. HHE Program data was used to document the scope and seriousness of work-related musculoskeletal disorders for the NIOSH statement on the OSHA Advanced Notice of Proposed Rule-making for the ergonomics standard.

OSHA used the HHE Program ergonomic reports and Elements of Ergonomics Programs as the outline for its ergonomics website [http://www.osha.gov/SLTC/ergonomics/ contributing_conditions.html].

An HHE investigator was one of four NIOSH staff on the first National Occupational Research Agenda team for MSDs. This team published its general musculoskeletal research agenda for the nation [NIOSH 2001b].

An HHE investigator organized and chaired the April 1998 Musculoskeletal Disorders and Health Care meeting. This meeting was the largest gathering of unions, management, consultants, and healthcare researchers ever assembled to discuss research needs and prevention issues of ergonomics and healthcare. As a result of this meeting, NIOSH and its partners (including OSHA) developed a research agenda and identified a strategy for implementation. This meeting also contributed to OSHA guidelines for the healthcare industry.

HHE investigators contributed to validation of the NIOSH lifting equation by applying it in field investigations. The lifting equation is a practical tool for assessing the risks of low back pain caused by manual lifting that was developed by NIOSH researchers in the NIOSH Musculoskeletal Disorders Cross-sector Program. HHE investigators found that the NIOSH lifting equation was a useful indicator for determining the risk of low back pain caused by manual lifting. The lifting equation is now used by occupational safety and health professionals worldwide.

As a direct result of an HHE evaluating poor ergonomic design and inadequate equipment during sonography [NIOSH 1999a], the Society of Diagnostic Medical Sonography (SDMS) convened a special meeting of international experts, including HHE investigators. They developed consensus standards for sonographers titled Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography. HHE investigators subsequently worked with SDMS to publish a NIOSH Workplace Solutions Document, Preventing Work-related MSDs in Sonography [NIOSH 2007], using results from the HHE.

In response to a Wal-Mart employee request concerning back injuries when changing automobile tires, HHE investigators contacted Wal-Mart's Employee Safety Division. A Wal-Mart representative gave the HHE investigator information about the tire-changing process, allowing the investigator to apply the NIOSH lifting equation. To reduce the MSD risk to workers, the HHE investigator determined that the height to which mechanics raised cars to change tires should be increased from 18 inches to 30 inches. Wal-Mart changed their policy per the HHE investigator's recommendations. This change eliminated the MSD hazard for workers in 3,800 stores in the U.S. and 3,800 international units.

End Outcomes. The methods developed in the HHE investigations have motivated primary prevention at worksites by implementing the screening tools to identify both ergonomic risk factors including forceful exertions, extreme postures, and repetitive exposures as well as early recognition of symptomatic workers. Medical management programs recommended by HHE investigators have motivated secondary prevention by identifying affected employees and getting them into restricted jobs with limited exposures to ergonomic risk factors.

External Factors. Legislative, regulatory, and policy actions at the federal and state level beginning in 1995 affected the goal of reducing workplace ergonomic hazards and preventing WRMSDs. These actions affected the HHE Program's partnerships relating to regulation of ergonomic hazards, but the HHE Program continued to work with its partners to develop guidance documents for specific industries and occupations.

The Congressional moratorium on ergonomics regulation in 1995, followed by the repeal of the newly enacted standard in 2001, and the continuation of the moratorium affected surveillance, research, and control of ergonomics hazards. These factors likely contributed to a decrease in the number of HHE requests in subsequent years.

An HHE investigator was the sole NIOSH representative on the American National Standards Institute Accredited Standards Committee on Control of Cumulative Trauma Disorders (Z365). This committee was developing consensus standards on ergonomics for private businesses, but no consensus was reached and the standards have yet to be issued.

Other factors affected the tracking of WRMSDs, making it more difficult for HHE investigators to document the effectiveness of workplace changes. One factor was the 2004 change to the OSHA-mandated workplace illness and injury logs, removing the column for disorders due to repetitive trauma. Another factor was the ending of NIOSH funding in 1998 to states for collecting data on carpal tunnel syndrome. Several states passed legislation removing carpal tunnel syndrome as a recordable work-related disorder for workers' compensation. In some states, such as Virginia, this followed the 1995 Congressional moratorium on OSHA ergonomics regulation. In other states, such as Illinois, this occurred around the time of the hearings on the 2000 OSHA ergonomic standard.

Noise and Hearing Loss

Issue. Noise-induced hearing loss is an irreversible, sensorineural condition that progresses with exposure. Although hearing ability declines with age in all populations, exposure to noise produces hearing loss greater than that resulting from the natural aging process. This noise-induced loss is caused by damage to nerve cells of the inner ear and, unlike some conductive hearing disorders, cannot be treated medically.

Since 1996, the HHE Program has received 110 requests concerning noise exposure or hearing loss. This narrative examines the impact that the Program has had on three groups of workers. HHE requests concerning law enforcement officers were made primarily by managers of federal agencies (e.g., U.S. Immigration Services) and state police agencies. HHE requests concerning carpenters were made by the United Brotherhood of Carpenters. HHE requests concerning animal shelter workers were made by managers at several facilities. Although these occupations are highlighted below, the HHE Program has done field investigations for noise hazards for many other occupations and in a wide variety of industries. In addition, many recent requests have concerned noise exposures in office settings where the issues primarily are interference with effective communication and comfort.

Approach. For most noise investigations, HHE investigators collected personal noise dosimetry data and area noise measurements; for others, they did spectral analyses and hearing tests. The HHE Program conducted hearing tests for 600 carpenters and apprentices at two national conventions in late 1995. Among law enforcement officers, issues related to firearms training were paramount. In two investigations, the HHE Program evaluated noise exposures associated with firearms training and proficiency qualification activities. Noise levels ranged from 159-169 decibels (dB), and were above the NIOSH exposure guidelines. Hazardous noise exposures were also identified by HHE investigators at animal shelters. During CDC's public health outreach in Louisiana in the aftermath of Hurricane Katrina, HHE investigators measured excessive noise levels from barking dogs for voluntary veterinary staff at an outdoor animal shelter. Subsequently, in a series of four investigations unrelated to Hurricane Katrina, they found that kennel workers were exposed to noise levels up to ten times the NIOSH Recommended Exposure Limit. Although the number of employees at each investigated facility was small, many young workers had hearing loss or showed early signs of hearing loss.

Outputs and Transfers. For investigations involving personal dosimetry, HHE investigators verbally informed participants of their results at the time of the test and subsequently sent written documentation to the participants and their physician (when requested). For each field evaluation, HHE investigators produced a written report and distributed it according to standard HHE protocols. In total, the HHE program produced 55 numbered reports (see Section 3.4, Supporting Evidence) and 10 letter reports for noise investigations since 1996. These included four reports concerning law enforcement officers [NIOSH 2003a,b; NIOSH 2005a; NIOSH 2006a] and four concerning animal shelter workers [NIOSH 2007a,b,c,d].

In addition to the well-recognized hazards of noise in many manufacturing settings, the HHE Program investigated and published the results of evaluations of noise exposures of race track employees exposed to otoxic chemicals in addition to noise [NIOSH 2000a; Van Campen et al. 2005], employees working at monster truck shows [NIOSH 1998a; Morley et al. 1999], employees of medical examiners' offices using cranial saws [NIOSH 1997a; Martinez et al 2001], airline employees during flights [NIOSH 1999a; Tubbs 2000], communication workers exposed to noise interference from headsets [NIOSH 1997b; Tubbs and Franks 1998], and construction workers exposed to noise from roofing saws [ NIOSH 2007e], among others. In these reports, HHE investigators recommended structural modifications or modifications to the noise source to reduce exposures, implementation or improvement of hearing conservation programs, training on the proper selection and use of hearing protection (especially with regards to integrating hearing protection with other personal protective equipment, and balancing hearing protection needs with communication considerations), and methods for identifying potential noise hazards. The HHE Program published a NIOSH numbered document summarizing noise HHEs from 1986 through 1997 to further disseminate the findings and recommendations from these HHEs [NIOSH 1999b].

Since 1996, NIOSH investigators published 11 scientific articles based on these HHEs (see Section 3.4, Supporting Evidence) and gave 29 technical presentations. HHE investigators routinely presented findings from their investigations at national professional conferences, including annual meetings of the National Hearing Conservation Association and the American Industrial Hygiene Conference and Exposition.

HHEs concerning indoor firing ranges are featured on the NIOSH safety and health topic page for indoor firing ranges [http://www.cdc.gov/niosh/topics/ranges/]. Additionally, a NIOSH Hazard Alert on firing ranges has been completed [NIOSH, in press]. HHE investigators were members of the NIOSH firing range document development team providing technical expertise on noise and lead hazards among law enforcement personnel and others firing weapons at these ranges.

Intermediate Outcomes. Audiometric testing data for the International Brotherhood of Carpenters was provided to researchers in the NIOSH Hearing Loss Prevention Program, who were beginning a research program on hearing conservation in the construction industry. They used the data to establish a baseline regarding the hearing health of carpenters. Other NIOSH researchers published these data in a book on hazards in the construction industry [Sweeney et al. 2000]. The International Brotherhood of Carpenters used the data in a training initiative for their members.

An HHE investigator was selected as the NIOSH representative on an Occupational Safety and Health Administration/National Association of Shooting Ranges/Sporting Arms and Ammunition Manufacturers Institute Alliance Implementation Team. This team was established to promote safe and healthful working conditions for employees in target shooting facilities. The Alliance sponsored an international workshop on firing ranges in Rome, Italy in 2005, where the HHE investigator presented the results of firing range HHEs. Utah State University utilized the state highway patrol HHE investigation data [NIOSH 2003a] for a grant application to review hearing data from highway patrol troopers and develop hearing loss prevention programs for the highway patrol.

What's Ahead. The HHE investigations of noise hazards at animal shelters [NIOSH 2006a; NIOSH 2007a,b,c,d; Achutan 2007] stimulated a research initiative by HHE investigators. They have initiated a demonstration project that will involve installing and evaluating noise control measures at selected facilities. Another new area of investigation has been initiated based on HHE requests from the International Brotherhood of Boilermakers. This union has asked the HHE Program to evaluate the hazards of impact noise, an issue that has been more difficult to study. HHE investigators are partnering with researchers in the Hearing Loss Prevention Program and others to identify better methods to assess and control impact noise exposures. The HHE Program is also initiating an effort to conduct followback evaluations of selected noise HHEs where a recommendation was made to develop a hearing loss prevention program. This work is being done to determine the effectiveness of the investigators' recommendations, and to understand the barriers to developing such programs at the investigated facilities. Additionally, the HHE Program is partnering with the Hearing Loss Prevention Program in their new initiative to establish a hearing conservation award program.

Mixed Hazards

Global Health

Issue. One of the three NIOSH strategic goals is to enhance global workplace safety and health through international collaborations. NIOSH works with international partner organizations on research, training, documents, and technical assistance to benefit workers everywhere. In many developing countries there is a severe shortage of trained occupational health professionals (e.g., industrial hygienists, occupational physicians) so the capacity to recognize, evaluate, and control occupational health hazards is nonexistent or inadequate. Over the past 10-15 years, NIOSH has increased efforts to provide technical assistance and training to developing nations through international collaborations and partnerships.

The HHE Program has provided assistance to evaluate occupational health hazards and to enhance industrial hygiene and occupational medicine program capabilities. The HHE Program's global work is done in response to external requests. Other centers or offices in CDC including the National Center for Environmental Health, Office of Global Health, Office of Global Health Division of Epidemiology and Surveillance Capacity Development, and the DEOC have asked the HHE Program for assistance. The following external partners have requested assistance: U.S. Department of Labor International Labor Affairs Bureau, Pan American Health Organization (PAHO), World Health Organization (WHO), International Labour Organization, Taiwan Department of Health, Health Canada, Republic of South Africa National Center for Occupational Health, South Korean Occupational Safety and Health Research Institute (KOSHA), El Salvador Ministry of Health and Social Assistance, and health ministries in other countries having good diplomatic relations with the U.S.

A number of requests for international workplace investigations and technical assistance have come from PAHO. These requests focused on evaluating occupational exposures and potentially hazardous working conditions at specific companies. The requests included developing government occupational safety and health capabilities to recognize and reduce occupational hazards, diagnose occupational diseases disease, evaluate occupational and community health hazards in and near large industrial facilities, and respond rapidly to global environmental and occupational health emergencies. Approach. HHE investigators provided training and technical assistance to government and university programs involved with occupational safety and health (workplace inspections, industrial hygiene methods, training inspectors and occupational health and safety professionals, exposure assessment, medical evaluation, and epidemiologic methods). In some cases, the training supplemented organized university courses. In other cases, HHE investigators developed practical, hands-on short courses or workshops to address specific training needs.

Spanish language training was offered at work for NIOSH staff during a 6-year period in the 1990s. As a result, training offered by HHE Program staff in Spanish speaking countries was frequently presented in Spanish. Countries in which HHE Program staff provided assistance include Bolivia, Brazil, Canada, Chile, Colombia, Dominican Republic, El Salvador, Jamaica, Mexico, Peru, Philippines, Republic of South Africa, South Korea, Taiwan, Thailand, Venezuela, and Vietnam.

HHE investigators conducted industrial hygiene needs assessments in Mexico (1997) and South Africa (1999-2000). Three HHE staff members completed international assignments that lasted over a year in-country, involving Mexico (two) and South Africa (one). HHE investigators responded to requests from PAHO by conducting a study of worker exposures to aromatic and aliphatic hydrocarbons at an oil refinery in Colombia, and a study of worker and community exposures to heavy metals and sulfur dioxide at a large tin smelter in Oruro, Bolivia. HHE investigators assisted the National Center for Occupational Health in conducting a comprehensive assessment of workplace exposures to manganese at a South African manganese smelter. HHE staff participated as CDC technical team members for emergency responses to global epidemics (SARS) and the tsunami in Thailand. HHE Program staff assisted with designing and evaluating ventilation modifications for infection control, developed guidelines for converting hospital rooms into SARS patient isolation rooms, prepared designs for the rapid conversion of a vacated military facility into a SARS screening and observation facility, assessed environmental aspects of dedicated SARS hospitals, and worked in concert with the Taiwanese to develop hospital ventilation guidelines.

An HHE investigator led a team of NIOSH staff in a multi-year project from 2005-2007 to provide technical assistance for controlling silica exposures in Chile. The HHE investigator and other NIOSH staff developed a technical course for the Chilean government staff on control banding, engineering control methodology, and laboratory quality assurance/sampling, and analytical method development as part of the collaborative project. The course was presented and joint field visits to assess workplaces with hazardous worker exposures to silica were done in Santiago, Chile in 2006. The collaboration is ongoing.

The HHE Program arranged for and sponsored guest researchers to train foreign scientists from South Korea and the Republic of South Africa. The HHE Program mentored a 2-year fellowship for a Chilean occupational physician as part of the CDC Epidemic Intelligence Service training program and unpaid internships of several weeks for two industrial hygienists from Chile. An industrial hygienist from Korea will be joining the HHE Program for 1 year as a guest researcher.

Outputs and Transfers. HHE Program staff provided information to participants through educational courses, hands-on workshops, mentoring opportunities, and field investigation activities. Participants observed and participated in actual field investigations, providing hands-on learning in the workplaces of their native countries. Materials produced for the training sessions included course manuals, often customized for developing countries. HHE investigation reports and MMWR reports were products from HHE Program global activities [CDC 2003, 2005; NIOSH 1994a,b,c]. The HHE investigation at a Colombian refinery found that workers had hazardous exposures to benzene. The HHE investigation at a Bolivian tin smelter found workers had very high exposures to arsenic, cadmium, and sulfur dioxide, and surfaces throughout the smelter were highly contaminated with heavy metals. Both HHEs provided recommendations for control of the hazards identified. Recommendations in the two HHE reports identified needs for further exposure assessment, implementation of engineering controls for reducing contaminant exposures, implementation and improvements in personal protective equipment programs, and implementation of medical surveillance [NIOSH 1994a,b,c].

A NIOSH-developed analytical method for visibly disclosing the presence of lead on workers' hands and workplace surfaces was included in a 2005 HHE training course on methods for sampling lead in the workplace and community in El Salvador. HHE investigators provided technical assessments and needs assessments for countries seeking to develop their occupational hygiene capacity (Mexico, Brazil). The HHE Program translated HHE reports and presentations into Spanish. The Program's technical assistance in South Africa resulted in completion of a research study and publication of two peer-reviewed papers on manganese occupational exposure assessment and the health effects of manganese exposure [Myers et al. 2003a,b].

The HHE Program trained six visiting KOSHA scientists from the mid-1990s to the present. An industrial hygienist from the National Center for Occupational Health, Republic of South Africa, was mentored and trained in the HHE Program for 6 months in 1999. The HHE Program trained a Jamaican occupational health scientist during a 2-month internship in 2005.

Due to his experience assessing industrial hygiene capacity in Mexico, an HHE Program staff industrial hygienist was invited to participate in an 18-country meeting sponsored by WHO, PAHO, the American Industrial Hygiene Association, and the ACGIH in Sao Paulo, Brazil regarding development of occupational hygiene professionals in Latin America. The meeting resulted in publication of a PAHO Spanish-language guide on how governments could develop occupational hygienists in Latin America [PAHO 2001].

Intermediate Outcomes. The HHE Program has provided technical support to the development of occupational medicine and occupational hygiene practice in other countries through the training and mentoring efforts of HHE investigators. Education provided in the respective countries has been used by native occupational safety and health practitioners to develop and enhance occupational health research studies (Mexico 1997, South Africa 1999-2000, El Salvador 2005). In January 2007, KOSHA's Occupational Safety and Health Research Institute of South Korea initiated a Workplace Health Partner Program patterned after the HHE Program. This program provides technical assistance, conducts workplace investigations, and performs epidemiologic investigations to assess the work relatedness of diseases upon request by employees, employers, managers, and the Ministry of Labor. As of April 2007, KOSHA had received 48 Workplace Health Partner requests for assistance. The NIOSH Authoritative Recommendations Program is using knowledge gained from HHE staff field visits and technical collaboration in Chile to develop information products to assist employers in Chile with controlling hazardous exposures to crystalline silica in mining.

External Factors. The success of global collaborations of the HHE Program ultimately depends on political, economic, and social factors among other countries and partner governments. In developing nations chronic high unemployment, poverty, corruption, a large "informal" sector, low government tax revenue, undereducated populations, basic health problems, lack of effective labor unions, and limited legal and human rights for workers can be challenges to improving occupational health. These factors, along with lack of adequate numbers of trained occupational health and safety professionals, result in inadequate capacity among developing nations for anticipation, recognition, evaluation, and control of occupational diseases and injuries. Improvements recommended by the HHE Program and other often are difficult to sustain.

Indoor Environmental Quality

Issue. Almost 70 percent of U.S. workers (approximately 89 million people) are employed in non-industrial, non-agricultural, indoor settings, referred to here as indoor work environments. Studies have associated some indoor environmental conditions with increased risks of nonspecific symptoms, respiratory disease (including asthma), and impaired performance. Available data suggest that improving building environments has the potential to result benefit the health of more than 15 million U.S. indoor workers, with estimated economic benefits of $5-$75 billion annually. Thus, research on this topic offers enormous potential health and economic returns. A historical review of the HHE Program showed that the proportion of indoor environmental quality (IEQ) requests since 1972 has increased hundredfold and now represents 56% of all requests. Over half of these mention mold or water damage as an environmental exposure concern, and about a quarter mention asthma as a health concern.

Approach. As experience was gained regarding the indoor work environment, HHE Program staff developed a standard building diagnostic protocol and health symptom questionnaire to perform IEQ evaluations. By the end of the 1980s, HHE Program results showed that more than half of the IEQ evaluations performed involved deficiencies in the buildings' heating, ventilating, and air-conditioning (HVAC) systems.

In October 1992, a CBS evening news broadcast segment about IEQ problems highlighted the NIOSH 800 number and encouraged viewers to contact NIOSH for assistance. As a direct result, the number of IEQ requests received by the HHE Program mushroomed to 814 in 1993. Because it was impossible for the HHE Program to respond with a field investigation for all of them, we selected 160 for study and evaluated each one using our standard protocol and questionnaire. The environmental and health information from these IEQ evaluations was then used to create a "problem building" database. Analysis of the database showed that reported symptoms were associated with indoor environmental factors.

As IEQ requests regarding mold, damp buildings, and asthma increased, HHE Program staff focused efforts to address these issues. These efforts have included the study of a damp hospital and comparison hospital in Montana, a community college in New York, and a state office building in Connecticut. In each, HHE investigators conducted employee health symptom questionnaire surveys, and in Connecticut, lung function testing. HHE investigators conducted environmental assessments using dampness indices and dust sampling for biomass. When the health outcome data were linked with environmental data, results showed associations between dampness indices, culturable fungi in dusts, endotoxins, and (1→3)-β-D-glucans exposures and risk of work-related respiratory symptoms. For the Connecticut office building, results showed that asthma incidence after employees occupied the building had increased sevenfold compared to asthma incidence before occupancy, suggesting a building-related cause of new onset asthma. The findings were supported by results of the lung function testing. HHE Program results also showed that remediation of one building with a history of water incursion problems failed to decrease building-related symptoms in persons whose symptoms had started prior to remediation.

HHE Program staff also developed a working collaboration with EPA (Region I) and the American Lung Association of Maine to evaluate IEQ problems resulting from mold contamination in a Maine middle school.

To develop and apply better tools for IEQ evaluations, HHE Program staff have collaborated with EPA (Cincinnati) on the development of serological monitoring assays for exposure assessments of fungi. To date, HHE investigators have used the immunoassay for stachylysin, a hemolysin produced by S. chartarum, as a biomarker for S. chartarum exposure during IEQ evaluations; results have been mixed. HHE Program staff have also collaborated with the University of Cincinnati's Department of Environmental Health on the development of immunoassay-compatible sampling techniques for fungal spores and fungal fragments. This collaboration has resulted in the development of a new two-stage bioaerosol sampler and a technique for the separation of fungal fragments from fungal spores. A prototype of this new bioaerosol sampler has successfully been used during HHE IEQ evaluations.

Outputs and Transfer. To date, more than 3,700 IEQ HHEs have been completed by the HHE Program, and information to assist in the resolution of their IEQ problem was provided to each. The great majority of these (3,567) have been completed since 1990, consisting of 643 field investigations, 150 numbered reports, and 3,417 letters and referrals. HHE Program staff have also contributed to more than 30 publications over the last decade describing the scientific information learned from these IEQ evaluations (see Section 3.4, Supporting Evidence).

In 1996, HHE Program staff published three articles describing environmental findings, thealth symptoms, and environmental factor-health symptom associations from the "problem building" database of the 160 buildings studied in 1993 [Crandall and Sieber 1996; Malkin et al. 1996; Sieber et al. 1996]. This was followed in 2002 by a publication reporting on a re-analysis of the associations between HVAC factors and health symptoms [Sieber et al. 2002].

In 2001, the final report for the IEQ evaluation of the damp hospital and comparison hospital in Montana was released by the HHE Program. This evaluation showed a positive association of environmental measures (mold exposure and dampness index) and risk of building-related respiratory symptoms. Recommendations included medical surveillance of employees and improved mold remediation practices [NIOSH 2001a].

In 2003 and 2004, IEQ evaluations carried out and reported by HHE Program staff at a middle school in Maine in collaboration with an EPA-funded Environmental Management System pilot project, and managed by the American Lung Association of Maine, helped keep the school open. This pilot project team was one of seven Maine groups out of 70 nominations to receive EPA 2005 Environmental Merit Awards that recognize significant contributions to environmental awareness and problem solving. The press release announcing the awards specifically mentioned the collaboration with the HHE Program [http://www.epa.gov/region01/pr/2005/may/dd050516.html].

For the Surgeon General's Workshop on Healthy Indoor Environments in 2005, HHE Program staff served on the planning committee, played a large role in setting the agenda, gave the presentation "Priority Research Needs for Improving the Health of Workers in Indoor Environments," and served as moderator for the closing session "Vision for the Future." Subsequently, the Surgeon General spoke on the key issues raised during this workshop at the White House Summit on federal sustainable buildings in January 2006 [http://www.surgeongeneral.gov/topics/indoorenv/].

In 2005, an interim report documenting health problems in a damp state building in Connecticut was completed by the HHE Program. The state of Connecticut subsequently commissioned an independent assessment by a private company specializing in IEQ. Their report corroborated HHE Program findings and, as a result, the building was kept open with no general relocation of employees but with alternative work locations given to employees with building-related health effects. The state of Connecticut is currently making repairs to the building based on these reports.

Recent noteworthy HHE Program peer-reviewed publications include, "Building-related Respiratory Symptoms Can be Predicted with Semi-quantitative Indices of Exposure to Dampness and Mold," which won the Best Paper Award from the Editorial Board of Indoor Air in 2005 [Park et al. 2004], and "Respiratory Morbidity in Office Workers in a Water-damaged Building," which received attention nationally and internationally due to a Market Wire press release in October 2005 that named the study as one of two landmark studies released in 2005 providing evidence that damp buildings are associated with developing asthma [Cox-Ganser et al. 2005]. The scientific information for the first of these publications was from the HHE Program evaluation of the community college in New York. The scientific information for the second of these publications was from the HHE Program evaluation of the state office building in Connecticut.

Intermediate Outcomes. In 1991, EPA and NIOSH published Building Air Quality - A Guide for Building Managers and Facility Owners. This document described the HHE Program building diagnostic protocol as a method to evaluate IEQ problems and provided additional information regarding how to establish an IEQ management plan, a recommendation typically made by HHE Program staff [EPA/NIOSH 1991]. This was followed in 1998 by the EPA/NIOSH document, Building Air Quality Action Plan that described in simpler language how to establish an IEQ management plan [EPA/NIOSH 1998].

In 1993, EPA developed the Building Assessment Survey and Evaluation (BASE) Study protocol for the study of 100 "non-problem" buildings. The HHE Program building diagnostic protocol served as a starting point and other required descriptive environmental measurements were added. The BASE Study health symptom questionnaire was so similar to the one used by the HHE Program that direct comparisons could be made between the HHE Program "problem building" and BASE Study "non-problem building" databases. One independent published comparison showed that symptom prevalence of building occupants in the HHE Program "problem building" database was significantly higher in all categories than those in the BASE Study "non-problem building" database [Brightman and Moss 2001].

In 1996, HHE Program staff provided technical expertise regarding IEQ to help prepare NIOSH testimony to OSHA during their rulemaking process for an indoor air quality standard. In this testimony, NIOSH supported the proposed OSHA standard citing results from the HHE Program and the scientific literature [Rosenstock 1996].

Also in 1996, NIOSH published NIOSH Manual of Analytical Methods Method 2549. This screening method for indoor volatile organic compounds (VOCs) was developed in response to an HHE Program need for a reliable method to qualitatively and quantitatively determine specific and total VOCs during the evaluation of IEQ problems potentially due to VOC exposure [NIOSH 2007].

HHE Program staff provided technical expertise regarding IEQ to the NORA Indoor Environment Team resulting in the 2002 publication, Improving the Health of Workers in Indoor Environments: Priority Research Needs for a National Occupational Research Agenda. This publication described estimates of health and economic benefits of improved IEQ and described needed IEQ research for the next 10 years [Mendell et al. 2002].

Findings from HHE Program IEQ evaluations of work-related asthma in office buildings and schools were highlighted in a June 2005 article on the need to improve IEQ in schools, Breathe Easy - What Every School Can Do to Improve Indoor Air Quality, published in the American School Board Journal, a publication of the National School Boards Association. That organization has over 40,000 school board members and school administrators as subscribers [Shorr 2005].

The EPA (Region I) sponsored an Environmental Management System (EMS) initiative at a middle school in Maine. The school and the EMS team, in collaboration with HHE Program staff, developed a process that helped to resolve IEQ problems originating from mold contamination [http://www.epa.gov/region01/pr/2005/may/dd050516.html].

In 2006, CDC published a document, Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods, to inform the public and health professionals regarding mold- and dampness-associated health risks and remediation steps [CDC 2006]. The need for this document was made apparent in the aftermath of Hurricane Katrina where mold and moisture damage were pronounced in New Orleans and across the Gulf Coast. Expertise of HHE Program staff and information from HHE IEQ Program investigations were used as a basis of this report.

In 2006, including invited technical expertise regarding IEQ from HHE Program staff, the findings of an IEQ workshop sponsored by the Lawrence Berkeley National Laboratory were published in, Causes and Prevention of Symptom Complaints in Office Buildings: Distilling the Experience of Indoor Environmental Quality Investigators. This publication described the current "state-of-practice" for the operation and maintenance of buildings to maintain acceptable IEQ and resolve IEQ problems as they may occur [Mendell et al. 2006]. This publication was subsequently selected as a Highly Commended Paper winner at the 2007 Emerald Literati Network Awards for Excellence.

The findings and needs from the HHE Program regarding mold, damp buildings, and asthma to develop and apply better tools for IEQ evaluations have also stimulated additional NIOSH research by the Exposure Assessment Emphasis Area. Examples of this research include animal model work on (1?3)-β-D-glucans, fungal fragments, and dusts from particular buildings; development of immunoassay biomarkers of exposure to fungi; and design of bioaerosol samplers amenable to biomass measurements.

End Outcomes. Environmental and health data generated by IEQ evaluations performed by HHE Program staff have motivated primary prevention at the buildings evaluated by implementing the recommendations made and have motivated secondary prevention by relocating some affected employees. Information received through the followback program for twelve buildings one year after the IEQ evaluation was completed (2001 through 2005) indicated that the HHE Program recommendations had been implemented and that there were fewer occupant health complaints. One respondent exclaimed, "what a difference!" For other IEQ evaluations, HHE Program staff have received information through more informal communication with building occupants that also indicate exposure reduction and improved health status of occupants for those buildings implementing the recommendations from the HHE Program.

External Factors. The October 1992 CBS news broadcast was unforeseen and resulted in an unprecedented demand for HHE Program IEQ evaluations. Although this was seen as a crisis at the time, it resulted in two very important improvements in the HHE Program and the state of IEQ knowledge: (1) implementation of the HHE Program triage process, and (2) creation of the HHE Program "problem building" database.

Although NIOSH provided testimony to OSHA during their indoor air quality rulemaking process in 1996, a final standard was never produced to regulate IEQ. Therefore, the HHE Program continues to use available consensus, state, and international IEQ standards as appropriate for the evaluation of IEQ problems in buildings.

What's Ahead. The HHE Program will continue to pursue the development and application of better assessment tools for the evaluation of IEQ problems in buildings. This includes the use of immunoassay biomarkers of exposure to fungi, the use of bioaerosol samplers for biomass, and evaluating the utility of assessing visual contrast sensitivity of damp building occupants.

The HHE Program will also continue to evaluate building dampness remediation and its resultant effect on the respiratory health of building occupants. This includes continuing the assessment of biomass and its association with respiratory symptoms. We will also continue to evaluate emerging IEQ issues such as airborne infectious disease transmission in the indoor environment.

In April 2007, the NIOSH Office of the Director convened a team of IEQ experts, largely from the HHE Program, to evaluate and upgrade the IEQ topic page on the NIOSH website to provide the most current and useful information regarding IEQ problems and their solutions. This ongoing effort will require the development of additional and more effective IEQ communication materials and eTools.

Metalworking Fluids

Issue. Metalworking fluids (MWFs) are fluids used during machining and grinding to prolong the life of the tool, carry away debris, and protect the surfaces of work pieces. NIOSH defines MWF aerosol as the mist and all contaminants in the mist generated during grinding and machining operations involving products from metal and metal substitutes.

Some 1.2 million workers in machine finishing, machine tooling, and other metal-working and metal-forming operations are potentially exposed to MWF and MWF contaminants. Occupational exposures to MWFs can cause a variety of health effects. Respiratory conditions include hypersensitivity pneumonitis, chronic bronchitis, and asthma. Dermatologic exposures are most commonly associated with, but not limited to, allergic and irritant dermatitis. In addition, substantial evidence shows that past exposures to some MWFs were associated with increased risk of cancer. Although actions taken in the last several decades have reduced that risk, it is not known if these actions have totally eliminated the risk.

Approach. The HHE Program completed 36 field investigations (see Section 3.4, Supporting Evidence) between January 1996 and June 2006 at facilities with tens to thousands of workers. Requestors included local and international unions, employees, management and labor representatives, and plant safety and health personnel. Health concerns involved dermatologic conditions; respiratory problems including hypersensitivity pneumonitis and asthma; kidney, bladder and prostate problems; skin and eye irritation; coughing; sore throats; headaches; sinus problems; allergic reactions; flu-like symptoms; and shortness of breath. MWFs were usually identified as a specific exposure of concern although other exposures were often cited and evaluated by the HHE investigators. HHE investigators conducted one or more site visits for all 36 of these requests.

HHE investigators conducted medical assessments and exposure assessments. Medical assessments included administration of health symptom questionnaires, pulmonary function tests, direct interviews, skin examinations, review of medical records, and evaluation of medical surveillance tools. Industrial hygiene evaluations included area and breathing zone sampling for airborne MWF levels, bulk MWF sampling for chemical components (including biocides and ethanolamines) and microbial contaminants (including endotoxin, fungal, and bacterial levels), and identification of microbial species (e.g., mycobacteria), assessing selection and use of personal protective equipment (e.g., gloves), evaluating engineering controls and their effectiveness (e.g., ventilation, enclosure of processes using MWFs), and documenting conditions of MWF use, and work, housekeeping, and personal hygiene practices. Other potential exposures evaluated included CO, polynuclear aromatic hydrocarbons, formaldehyde, isocyanates, metals, welding fumes, acids, and nitrosamines.

Sampling results varied across investigated facilities, with 17 having airborne exposure over the NIOSH Recommended Exposure Limit, 5 with less than the Recommended Exposure Limit, and 14 with no air sampling for MWF aerosols. For some facilities the ventilation and equipment enclosures controlled airborne levels of MWF very well whereas control equipment at other facilities were ineffective. In some instances, housekeeping and preventive maintenance problems were identified. HHE investigators identified or reaffirmed cases of hypersensitivity pneumonitis, work-related asthma, and dermatitis that could be associated with MWF exposures.

Outputs and Transfers: HHE investigators wrote 17 numbered reports and 17 letter reports; two additional reports are forthcoming (see Section 3.4, Supporting Evidence). All 34 were distributed according to standard HHE protocols.

The HHE Program collaborates with the NIOSH Exposure Assessment Emphasis Area in certain HHEs for which new exposure assessment methods are needed. In response, the Exposure Assessment Emphasis Area has worked with HHE investigators to develop and/or apply new test methods, such as a new method to evaluate the presence of triazine in MWFs [Pretty et al. 2004]. In another HHE nearing completion, HHE investigators partnered with NIOSH researchers from the Exposure Assessment Emphasis Area to analyze MWFs associated with contact dermatitis for irritants and allergens. In turn, the Exposure Assessment Emphasis Area is using HHE MWF samples to test new analytical methods for chemical analysis and also will test the samples for allergic sensitization using local lymph node assays.

HHE investigators served as authors or co-authors in six publications, including a book chapter [Freeman et al. 1998; CDC 1996; Trout et al. 2003; Weiss et al. 2002; Fink et al. 2005; Martinez et al. 2002].

HHE investigators made presentations pertaining to field investigations at three workshops: one by NIH (NIH Workshop 2004), one corporate-sponsored (TRW Corporate Workshop 2001), and one by a joint management-union committee on health and safety (UAW-Chrysler National Joint Committee on Health and Safety 1997). HHE staff presented information from these investigations at 12 symposia, seminars, and conferences including one MWF-specific symposium (ACGIH Symposium on Metal Removal Fluids 2002), eight occupational health professional conferences (Conference on Biological Contamination of Indoor Environment 1997; NIOSH Aerosol Symposium 1997; Northeast Ohio American Industrial Hygienists Association Meeting 1998; Public Health Professional Conference 2002; Ohio Bureau of Workers' Compensation Seminar 2002; American College of Occupational and Environmental Medicine State of the Art Conference 2000; North Central Occupational and Environmental Medicine Association 1997; American Occupational Health Conference 1998), two trade conferences (Manufacturing Conference 1998; Moldmaking Convention 1999), and one professional engineering conference (Society of Manufacturing Engineers Conference 1999).

HHE investigators provided the HHE requestors with a wide range of recommendations. Recommendations addressed the following areas: housekeeping; preventive/periodic maintenance on ventilation and MWF handling systems; work practice modifications; worker training about the health effects of exposures to cutting fluids, oils, and additives; proper selection and use of personal protective equipment to minimize skin contact; personal hygiene practices (eliminate smoking, eating, drinking in MWF areas; proper cleaning of skin to regularly removeMWFs); implementation and proper use of respirators and a respiratory protection program; reduction of airborne levels of MWF through the use of ventilation controls and enclosures; elimination or avoidance of specific types of components in MWFs (e.g., triazines); repair of equipment enclosures to contain aerosols generated internally; and provision of periodic medical monitoring.

Intermediate Outcomes. The NIOSH Authoritative Recommendations Program referenced seven HHE reports in the Criteria for a Recommended Standard: Occupational Exposure to Metalworking Fluid [NIOSH 1998a]. The condensed version of the criteria document was generated as a separate publication [NIOSH 1998b]. To date, over 12,000 copies of the original document and nearly 30,000 of the condensed version have been distributed. OSHA cited three HHE field investigations (NIOSH 1996, 1997, 1998] in the OSHA Metalworking Fluids Advisory Report [http://www.osha.gov/SLTC/metalworkingfluids/mwf_finalreport.pdf].

Seven websites reference the NIOSH Criteria Document on Metalworking Fluids, the condensed version of the criteria document, HHE reports, and NIOSH sponsored seminars on MWFs (websites include: Independent Lubricant Manufacturers Association; OSHA; Center for Research on Occupational and Environmental Toxicology; Metalworking Fluid Magazine; Organization Resources Counselors, Inc.; Occupational Hazards; HandS™ Health and Safety Resources). Independent Lubricant Manufacturers Association, a national trade association of 146 companies, released a white paper in 2003 regarding the management and use of MWFs. This paper cited the 1996 and 2002 CDC MMWR articles (authored by HHE investigators) addressing MWFs. The Washington State Department of Labor and Industries' Safety and Health Assessment and Research for Prevention Program produced a MWF technical report for employers in the state of Washington [Washington State Department of Labor and Industries 1997]. This document acknowledges that much of the information provided in the booklet was derived from the draft NIOSH Criteria Document on Metalworking Fluids, which incorporated HHE investigation findings.

End Outcomes. One HHE facility had a follow-up visit; according to an employee, 9 of 17 of the HHE investigators' recommendations had been implemented. In addition, a followback survey was received from an employee of a different facility who reported more that half of the recommendations had been implemented. At one facility, HHE investigators found high amounts of triazine (which the facility had previously eliminated from the workplace). The quality control manager of this facility found that the wrong fluid had been sent by the supplier, and this error was corrected.

External Factors. In 2001, the ACGIH proposed a new TLV advisory occupational exposure limit for MWFs of 0.2 mg/m³ (lower than the NIOSH Recommended Exposure Limit of 0.5 mg/m3 total particulate mass and 0.4 mg/m³ thoracic particulate mass). The proposed Threshold Limit Value was withdrawn by ACGIH some months later, but was proposed again in mid-2006. If this new TLV is adopted, responsible facility management will implement additional engineering and/or administrative controls to meet it; this may increase demand on the HHE Program.

What's Ahead. The HHE Program has initiated a strategic planning committee on MWFs to develop consistent evaluation methods and recommendations. The committee plans to contact industry and labor representatives with an interest in MWF to discuss current concerns, realistic recommendations, and best practices in facilities using MWFs. A comprehensive literature search, focusing on the time period since the NIOSH Criteria Document was published, is also planned. The committee hopes to contribute to the scientific knowledge in this area and improve guidance to facilities that use MWF.

3.2  Strategic Goal 2. Promote Occupational Safety and Health Research on Emerging Issues

This section summarizes five areas where the HHE Program influenced research on emerging issues. Emerging issues can include identification of a new health hazard (e.g., flock-related lung disease) and the recognition that a known hazardous agent is now found in a new industry or working population (e.g. silica exposure among Hispanic workers in the roofing industry). The first two investigation areas described in this section, exposures to flock and flavorings, reflect instances in which a comprehensive research program involving field and laboratory components arose from a series of HHEs. In these instances, HHE investigators remained integral to the conduct of the research. As seen in other investigation areas described in this section, such as exposure to silica in roofing tiles and the hazards of CO from recreational boating, research on emerging issues often is transferred from the HHE Program to other NIOSH programs, particularly when that research involves engineering controls and analytical methods. Another investigation area described in this section, SARS, is a research initiative that arose out of the HHE Program's emergency response activities. In this case, some research activities initially were done by HHE Program staff; others were transferred to other NIOSH programs. The relationship of the HHE Program to NIOSH research activities is complex. HHEs themselves often provide a venue for opportunistic research when new situations come to light (e.g., SARS, methamphetamines), they offer a venue for NIOSH researchers to test new methods (e.g., field testing of a sampling device for mold, wipe methods for lead), and they stimulate the initiation of large-scale research efforts (e.g., flock and lung disease).

Flock-related Lung Disease

Issue. In 1996, an occupational medicine physician at Brown University in Rhode Island identified unusual interstitial lung disease cases in two young workers at one plant. Interstitial lung disease is rare in the general population and can be life-threatening. Many occupations with dust exposure are at risk for interstitial lung disease, such as the lung scarring due to silica dust and coal mine dust. The facility with two affected workers made carpet-like material for use in automobile upholstery. To make this material, workers cut long nylon fiber strands into short nylon fibers called flock. The flock was then impacted onto adhesive-coated fabric to make a carpet-like product. The flock was not of respirable size. No known respiratory hazard existed in this industry, which employs about 3,000 people. However, two case patients with a rare disease prompted their employer, Microfibres, Inc., to request an investigation by the HHE Program to explore the unknown cause.

NIOSH work arising from this HHE request has shown that flock-related interstitial lung disease is pathologically-unique, severe (with some cases requiring intensive care unit ventilation), slowly reversible over months to years, and present in other flock plants using nylon and rayon flock fibers. International scientists have recently identified this disease in relation to two other synthetic polymers used in flock, polyethylene and polypropylene. Thus the identification of two sentinel cases of interstitial lung disease by an occupational physician spurred recognition and characterization of an emerging respiratory hazard.

Approach. HHE investigators conducted a cross-sectional study of employees at Microfibres, Inc. that included health questionnaires, chest radiographs, and pulmonary function tests including diffusing capacity of the lung (a measure of the ability of the lung to exchange gases with inhaled air). HHE Program investigators conducted environmental sampling of respirable dust in different job areas and examined cut flock and dust samples microscopically. NIOSH investigators found that nylon fragments in the respirable size range were generated during cutting of the nylon strands and milling the resulting flock fibers. They found associations between flock dust exposure and symptoms, diagnoses, and pulmonary function abnormalities, in an exposure-response pattern. These associations supported attribution of a new interstitial lung disease to flock-associated dusts.

Dissemination of HHE Program findings about this new lung disease risk at Microfibres, Inc. in 1998 resulted in requests for HHE investigations at two Massachusetts flock companies, each of which had a biopsy-confirmed case. These findings also triggered a request for an HHE field investigation at a Kansas greeting card manufacturing facility that used rayon flock to make soft, fuzzy greeting cards. In all three plants, HHE investigators showed exposure-response relations between respirable flock-associated dust and respiratory health outcomes assessed by pulmonary functions and/or symptom surveys. At the request of a state health department, the HHE Program conducted a follow up investigation at a previously evaluated flock plant after a new case was identified in 2005. This investigation of employee symptoms and respirable dust levels showed that the earlier NIOSH recommendation to avoid use of compressed air for cleaning flock equipment had not been considered feasible by the company, and that exposures had not decreased.

Outputs and Transfer. The five HHE investigations of flock-exposed work forces resulted in company-specific final reports [NIOSH 1998; 2000a,b; 2006a,b]; presentations at four American Flock Association national meetings in 1999, 2000, 2005, and 2006; a pathology workshop that described the unique pathology; presentations at the 6th International Conference on Environmental and Occupational Lung Disease in 1999; and seven peer-reviewed research publications [CDC 1997; Boag et al. 1999; Burkhart et al. 1999; Eschenbacher et al. 1999; Washko et al. 2000; Daroowalla et al. 2005; Antao et al. 2007].

Intermediate Outcomes. As previously noted, the initial HHE field investigation raised awareness of this newly identified interstitial lung disease in the flock industry, leading to recognition of new cases and to other HHE requests. In addition, HHE Program results motivated the implementation of engineering controls at the initial Rhode Island facility, as well as at the Massachusetts and Kansas facilities. The Rhode Island facility plant manager became an advocate for workplace safety, which resulted in his facility achieving lower injury claim rates at well below the textile industry average (presented at American Flock Association meeting). His company again consulted the HHE Program in 2004 regarding a case of what has now become known as "flock workers' lung" in a worker at their North Carolina flock plant.

As a result of the HHE Program investigations, the American Flock Association established a new Occupational Health Committee that translated HHE Program findings regarding the risk of interstitial lung disease in relation to respirable flock dust exposure into a toxicity alert regarding the newly recognized hazard and how to prevent it (posted on their website but restricted to members of the American Flock Association). This alert was distributed to all American Flock Association member companies in the U.S. representing approximately 3,000 employees.

As a result of the HHE Program investigations, the international trade journal, Flock, published an editorial about the need for flock company managers to take action to prevent flock workers' lung and later published a scientific paper summarizing the HHE Program investigations [Castellan et al. 1999].

Animal studies at NIOSH stimulated by findings of this HHE Program investigation supported the biologic plausibility of respirable nylon flock causing lung pathology [Porter et al. 1999]. Dupont scientists conducted additional animal studies [Warheit et al. 2001].

Following the lead of HHE Program investigators, researchers in other countries have also undertaken investigations of flock workers and have documented previously unrecognized occupational respiratory disease among polypropylene or polyethylene flock workers in Spain and Turkey [Barroso et al. 2002; Atis et al 2005].

End Outcomes. The Microfibres, Inc., Rhode Island facility has reported no new cases of flock workers' lung since the HHE Program investigation. Likewise, very few cases have been reported in the U.S. since, suggesting that the occurrence of flock workers' lung has been reduced.

What's Ahead. The Engineering Controls Emphasis Area and HHE Program staffs are currently engaged with four flock companies in a project to reduce exposures to airborne respirable flock dust. This project addresses the lack of acceptance of the HHE Program recommendation to eliminate use of compressed air to clean loose flock from manufacturing equipment, a practice known to be associated with the generation of extremely high dust concentrations. NIOSH staff have demonstrated and modified a shrouded compressed air cleaning device, but this has proved inefficient and unacceptable to the industry. The focus of the intervention project now is to evaluate and disseminate best practices for reducing airborne dust exposure, including central vacuum systems, robotic cleaning devices, and enclosure of processes requiring compressed air cleaning.

Flavorings

Issue. Bronchiolitis obliterans related to artificial butter flavoring inhalation came to the attention of the HHE Program through an August 2000 request from the Missouri Department of Health and Senior Services, which had received medical reports of severe obstructive airway disease among eight former workers of a small microwave popcorn manufacturing facility. Four of these eight former workers were on lung transplant lists.

Approximately 11,000 production workers in the microwave popcorn and flavoring manufacturing industries are potentially at risk of developing this severe and irreversible disease. Approximately 150,000 additional workers at food production companies may also face some risk for developing this disease from inhalation exposures to artificial butter flavoring chemicals. Cases of this disabling, severe, irreversible lung disease have now been recognized in microwave popcorn manufacturing, flavoring manufacturing, other food production, and diacetyl manufacturing facilities.

Approach. HHE investigators established that excess respiratory disease (bronchiolitis obliterans) existed within the Missouri microwave popcorn manufacturing facility by comparing symptom, pulmonary function, and physician diagnosis data to national prevalence data and by examining the distribution of abnormalities within job and work area subgroups. To determine the likely etiology of the lung disease, HHE investigators combined the findings from health surveys and medical testing for objective abnormalities with flavoring chemical exposure measurements for jobs within the facilities, and examined exposure-response relationships. Exposure to diacetyl, a major component of artificial butter flavoring, was used as a marker of exposure to the complex artificial butter flavoring mixture.

As interventions were introduced at this microwave popcorn manufacturing facility to reduce exposures, HHE investigators studied workers over time to demonstrate that disease abnormalities stabilized in affected workers and that the risk of exposure was greatly reduced for new workers. Findings from these follow-up investigations resulted in additional requests for HHEs from companies, state health departments, and workers. Further HHE Program investigations allowed us to make generalizations across the industry about high risk jobs, exposures associated with lung disease risk, the likely importance of peak exposures, and the exposures associated with powdered flavorings and liquid/paste flavorings.

Outputs and Transfer. HHE Program investigations have resulted in six company-specific reports to date [NIOSH 2003a; 2004a,b; 2006; 2007a,b]; a NIOSH Alert, Preventing Lung Disease in Workers Who Use or Make Flavorings, disseminated to more than 6,600 companies [NIOSH 2003b]; two workshops for the Flavoring Extract Manufacturers Association, meetings with the American Popcorn Board, the Flavoring and Extract Manufacturing Association, and interested medical professionals; stimulation of animal toxicology research at NIOSH and the National Toxicology Program of the NIEHS; and ten peer-reviewed research publications [CDC 2002; Kreiss et al. 2002; Akpinar-Elci et al. 2004a,b; Kullman et al. 2005; Akpinar-Elci et al. 2005; Kanwall et al. 2006; Boylstein et al. 2006; Kreiss 2007; CDC 2007].

Intermediate Outcomes. In follow-up visits to four microwave popcorn facilities investigated by the HHE Program, HHE investigators have confirmed that companies have followed their prevention recommendations with regard to engineering controls, respiratory protection programs, and medical surveillance.

Further confirmation that the microwave popcorn manufacturers used HHE Program recommendations to good effect is the observation that three companies are actively pursuing ways to re-engineer their production processes to further decrease exposure. One of the microwave popcorn manufacturers is attempting a demonstration project to determine whether less costly exhaust ventilation is a feasible control option. Using HHE Program recommendations, the larger companies manufacturing microwave popcorn (including those not investigated by the HHE Program) have now protected most of their employees from exposure to artificial butter flavoring.

To increase awareness of potential occupational lung disease risk from inhalation exposure to flavoring chemicals, the Flavor and Extract Manufacturers Association developed and published a guidance document for both member and non-member companies. The document included information on the HHE Program investigations, work practices, and exposures that may pose risk to flavoring workers, and recommendations to minimize worker risk. This trade association has made this document freely accessible on its website [http://www.femaflavor.org/html/public/ RespiratoryRpt.pdf].

With input by HHE Program staff, NIOSH produced a comprehensive and informative "Flavorings-Related Lung Disease" topic page, which is posted on the NIOSH website [http://www.cdc.gov/niosh/topics/flavorings/].

In response to these HHE Program investigations, the NIOSH Authoritative Recommendations Program has begun the development of a recommended exposure limit for artificial butter flavoring chemicals. Additionally, the NIOSH Exposure Assessment and Engineering Control Emphasis Areas have begun an industrywide study of exposures and engineering control solutions in the flavorings and food industries. Results of this research will identify other worker populations potentially at risk and provide solutions to reduce their exposures.

That this HHE Program work has influenced others is evidenced by requests from groups including labor unions, public health experts, and academics to California OSHA and federal OSHA to develop emergency temporary standards for diacetyl. California OSHA and the California Department of Health Services are involving all California flavoring companies in a voluntary medical screening and exposure control program. The HHE Program is providing technical assistance.

End Outcomes. At the Missouri facility, exposures to artificial butter flavoring chemicals declined two to three orders of magnitude after implementation of engineering controls, significantly reducing exposure. Furthermore, HHE investigators have received no reports since 2003 that workers in any of the microwave popcorn manufacturing facilities investigated have developed artificial butter flavoring-related lung disease after exposure controls and medical monitoring were implemented. This suggests occupational lung disease risk for microwave popcorn production workers has been reduced at these facilities along with the demonstrated decrease in exposure to artificial butter flavoring chemicals.

What's Ahead. Several HHE Program activities are currently in progress. One recent HHE request resulted in an evaluation of a Montana popcorn-popping operation. A technical assistance request from California OSHA and the California Department of Health Services resulted in an investigation of a flavoring manufacturing plant in California that was the site of a documented case of flavorings-induced bronchiolitis obliterans. Finally, California OSHA has requested technical assistance in analyzing the voluntary compliance program medical screening data, and assessing flavorings exposures and developing potential control technology solutions across the California flavoring manufacturing industry. These California efforts are being done in collaboration with the NIOSH Exposure Assessment and Engineering Control Emphasis Areas industrywide study of exposures and engineering control solutions in the flavorings and food industries. HHE investigators will complete these efforts and take on others as requested as part of the effort to eliminate this severe, irreversible lung disease.

Severe Acute Respiratory Syndrome

Issue. The rapid spread of SARS from Hong Kong to China, Vietnam, Canada, and Taiwan during the first quarter of 2003 caused the WHO to issue a global alert. The agent responsible for the illness was rapidly identified as a novel coronavirus. However, the routes of transmission of the agent were not fully known during the outbreak, causing confusion and debate over the types of environmental controls and personal protective equipment needed to stop the spread of this disease. Airborne transmission of the disease would require the use of respiratory protection and airborne infection isolation rooms, while droplet and contact transmission would not require this level of protection. In April 2003, the Taiwan Centers for Disease Control asked CDC to investigate the impact of SARS among Taiwanese healthcare workers and to provide guidance on general infection control. In addition, the Taiwan Centers for Disease Control requested assistance in developing guidance for hospitals regarding patient isolation rooms, personal protective equipment, and general hospital health and safety. HHE Program industrial hygienists were part of the CDC team that addressed these issues.

During this same period, the Canadian government asked CDC for assistance with the investigation of an outbreak of SARS cases among healthcare workers in the Greater Toronto area. The first cluster of cases occurred among healthcare workers who had become infected while caring for SARS patients after directives for contact, droplet, and airborne precautions were instituted in March 2003. An industrial hygienist from the HHE Program participated in a three-person CDC SARS Investigative Team. A second request from the Canadian government was made in May 2003, when another cluster of SARS cases was reported following attempted cardiopulmonary resuscitation of a SARS patient. A second industrial hygienist from the HHE Program assisted during this phase of the investigation. Approach. The HHE Program sent three teams of two industrial hygienists each to Taiwan between April 2003 and June 2003 in response to the request for assistance in developing guidance for hospitals about patient isolation rooms, personal protective equipment, and general health and safety. In addition to working with the Taiwan Centers for Disease Control, the HHE investigators also worked with the Taiwan Department of Health, the National Taiwan University College of Public Health, and the Taiwan Institute for Occupational Safety and Health.

In Taiwan, HHE investigators initially focused on isolating SARS patients, protecting healthcare workers during fever screening and patient care, and providing advice on disinfection, direct contact, and airborne precautions. Eleven dedicated SARS hospitals were evaluated by HHE investigators to assess airborne infection isolation rooms, infection control practices, healthcare worker and patient entrance and egress pathways, protective equipment practices, and healthcare worker training. As the SARS epidemic waned in Taiwan, efforts by HHE investigators turned to assessing infection control practices, strategies for handling future SARS patients, designs for effective patient isolation and fever screening stations, personal protective equipment practices, and healthcare worker training [Esswein et al. 2004]. Thirty-two hospitals or medical centers that were treating SARS patients or were under consideration for use as SARS treatment facilities were visited. HHE investigators worked with Taiwanese government and academic scientists to carry out environmental assessments and facilitate the major infrastructure modifications necessary to increase capacity to triage and treat seriously ill patients, while at the same time protecting healthcare workers [Esswein et al. 2004].

An HHE investigator visited four healthcare facilities in the Toronto area to review infection control precautions, assess ventilation characteristics, and observe the use of personal protective equipment in facilities providing care for SARS patients. Additionally, the team participated in meetings with local and national health agencies. Recommendations were made during these meetings to implement respirator fit testing of healthcare workers to ensure adequate respiratory protection against airborne viral particles. The CDC team also participated in meetings with representatives from Health Canada, Toronto Public Health, and affected healthcare facilities to further understand the circumstances leading to the transmission of SARS to healthcare workers despite apparent compliance with recommended precautions. The initial Toronto cluster investigation did not definitively identify the cause of the healthcare worker infections. Healthcare workers may have become infected with SARS from improper removal of personal protective equipment, lapses in hygiene, or inadequate fit of masks [CDC 2003]. The Canadian investigations suggested a systematic approach was needed to the problem of healthcare worker-acquired SARS infections in the absence of definitive knowledge on the relative importance of the various routes of transmission.

To further evaluate potential routes of transmission, the team conducted air and surface sampling for the SARS coronavirus at two healthcare facilities. Because this was a newly discovered agent and there were no validated environmental sampling methods available, the investigators utilized sampling techniques that had been successful in recovering other viruses from air and surfaces. Samples were sent to Health Canada's National Microbiology Laboratory and to CDC for analysis by polymerase chain reaction and culture. Three surface swab samples from a patient room and a medicine refrigerator handle were polymerase chain reaction-positive. These samples were negative by culture, however it could not be determined whether this represented the presence of non-viable/non-infectious organisms, or problems with collection, transport, or analysis rendering the organisms non-culturable.

On the second evaluation in Toronto, an HHE investigator worked with local public health professionals and representatives from Health Canada to evaluate the personal protective system worn by some workers involved in the second cluster of cases among healthcare workers in Toronto [Christian et al. 2004]. This protective system was originally designed to protect patients in a sterile operating field from infectious particles released by the surgical staff. Investigators suggested that there may have been problems with the use of the personal protective equipment and that the characteristics of these systems were not sufficient to provide true respiratory protection, only barrier protection.

Outputs and Transfers. HHE investigators provided officials in Taiwan with written documentation of the results from the surveys of 11 dedicated SARS hospitals evaluated for airborne infection isolation rooms and wards, infection control practices, healthcare workers and patient entrance and egress pathways, protective equipment practices, and healthcare worker training.

HHE investigators provided results of their evaluation of 32 hospitals to the Taiwan Center for Disease Control. They addressed appropriate infection control practices, expedient hospital ventilation modifications, guidelines for converting hospital rooms into SARS patient isolation rooms, and design and oversight for construction and rapid conversion of a vacated military facility into a SARS screening and observation facility.

Results of the air and surface samples collected by HHE investigators and analyzed by scientists from the National Microbiological Laboratory of Health Canada, were published in the peer-reviewed literature [Booth et al. 2005]. This work demonstrated the presence of viral material on surfaces in a SARS patient room. Difficulties in conducting environmental sampling for infectious agents in the workplace were highlighted during the Toronto investigation. An HHE investigator brought this important matter to the attention of the CDC Director later that year by giving a presentation titled "The Critical Role of Environmental Sampling in Infectious Disease Investigations: Improving CDC Preparedness." Problems in adapting traditional clinical methods for use with environmental sampling were discussed in the formal presentation using experience gained from the SARS investigations of 2003 and the anthrax investigations of 2001 where extensive sampling was conducted by the HHE Program in U.S. workplaces.

In 2004, in response to the continuing debate over the use of respiratory protection to prevent SARS transmission to healthcare workers, The Change Foundation, a foundation established to promote and improve healthcare delivery in Ontario, funded a project to evaluate facial protection of healthcare workers. HHE investigators who had participated in the Toronto investigations were invited to be on the panel to determine the scope of work, review project proposals, and select awardees. The final report of this work was published in 2004 and included a review of the scientific literature on bioaerosols, filtration, design and performance of facial protective equipment (respirators and masks), and organizational factors affecting worker protection. The report also included a list of priorities for further study [Yassi et al. 2004].

HHE investigators authored three peer-reviewed journal articles from these evaluations and made 10 presentations to professional and occupational safety and health audiences to further disseminate the information gained from the investigations (see Section 3.4, Supporting Evidence). In addition, after returning from these investigations, HHE investigators assisted in the development of CDC guidance documents that were posted on the CDC SARS website dealing with SARS transmission to airline staff, healthcare workers, and lab workers, with particular emphasis on documents dealing with the use of respiratory protection and aerosol-generating procedures [http://www.cdc.gov/ncidod/sars/ic.htm].

Intermediate Outcomes. The Taiwan Institute for Occupational Safety and Health electronically disseminated guidelines developed with input by HHE investigators for the rapid conversion of hospital rooms to negative pressure isolation rooms for SARS patients to facilities engineers working in all of the nation's public and private hospitals. A total of 698 negative pressure airborne infection isolation rooms were completed in Taiwan as a nationwide project in approximately 13 days [Esswein et al. 2004]. On May 27, 2003, the Mayor of Kaohsiung, Taiwan sent a letter to the HHE investigators acknowledging their "fine contribution to fighting against SARS in Kaohsiung" and to express his "highest esteem for the respectful work." The team also received an award from the Taiwan Department of Health and Taiwan Center for Disease Control for contributions towards the containment of the SARS outbreak in Taiwan.

Using information from the surveys of 11 dedicated SARS hospitals, Taiwan Institute for Occupational Safety and Health engineers developed an Inflatable Negative Pressure Isolation Chamber. This is a compact, easy-to-use disposable isolation chamber that can be attached to many types of moving equipment, including stretchers, carts, and dollies. It is intended to protect all operators involved in the transporting of patients with unidentified fevers [IOSH 2007].

At one Toronto facility, a room that was going to be used to intubate a SARS patient (a procedure that generates infectious aerosols and had been associated with the initial cluster of SARS infections) was determined by the HHE investigator to be under positive pressure. This information was immediately conveyed to the hospital staff and the procedure was relocated to a room that was under negative pressure. This action eliminated the potential for exposure to aerosols containing the SARS virus to unprotected patients and hospital staff.

In 2004, NIOSH was asked to participate in the CDC Environmental Microbiology Working Group to assess CDC's current environmental microbiology capacity and make recommendations to the Director on future directions. This group was formed in response to concerns raised during the SARS and anthrax investigations where the importance of environmental sampling in assessing health risks and determining the efficacy of remediation efforts was highlighted. An HHE investigator participated in these meetings and the Working Group developed a white paper with recommendations for enhancing environmental microbiology capacity at CDC [CDC 2004]. The document included an appendix which outlined the experience gained during the Toronto investigations including limitations in interpreting the sampling data due to a lack of validated methods and uncertainty over the significance of polymerase chain reaction-positive, culture negative results. The proposal was supported by the CDC Director, and plans are underway to develop a new facility dedicated to environmental microbiology. Possible sites for the new activity have been proposed and include Cincinnati, Ohio, which is close to the NIOSH laboratories.

In recognition of their international efforts to control SARS in Taiwan and Canada, HHE investigators received the U.S. Department of Health and Human Services Secretary's Recognition Award for Extraordinary Teamwork, Productivity, and Scientific Excellence.

End Outcomes. Working with Taiwan's public health agencies, HHE investigators contributed to increased isolation room capacity in Taiwan. Eleven dedicated SARS hospitals and medical centers were established. Hundreds of new isolation rooms are now available for future responses to emerging infectious respiratory diseases including pandemic influenza. This increased capacity is expected to reduce the potential for healthcare worker exposures to SARS and other airborne infectious agents. Though it is not possible to determine in a more comprehensive manner the broad impact of this work, the HHE investigators' involvement, as demonstrated by the activities and outcomes noted above, played a role in the control of the SARS outbreak. In July 2003, no new SARS cases were reported and the WHO declared the global outbreak to be over.

External Factors. The ability of the HHE Program's activities to have an impact on SARS prevention was enhanced by the modern universal healthcare system in Taiwan. Additionally, excellent working relationships with the Taiwanese partners, the participation of agency and academic professionals with strong technical skills and a strong public health infrastructure facilitated getting the work done quickly, establishing effective routes of communication, and ensuring that the work would continue when the HHE investigators departed.

Silica in the Roofing Industry

Issue. Exposure to respirable-sized crystalline silica particles places workers at risk for the development of silicosis, an irreversible condition that decreases lung function and increases the risk for lung cancer. Workers who develop silicosis can have a marked decrease in their quality of life due to difficulty breathing, cough, chest pain, and exercise intolerance. To diagnose silicosis the treating physician must know that the patient has a history of work-related exposure to respirable silica confirmed by either a chest x-ray or a lung biopsy. Without the exposure history, silicosis can be misdiagnosed as other chronic lung ailments such as emphysema or generic pulmonary fibrosis.

The HHE Program received a union request for an HHE in March 2003 at Diversified Roofing, a roofing contractor in Arizona. The request stated that there was concern that employees were exposed to hazardous levels of dust during cutting of cement tiles, but the employees were unaware of the potential for silica exposure. The HHE Program received three additional requests from the union regarding similar exposures to members working for three other Arizona roofing companies. Roofing projects using cement tiles occur primarily in Arizona, Florida, New Mexico, and southern California.

In one community, Diversified Roofing installs approximately 800 roofs per month and is expected to continue at this location until 2008. Diversified Roofing employs 375-400 workers, while the other three companies were smaller contractors. Spanish is the primary language for most of the employees. In May 2005, the BLS estimated 195,520 employees in the relevant roofing industry class.

Approach. HHE investigators made an initial site visit in April 2003 with follow-up visits in June 2003 and three site visits in 2005. HHE investigators collected samples of cement tile dust, ran spot checks on noise and CO, and gathered data on dust particle size during the initial visit. Subsequent visits included measurement of personal exposures to total and respirable airborne particulate fractions, CO, silica, and noise. Respirable particulate air samples provided the crystalline silica data. Employees monitored for workplace exposures responded to questions about their work practices, use of personal protective equipment, and general health symptoms. HHE investigators medically screened employees from the four companies involved in the HHE requests. The screening for consisted of a medical questionnaire, lung function testing (spirometry/pulmonary function test), and a chest x-ray.

Based upon the four industrial hygiene evaluations, HHE investigators determined that some employees exceed OELs for noise, CO, and total and respirable dust. The respirable silica exposure results showed that greater than 75% of the employees' levels exceeded OELs. This series of HHEs was the first time that respirable silica overexposures were documented in the roofing industry. All employees' exposures to respirable silica are potentially aggravated by the use of a gas-powered leaf blower to remove dust and debris from the tiles after the roof is completed. Preliminary evaluations of engineering controls on roofing tile saws revealed that dust levels were not reduced to a level that would result in silica exposures below OELs.

The medical screenings revealed that most participating roofers had normal lung function. Of those with abnormal lung function, none had moderate or severe impairments. After controlling for the effects of smoking, HHE investigators found that lung function decreased with increasing years of dry cutting cement tiles. No chest x-rays showed findings consistent with silicosis. Informal employee interviews revealed that respirators and hearing protection were infrequently worn, and none of the employees reported that they knew the hazards of silica overexposure even though some employees reported respiratory symptoms consistent with silica overexposures, such as difficulty breathing and/or cough.

Outputs and Transfers. The HHE Program delivered one HHE numbered report and two letter reports according to standard HHE Program protocols [NIOSH 2006a]. Recommendations provided in the final report addressed preventing or minimizing exposures to respirable silica, noise, and heat; monitoring employees' respiratory health; and educating employees regarding the hazards of silica exposure. Three journal publications and a national union newsletter carried articles about findings from this HHE [Eisenberg and Sollberger 2005, 2006; McCleery 2007]. HHE investigators initiated and contributed to a NIOSH numbered publication addressing the silica hazard of cement roofing tiles [NIOSH 2006b]. An HHE investigator is currently collaborating with a local Spanish language television station, Telenovela, to incorporate a public service message on silicosis into the story line of one of its programs, which are very popular in the Spanish community.

Presentations by HHE investigators included four national and one regional occupational safety and health meetings. Presentation of the findings occurred in 2005 and 2006 at the International Roofing Expo (average 9,000 attendees annually). HHE investigators participated in a multidisciplinary meeting in 2005 regarding silica exposure in the roofing industry attended by federal and state OSHA, national and local roofers' union representatives, National Roofing Contractors Association, Homebuilders Association, Center to Protect Workers' Rights, several roofing contractors, and the safety director of the largest cement tile manufacturer in the U.S. The National Roofing Contractors Association hosted a webinar on the topic of silica exposure in the roofing industry [NRCA 2006].

The HHE Program identified the need for evaluation and development of engineering controls to control generated tile dust and therefore shifted the task of continued research and study of dust control measures to the NIOSH Engineering Control Emphasis Area.

Intermediate Outcomes. Roofers included in the HHE Program investigations obtained medical screening results. For most participants, these results will provide a baseline for monitoring programs developed by their employer pursuant to the directives in the OSHA 1996 Special Emphasis Program on Silicosis. This directive outlines the medical monitoring requirements that employers must sponsor for their employees exposed to respirable silica on the job.

Materials from this HHE Program investigation and information presented on the silicosis surveillance system implemented in New Mexico in 2003 were requested by the Occupational Medicine program at the University of Arizona. Driven in part by the data from HHE Program investigations, the University of Arizona Occupational Medicine Program is working with the Arizona State Epidemiologist to establish a state silicosis surveillance program.

Groups such as the National Safety Management Society in its April 2006 Digest and Lab Safety Supply (Saf-T-News™) discuss the HHE Program silica and roofing tile investigation data, the symptoms of silicosis, and ways to protect workers [LSS 2006; NSMS 2006].

The NIOSH Engineering Control Emphasis Area is working with roofing contractors to evaluate new saw blades that produce less dust and local exhaust ventilation systems that capture saw emissions. The NIOSH Engineering Control Emphasis Area has produced two NIOSH numbered publications and has presented at two professional conferences [NIOSH 2006c,d].

External Factors. Several factors are likely to influence the extent to which the HHE investigators' recommendations are acted upon, but the extent of their influence is unknown. First, when the HHE report was released, the company for which the union originally requested the HHE was no longer a unionized shop. Second, the language barriers between the company management and employees may impede the ability of the employer to effectively communicate the nature and severity of the health hazard and may reduce the likelihood that employees will fully contribute to the hazard reduction activities. Finally, the hot climate is a disincentive to wearing respiratory protection.

To overcome the language barriers, the HHE investigators continue to educate roofing companies on the dangers of silica in cement roofing tiles and encourage them to work with their bilingual employees for dissemination of this information to Spanish-speaking workers.

Carbon Monoxide and Houseboats

Issue. In August 2000, after the death of two young brothers swimming near their family houseboat, the U.S. Department of Interior requested assistance from the HHE Program to determine the potential exposures to CO from generators on houseboats on Lake Powell (Utah and Arizona), within the Glen Canyon National Recreational Area. DOI expressed interest in evaluating CO exposures to employees who worked on or around houseboats while the generators operated as well as exposures to the boat-operating public.

The HHE Program received another request in August 2002 for assistance in evaluating CO at the Bridgewater Channel in Lake Havasu City, Arizona. The request expressed concern about Lake Havasu City police and fire department personnel who patrolled the Channel on holiday weekends, and about visitors in the Channel who had been treated for CO poisoning in the Havasu Regional Medical Center Emergency Department. These visitors had carboxyhemoglobin concentrations greater than 30%, indicating severe poisoning.

The Houseboat Industry Association submitted a request to the HHE Program and to the Coast Guard Office of Boating Safety in July 2003. The Association requested further testing of houseboats for CO exposures and engineering controls associated with gasoline-powered generator exhaust.

Approach. HHE investigators conducted 12 site visits for the August 2000 and August 2002 requests. HHE investigators worked with DOI and U.S. National Park Service in searching law enforcement, emergency medical services, and hospital records to identify cases of diagnosed boat-related CO poisoning on Lake Powell. The HHE investigators measured CO concentrations on and near houseboats and other types of recreational boats, and occupational exposures to CO (park rangers, concessionaires, dock personnel, maintenance personnel, fire fighters, police officers, and others).

Through case identification and surveillance, HHE investigators determined that between 1990 and 2004, 176 acute boat-related CO poisonings occurred on Lake Powell, 14 of which resulted in death. In their characterization of CO concentrations, HHE investigators measured CO concentrations as high as 30,000 parts per million in the airspace under the rear swim platform of houseboats and up to 88,200 parts per million when propulsion engines operated alone; the airborne CO concentration regarded as immediately dangerous to life and health is 1,200 parts per million [NIOSH 2000, 2003]. "Teak surfing" on ski boat platforms also resulted in high CO exposure [NIOSH 2001].

HHE investigators evaluated worker exposures at the Bridgewater Channel by measuring CO in air and exhaled breath. Real-time monitoring of 78 workshifts revealed many CO levels that exceeded OELs. Exhaled breath analysis on 81 workshifts revealed excessive post-shift carboxyhemoglobin levels.

Using information gathered in previous evaluations of exhaust stack design while collaborating with the NIOSH Engineering Control Emphasis Area, HHE investigators responded to the Houseboat Industry HHE request by evaluating controls for exhaust emissions at Table Rock Lake, Missouri. They concluded that exhaust stack controls performed better than side exhaust controls.

Outputs and Transfers. Following standard HHE protocols, HHE reports were distributed for the Glen Canyon National Recreational Area and Lake Havasu City investigations, and for the exhaust stack evaluations [NIOSH 2004a,b; 2005]. Letter responses were provided for four additional HHE requests. The HHE Program transferred the findings of the Engineering Control Emphasis Area evaluations and shifted the task of continued research and study of CO control measures to the NIOSH Engineering Control Emphasis Area.

HHE investigators produced a NIOSH website topic page addressing CO dangers in boating. HHE investigators produced two MMWR articles, two peer-reviewed articles, and gave over 40 presentations (see Section 3.4, Supporting Evidence). Presentation venues included professional and technical conferences; regulatory and advisory groups; trade groups and manufacturers; government groups at the international, national, state, and local levels; congressional testimony; and victims' advocate groups [House of Representatives 2001; McCammon and Baron 2001, 2004]. HHE investigators participated in the production of two videocassettes produced by the Canadian Safe Boating Council - Quiet Death on the Lake: Boat-Related Carbon Monoxide Poisonings and Carbon Monoxide - Where Do We Stand? One Year Later, which describes the developments one year after the HHE investigators began their evaluation of the Glen Canyon National Recreational Area and describes the investigation, the findings, and how they relate to other U.S. waterways [CSBC 2001, 2002].

In the interim and final reports, HHE investigators provided recommendations pertaining to CO exposures for workers and the boating public. Recommendations addressed engineering controls, houseboat design modifications, administrative controls, and work practice changes.

Intermediate Outcomes. The NIOSH Engineering Control Emphasis Area conducted extensive investigations evaluating CO sources and source modifications as indicated by producing 16 evaluation reports and five peer-reviewed publications. NIOSH Engineering Control Emphasis Area investigators provided approximately 15 additional technical presentations at professional and trade conferences.

DOI and the National Park Service staff participated in additional opportunities (conferences, meetings, preparation and distribution of educational materials) to disseminate information about the hazards of CO associated with boating. OSHA worked with HHE investigators to use and improve the OSHA computer application for calculating exposure concentrations to CO based upon carboxyhemoglobin and exposure time estimates.

Local and state government agencies as well as other organizations such as Lake Havasu City, the Chapman School of Seamanship, the Connecticut Department of Environmental Protection Boating Division, The Sydney Australia Waterways Authority, and the State of Kansas engaged in subsequent activities based upon the HHE Program investigations. These activities included information dissemination programs for 52 lakes and school-based education programs; developing educational materials and policy statements; serving as a source of technical input for related studies of CO exposures on waterways; solving CO-related problems; and initiating an epidemiologic study in four counties surrounding a large man-made lake used for recreational boating. The Eighth Western Rivers U.S. Coast Guard Auxiliary District Operation Boat Smart received a grant to purchase copies of the Where Do We Stand? CO videos for educational purposes. The group purchased 94 tapes, which were distributed to the 15 Division Captains of Eighth Western Rivers. Additional materials for public education were provided at the same time for later distribution to boat users. An estimated 1,200 of the 1790 members of the Eighth Western Rivers have viewed the video. Several colleges and other organizations (such as the U.S. Army Corps of Engineers and the Arkansas Game and Fish Commission) showed the video to their staffs.

HHE Program findings regarding CO and boating influenced state and local legislative actions, bills, regulatory amendments, codes, and ordinances. California, Nevada, Oregon, Pennsylvania, and Washington now have laws prohibiting the operation of motorboats while people are teak surfing, platform dragging, and body surfing, and when people are standing, sitting, or riding on the swim ladder or rear swim platform [California 2004; Nevada 2004; Oregon 2005; Pennsylvania 2004; Washington 2006]. In its Act, California specifically mentions HHE investigators' findings concerning surveillance of poisonings and death from CO exposure, the levels of CO produced by generators, and results of teak surfing studies. Washington State requires that any new or used boat sold must have a CO sticker placed on it, and the new owner must receive a brochure describing the dangers of CO. The Lake Havasu City Council passed ordinances prohibiting boats from idling on the Bridgewater Channel beach and permitting closure of the Channel when the measured air quality deteriorates [LHC 2004]. Lake Havasu City implemented an air quality assurance program and an employee monitoring program, prepared public awareness brochures highlighting HHE investigators' findings, and posted signs to alert the public of the potential danger before they entered the Bridgewater Channel area.

In 2001, a manufacturer and the U.S. Coast Guard announced houseboat recalls. Sumerset Custom Houseboats, a major houseboat manufacturer, announced a voluntary recall of its houseboats manufactured from the years 1953-1996 and its willingness to retrofit its competitors' boats [Sumerset 2001]. The Coast Guard issued a Media Advisory based on the HHE investigators' findings of CO near the swim platform [USCG 2001a].

As the HHE Program discovered new CO problems such as the initial hazard on the swim platform, hazards on (non-houseboat) watercraft, and teak surfing, the Coast Guard and National Park Service produced advisories and alerts to warn boaters about the potential harm from exposure to CO [USNPS 2001a,b; USCG 2001b].

The National Association of State Boating Law Administrators approved an act that prohibits operating a boat, "…while a person is teak surfing, platform dragging, or body surfing behind the motorboat…" and "…while a person is occupying or holding onto the swim platform, swim deck, swim step, or swim ladder of the motorboat…" [NASBLA 2005].

The American Boat and Yacht Council updated its standards and technical reports including exhaust systems and the design, construction, and testing of boats [ABYC 2002, 2004].

The 2004 California Boating Safety Report, Department of Boating and Waterways aired a radio message called "CO Kills" and discussed California's new law prohibiting teak surfing. In addition, the Department distributed 25,000 brochures to educate boaters on CO poisoning [DBW 2004].

End Outcomes. In July 2007, the first death recognized as being due to carbon monoxide poisoning since 2002 occurred on Lake Powell, where the problem first came to light. Awareness of the problem, however, may have contributed to early recognition and treatment of 21 persons who had symptoms of carbon monoxide poisoning, also in July 2007.

External Factors. The tragic death of young people caused federal, state, and local agencies; medical groups; private companies; consumer advocates and organizations; standards-setting organizations; and the news media to take notice. The situation involved a hazard that affected both the workforce and its customers. This convergence helped draw attention to the issues and provided additional motivation to act. The recent death and large poisoning episode, however, highlight the challenges of changing behavior.

Surface Wipe Methods for Chemical Detection and Decontamination

Issue. Lead poisoning and exposure to methamphetamine residues are serious occupational and public health hazards. Two separate requests received by the HHE Program, one in May 1994 and the other in October 2002, sought to evaluate worker exposures to these contaminants. Management at a battery manufacturing facility submitted the 1994 request through the Texas Department of Health, requesting an evaluation of their facility to determine if improved engineering controls had reduced occupational lead exposures. The Texas Department of Health had found elevated blood lead levels in children of the battery manufacturing facility workers and sought assistance to determine if the workers were carrying lead contamination home to their families. The Tri-County Health Department (Colorado) submitted the 2002 request for assistance to evaluate potential chemical exposures to law enforcement and emergency response personnel regarding clandestine methamphetamine laboratory seizures and to determine appropriate personal protective equipment and medical monitoring requirements.

Approach. Lead Exposure Assessment. HHE investigators conducted an evaluation at a Texas battery manufacturing facility to determine the effectiveness of engineering controls and to assess whether workers were carrying lead contamination home to their families. The plant had recently installed engineering controls, and virtually all the workers wore air-purifying respirators. Despite these controls, average blood lead levels were at the OSHA medical removal level for workers in the 3-month period prior to the evaluation by HHE investigators. The HHE Program evaluation of this facility also documented occupational lead exposures ten times the OSHA Permissible Exposure Limit in some locations. Additionally, dermal exposure assessment revealed that up to thousands of micrograms of lead could be detected on the workers' hands and on a variety of high contact surfaces at the facility (especially the cafeteria). HHE investigators then realized that dermal exposure was a critical route of exposure that had not been investigated sufficiently. This led to the idea of developing a real-time colorimetric method that could safely detect lead contamination on workers' skin and on environmental surfaces.

HHE investigators also initiated the development of a method to remove lead contamination from workers' skin. A skin cleansing method incorporating a system of decontamination (pH adjustment, mechanical removal, surfaction, and chelation) was developed with the intent to be more effective in removing lead contamination than soap and water and, at the same time, not harm workers' skin. Development of this method took more than a year of research and experimentation.

Methamphetamine Exposure Assessment: At the request of the Tri-County Health Department (Colorado), and in collaboration with the National Jewish Medical and Research Center, HHE investigators performed exposure assessments during 16 search and seizure operations of suspected clandestine methamphetamine laboratories in the Denver area. Exposure assessment concerns included identifying primary chemical exposures, determining which phases of the response posed the highest risk for the responders, determining appropriate types of personal protective equipment required during various phases of these seizures, and determining appropriate medical monitoring for responders. Methamphetamine residues ranging up to tens of thousands of micrograms were detected on surface wipe samples at every site, making it the most common exposure hazard identified. Subsequently, a NIOSH team composed of members from the HHE Program and the Exposure Assessment Emphasis Area convened in late 2005 to discuss possible approaches to developing a surface detection method for methamphetamine. Method development, bench testing, performance evaluation, licensing, and commercialization all occurred during 2006.

Outputs and Transfer. The need for HHE investigators to evaluate non-airborne exposure routes of lead at the battery manufacturing facility and methamphetamine at clandestine methamphetamine laboratories led to the development and commercialization of two novel surface wipe methods for chemical detection and an effective method for removal of toxic metals from skin.

In December 1996, the final report for the investigation of the Texas battery manufacturing facility was released by the HHE Program [NIOSH 1996]. HHE investigators also published a trade journal article pertaining to this investigation and development of the surface wipe method for lead [Esswein and Boeniger 2005]. U.S. Patent 6,248,593 was issued to HHE investigators in January 2006 for the "Handwipe Disclosing Method for the Presence of Lead." HHE investigators presented this method and its development at six occupational safety and health professional conferences and meetings (regional, national, and international) between April 2003 and October 2005. This method won the Southeast Region Technology Transfer Award in 2003 and the National Technology Transfer Award in 2004. A U.S. Patent application (11/093/178) for Wipes and Methods for Removal of Metals Contamination from Surfaces has been filed (patent pending). NIOSH eNews announced the availability of this technology to prospective manufacturers. Licensing for the "Handwipe Removal Method for Toxic Metals" will follow.

HHE investigators, staff from the Tri-County Health Department, and staff from the National Jewish Medical and Research Center prepared a joint report, "Chemical Exposures Associated with Clandestine Methamphetamine Laboratories." The report described results from the methamphetamine exposure assessment during the 16 search and seizure operations of suspected clandestine methamphetamine laboratories in the Denver area and demonstrated the need for a surface wipe method for methamphetamine [Martyny et al. 2004]. A peer-reviewed article has been accepted for publication in the Journal of Chemical Health and Safety [Martyny et al., in press].

Intermediate Outcomes. The "Handwipe Disclosing Method for the Presence of Lead" technology was licensed to SKC Inc. by the CDC Office of Technology Transfer in February 2003 [http://www.leadwipe.com]. Licensing for the "Handwipe Removal Method for Toxic Metals" is pending although a verbal agreement of intent to license has been given by MEDTOX Inc. and they are currently completing the licensing application.

The joint report, "Chemical Exposures Associated with Clandestine Methamphetamine Laboratories," describing the results from the methamphetamine exposure assessment during the 16 search and seizure operations of suspected clandestine methamphetamine laboratories in the Denver area is now publicly available on the National Jewish Medical and Research Center website, the Colorado Alliance for Drug Endangered Children website, and numerous other websites dedicated to the public health aspects of clandestine methamphetamine laboratories.

The NIOSH team that convened in late 2005 developed two surface detection methods for methamphetamine, a colorimetric surface detection method (similar to the one for lead) and an immunochemical surface detection method. Both methods for methamphetamine (MethAlert and MethChek) have been licensed by the CDC Office of Technology Transfer and are now commercially available [http://www.methwipe.com]. These methods are used by police, fire, and other responders as well as unanticipated users such as real estate agents, home inspectors, and the general public.

The surface wipe methods for chemical detection and the method for the removal of toxic metals from skin represent new technology and have only recently been made commercially available. Therefore, no information exists regarding how effective they are in reducing occupational exposure or illness. However, these methods have the promise of being able to effectively reduce occupational exposures to lead, other metals, and methamphetamine by allowing the easy detection of contamination on skin and surfaces, and a more effective removal of metals from the skin once found.

3.3  Strategic Goal 3. Protect the Health and Safety of Workers during Public Health Emergencies

Throughout its history, the HHE Program has provided technical assistance to individual worksites directly or through other government agencies following public health emergencies. The nature and extent of that assistance, however, dramatically changed after the terrorist attack on the World Trade Center in 2001. Involvement in the federal response to that event and to subsequent disasters including the tsunami in Southeast Asia, SARS in Taiwan and Canada, and anthrax in the U.S. mail, has broadened the mission of the HHE Program to explicitly acknowledge new responsibilities related to public health disaster preparedness and response. These responsibilities, however, are a direct outgrowth of the more traditional role of the HHE Program. The new responsibilities have given the HHE Program opportunities to transfer the knowledge and skills gained from thousands of field investigations to new partners and customers and broadened the arena in which the HHE Program operates.

The HHE Program works closely with the NIOSH Emergency Preparedness and Response Office, which has primary responsibility for planning for emergencies and coordinating response activities. This Office relies heavily, but not exclusively, on the HHE Program to provide field responders, subject matter experts, and operations center team leaders during events of national significance. Under the National Response Plan, NIOSH is responsible for occupational exposure assessments for complex environments.

Anthrax

Issue. Anthrax is a bacterial disease caused by exposure to Bacillus anthracis spores. Though anthrax spores are ubiquitous, few reports of the disease in humans have been reported. Anthrax can develop in persons who have inhaled or ingested spores, or have direct skin contact with the spores through open cuts and abrasions. The resulting infection, especially the inhalational form, can be fatal, but prompt treatment with antibiotics can be curative.

In 2001, one week after the terrorist attacks on the World Trade Center, an envelope containing B. anthracis spores was mailed to the American Media Inc. building in Boca Raton, Florida. After an American Media Inc. employee's illness was attributed to anthrax, the state of Florida and several federal agencies requested assistance from CDC. HHE investigators participated on the investigation team and were asked to conduct an environmental evaluation of the American Media Inc. building to look for evidence of contamination with anthrax spores. A subsequent request for technical assistance was received from the U.S. Postal Service to evaluate postal facilities in Boca Raton, Florida for B. anthracis contamination; HHE investigators responded by conducting environmental evaluations at these facilities. This was in response to a concern that postal employees may also have been exposed to the spores while handling the B. anthracis-containing envelope sent through the mail. The FBI later requested assistance from HHE investigators as part of their ongoing criminal investigation to determine more precisely where B. anthracis spores were present throughout the American Media Inc. building.

Shortly after the initial case was identified in Florida, additional envelopes containing anthrax spores were mailed to several news media offices in New York City and the offices of two U.S. Senators. During these attacks, 17 individuals became infected with anthrax; five died. HHE investigators participated in 26 emergency response investigations involving facilities in Washington D.C., Florida, Connecticut, New Jersey, New York, Missouri, and Texas. In many locations multiple sites were evaluated. For example, 55 separate facilities were evaluated in the Trenton, New Jersey, area by HHE investigators. Because of the extensive nature of the assistance requested, NIOSH staff from other programs assisted the HHE Program in conducting these emergency response investigations.

Approach. Environmental Sampling. HHE investigators collaborated with local, state, and federal health partners at the investigated facilities to design sampling protocols for the American Media Inc facility, postal facilities, Congressional offices, and media offices as part of the initial responses to the anthrax attacks. Using experience gained from HHE field investigations, HHE investigators combined traditional approaches for collecting surface and air samples at these facilities (such as dry swabs and wipes) with innovative sampling technologies. For example, a surface vacuuming technique using a dust collection filter sock, initially developed for allergen sampling, was used to collect anthrax spores from porous surfaces at large postal facilities.

Medical Monitoring and Surveillance. HHE investigators provided guidance on medical surveillance and prophylaxis for workers potentially exposed to anthrax, including remediation workers. HHE investigators coordinated biologic monitoring (measurement of an antigen-specific IgG in serum) before and after workers entered the American Media Inc. building to determine if their personal protective equipment and antibiotic prophylaxis were adequate. HHE investigators determined that environmental sampling workers did not have antibody responses to B. anthracis, either because their personal protective equipment prevented sufficient exposure, or because their prophylactic antibiotic therapy prevented an immune response.

Decontamination Procedures and Post-Clean-up Assessments. HHE investigators worked with EPA, OSHA, the Office of the Senate Sergeant at Arms, U.S. Capitol Police, state and local health departments, and others to determine if remediated Congressional buildings and post offices were ready for occupancy. As members of four multi-disciplinary Environmental Clearance Committees, HHE investigators were responsible for developing anthrax decontamination protocols and reviewing environmental sampling data to determine if the decontamination process was successful.

Sampling Methodology Research. Because validated air sampling methods for B. anthracis were not available, HHE investigators conducted research to determine the most appropriate methods for evaluating environmental contamination with this agent. This field research involved sampling in and around a postal machine in New Jersey that had processed four of the original anthrax-contaminated letters. Important findings from this work were that: (1) walking and light work were sufficient to re-aerosolize the spores, (2) the Andersen™ sampling method was the most sensitive for B. anthracis spore collection, and (3) to obtain maximum sensitivity, the lab should analyze the entire sample extract rather than just an aliquot, as had commonly been done.

HHE investigators assisted other NIOSH staff in a study comparing the relative effectiveness of sampling methods for collecting spores from surfaces in the Brentwood postal facility in Washington D.C., which was known to be highly contaminated with anthrax spores. This work showed that there was good agreement between results with the vacuum sampling method and wipe sampling, but that swab sampling was not as efficient in recovering spores in this environment.

As a result of the experience gained from conducting environmental sampling for B. anthracis during the anthrax attacks, Sandia National Laboratories invited HHE investigators to participate in an exercise to evaluate BROOM (Building Restoration Operations Optimization Model), a software-based tool to aid in the collection and management of environmental samples following a release of biological agents in a public facility. HHE investigators participated in the exercise and made recommendations to the researchers for improving the software.

At the request of the Defense Research and Development Canada, HHE investigators participated in a research study to investigate the effects of work practices, office layout, and ventilation patterns on dispersion of an anthrax surrogate during mail opening in an office building. HHE investigators provided ventilation expertise and conducted a tracer gas evaluation to document airflow patterns and air change rates. This work was done to evaluate the efficacy of published protocols for handling suspicious mail.

Case Investigations. In 2002, the HHE Program investigated a case of cutaneous anthrax involving a technician at a laboratory that had processed environmental samples for B. anthracis in support of the CDC anthrax investigations. The HHE Program determined that the laboratory technician with cutaneous anthrax likely had skin contact with a B. anthracis contaminated surface. This was believed to result from the use of alcohol instead of bleach to clean the laboratory surface. This represented the first case of laboratory-acquired anthrax in the U.S. since the late 1950s.

In 2006, the HHE Program investigated of a case of inhalation anthrax in an artist who made African drums from imported animal hides. The HHE Program's targeted environmental evaluation, in partnership with the New York City Department of Health and Mental Hygiene, confirmed the presence of B. anthracis in the individual's workspace with secondary contamination in the individual's van and apartment.

Development of Guidance Documents. The HHE Program sent investigators to the DEOC to respond to requests for help and information from workers, employers, and the general public during the anthrax investigations. In subsequent months, HHE investigators continued to be involved in preparedness activities and worked with other CDC scientists to develop guidance for employers, state and local health departments, emergency responders, hospitals, health-care providers, and others who use automatic detection systems in workplaces with machinery or production facilities that might aerosolize B. anthracis spores mechanically. Voluntary guidelines on consequence management were developed to assist responders in the event of a positive signal from the detection systems.

Outputs and Transfers. HHE investigators authored or co-authored 17 peer-reviewed publications from their anthrax work, made 38 technical presentations, and published one NIOSH numbered document and three web-based guidance documents (see Section 3.4, Supporting Evidence). The anthrax presentations were at national meetings (e.g., American Industrial Hygiene Conference and Exposition, National Conference on Environmental Sampling for Bio-Threat Agents, Association of Energy Engineers, American Society of Public Administrators, American Biological Safety Association, International Aerosol Conference, and American Public Health Laboratories, among others) and local meetings of EPA, FBI, CDC, and USPS. In addition, an HHE investigator provided oral and written testimony to the U.S. House of Representatives Committee on Government Reform Subcommittee on National Security, Emerging Threats, and International Relations regarding microbiological sampling methods for anthrax [Martinez 2003].

Environmental Sampling Efforts. Environmental sampling data collected by HHE investigators (or under their direction) were used to assess the extent of contamination within each facility, the need for remedial action, and the need for continued antibiotic prophylaxis of workers. Because of the need for immediate action when environmental sampling results became available, traditional HHE reports were not a common output of the HHE investigators' work. Rather, laboratory data from environmental investigations were shared immediately with the affected parties while HHE investigators were still in the field. HHE investigators participated in meetings with facility representatives, other CDC staff, and health department representatives to determine appropriate actions based on the environmental data. Later, HHE investigators co-authored journal articles with other CDC colleagues to further disseminate the information from the investigations in Connecticut [Teshale et al. 2002], New Jersey [Greene et al. 2003; Valiante et al. 2003], New York [Holtz et al. 2003], and Washington D.C. [CDC 2001a; Sanderson et al. 2002, 2004]. Lessons learned from the emergency response investigations in Washington D.C. prompted HHE investigators to publish recommendations that, if implemented, should reduce the potential for cross-contamination in future national and international emergency response activities [McKernan et al. 2003]. Technical assistance reports prepared by the CDC investigation teams (including HHE investigators) were shared with the facility representatives at the investigated sites for the investigations at selected USPS facilities in New York [CDC 2002a] and the Missouri stamp fulfillment center [CDC 2001b].

HHE investigators recognized the need to standardize procedures for collecting environmental samples for B. anthracis during the initial American Media Inc. investigation. Working with colleagues from other CDC Centers and researchers from public health and military laboratories responsible for sample analyses, HHE investigators refined procedures for collecting samples. This led to the development of a web-based publication on comprehensive procedures for collecting environmental samples [CDC 2002b]. Since this was the first time anthrax had been used in this manner, guidelines for respirator use to protect against exposure to B. anthracis were not available. HHE investigators worked quickly to develop recommendations on personal protective equipment use for NIOSH investigators who were conducting environmental sampling in contaminated facilities. These guidelines were later posted on the CDC website for use by other investigators responsible for conducting environmental sampling [CDC 2001c].

Medical Monitoring and Surveillance. Medical surveillance guidelines developed by HHE investigators for decontamination workers were disseminated throughout the public health community [CDC 2002c]. In addition, the findings from the biologic monitoring assessment of environmental sampling workers were published in the peer-reviewed literature [Biagini et al. 2004]. Although this publication included details of a method developed for use by HHE investigators at the American Media Inc. investigation, it has since become a standard method at CDC for measuring antibodies to B. anthracis in exposed individuals.

Decontamination Procedures and Post-Clean-up Assessments. EPA requested participation of an HHE investigator in a Peer Review Workshop to evaluate technical issues related to anthrax contamination of the Morgan postal facility in New York. The investigator responded to written questions from the group and made a verbal presentation to meeting participants. Federal Environmental Clearance Committees, with participation by HHE investigators, completed assessments of anthrax decontamination efficacy efforts in the Hart Senate Office Building, Longworth House Office Building, SA-32 mail facility annex, two USPS processing and distribution centers in Washington, D.C., and the USPS processing and distribution center in Trenton, New Jersey. Formal re-occupancy letters of recommendation for the USPS processing and distribution centers in Washington D.C. and New Jersey were issued by the committee chairs indicating that the decontamination processes were successfully completed and the facilities were safe for entry by employees and the public. For the Hart Senate Office Building and the Longworth House Office Building, the HHE investigator and other committee members were sequestered for about one week, during which time they reviewed sampling methods, remediation strategies, and analytical sampling results before finalizing their recommendation to release the buildings for re-occupancy.

Sampling Methodology Research. HHE investigators identified the most appropriate air sampling techniques to use when evaluating B. anthracis contamination in the work environment and delivered a numbered HHE report on this work [NIOSH 2004]. As the information became available, it was verbally communicated to NIOSH investigators who were participating in Environmental Clearance Committees mentioned above to aid in evaluating cleanup methods and sample results.

Results of the field study comparing the relative effectiveness of sampling methods for collecting anthrax spores from contaminated surfaces at the Brentwood postal facility provided much needed guidance to environmental sampling personnel. The results were published to achieve wider dissemination [Sanderson et al. 2002, 2004].

The HHE investigators transferred information learned from microbiological sampling events in contaminated postal and office facilities to researchers from Sandia National Laboratories verbally at the end of the exercise to support further development of their BROOM software.

The HHE Program transferred information both verbally and in writing to the Defense Research and Development Canada regarding microbiological sampling, video exposure monitoring, and computational fluid dynamics, to aid in the study of contaminant dispersion of an anthrax surrogate during letter opening in a typical office environment. Initial findings were presented at the Second National Conference on Environmental Sampling and Detection for Bio-Agents in New York in 2006.

Case Investigations. Results of the contact investigation where a microbiology laboratory employee developed cutaneous anthrax were published in the CDC MMWR and Archives of Dermatology [CDC 2002d,e; Mackey et al. 2002]. Results of the investigation of the inhalation anthrax case in the drum maker working with dried animal hides were published in the MMWR [CDC 2006]. This case represented the first case of naturally acquired anthrax in the U.S. since 1976. The rapid and coordinated epidemiologic and environmental responses were critical to minimizing risk for exposure and infection and alleviating concern among the public.

Development of Guidance Documents. Web-based guidance on protecting workers from exposure to anthrax in worksites where mail is handled or processed, protecting investigators performing sampling, and procedures for collecting environmental samples were developed by HHE investigators and other NIOSH staff [CDC 2001c,d; 2002b]. In addition, HHE investigators contributed to the development of recommendations for responding to detection of B. anthracis in autonomous detection systems, such as those used in some postal facilities after the anthrax attacks [CDC 2004].

Intermediate Outcomes. On its anthrax eTool website, OSHA describes the new vacuuming technique with dust collection filter socks used by HHE investigators during the anthrax investigations [http://www.osha.gov/SLTC/etools/anthrax/index.html]. In addition, the comprehensive procedures document on environmental sampling for anthrax developed by HHE investigators was republished in a bioterrorism guidebook [Farb 2005].

Researchers at Sandia National Laboratory completed development of BROOM, a system simplifying the collecting and processing of samples needed to evaluate a facility after a biological attack, using input from HHE investigators [Sandia 2006].

The microbiology laboratory where the anthrax case was identified corrected exhaust ventilation system deficiencies of their Class II, Type A biological safety cabinet room used to open samples in preparation for analysis. Additionally, a safety memorandum was prepared by the CDC contract laboratory director and provided to all technical personnel concerning the use of personal protective equipment and safe work practices when handling vials containing or potentially contaminated with biohazard agents and materials [CDC 2002d,e; Mackey et al. 2002].

End Outcomes. No new cases of anthrax occurred at any of the contaminated facilities that were cleaned and cleared for re-occupancy by committees involving HHE investigators. The investigation at the Missouri stamp fulfillment center did not detect contamination, and investigators recommended discontinuing the prophylaxis of close to 200 workers [CDC 2001b]. This eliminated the potential for side effects to develop in persons taking the medications; the re-occupancy of that facility resulted in no anthrax infections.

External Factors. Because many of these environments were evaluated by HHE investigators as part of an ongoing crime scene investigation, the disclosure of sampling methods, sampling locations, and results was occasionally restricted by law enforcement authorities. Despite these restrictions, the HHE Program immediately shared the knowledge gained from these and all other investigations with local, state, and federal health agencies that acted on this information and on the recommendations provided by the HHE investigators.

What's Ahead. HHE investigators are continuing to collaborate with researchers at the Defense Research and Development Canada with the ultimate goal of developing revised procedures for handling anthrax contaminated mail in office settings.

HHE investigators also are working with staff from other NIOSH programs to develop statistical sampling approaches for sampling contaminants in the workplace, which in their design, will provide confidence in the determination of contamination in buildings.

Irradiated Mail

Issue. Following the anthrax attacks of October 2001, USPS and government officials recognized the need to improve the safety of the mail. To make the mail safe from biohazards in a timely fashion, in the fall of 2001, the USPS began irradiating mail destined for government offices in specified ZIP Codes in the Washington, D.C. area. Irradiation destroys bacteria and viruses that could be present in mailed envelopes or packages.

Shortly after the irradiation began, federal office workers and postal workers began reporting health symptoms they believed were related to handling irradiated mail. Amid a period of intense media attention, the HHE program received three separate requests for HHEs to evaluate these concerns. The USPS submitted a request to address concerns for hundreds of employees at two mail handling facilities in Washington D. C. that were receiving and distributing mail from an out-of-state irradiation facility. Managers at the U.S. Office of Personnel Management headquarters submitted a request to address concerns among their office workers. And, the Sergeant at Arms of the U.S. Senate and the Chief Administrative Officer of the U.S. House of Representatives submitted a request to address concerns among the thousands of Legislative Branch employees working in the many office buildings on Capitol Hill.

Approach. In response to these requests, the HHE program conducted three field investigations from December 2001 through February 2002. HHE teams of industrial hygienists and occupational medicine physicians interviewed employees about their symptoms, reviewed health clinic records, monitored the air for chemical byproducts that could be released from the mail, and, in the offices, measured standard parameters used to assess IEQ.

Concentrations of measured contaminants in offices were non-detectable or very low. The types and levels of substances found in areas where irradiated mail was handled were indistinguishable from those measured in areas where irradiated mail was not handled, and were similar to what HHE investigators previously had found in other offices. At one postal facility, HHE investigators measured area CO levels that indicated a potential for concentrations to exceed OELs when workers first opened the sealed boxes of mail. All personal air samples, however, at this facility indicated concentrations below OELs. Recommendations to continue "airing out the mail" prior to processing were made at the USPS facility to reduce potential exposures.

Across all office facilities evaluated, employees reported skin, eye, nose, and throat irritation; headaches; and nausea. Together with the environmental findings, the health information gathered by the HHE teams lead them to conclude that symptoms reported by office workers likely resulted from a combination of factors, including suboptimal environmental humidity, drying effects on the skin of handling irradiated paper, odors, and stress. HHE investigators recommended keeping logs of reported symptoms, providing non-latex, powder-free gloves for employees who choose to wear gloves, using hand cream or lotion when employees frequently wash their hands after handling irradiated mail, and adjusting humidity levels.

Outputs and Transfers. The HHE investigators produced one numbered report [NIOSH 2002] and two letter reports and distributed them according to standard HHE program protocols. The lead HHE investigators returned to the House of Representatives and Senate offices to present the findings to employees in open meetings. Additionally, they gave a presentation on irradiated mail and presented their field investigation findings at a meeting of employees of the General Services Administration in February 2002. HHE Program staff advised occupational medicine providers in the Federal Occupational Health Service via telephone regarding related investigations. Other agencies were informed of the HHE investigators' findings and were given the HHE reports through participation in the Legislative Mail Task Force.

The Senate Sergeant at Arms and the House Chief Administrative Officer invited HHE Program staff to participate in the Legislative Mail Task Force beginning in January 2002. Other participants included representatives of the House and Senate administrative offices, the Architect of the Capitol, the Office of the Attending Physician, the White House Office of Science and Technology Policy, the USPS, the General Services Administration, the Armed Forces Radiobiology Research Institute, the Defense Advanced Research Projects Agency, and the Federal Protective Service. Scientists from other government agencies and the private sector (including representatives of the paper manufacturing industry) participated in meetings as the discussion focused on their areas of expertise. This group met routinely for nearly one year to monitor the situation, gather new information, and recommend new actions, as needed. In October 2002, HHE program staff participated in meetings of a Technical Subcommittee to the Legislative Mail Task Force to assess whether additional study of the health and safety effects of irradiated mail in the Capitol Hill community were warranted. Academic experts in occupational medicine and public health from The Johns Hopkins University joined HHE program staff and other government scientists on this committee. Further study was not undertaken.

Intermediate Outcomes. Based on the findings of the HHE field investigations and with advice from HHE investigators, several agencies and organizations created informational materials for their employees. The Senate Sergeant at Arms and House Chief Administrative Officer developed and distributed Irradiated Mail Updates to keep employees informed throughout the crisis period. The office of the Attending Physician developed and distributed a document titled Handling Irradiated Mail for Non-Postal Employees Working at the United States Capital Complex. The General Services Administration developed Guidelines for Opening Irradiated Mail, which was posted on their website for use by all federal agencies [http://www.gsa.gov/Portal/gsa/ep/ contentView.do?contentType=GSA_BASIC&contentId=8855&noc=T]. The U.S. Army Center for Health Promotion and Preventive Medicine developed a Fact Sheet on irradiated mail using HHE findings and posted it on their website [http://chppm-www.apgea.army.mil/documents/FACT/55-006-0302.pdf]. The Federal Occupational Health Service adopted the HHE Program's recommendations regarding handling of irradiated mail in fact sheets they prepared for their clients (various federal agencies). The report of the Office of Compliance investigation of the health effects of irradiated mail included information from the HHEs [http://www.compliance.gov/reports-studies/irradiatedmail/irradiatedmail_07-02.pdf]. Local Washington D.C. television and print news media outlets distributed stories about the HHE field investigations and resulting recommendations.

The Architect of the Capitol conducted office evaluations in specific areas where problems were discovered by the HHE teams and, based on the HHE recommendations, undertook office renovation projects to alleviate crowded working conditions in at least one location and improved ventilation in several Capitol Hill offices.

End Outcomes. In meetings of the Legislative Mail Task Force, the Office of the Attending Physician reported that following completion of the HHEs, the number of employee reports with health problems decreased over time. One year after the problem arose, new cases were not identified by the Office of the Attending Physician and only a handful of employees continued to have problems, which were addressed on an individual basis.

Natural Disasters

Issue. As a federal resource, the HHE Program received requests to provide support in at least six domestic natural disasters from 1989 through 2005. Requests included evaluating hospitals damaged by Hurricane Hugo in 1989, providing technical assistance to the Federal Emergency Management Agency (FEMA) Disaster Field Office to address flooding and mold concerns caused by Hurricane Andrew in 1992, responding to requests for technical assistance from the states of North Dakota and Kentucky, and the DHHS Department of Emergency Response, during the 1997 floods. The HHE Program responded to requests for technical assistance from FEMA in 1999 following Hurricane Floyd in North Carolina and in 2003 following Hurricane Isabel in Virginia. The HHE Program mobilized three response teams for the CDC response to Hurricane Katrina in 2005, and several HHE personnel were mobilized to the DEOC. At least two NIOSH responders were mobilized to provide on-site assistance during most responses; the Katrina response required mobilization of approximately 18 responders. Long-distance support was provided to HHE Program responders by NIOSH staff located in permanent NIOSH offices/facilities. HHE investigators also responded to the 2004 Asian tsunami and earthquake by staffing the DEOC and a CDC international assessment team in Thailand.

Approach. HHE investigators evaluated work sites to identify and assess risks to workers, measured exposure, provided guidance for selection and use of personal protective equipment, made occupational safety and health recommendations, developed public health information and disseminated this information among workers and the affected community, reviewed health and safety programs, provided health and safety input for remediation or decontamination plans, and provided other non-routine assistance, such as loaning industrial hygiene sampling equipment to a local health department. On-site HHE staff received support and technical assistance from various HHE Program staff via conference calls and e-mail.

DEOC to assume several important positions during recent natural disasters, including Operation Earthquake during the Asian tsunami and Hurricane Katrina. HHE investigators were placed in charge of the Environmental and Occupational Team during each of these disasters, and coordinated with the National Center for Environmental Health and NIOSH, as well as the other seven Centers within CDC to address all worker health and safety issues during the disasters. For Hurricane Katrina, two HHE investigators were also put in charge of the Public Health Services Group, which was responsible for making all scientific, funding, document, and communication decisions.

After the severe earthquake and tsunami devastated the province of Banda Aceh, Indonesia in December 2004, an HHE investigator led an occupational health team in the DEOC to contact affected Indonesian electrical workers who were restoring power to hospitals, businesses, and high priority public services. These workers were doing electrical repairs without adequate personal protection, putting themselves at serious risk of injury, burns, and electrocution. HHE investigators worked with several agencies and manufacturers (the International Safety Equipment Association, World Health Organization, American Federation of Labor - Congress of Industrial Relations) to assist in donating appropriate PPE to protect workers and speed up vital utility system repairs.

Outputs and Transfers. HHE investigators provided written reports [NIOSH 1989; 1993; 1997a,b; 2003; 2006] containing observations, discussions, and recommendations to management representatives at investigated sites. A joint technical assistance report was prepared with the CDC National Center for Environmental Health following the response to Hurricane Floyd [NIOSH 1999]. Key issues that were emphasized in the joint report were risks to workers and the general public due to electrical hazards and CO exposures resulting from use of gasoline-powered electrical generators. This report called for increased public health surveillance and awareness of these hazards. For Hurricane Katrina, HHE investigators produced three HHE numbered reports [NIOSH 2005, 2006a,b] and a letter report, contributed to a press release for the New Orleans Mayor's Office, and provided field consultations with employers and employees at New Orleans job sites. The most recent HHE report notes that the safety and health hazards identified during the response to Hurricane Katrina were generally similar in nature, if greater in extent, than those described during previous NIOSH responses. HHE investigators identified, described, and reported depressive symptoms and post-traumatic stress disorder among New Orleans fire fighters and police officers. [NIOSH 2006a,b] The published HHE reports contain recommendations that other public safety departments can use to prepare for future responses to natural disasters.

The findings of the HHE response team to Hurricane Katrina resulted in a case study describing the assessment of occupational noise levels during emergency relief operations. This case study has been accepted for publication in a peer-reviewed journal [Achutan 2007].

HHE Program staff disseminated occupational health and safety literature and messages to workers and the residents of the greater New Orleans area. Information was provided to non-governmental organizations and local agencies for distribution. This included disseminating information on well known hazards of CO associated with gasoline powered pumps, pressure washers, and electricity generators [http://www.cdc.gov/niosh/topics/co/].

HHE investigators worked with partners in other CDC centers to address issues related to disposal of liquid waste from autopsies following the Asian tsunami. Contributions from the HHE program were were sought because of expertise acquired from prior HHEs dealing with biosolids. The product of this collaborative effort was the document Disposing of liquid waste from autopsies in tsunami-affected areas: interim guidance from the Centers forDisease Control and Prevention. This document was posted on the CDC website [http://www.bt.cdc.gov/disasters/tsunamis/pdf/tsunami-autopsyliquidwaste.pdf].

Intermediate Outcomes. HHE investigators conducted a field consultation with cleanup workers in New Orleans that resulted in the workers obtaining needed immunizations from a nearby Disaster Medical Assistance Team. They hand-delivered written materials regarding ways to minimize hazards to approximately 12 partner-groups for further dissemination following Hurricane Katrina (e.g., New Orleans Fire Department, Hispanic community leaders, health clinics, a Latino liaison, the Red Cross, faith-based organizations, and local/state/federal government agencies).

A written report containing observations, discussion, and recommendations mailed by HHE investigators to the FEMA occupational safety and health manager following Hurricane Isabel was used as guidance by NIOSH for the evaluation of hazards at debris reduction sites in Louisiana following Hurricane Katrina [NIOSH 2003].

End Outcomes. For the Indonesian electrical workers restoring power after the tsunami, HHE investigators coordinated and prioritized donations to reduce redundancy and to speed the selection and manufacturing of appropriately sized and configured personal protective equipment and other related equipment. Seven International Safety Equipment Association member companies donated over $37,000 worth of new equipment to the electrical workers in Banda Aceh. This equipment prevented electrical injuries, falls, and electrocution among these workers in their efforts to quickly provide power to the devastated region. The personal protective equipment was sustainable and continues to protect electrical workers in Banda Aceh, Indonesia long after the acute stage of clean-up was accomplished. The HHE investigators forged new relationships with the International Unions, International Safety Equipment Association Members, and WHO, which are invaluable for future events.

Two specific examples of the influence of HHE investigators are the reduction of CO concentrations from 220 parts per million to 25 parts per million where workers were using a gasoline-powered pump and alleviating the reluctance of New Orleans police officers to enter Memorial Hospital in order to collect evidence. In the first instance, an HHE investigator used a direct-read CO monitor to identify excessive CO levels; he then advised workers to move the pump outdoors, which resulted in an immediate reduction in CO levels. In the second instance, HHE investigators conducted a walk-through evaluation at Memorial Hospital and concluded that police officers would not be at risk due to mold or other environmental or biological hazards while gathering evidence. Their findings, communicated to management officials, paved the way for responders to continue their assigned duties.

External Factors. The HHE Program participated in responses to natural disasters as part of multi-agency efforts. As such, its flexibility to address specific issues and follow-up on identified hazards is defined by the mandates of federal response plans. The authority of FEMA and other federal agencies ensuring continuity and uniformity of site occupational safety and health programs during disaster responses is limited; thus, the guidance and technical assistance provided by the HHE Program may not be incorporated into operating procedures for future disaster responses. The NIOSH Office of Emergency Preparedness and Response is working with other federal agencies to address these concerns.

World Trade Center

Issue. The destruction of the World Trade Center on September 11, 2001, from terrorist attacks killed 450 emergency responders, immediately injured 320, and exposed thousands of rescue and recovery workers in New York City to high levels of risk for job-related illness and injury. For 4 months, fires smoldered, and workers dealt with exposures involved in one of the most complex demolition projects ever undertaken. The scale was unprecedented; the pressure to finish quickly was immense.

Workers included fire fighters, law enforcement personnel, emergency medical services, construction and demolition trades, health and safety personnel, volunteer workers, and local, state and federal agency workers. Thousands of people, both workers and the public, were initially exposed to a huge dust cloud. In subsequent weeks, exposure to dust, particulates, and combustion and pyrolysis products occurred among those involved in demolition and clean up. Reports of adverse health effects from these exposures have been growing steadily in the years since.

Approach. NIOSH responded swiftly and addressed workers' immediate protection needs in the aftermath of the attacks. Some 15 HHE Program staff along with other NIOSH staff were deployed to the site. They carried out the following activities:

• Developed and disseminated written guidelines to help site managers and supervisors integrate worker safety and health into site operations. Among other topics, this information addressed selection and use of sampling equipment, procedures for sample analysis, and selection of personal protective equipment, especially respirators for rescue and recovery workers.


• Provided technical assistance regarding a broad range of health and safety issues to federal, state, and local agencies. These included the New York City Department of Health, FEMA, EPA, New York City Fire Department (NYFD), and the New York City Department of Design and Construction.


• Monitored and characterized occupational exposures to asbestos, CO, chlorodifluoromethane, diesel exhaust, hydrogen sulfide, inorganic acids, mercury and other metals, polynuclear aromatic hydrocarbons, respirable particulates, silica, and volatile organic compounds. For some contaminants, they used real-time monitoring equipment; for others they collected samples, which were analyzed by NIOSH-contracted laboratories. Monitoring occurred from September 18 through October 4, 2001. Although the majority of exposures were below applicable OELs, HHE investigators identified hazardous exposures to CO from the use of gasoline-powered cutting saws.


• Worked with NYFD to evaluate occupational health hazards and exposures for the 10,000 NYFD personnel involved in the response. This work included the following: (a) a survey of a sample of NYFD responders regarding acute symptoms and personal protective equipment use, (b) establishing a partnership with the CDC National Center for Environmental Health to analyze for 110 chemicals in blood and urine specimens from 321 fire fighters who responded, and (c) helping NYFD initiate its medical follow-up program.


• Helped establish guidelines for long-term follow up of the estimated 40,000 workers who responded to the disaster, working with various partners, including Mount Sinai Medical Center, NYFD, and New York State and City Health Departments.

Between November 2001 and January 2002, the HHE Program received five HHE requests to evaluate various groups working near the World Trade Center towers at the time of the collapse. These included employees in the Federal building at 26 Federal Plaza, New York State employees in an office building, employees in a city high school, employees at a community college, and transit workers. For each office and school facility, HHE investigators identified and evaluated a comparison building. For the Federal building, the comparison site was in Dallas, Texas. For the other buildings, the comparison sites were in New York City outside the area affected by the World Trade Center collapse. At all locations, HHE investigators carried out a questionnaire survey of acute health effects, including respiratory and mental health symptoms. At the Federal Building, they did air sampling; at the other facilities they did observational walk-through surveys following a standard protocol to ensure that there were no significant differences between the facility near the World Trade Center and its comparison facility with regards to indoor environmental factors.

Although results varied by site, HHE investigators determined that a substantial burden of symptoms of depression, post-traumatic stress disorder, eye irritation, and upper airway irritation, was evident among those surveyed in offices and schools. The prevalence of these symptoms among employees at some facilities was higher than among employees at the comparison facilities. Transit workers exposed to the dust cloud on September 11, 2001, had a significantly higher risk of persistent lower respiratory and mucous membrane symptoms, and depressive and posttraumatic stress disorder symptoms 7½ months later compared to those not exposed to the dust cloud.

Outputs and Transfers. In the field, HHE investigators participated in daily briefings held by the New York City Department of Health, which had a lead role in coordinating the response. Based on their observations, the HHE investigators contributed to discussions at these briefings regarding occupational health and safety issues. They also provided summaries of their exposure monitoring results and, in the case of CO overexposures, recommended control measures.

HHE staff participated in the Environmental Assessment Work Group for the World Trade Center. This group was led by EPA, Agency for Toxic Substances and Disease Registry, and OSHA, and included the New York City Departments of Health and Environmental Protection, New York State Department of Environmental Conservation, and NIOSH. This work group was formed the weekend after September 11 to assist New York City in synthesizing and developing action plans in response to environmental exposure assessments being done by EPA Region II, New York City, and New York State, and occupational exposure assessments being done by OSHA and NIOSH. The work group held teleconferences twice weekly to discuss data and to prepare recommendations for further action. Accomplishments included: (1) establishing a multi-agency database of environmental and occupational exposure measurements, (2) developing an asbestos action level for building reentry by the general public, (3) developing a residential sampling protocol for buildings in the immediate vicinity to characterize indoor contamination from the World Trade Center collapse, and (4) directing a study of 34 buildings to characterize contamination and determine if additional public health actions were needed. This work group stopped meeting around the time that the World Trade Center cleanup effort was finished.

HHE Program staff in Cincinnati, Ohio, prepared four fact sheets addressing hazard and exposure reduction for work at the disaster site. They also assisted in compiling and creating materials for a topic page on the NIOSH website [http://www.cdc.gov/niosh/topics/wtc/]. They provided these materials to NIOSH staff at the disaster site to distribute to government and private sector partners.

The HHE Program initially produced two numbered and three letter reports for the field investigations [NIOSH 2002, 2005]. Subsequently, they compiled the results for the three investigations previously described in the letter reports into a numbered report [NIOSH 2006]. All reports were distributed according to standard HHE protocols.

HHE investigators helped establish an informal network of occupational medicine specialists who discussed their findings and began to define the type and severity of health problems they were seeing among responders. The initial activities by the HHE Program to provide technical assistance to the NYFD Medical Monitoring Program and the World Trade Center Medical Monitoring Program were transferred to other NIOSH programs as the level of activity increased beyond the scope of the HHE Program.

HHE investigators authored or co-authored seven peer-reviewed articles and prepared congressional testimony for a field hearing held by the Subcommittee on National Security, Emerging Threats, and International Relations Committee on Government Reform, U.S. House of Representatives, in New York City in October 2003.

HHE Program staff participated in a series of workshops organized by the RAND Corporation Science and Technology Policy Institute. The workshops included 190 representatives from 83 organizations. Input from these workshops provided the basis for four reports [Jackson et al. 2002; Jackson et al. 2004; LaTourrette et al. 2002; Willis et al. 2006]. These reports define technology needs and research priorities for personal protection for emergency responders.

Intermediate Outcomes. The informal network of occupational medicine specialists, established with the assistance of HHE investigators, wrote a guidance document to assist community-based physicians with the appropriate evaluation of patients exposed to World Trade Center dust. The work of this network helped lay the groundwork for creating the comprehensive medical screening program that continues today through NIOSH extramural funding. Documentation that so many were sick motivated the federal government to provide funding to NIOSH to support $55 million in treatment services for the 40,000 responders exposed to the World Trade Center collapse.

3.4 Supporting Evidence

Biosolids

HHE Numbered Reports

NIOSH [1999]. Bio-Solids Land Application Process, LeSourdsville, OH. NIOSH HETA Report No. 1998-0118-2748.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0118-2748.pdf].

NIOSH [2003]. Waste Management, Inc. Outer Loop Landfill, Louisville, KY. NIOSH HETA Report No. 2003-0078-2918.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0078-2918.pdf].

Journal Articles

NIOSH [2001]. Workers exposed to Class B biosolids during and after field application. J Appl Occup Environ Hyg 16(2):105-107.

NIOSH Numbered Documents

NIOSH [2000]. NIOSH Hazard ID #10: Workers exposed to Class B biosolids during and after field application. DHHS (NIOSH) Publication No. 2000-158.
[http://www.cdc.gov/ niosh/hid10.html].

NIOSH [2002]. Guidance for controlling potential risks to workers exposed to Class B biosolids. DHHS (NIOSH) Publication No. 2002-149.

Other Publications

National Research Council [2002]. Biosolids applied to land: advancing standards and practices. Washington, D.C.: The National Academies Press.
[http://books.nap.edu/ openbook/0309084865/html/106.html].

Brucellosis

HHE Numbered Reports

NIOSH [1994]. The Lundy Packing Company, Clinton, NC. NIOSH Report No. 1993-0775-2398.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0775-2398.pdf].

Journal Articles

CDC [1994]. Brucellosis Outbreak at a Pork Processing Plant - North Carolina, 1992 MMWR 43(7):113-116.

Trout D, Gomez TM, Bernard BP, Mueller CA, Smith CG, Hunter L, Kiefer M [1995]. Outbreak of brucellosis at a United States pork packing plant. J Occup Environ Med. 37(6):697-703.

Latex

HHE Numbered Reports

NIOSH [1995]. St. Vincent Medical Center, Staten Island, NY. NIOSH HETA Report No. 1995-0239-2553.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0239-2553.pdf].

NIOSH [1999]. LDS Hospital/Intermountain Health Care, Salt Lake City, UT. NIOSH HETA Report No. 1999-0035-2757.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0035-2757.pdf].

NIOSH [2000a]. Exempla St. Joseph Hospital, Denver, CO. NIOSH HETA Report No. 1999-0294-2775.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0294-2775.pdf].

NIOSH [2000b]. Exempla St. Joseph Hospital, Denver, CO. NIOSH HETA Report No. 1998-0096-2737.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0096-2737.pdf].

NIOSH [2001]. Benefis Healthcare, Great Falls, MT. NIOSH HETA Report No. 2000-0255-2868.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0255-2868.pdf].

Journal Articles

Anonymous [1997a]. Latex sensitivity: current issues. Health Hazard Mater Manage 10(9):1-12.

Anonymous [1997b]. NIOSH alert: preventing allergic reactions to natural rubber latex in the workplace. Hospital Technology Series 16(7):10-3.

Anonymous [1997c]. NIOSH alert recommends the use of powder-free gloves. OR Manager 13(8):1-8.

Anonymous [1997d]. NIOSH recommends steps for reducing work-related exposure to latex. Am J Health Syst Pharm 54(15):1688-1691.

Anonymous [1997e]. NIOSH targets latex allergy. Occup Health Saf 66(9):12.

Anonymous [1997f]. Nurses warned about preventing allergic reactions to latex at work. Pa Nurse 52(10):9.

Anonymous [1998]. Health department warns about latex allergies. NY State Dent J 64(7):46.

Maxfield AM, Lewis MJ, Tisdale JA, Lachenmayr S, Lum M [1999]. Effects of a preventive message in the organizational context: occupational latex allergy in hospitals. Am J Ind Med Suppl 1:125-127.

Maxfield AM, Lewis J, Lachenmayr S, Tisdale J, Lum M [2000]. A National Institute for Occupational Safety and Health Alert sent to hospitals and the intentions of hospital decision makers to advocate for latex allergy control measures. Health Ed Res 15: 463-467.

Page EH, Esswein EJ, Petersen MR, Lewis DM, Bledsoe TA [2000a]. Natural rubber latex: glove use, sensitization, airborne and latent dust concentrations at a Denver hospital. J Occup Environ Med 42(6):613-620.

Page EH, Astles JR [2000b]. Use of the laboratory in the diagnosis of latex allergy. Diagnostic Immunol Metabol 18(7):201-204.

Page EH [2001]. Prevalence of latex allergy [letter]. Ann All Asthma Immunol 87(2):164.

Pinkerton LE, Page EH, Petersen MR, Esswein EJ, Biagini RE, Bledsoe TA, MacKenzie BA, Ward EM [forthcoming]. Evaluation of latex-specific IgG as a marker of exposure to natural rubber latex among hospital employees.

Reddy S [1998]. Latex allergy. Am Fam Physician 57(1):93-102.

Toland PK [1997]. NIOSH alerts health care workers to risk of developing latex allergy. Oreg Nurse 62(3):7.

West K [1998]. Latex allergy: an emerging problem. Emerg Med Serv 27(10):54-56.

Zeiss CR, Gomaa A, Murphy FM, Weissman DN, Hodgson M, Foster D, Dejativongse S, Colella K, Kestenberg K, Kurup VP, Bush RK, Chiu AM, Kelly KJ, Fink JN [2003]. Latex hypersensitivity in Department of Veterans Affairs health care workers: glove use, symptoms, and sensitization. Ann Allergy Asthma Immunol 91(6):539-545.

NIOSH Numbered Documents

NIOSH [1997]. NIOSH Alert: Preventing allergic reactions to natural rubber latex in the workplace. DHHS (NIOSH) Publication No. 97-135.
[http://www.cdc.gov/niosh/ latexalt.html].

NIOSH [1998]. Latex allergy: a prevention guide. DHHS (NIOSH) Publication No. 98-113.
[http://www.cdc.gov/niosh/98-113.html].

Other Publications

ACGIH® [2007]. 2007 TLVs® and BEIs®: threshold limit values for chemical substances and physical agents. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

Tuberculosis

HHE Numbered Reports

NIOSH [1990]. San Francisco General Hospital Medical Center, San Francisco, CA. NIOSH HETA Report No. 1990-122-L2073.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1990-0122-2073.pdf].

NIOSH [1992a]. Onondaga County Medical Examiner's Office, Syracuse, NY. NIOSH HETA Report No. 1992-171-2255.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0171-2255.pdf].

NIOSH [1992b]. George Washington University Medical Center, Washington, DC. NIOSH HETA Report No. 1990-140-2221.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1990-0140-2221.pdf].

NIOSH [1992c]. John C. Murphy Family Health Center, Berkely, MO. NIOSH HETA Report No. 1991-148-2236.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0148-2236.pdf].

NIOSH [1992d]. Veterans Administration Medical Center, East Orange, NJ. NIOSH HETA Report No. 1992-296-2243.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0296-2243.pdf].

NIOSH [1992e]. A.G. Holley State Hospital, Lantana, FL. NIOSH HETA Report No. 1992-215-2268.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0215-2268.pdf].

NIOSH [1993a]. Warren Correctional Institution, Lebanon, OH. NIOSH HETA Report No. 1992-282-2297.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0282-2297.pdf].

NIOSH [1993b]. Puerto Rico Department of Health, San Juan, PR. NIOSH HETA Report No. 1992-298-2325.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0298-2325.pdf].

NIOSH [1993c]. District of Columbia, Board of Parole, Washington, DC. NIOSH HETA Report No. 1992-0271-2349.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0271-2349.pdf].

NIOSH [1993d]. 44th Street Independence Support Center, New York, NY. NIOSH HETA Report No. 1992-0320-2357.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0320-2357.pdf].

NIOSH [1993e]. Manatee Memorial Hospital, Bradenton, FL. NIOSH HETA Report No. 1993-0282-2303.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0282-2303.pdf].

NIOSH [1994a]. Providence Ambulatory Health Care Foundation, Providence, RI. NIOSH HETA Report 1993-0751-2408.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0751-2408.pdf].

NIOSH [1994b]. Providence Ambulatory Health Care Foundation, Providence, RI. NIOSH HETA Report No. 1993-0847-2384.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1993-0847-2384.pdf].

NIOSH [1994c]. Providence Health Care Foundation, Providence, RI. NIOSH HETA Report No. 1993-0846-2386.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0846-2386.pdf].

NIOSH [1994d]. Providence Health Care Foundation, Providence, RI. NIOSH HETA Report No. 1993-0845-2367.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0845-2367.pdf].

NIOSH [1994e]. Providence Health Care Foundation, Providence, RI. NIOSH HETA Report No. 1993-0848-2399.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0848-2399.pdf].

NIOSH [1994f]. Spectrum Health Care, Inc., Newark, NJ. NIOSH HETA Report No. 1993-0365-2421.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0365-2421.pdf].

NIOSH [1994g]. Essex County Division of Welfare, Newark, NJ. NIOSH HETA No. 1993-0891-2430.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0891-2430.pdf].

NIOSH [1994h]. Alaskan AIDS Assistance Association, Anchorage, AK. NIOSH HETA Report No. 1993-0771-2437.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0771-2437.pdf].

NIOSH [1994i]. Orange County Employees, Goshen, NY. NIOSH HETA Report No. 1992-0345-2457.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0345-2457.pdf].

NIOSH [1994j]. New York City Health and Hospitals Corporation, New York, NY. NIOSH HETA Report No. 1990-0330-2479.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1990-0330-2479.pdf].

NIOSH [1995a]. Jackson Memorial Hospital, Miami, FL. NIOSH HETA Report No. 1991-0187-2544. [ http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0187-2544.pdf].

NIOSH [1995b]. Southcentral Regional Public Health Laboratory, Anchorage, AK. NIOSH HETA Report No. 1993-0769-2489.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1993-0769-2489.pdf].

NIOSH [1995c]. U.S. Marshals Service, Los Angeles, CA. NIOSH HETA Report No. 1994-0238-2484.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0238-2484.pdf].

NIOSH [1995d]. U.S. Marshals Service, Miami, FL. NIOSH HETA Report No. 1995-0024-2518.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0024-2518.pdf].

NIOSH [1996]. University of Medicine and Dentistry of New Jersey, Newark, NJ. NIOSH HETA Report No. 1995-0031-2601.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1995-0031-2601.pdf].

NIOSH [1997a]. Los Angeles County Department of Coroner, Los Angeles, CA. NIOSH HETA Report No. 1996-0019-2666.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1996-0019-2666.pdf].

NIOSH [1997b]. OshKosh B'Gosh, Byrdstown, TN. NIOSH HETA Report No. 1995-0328-2630.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0328-2630.pdf].

NIOSH [1997c]. Health and Rehabilitative Service, Office of Laboratory Services, Jacksonville, FL. NIOSH HETA Report No. 1992-0377-2625.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/1995-0328-2630.pdf].

NIOSH [1998a]. Stericycle, Inc., Morton, WA. NIOSH HETA Report No. 1998-0027-2709.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0027-2709.pdf].

NIOSH [1999]. Grady Memorial Hospital, Atlanta, GA. NIOSH HETA Report No. 1992-0232-2767.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0232-2767.pdf].

NIOSH [2000a]. Hawaii State Department of Health, Honolulu, HI. NIOSH HETA Report No. 2000-0040-2800.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0040-2800.pdf].

NIOSH [2000b]. United States Department of Agriculture, Animal and Plant Health Inspection Service, Riverdale, MD. NIOSH HETA Report No. 1998-0339-2806.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0339-2806.pdf].

NIOSH [2004]. City of Altus Police Department and Jail, Altus, OK. NIOSH HETA Report No. 2002-0165-2938.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0165-2938.pdf].

NIOSH [2005a]. El Dorado County Health Department, Placerville, CA and South Lake Tahoe, CA. NIOSH HETA Report No. 2004-0417-2987.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2004-0417-2987.pdf].

NIOSH [2005b. Salvation Army Harbor Light Center, St. Louis, MO. NIOSH HETA Report No. 2003-0346-2969.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0346-2969.pdf].

NIOSH [2006a]. New York University School of Medicine, New York, NY. NIOSH HETA Report No. 2004-0081-3002.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0081-3002.pdf].

NIOSH [2006b]. North Carolina Dept of Juvenile Justice & Delinquency Prevention, Swannanoa Valley Youth Development Center, Swannanowa, NC. NIOSH HETA Report No. 2005-0329-2995.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0329-2995.pdf].

NIOSH [2007]. City of Meridian, Meridian Fire Department, Meridian, MS. NIOSH HETA Report No. 2007-0012-3046.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2007-0012-3046.pdf].

Journal Articles

Boudreau AY, Baron SL, Steenland NK, Van Gilder TJ, Decker JA, Galson SK, Seitz T [1997]. Occupational risk of Mycobacterium tuberculosis infection in hospital workers. Am J Ind Med 32(5):528-534.

Decker JA, Seitz TA, Shults RA, Deitchman S, Tucker SP, Belinky BR, Clark NJ [1992]. Occupational exposures to aerosolized pharmaceuticals and control strategies. Scand J Work Environ Health 18(Suppl 2):100-102.

Decker J [1995]. Evaluation of isolation rooms in health care settings using tracer gas analysis. Appl Occup Environ Hyg 10(11):887-891.

Garcia-Garcia ML, Jimenez-Corona A, Jimenez-Corona ME, Ferreya-Reyes L, Martinez K, Rivera-Chavira B, Martínez-Tapia ME, Valenzuela-Miramontes E, Palacios-Martínez M, Juárez-Sandino L, Valdespino-Gómez JL [2001]. Factors associated with tuberculin reactivity in two general hospitals in Mexico. Infect Control Hosp Epidemiol 22:88-93.

Johnson KR, Braden CR, Cairns KL, Field KW, Colombel AC, Yang Z, Woodley CL, Morlock GP, Weber AM, Boudreau, AY, Bell TA, Onorato IM, Valway SE, Stehr-Green PA [2000]. Transmission of Mycobacterium tuberculosis from medical waste. JAMA 284(13):1683-1688.

Lenhart SW, Seitz TA, Trout D, Bollinger N [2004]. Issues affecting respirator selection for workers exposed to infectious aerosols: emphasis on healthcare settings. Appl Biosaf 9(1):20-36. Macher JM, Alevantis LE, Chang Y-L, Liu K-S [1992]. Effect of ultraviolet germicidal lamps on airborne microorganisms in an outpatient waiting room. Appl Occup Environ Hyg 7(8):505-513.

Martinez K, Tubbs R, Ow P [2001]. Use of local exhaust ventilation to control aerosol exposures resulting from the use of a reciprocating saw during autopsy. Appl Occup Environ Hyg 16(7):709-717.

Miller AK, Tepper A, Sieber K [2002]. Historical risks of tuberculin skin test conversion among non-physician staff at a large urban hospital. Am J Ind Med 42(3):228-235.

Moss CE, Seitz TA [1991]. Ultraviolet radiation exposure to health care workers from germicidal lamps. Appl Occup Environ Hyg 6(3):168-170.

Rahn RO, Xu P, Miller SL [1999]. Dosimetry of room-air germicidal (254 nm) radiation using spherical actinometry. Photochem Photobiol 70(3):314-318.

Schafer MP, Fernback JE, Jensen PA [1998]. Sampling and analytical method development for qualitative assessment of airborne mycobacterial species of the Mycobacterium tuberculosis complex. Am Ind Hyg Assoc J 59(8):540-546.

Schafer MP, Martinez KF, Mathews ES [2003]. Rapid detection and determination of the aerodynamic size range of airborne Mycobacteria associated with whirlpools. Appl Occup Environ Hyg 18(1):41-50.

Seitz T, Mortimer V, Martinez K [1998]. A tracer gas evaluation at a garment manufacturing facility with extensive transmission of tuberculosis. Appl Occup Environ Hyg 13(6):335-342.

Tucker SP, Seitz TA [1991]. A procedure for the analysis of pentamidine isethionate in air. Appl Occup Environ Hyg 6(11):920-921.

Tucker SP, Belinky BR, Seitz TA, Foley GD [1993]. Determination of pentamidine isethionate in air. Am Ind Hyg Assoc J 54(10):628-632.

Ussery XT, Bierman JA, Valway SE, Seitz TA, Diferdinando GT, Ostroff SM [1995]. Transmission of multidrug-resistant Mycobacterium tuberculosis among persons exposed at a medical examiner's office, New York. Infect Control Hosp Epidemiol 16(3):160-165.

Weber A, Martinez K, Kelly J [1995]. Tuberculosis in the microbacteriology laboratory. Appl Occup Environ Hyg 10(8):645-651.

Weber AM, Boudreau Y, Mortimer VD [2000]. A tuberculosis outbreak among medical waste workers. J Am Biol Saf Assoc 5(2):70-88.

Xu P, Kujundzic E, Peccia J, Schafer MP, Moss G, Hernandez M, Miller SL [2005]. Impact of environmental factors on efficacy of upper-room air ultraviolet germicidal irradiation for inactivating airborne mycobacteria. Environ Sci Technol 39(24):9656-9664.

NIOSH Numbered Documents

NIOSH [1994k]. Proceedings of the workshop on engineering controls for preventing airborne infections in workers in health care and related facilities. DHHS (NIOSH) Publication No. 94-106.
[http://www.cdc.gov/niosh/docs/94-106/pdfs/94-106.pdf].

NIOSH [2001]. Health hazard evaluations: tuberculosis 1990 to 1999. DHHS (NIOSH) Publication No. 2001-116.
[http://www.cdc.gov/niosh/2001-116.html].

NIOSH [2007]. NIOSH manual of analytical methods (NMAM®). 4th ed. DHHS (NIOSH) Publication 94-113 (August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 2003-154.
[http://www.cdc.gov/ niosh/nmam/].

Other Publications

Boudreau Y [2005]. Tuberculosis in Preventing Occupational Disease and Injury, Second Edition. Levy BS, Wagner GR, Rest KM, Weeks JL, eds., Washington, DC: American Public Health Association, pp. 492-499.

CDC [1994]. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR 43(RR13):1-132.

CDC [2004]. Workshop on Respiratory Protection for Airborne Infectious Agents.
[http://www.cdc.gov/niosh/npptl/resources/pressrel/announcements/113004wkshp/presentations.html].

CDC [2005]. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 54(RR17):1-141.

CDC [2006]. Prevention and control of tuberculosis in correctional and detention facilities: recommendations from CDC. MMWR 55(RR9):1-59.

Jensen PA [2001]. HETA 2000-0131 close-out letter to Feliciane Green, South Carolina Department of Corrections, from Paul Jensen, National Institute for Occupational Safety and Health, January 25, 2001.

NIOSH [1998b]. Testimony of the National Institute for Occupational Safety and Health on the Occupational Safety and Health Administration Proposed Rule on Occupational Exposure to Tuberculosis (Docket No. H-371), April 7, 1998.

OSHA [1997]. 29 CFR 1910 Occupational Exposure to Tuberculosis; Proposed Rule. Federal Register October 17, 1997.

Weber A, Martinez K [1996]. Tuberculosis infection control strategies in mycobacteriology laboratories. In: Proceedings of the 19th World Energy Engineering Congress, November 1995, Vision 2001: Energy and Environmental Engineering, Chapter 14.

Tertiary Amines

HHE Numbered Reports

NIOSH [2001]. Superior Label Systems, Mason, OH. NIOSH HETA Report No. 2001-0144-2867.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0144-2867.pdf].

NIOSH [2003]. Superior Label Systems, Mason, OH. NIOSH HETA Report No. 2002-0379-2901.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0379-2901.pdf].

Journal Articles

Page EH, CookCK, Hater MA, Mueller CA, Grote AA, Mortimer VD, [2003]. Visual and ocular changes associated with exposure to tow amines. Occup Environ Med 60(1): 69-74.

Other Publications

EPA [2002]. Flexographic Ink Options: A Cleaner Technologies Substitutes Assessment.
[http://www.epa.gov/dfe/pubs/flexo/ctsa/index.html].

Asphalt

HHE Numbered Reports

NIOSH [1996a]. Spartan Paving Company, Lansing, MI. NIOSH HETA Report No. 1994-0365-2563.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0365-2563.pdf].

NIOSH [1996b]. Granite Construction Company, Sacramento, CA. NIOSH HETA Report No. 1994-0408-2564.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0408-2564.pdf].

NIOSH [1996c]. Martin Paving Company, Yeehaw Junction, FL. NIOSH HETA Report No. 1995-0118-2565.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0118-2565.pdf].

NIOSH [1996d]. Koester Equipment Company, Evansville, IN. NIOSH HETA Report No. 1995-0307-2602.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0307-2602.pdf].

NIOSH [1996e]. Staker Construction Company, Casa Grande, AZ. NIOSH HETA Report No. 1996-0072-2603.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0072-2603.pdf].

NIOSH [1996f]. Sim J. Harris Company, San Diego, CA. NIOSH HETA Report No. 1996-0130-2619.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0130-2619.pdf].

NIOSH [1998]. Bardon-Trimount, Stoughton, MA. NIOSH HETA Report No. 1997-0232-2674.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0232-2674.pdf].

NIOSH [2001]. Crumb-rubber modified asphalt paving: occupational exposures and acute health effects. NIOSH HETA Report No. 2001-0536-2864.
[http://www.cdc. gov/niosh/hhe/reports/pdfs/2001-0536-2864.pdf].

Journal Articles

Jaycox LB, Olsen LD [2000]. Determination of total sulfur compounds and benzothiazole in asphalt fume samples by gas chromatography with sulfur chemiluminescence detection. Appl Occ Environ Hyg 15(9):695-704.

Mead KR, Mickelsen RL, Brumagin TE [1997]. Engineering controls for asphalt paving equipment: paving the path to progress. The Synergist 8(9):30-31.

Mead KR, Mickelsen RL, Brumagin TE [1999]. Factory performance evaluations of engineering controls for asphalt paving equipment. Appl Occup Env Hyg 14(8):565-573.

Mickelsen RL, Mead KR, Shulman SA, Brumagin, TE [1999]. Evaluating engineering controls during asphalt paving using a portable tracer gas method. Am J Ind Med 36(S1): 77-79.

Mickelsen RL, Shulman SA, Kriech AJ, Osborn LV, Redman AP [2006]. Status of worker exposure to asphalt paving fumes with the use of engineering controls. Environ Sci Technol 40(18):5661-5667.

Moran JB, Kajola B, Melius J [1997]. Asphalt paving exposure controls: a model for the future? Appl Occup Env Hyg 12(6):407-409.

Tepper AL, Burr GA, Feng HA, Singal M, Miller AK, Hanley KW, Olsen LD [2006]. Acute symptoms associated with asphalt fume exposure among road pavers. Am J Ind Med 49(9):728-739.

NIOSH Numbered Documents

NIOSH [1997]. Engineering control guidelines for hot mix asphalt pavers. DHHS (NIOSH) Publication. No. 97-105.
[http://www.cdc.gov/niosh/asphalt.html].

NIOSH [2000]. Hazard review: health effects of occupational exposure to asphalt. DHHS (NIOSH) Publication No. 2001-110.
[http://www.cdc.gov/niosh/pdfs/01-110.pdf].

NIOSH [2007]. NIOSH manual of analytical methods (NMAM®). 4th ed. DHHS (NIOSH) Publication 94-113 (August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 2003-154.
[http://www.cdc.gov/ niosh/nmam/].

Other Publications

CSA [2007]. Construction safety alliance-Purdue University, West Lafayette, Indiana. [https://engineering.purdue.edu/CSA/technologies/asphalt_paver_engineering_contro/].

OHCOW [2004]. Report submission to the Ministry of Labour, occupational exposure limits-proposed changes 2004. Occupational Health Clinics of Ontario Workers, Inc.

Chlorinated Compounds

HHE Numbered Reports

NIOSH [2000]. Wampler Foods, Inc., Hinton, VA. NIOSH HETA Report No. 2000-0105-2794.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0105-2794.pdf].

NIOSH [2003]. Bil Mar Foods, Storm Lake, IA. NIOSH HETA Report No. 2002-0257-2916.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0257-2916.pdf].

NIOSH [2006]. Sara Lee Foods, Storm Lake IA. NIOSH HETA Report No. 2006-0153-3022.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0153-3022.pdf].

Journal Articles

King B, Page E, Mueller C, Dollberg D, Gomez K, Warren A [2006]. Eye and respiratory symptoms in poultry processing workers exposed to chlorine byproducts. Am J Industr Med 49:119-126.

NIOSH Numbered Publications

NIOSH [2007]. NIOSH manual of analytical methods (NMAM®). 4th ed. DHHS (NIOSH) Publication 94-113 (August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 2003-154.
[http://www.cdc.gov/ niosh/nmam/]. Lead in the Abatement and Construction Industries HHE Numbered Reports

NIOSH [1992a]. HUD Lead-Based Paint Abatement Demonstration Project. NIOSH HETA Report No. 1990-070-2181.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0070-2181.pdf].

NIOSH [1992b]. Seaway Painting, Inc., Annapolis, MD. NIOSH HETA Report No. 1991-209-2249.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0209-2249.pdf].

NIOSH [1992c]. M and J Painting Company, Covington, KY. NIOSH HETA Report No. 1991-006-2193.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0006-2193.pdf].

NIOSH [1993]. Ohio University, Athens OH. NIOSH HETA Report No. 1992-095-2317.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0095-2317.pdf].

NIOSH [1995a]. University of Maryland, College Park, MD. NIOSH HETA Report No. 1994-0374-2534.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0374-2534.pdf].

NIOSH [1995b]. George Campbell Painting Company, Groton, CT. NIOSH HETA Report No. 1993-0502-2503.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0502-2503.pdf].

NIOSH [1997]. People Working Cooperatively, Cincinnati, OH. NIOSH HETA Report No. 1993-0818-2646.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0818-2646.pdf].

NIOSH [2000]. Rhode Island Department of Health, Providence, RI. NIOSH HETA Report No. 1996-0200-2799.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0200-2799.pdf].

NIOSH [2001]. University of California, Berkeley, Berkeley, CA. NIOSH HETA Report No. 1999-0113-2853.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0113-2853.pdf].

NIOSH [2002]. Lead Safe Services, Inc., Neenah, WI. NIOSH HETA Report No. 1999-0305-2878.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0305-2878.pdf].

NIOSH [2005]. Vermont Housing & Conservation Board, Montpelier, VT. NIOSH HETA Report No. 1998-0285-2989.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0285-2989.pdf].

Journal Articles

Sussell A, Tubbs R, Montopoli M [1992]. Occupational exposures during abrasive blasting removal of lead-based paint on a highway bridge. Appl Occup Environ Hyg 7(8):497-499.

Sussell A, Singal M, Wainwright S [1996]. Occupational exposures to heavy metals at a Bolivian smelter. Appl Occup Environ Hyg 11(7):591-595.

Sussell A, Hart C, Wild D, Ashley K [1999]. An evaluation of worker lead exposures and cleaning effectiveness during removal of deteriorated lead-based paint. Appl Occup Environ Hyg 14:177-185.

Sussell A, Ashley K [2002]. Field measurement of lead in workplace air and paint chip samples by ultrasonic extraction and portable anodic stripping voltammetry. J Environ Monit 4(1):156-161.

Drake P, Lawryk N, Ashley K, Sussell A, Hazelwood K, Song R [2003]. Evaluation of two portable lead-monitoring methods at mining sites. J Hazard Mater 102(1):29-38.

NIOSH Numbered Documents

NIOSH, ed. [1997]. Protecting workers exposed to lead-based paint hazards: a report to Congress. DHHS (NIOSH) Publication No. 98-112.
[http://www.cdc.gov/niosh/98-112pd.html].

NIOSH [2007]. NIOSH manual of analytical methods (NMAM®). 4th ed. DHHS (NIOSH) Publication 94-113 (August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 2003-154.
[http://www.cdc.gov/ niosh/nmam/].

Other Publications

ASTM [2007a]. Standard Practice for the determination of lead paint, settled dust, soil and air particulate by field-portable electroanalysis. Active Standard E2051-01, in Book of Standards Volume 04.12. West Conshohocken, PA: American Society for Testing and Materials.

ASTM [2007b]. Standard Practice for ultrasonic extraction of paint, settled dust, soil and air samples for subsequent determination of lead. Active Standard E1979-04, in Book of Standards Volume 04.12. West Conshohocken, PA: American Society for Testing and Materials.

EPA [1994]. Reducing lead hazards when remodeling your home. Washington, DC: U.S. Environmental Protection Agency. Publication No. EPA 747-R-94-002.

EPA [1998]. Lead exposure associated with renovation and remodeling activities: Phase IV worker characterization and blood-lead study of R&R workers who specialize in renovation of old or historic buildings. U.S. Environmental Protection Agency. EPA Contract No. 68-D5-0008, Task 3-21. Report prepared by Batelle, Inc.

HUD [1991]. The HUD lead-based paint abatement demonstration (FHA). Washington, DC: U.S. Department of Housing and Urban Development, Dewberry & Davis contract report HC-5831, August 1991.

HUD [1995]. HUD Technical Guidelines for the evaluation and control of lead-based paint hazards in housing. Washington, DC: U.S. Department of Housing and Urban Development, Office of Lead Hazard Control.

HUD [1999]. Lead paint safety, a field guide for painting, home maintenance and renovation work. Washington, DC: U.S. Department of Housing and Urban Development, Office of Lead Hazard Control. Publication No. HUD 1779-LHC.

OSHA [1993a]. 29 CFR 1926.62, Lead Exposure in Construction: Interim Final Rule -- Inspection and Compliance Procedures. Department of Labor, Occupational Safety and Health Administration. Directive CPL 02-02-058.

OSHA [1993b]. Lead Exposure in Construction: Interim Final Rule -- Supplementary Information. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1926. Vol 58, No. 84, Tuesday, May 4, 1993, p 26596.

Sussell A, Weber A, Wild D, Wall D, Ashley K [1995]. An evaluation of airborne and surface lead concentrations from preliminary cleaning of a building contaminated with deteriorated lead-based paint. In: Beard M, Iske S, eds. Lead in paint, soil and dust: health risks, exposure studies, control measures, measurement methods, and quality assurance. Philadelphia, PA: American Society for Testing and Materials, pp. 145-161.

Ergonomics and Musculoskeletal Disorders

HHE Numbered Reports

NIOSH [1989]. John Morrell and Co., Sioux Falls, SD. NIOSH HETA Report No. 1988-180-1958.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1988-0180-1958.pdf].

NIOSH [1990a]. Newsday, Inc., Melville, NY. NIOSH HETA Report No. 1989-250-2046.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1989-0250-2046.pdf].

NIOSH [1990b]. Kroger Company, Oxford, OH. HETA Report No. 1988-345-2031.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1988-0345-2031.pdf].

NIOSH [1991]. Shoprite Supermarkets, NJ-NY. NIOSH HETA Report No. 1988-344-2092.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1988-0344-2092.pdf].

NIOSH [1992]. US West Communications, Phoenix, AZ; Minneapolis, MN; Denver, CO. NIOSH HETA Report No. 1989-299-2230.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1989-0299-2230.pdf].

NIOSH [1993a]. Los Angeles Times, Los Angeles, CA. NIOSH HETA Report No. 1990-013-2277.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0013-2277.pdf].

NIOSH [1993b]. Social Security Administration Teleservice Centers, Boston, MA; Fort Lauderdale, FL. NIOSH HETA Report No. 1992-0382-2450.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/1992-0382-2450.pdf].

NIOSH [1993c]. Schnuck's, National and Dierberg's Supermarkets, St. Louis, MO. NIOSH HETA Report No. 1992-294-2301.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1992-0294-2301.pdf].

NIOSH [1994]. WBZ-TV News, Boston, MA. NIOSH HETA Report No. 1993-0860-2438.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0860-2438.pdf].

NIOSH [1995]. Kroger Grocery Warehouse, Nashville, TN. NIOSH HETA Report No. 1993-0920-2548.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0920-2548.pdf].

NIOSH [1996a]. Trus Joist MacMillan, Deerwood, MN. NIOSH HETA Report No. 1993-0436-2569.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0436-2569.pdf].

NIOSH [1996b]. Bundy Corporation, Cynthiana, KY. NIOSH HETA Report No. 1993-0667-2585.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0667-2585.pdf].

NIOSH [1996c]. Hanover Shoe Company, Franklin, WV. NIOSH HETA Report No. 1994-0245-2577.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0245-2577.pdf].

NIOSH [1996d]. Green Circle Growers, Inc., Oberlin, OH. NIOSH HETA Report No. 1994-0376-2576.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0376-2576.pdf].

NIOSH [1996e]. Scientific Application International Corporation, Frederick, MD. NIOSH HETA Report No. 1995-0294-2594.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1995-0294-2594.pdf].

NIOSH [1996f]. Schrock Cabinet Company, Arthur, IL. NIOSH HETA Report No. 1995-0335-2566.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0335-2566.pdf].

NIOSH [1996g]. Cooper Power Systems, East Stroudsburg, PA. NIOSH HETA Report No. 1995-0386-2582.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0386-2582.pdf].

NIOSH [1996h]. Weyerhaeuser Paper Company, Belleville, IL. NIOSH HETA Report No. 1996-0062-2588.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0062-2588.pdf].

NIOSH [1996i]. Acton Post Office, Acton, MA. NIOSH HETA Report No. 1996-0120-2608.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0120-2608.pdf].

NIOSH [1997a]. Dana Corporation, Spicer Axle Division, Fort Wayne, IN. NIOSH HETA Report No. 1995-0293-2655.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0293-2655.pdf].

NIOSH [1997b]. University of Cincinnati Hospital, Cincinnati, OH. NIOSH HETA Report No. 1995-0403-2627.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0403-2627.pdf].

NIOSH [1997c]. A.W. Dimock Laboratory, Cornell University, Ithaca, NY. NIOSH HETA Report No. 1996-0032-2649.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0032-2649.pdf].

NIOSH [1997d]. Midland Steel Products Company, Janesville, WI. NIOSH HETA Report No. 1996-0101-2476.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0101-2476.pdf].

NIOSH [1997e]. Oscar Mayer Foods Corporation, Madison, WI. NIOSH HETA Report No. 1996-0213-2638.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0213-2638.pdf].

NIOSH [1997f]. U.S. Fish and Wildlife Service, Warm Springs Regional Fisheries Center, Warm Springs, GA. NIOSH HETA Report No. 1997-0327-2665.
[http://www. cdc.gov/niosh/hhe/reports/pdfs/1997-0327-2665.pdf].

NIOSH [1998a]. U.S. Department of Agriculture, U.S. Forest Service, Washington, D.C. NIOSH HETA Report No. 1993-1035-2686.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1993-1035-2686.pdf].

NIOSH [1998b]. Especially for You, Limited, Coloma, WI. NIOSH HETA Report No. 1996-0145-2684.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0145-2684.pdf].

NIOSH [1998c]. General Dynamics, Electric Boat Division, Groton, CT. NIOSH HETA Report No. 1996-0253-2682.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0253-2682.pdf].

NIOSH [1998d]. Foss Manufacturing Company, Inc., Hampton, NH. NIOSH HETA Report No. 1996-0258-2673.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0258-2673.pdf].

NIOSH [1998e]. Hagerman Fossil Beds National Monument, National Park Service, U.S. Department of the Interior, Hagerman, ID. NIOSH HETA Report No. 1996-0264-2713.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0264-2713.pdf].

NIOSH [1998f]. International Association of Fire Fighters, Indianapolis, IN. NIOSH HETA Report No. 1997-0034-2683.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0034-2683.pdf].

NIOSH [1998g]. Victoria Vogue, Inc., Bethlehem, PA. NIOSH HETA Report No. 1997-0119-2707.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0119-2707.pdf].

NIOSH [1998h]. Siemens Energy & Automation, Inc., Distribution Products Division, Urbana, OH. NIOSH HETA Report No. 1997-0154-2693.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/1997-0154-2693.pdf].

NIOSH [1998i]. Active Industries, Inc., Clifton Park, NY. NIOSH HETA Report No. 1997-0219-2708.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0219-2708.pdf].

NIOSH [1998j]. Remington Industries, Inc., Benton, TN. NIOSH HETA Report No. 1997-0220-2671.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0220-2671.pdf].

NIOSH [1998k]. Peerless-Premier Appliance Company, Belleville, IL. NIOSH HETA Report No. 1997-0231-2705.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0231-2705.pdf].

NIOSH [1998l]. Potlatch Corporation-Minnesota Pulp and Paper Division, Cloquet, MN. NIOSH HETA Report No. 1998-0003-2698.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1998-0003-2698.pdf].

NIOSH [1998m]. Inland Eastex, Evadale, TX. NIOSH HETA Report No. 1998-0062-2710.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0062-2710.pdf].

NIOSH [1998n]. Aurora Casket Company, Aurora, IN. NIOSH HETA Report No. 1998-0085-2715.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0085-2715.pdf].

NIOSH [1998o]. U.S. Precision Lens Incorporated, Cincinnati, OH. NIOSH HETA Report No. 1998-0131-2704.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0131-2704.pdf].

NIOSH [1999a]. University of Medicine and Dentistry of New Jersey, Piscataway, NJ. NIOSH HETA Report No. 1999-0093-2749.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1999-0093-2749.pdf].

NIOSH [1999b]. Met-Tech Industries, Inc., Cambridge, OH. NIOSH HETA Report No. 1996-0232-2776.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0232-2776.pdf].

NIOSH [1999c]. Astoria Metal Corporation, Hunters Point Naval Shipyard, San Francisco, CA. NIOSH HETA Report No. 1997-0196-2755.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/1997-0196-2755.pdf].

NIOSH [1999d]. U.S. Department of the Interior, Yosemite National Park, CA. NIOSH HETA Report No. 1997-0199-2680.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0199-2680.pdf].

NIOSH [1999e]. Owens Corning, Amarillo, TX. NIOSH HETA Report No. 1997-0276-2724.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0276-2724.pdf].

NIOSH [1999f]. Allgrind Plastics, Inc., West Portal, NJ. NIOSH HETA Report No. 1998-0072-2762.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0072-2762.pdf].

NIOSH [1999g]. Safelite Auto Glass, Cincinnati, OH. NIOSH HETA Report No. 1998-0291-2750.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0291-2750.pdf].

NIOSH [1999h]. Oakes and Parkhurst Glass, Winslow, ME. NIOSH HETA Report No. 1999-0025-2756.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0025-2756.pdf].

NIOSH [1999i]. U.S. Precision Lens, Incorporated, Cincinnati, OH. NIOSH HETA Report No. 1999-0085-2736.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0085-2736.pdf].

NIOSH [2000a]. Coors Distributing Company, Golden, CO. NIOSH HETA Report No. 1997-0076-2805.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0076-2805.pdf].

NIOSH [2000b]. Indian Health Service Dental Clinics, Arizona. NIOSH HETA Report No. 1998-0032-2795.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0032-2795.pdf].

NIOSH [2000c]. General Electric - Evendale, Cincinnati, OH. NIOSH HETA Report No. 1998-0263-2817.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0263-2817.pdf].

NIOSH [2000d]. Wonder Industries, Wyoming, MN. NIOSH HETA Report No. 1999-0185-2787.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0185-2787.pdf].

NIOSH [2000e]. Fremont Beef Company, Fremont, NE. NIOSH HETA Report No. 1999-0348-2786.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0348-2786.pdf].

NIOSH [2000f]. United States Postal Service, Dayton, OH. NIOSH HETA Report No. 2000-0014-2792.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0014-2792.pdf].

NIOSH [2000g]. Material Sciences Corporation, Pinole Point Steel, Richmond, CA. NIOSH HETA Report No. 2000-0316-2811.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2000-0316-2811.pdf].

NIOSH [2001a]. Special Metals Corporation, Princeton Powder Division, Princeton, KY. NIOSH HETA Report No. 1997-0141-2819.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1997-0141-2819.pdf].

NIOSH [2001b]. Indian Health Service. NIOSH HETA Report No. 1999-0106-2838.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0106-2838.pdf].

NIOSH [2001c]. Yellowstone National Park, Yellowstone National Park, Wyoming. NIOSH HETA Report No. 1999-0283-2855.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1999-0283-2855.pdf].

NIOSH [2001d]. Pappas Chiropractic Center, Piscataway, NJ. NIOSH HETA Report No. 2000-0363-2834.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0363-2834.pdf].

NIOSH [2002a]. Thomas Steel Strip Corporation, Warren, OH. NIOSH HETA Report No. 1999-0343-2882.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0343-2882.pdf].

NIOSH [2002b]. Tenneco Automotive, Milan, OH. NIOSH HETA Report No. 2000-0124-2875.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0124-2875.pdf].

NIOSH [2002c]. City of Cincinnati Sewers, Water Works & Public Services, Cincinnati, OH. NIOSH HETA Report No. 2001-0073-2869.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/2001-0073-2869.pdf].

NIOSH [2003]. The Concrete Revolution, Denver, CO. NIOSH HETA Report No. 2001-0461-2889.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0461-2889.pdf].

NIOSH [2004a]. Alameda County Public Authority for In-Home Support Services, Alameda, CA. NIOSH HETA Report No. 2001-0139-2930.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2001-0139-2930.pdf].

NIOSH [2004b]. United States Postal Service, Norman, OK. NIOSH HETA Report No. 2002-0239-2922.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0239-2922.pdf].

NIOSH [2004c]. Alstom Power, Inc., Chattanooga, TN. NIOSH HETA Report No. 2003-0383-2942.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0383-2942.pdf].

NIOSH [2004d]. Superior Dairy, Canton, OH. NIOSH HETA Report No. 2004-0001-2937.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0001-2937.pdf].

NIOSH [2004e]. Navajo Agricultural Products Industry, Farmington, NM. NIOSH HETA Report No. 2004-0014-2929.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0014-2929.pdf].

NIOSH [2005a]. Genesis Steel Services, Inc., Baltimore, MD. NIOSH HETA Report No. 2003-0146-2976.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0146-2976.pdf].

NIOSH [2005b]. Freudenberg-NOK, High Quality Plastics Division, Findlay, OH. NIOSH HETA Report No. 2003-0351-2972.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2003-0351-2972.pdf].

NIOSH [2005c]. U.S. Roofing Contractors, Philadelphia, PA. NIOSH HETA Report No. 2004-0038-2966.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0038-2966.pdf].

NIOSH [2005d]. ZF Industries, Tuscaloosa, AL. NIOSH HETA Report No. 2004-0116-2977.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0116-2977.pdf].

NIOSH [2005e]. Good Humor-Breyers Ice Cream, Hagerstown, MD. NIOSH HETA Report No. 2004-0117-2964.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0117-2964.pdf].

NIOSH [2005f]. Meijer, East Lansing, MI. NIOSH HETA Report No. 2004-0415-2963.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0415-2963.pdf].

NIOSH [2006]. BlueLinx Corporation, Bellingham, MA. NIOSH HETA Report No. 2005-0318-3006.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0318-3006.pdf].

NIOSH [2007]. General Electric Aviation, Engine Services Distribution Center, Erlanger, KY. NIOSH HETA Report No. 2006-0239-3040.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2006-0239-3040.pdf].

Journal Articles

Baron SL, Habes D [1992].Occupational musculoskeletal disorders among supermarket cashiers. Scand J Work Environ Health 18 Suppl 2:127-129.

Baron S, Hales T, Hurrell J [1996]. Evaluation of symptom surveys for occupational musculoskeletal disorders. Am J Ind Med 29:609-617.

Bernard B, Nelson N, Estill CF, Fine L [1998]. The NIOSH review of hand-arm vibration syndrome: vigilance is crucial. J Occup Environ Med 40(9):780-785.

Dickinson CE, Campion K, Foster AF, Newman SJ, O'Rourke AM, Thomas PG [1992]. Questionnaire development: an examination of the Nordic musculoskeletal questionnaire. Appl Ergon 3:197-201.

Fogleman M, Lewis RJ [2002]. Factors associated with self-reported musculoskeletal discomfort in video display terminal (VDT) users. Internat J Indust Ergon 29(6):311-318.

Gerr F, Marcus M, Ensor C, Kleinbaum D, Cohen S, Edwards A, Gentry E, Ortiz DJ, Monteilh C [2002]. A prospective study of computer users: I. Study design and incidence of musculoskeletal symptoms and disorders. Am J Ind Med 41(4):221-235.

Grant KA, Habes DJ, Baron SL [1994]. An ergonomics evaluation of cashier work activities at checker-unload workstations. Appl Ergon 25(5):310-318.

Grant KA, Habes DJ, Bertsche PK [1997]. Lifting hazards at a cabinet manufacturing company: evaluation and recommended controls. Appl Occup Environ Hyg 12(4):253-258.

Habes DJ, Grant KA [1997]. An electromyographic study of maximum torques and upper extremity muscle activity in simulated screwdriver tasks. Int J Ind Ergon 20:339-346.

Habes D, Schiefer M [1999]. Case studies: an ergonomic evaluation of trail workers at Yosemite National Park. Appl Occup Environ Hyg 14(5):276-284.

Habes D, Baron S [2000]. Ergonomic evaluation of antenatal ultrasound testing procedures. Appl Occup Environ Hyg 15(7):521-528.

Habes DJ [2001]. Case studies: ergonomic evaluation of zinc pot skimming. Appl Occup Environ Hyg 16(4):419-425.

Habes DJ, Dick RB, Tubbs RL, Biggs FR, Burt SE [2003]. Case studies: an ergonomic evaluation of snowmobiles. Appl Occup Environ Hyg 18(4):213-225.

Hannan LM, Monteilh CP, Gerr F, Kleinbaum DG, Marcus M [2005]. Job strain and risk of musculoskeletal symptoms among a prospective cohort of occupational computer users. Scand J Work Environ Health 31(5):375-386.

Hudock SD, Wurzelbacher SJ, Reed LD, Hales TR, Siegfried KV [2001]. A precursor to ergonomics best practices for the shipyard industries. J Ship Produc 17(3):145-150.

Morse T, Dillon M, Warren N, Hall C, Hovey D[2001]. Capture-recapture estimation of unreported work-related musculoskeletal disorders in Connecticut, Am J Ind Med 39:636-642.

Rempel D, Evanoff B, Amadio P C, de Krom M, Franklin G, Franzblau A, Gray R, Gerr F, Hagberg M, Hales T, Katz JN, Pransky G [1998]. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies Am J Public Health 88(10):1447-1451.

Smith DR, Ohmura K, Yamagata Z, Minai J [2003]. Musculoskeletal disorders among female nurses in a rural Japanese hospital. Nurs Health Sci 5(3):185-188.

Waters TR, Baron SL, Piacitelli LA, Anderson VP, Skov T, Haring-Sweeney M, Wall DK, Fine LJ [1999]. Evaluation of the revised NIOSH lifting equation. A cross-sectional epidemiologic study. Spine 24(4):386-394.

Waters TR, Baron SL, Kemmlert K [1998].Accuracy of measurements for the revised NIOSH lifting equation. Appl Ergon 29(6):433-438.

Waters TR, Putz-Anderson V, Baron S [1998]. Methods for assessing the physical demands of manual lifting: A review and case study from warehousing. Am Ind Hyg Assoc J 9(12):871-881.

NIOSH Numbered Documents

NIOSH [1994]. Applications manual for the revised NIOSH lifting equation DHHS (NIOSH) Publication 94-110.
[http://www.cdc.gov/niosh/docs/94-110/pdfs/94-110.pdf].

NIOSH [1997a]. NIOSH testimony to OSHA - comments on the proposed ergonomics program - 29 CFR Part 1910 Docket No. S-177. DHHS (NIOSH) Publication 97-117.
[http://www.cdc.gov/niosh/docs/2001-108/pdfs/2001-108.pdf].

NIOSH [1997b]. Musculoskeletal disorders and workplace factors. DHHS (NIOSH) Publication No. 97-141.
[http://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf].

NIOSH [1997c]. Elements of ergonomics programs. a primer based on workplace evaluations of musculoskeletal disorders. DHHS (NIOSH) Publication No. 97-117. [http://www.cdc.gov/niosh/pdfs/97-117.pdf].

NIOSH [1999]. NIOSH publications on video display terminals. DHHS (NIOSH) Publication No. 99-135.
[http://www.cdc.gov/niosh/pdfs/99-135.pdf].

NIOSH [2001]. Simple solutions. Ergonomics for farmworkers. DHHS (NIOSH) Publication No. 2001-111.
[http://www.cdc.gov/niosh/pdfs/01-111.pdf].

NIOSH Testimony to OSHA [2001a]. Comments on the proposed ergonomics program, docket S-777. [www.cdc.gov/niosh/docs/2001-108/pdfs/2001-108.pdf].

NIOSH [2001b]. NORA Musculoskeletal Agenda.
[http://www.cdc.gov/niosh/2001-117d.html].

NIOSH [2007]. Preventing work-related musculoskeletal disorders in sonography - workplace solutions. DHHS (NIOSH) Publication No. 2006-148 [http://www.cdc.gov/niosh/docs/wp-solutions/2006-148/pdfs/2006-148.pdf].

Other Publications

Bernard B, Booth Jones A, Estill CF, Fine L, Habes D, Hales T, Anderson VP, Votaw D [2000]. The Magnitude, Science Base, and Solutions for One of the Largest Occupational Health Problems in the United States. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 4:5-8.

Bhattacharya A, Habes D, Dewees J [2006]. Workplace-related lower extremity disorders: workplace adaptations with case studies. In: Nordin M, Andersson G, Pope M, eds. Musculoskeletal disorders in the workplace. 2nd ed. Philadelphia, PA: Mosby Elsevier, p. 309.

Hales T, Bernard B [1996]. Chapter: The Epidemiology and Changing Character of Work Related Disorders, in The Orthopedic Clinics of North America on Occupational Disorder Management, eds. Millender L, Tromanhauser S, Gaynor S., W. B. Saunders, Philadelphia, Pa.

Hales TR [2002]. Ergonomics and upper extremity musculoskeletal disorders. In: Wald PH, Stave GM, eds. Physical and biological hazards of the workplace. New York: John Wiley and Sons, Inc., p. 19.

Hurrell J, Bernard B, Hales TR, Sauter SL, Hoekstra EJ [1996]. Chapter: Psychosocial Factors and Musculoskeletal Disorders: Summary and Implications of three NIOSH Health Hazard Evaluations of Video Display Terminal Work; in Beyond Biomechanics ed. Sauter SL, Moon SD, 99-107.

Mansdorf Z [1999]. Does your ergonomics program need a tune-up?
[http://www.oehs. wayne.edu/anicon/ergo%20survey%20OEHS-1-24-02.pdf].

NIEHS [2004]. Health and safety manual. Miscellaneous safety policies: safety and health program for video display terminal operators.
[http://www.niehs.nih.gov/odhsb/ manual/home.htm].

OSHA [1993a]. Ergonomic Meatpacking Guidelines.
[http://www.osha.gov/Publications/ osha3123.pdf].

HHE Numbered Reports

NIOSH [1996a]. Dirty Bird, Inc., Grady, AK. NIOSH HETA Report No. 1995-0248-2562.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0248-2562.pdf].

NIOSH [1996b]. FBI Academy, Quantico, VA. NIOSH HETA Report No. 1991-0346-2572.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0346-2572.pdf].

NIOSH [1996c]. Martin's Carstar, Inc., Lakewood, CO. NIOSH HETA Report No. 1995-0311-2593.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0311-2593.pdf].

NIOSH [1996d]. Matrix Auto Body, Englewood, CO. NIOSH HETA Report No. 1995-0406-2609.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0406-2609.pdf].

NIOSH [1996e]. Spence's Carstar, Inc., Denver, CO. NIOSH HETA Report No. 1995-0405-2600.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0405-2600.pdf].

NIOSH [1997a]. Los Angeles County Department of Coroner, Los Angeles, CA. NIOSH HETA Report No. 1996-0019-2666.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0019-2666.pdf ].

NIOSH [1997b]. Department of Transportation, Federal Aviation Administration, Bradley Airfield, Windsor Locks, CT. NIOSH HETA Report No. 1996-0184-2663.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0184-2663.pdf].

NIOSH [1997c]. Woodward Governor Co., Fort Collins, CO. NIOSH HETA Report No. 1997-0084-2669.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0084-2669.pdf].

NIOSH [1998a]. The Crown: U.S. Hot Rod Monster Truck and Motocross Show, Cincinnati, OH. NIOSH HETA Report No. 1998-0093-2717.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/1998-0093-2717.pdf].

NIOSH [1998b]. Immigration and Naturalization Service, San Ysidro, CA. NIOSH HETA Report No. 1997-0291-2681.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0291-2681.pdf].

NIOSH [1999a]. Continental and Continental Express Airlines, Newark, NJ. NIOSH HETA Report No. 1999-0060-2766.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0060-2766.pdf].

NIOSH [1999c]. Edgcomb Metals, Cincinnati, OH. NIOSH HETA Report No. 1999-0047-2746.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0047-2746.pdf].

NIOSH [1999d]. RMC LONESTAR, San Francisco, CA. NIOSH HETA Report No. 1998-0289-2742.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0289-2742.pdf].

NIOSH [1999e]. U.S. Army Corps of Engineers: Libby Dam Project, Libby, MT. NIOSH HETA Report No. 1998-0149-2734.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0149-2734.pdf].

NIOSH [2000a]. NASCAR, ST Motor Sports, Stanfield, NC. NIOSH HETA Report No. 2000-0110-2849.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0110-2849.pdf].

NIOSH [2000b]. Department of Homeland Security, Immigration and Naturalization Service, Salt Lake City, UT. NIOSH HETA Report No. 99-0320-2791.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0320-2791.pdf].

NIOSH [2000c]. White Path Fab-Tech, Ellijdy, GA. NIOSH HETA Report No. 2000-0232-2814.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0232-2814.pdf].

NIOSH [2000d]. Wire Rope Corporation of America, Sedalia, MO. NIOSH HETA Report No. 2000-0181-2841.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0181-2841.pdf].

NIOSH [2001a]. Department of Transportation, Federal Aviation Administration, Burlington, MA. NIOSH HETA Report No. 2000-0408-2825.
[http://www.cdc.gov/ niosh/hhe/reports/pdfs/2000-0408-2825.pdf].

NIOSH [2001b]. Human Performance International, Inc., Charlotte, NC. NIOSH HETA Report No. 2000-0110-2849.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0110-2849.pdf].

NIOSH [2001c]. Lac Vieux Desert Casino, Watersmeet, MI. NIOSH HETA Report No. 2001-0109-2835.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0109-2835.pdf].

NIOSH [2001d]. Oklahoma City Community Bookstore, Oklahoma City, OK. NIOSH HETA Report No. 2001-0496-2866.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0496-2866.pdf].

NIOSH [2002]. Marion County Board of Education, Fairmont, WV. NIOSH HETA Report No. 2002-0222-2879.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0222-2879.pdf].

NIOSH [2003a]. Utah Department of Public Safety -Utah Highway Patrol, Salt Lake City, Utah. NIOSH HETA Report No.2003-0094-2919.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2003-0094-2919.pdf].

NIOSH [2003b]. Fort Collins Police Services, Fort Collins, Colorado. NIOSH HETA Report No. 2002-0131-2898.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0131-2898.pdf].

NIOSH [2003c]. The Concrete Revolution, Denver, CO. NIOSH HETA Report No. 2001-0461-2889.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0461-2889.pdf].

NIOSH [2003d]. Capitol Heat and Power, State of Wisconsin, Madison, WI. NIOSH HETA Report No. 2002-0284-2908.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0284-2908.pdf].

NIOSH [2003e]. Blue Ribbon Packing, Indianapolis, IN. NIOSH HETA Report No. 2002-0253-2894.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0253-2894.pdf].

NIOSH [2004a]. Department of Health and Human Services, Navajo Agricultural Products Industry, Farmington, NM. NIOSH HETA Report No.2004-0014-2929.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0014-2929.pdf].

NIOSH [2004b]. Horizon Airlines, Seattle, WA. NIOSH HETA Report No. 2002-0354-2931.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0284-2908.pdf].

NIOSH [2004c]. Kirkwood Community College Iowa City, IA. NIOSH HETA Report No. 2004-0046-2950.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0046-2950.pdf].

NIOSH [2004d]. Spirit Mountain Casino, Grand Ronde, OR. NIOSH HETA Report No. 2003-0157-2934.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0157-2934.pdf].

NIOSH [2004e]. Transportation Security Administration, Baltimore-Washington International Airport, Linthicum, MD. NIOSH HETA Report No. 2004-0101-2953.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0101-2953.pdf].

NIOSH [2004f]. Transportation Security Administration, Miami International Airport, Miami, FL. NIOSH HETA Report No. 2004-0146-2947.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2004-0146-2947.pdf].

NIOSH [2004g]. Transportation Security Administration, Palm Beach International Airport, West Palm Beach, FL. NIOSH HETA Report No. 2004-0130-2945.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0130-2945.pdf].

NIOSH [2004h]. Transportation Security Administration, Washington-Dulles International Airport, VA. NIOSH HETA Report No. 2004-0100-2946.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0100-2946.pdf].

NIOSH [2005a]. Immigration and Naturalization Service, Altoona, PA. NIOSH HETA Report No. 2000-0191-2960.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0191-2960.pdf].

NIOSH [2005b]. Kaiser Permanente Redwood City Medical Center, Redwood City, CA. NIOSH HETA Report No. 2003-0280-2974.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2003-0280-2974.pdf].

NIOSH [2005c]. Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA. NIOSH HETA Report No. 2003-0287-2974.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2003-0287-2974.pdf].

NIOSH [2005d]. Kentucky Sanitation District # 1, Fort Wright, KY. NIOSH HETA Report No. 2005-0035-2988.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0035-2988.pdf].

NIOSH [2005e]. Meijer, Inc., East Lansing, MI. NIOSH HETA Report No. 2004-0415-2963.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0415-2963.pdf].

NIOSH [2005f]. Transportation Security Administration Composite Report, Washington, DC. NIOSH HETA Report No. 2005-0091-2957.
[http://www.cdc.gov/niosh/hhe/ reports/pdfs/2005-0091-2957.pdf].

NIOSH [2005g]. Walace Computer Services, Clinton, IL. NIOSH HETA Report No. 2003-0203-2952.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0203-2952.pdf].

NIOSH [2006a]. Cincinnati Police Canine Unit, Cincinnati, OH. NIOSH HETA Report No. 2006-0223-3029.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0223-3029.pdf]

NIOSH [2006b]. Dixie Cultured Marble, Birmingham, AL. NIOSH HETA Report No. 2001-0326-2999.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0326-2999.pdf]

NIOSH [2006c]. Mesaba Airlines Inc., Minneapolis, MN. NIOSH HETA Report No. 2006-0364-3012.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0364-3012.pdf].

NIOSH [2006d]. Transportation Security Administration, Northern Kentucky International Airport, Erlanger, KY. NIOSH HETA Report No. 2005-0197-3010.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0197-3010.pdf].

NIOSH [2007a]. Kenton County Animal Shelter, Covington, KY. NIOSH HETA Report No. 2006-0212-3035.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0212-3035.pdf].

NIOSH [2007b]. Liberty Veterinary Hospital, Liberty Township, OH. NIOSH HETA Report No. 2006-0196-3036.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0196-3036.pdf].

NIOSH [2007c]. Louisiana Society for the Prevention of Cruelty to Animals, Algiers, LA. NIOSH HETA Report No. 2007-0068-3042.
[http://www.cdc.gov/niosh/hhe/ reports/pdfs/2007-0068-3042.pdf].

NIOSH [2007d]. Society for the Prevention of Cruelty to Animals, Cincinnati, OH. NIOSH HETA Report No. 2006-0222-3037.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2006-0222-3037.pdf].

NIOSH [2007e]. Diversified Roofing, Phoenix, AZ. NIOSH HETA Report No. 2003-0209-3015.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0209-3015.pdf].

NIOSH [2007f]. L-3 Communications Space & Navigation Systems, Budd Lake, NJ. NIOSH HETA Report No. 2005-0188-3038.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2005-0188-3038.pdf].

NIOSH [2007g]. COL-FIN Specialty Steel, Fallston, PA. NIOSH HETA Report No. 2003-0175-3033.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0175-3033.pdf].

Journal Articles

Achutan C [2007]. Occupational noise levels during emergency relief operations in the aftermath of Hurricane Katrina. J Occup Environ Hyg 4(4):D33-D35.

Achutan C, Tubbs RL (in press). A task-based assessment of noise levels at a swine confinement. J Agro Med.

Achutan C, Tubbs RL (forthcoming). Potato processing and manufacture of animal feed. J Agric Saf Health.

Martinez K, Tubbs RL, Ow P [2001]. Use of local exhaust ventilation to control aerosol exposures resulting from the use of a reciprocating saw during autopsy. Appl Occ Environ Hyg 16(7):709-717.

Morley JC, Seitz T, Tubbs R [1999]. Carbon monoxide and noise exposure at a monster truck and motorcross show. Appl Occup Environ Hyg 14(10):645-655.

Tubbs RL [1998]. Elevator music in the open office environment. Appl Occup Environ Hyg 13(8):563-566.

Tubbs RL, Franks JR [1998]. Transient sounds through communication headsets. Appl Occup Environ Hyg 13(10):691-697.

Tubbs R [2000]. Noise exposure to airline ramp employees. Appl Occup Environ Hyg 15(9):657-663.

Tubbs R, Seitz T [2000]. Evaluation of verbal communication problems and indoor environmental quality at a government service office. Appl Occup Environ Hyg 15(12):869-878.

Tubbs RL [2001]. Excessive noise levels in laboratory work spaces produced by the heating, ventilation, and air conditioning systems. Appl Occup Environ Hyg 16(5):497-501.

Tubbs RL [2003]. Noise problems associated with relocating a bookstore in a gymnasium. Appl Occup Environ Hyg 18(2):75-81.

Van Campen L, Morata T, Kardous C, Gwin K, Wallingford K, Dallaire J, Alvarez F [2005]. Ototoxic occupational exposures for a stock car racing team: I. Noise surveys. J Occup Environ Hyg 2(8):383-390.

NIOSH Numbered Documents

NIOSH [1999b]. Health hazard evaluations: noise and hearing loss, 1986-1997. DHHS (NIOSH) Publication No. 99-106.
[http://www.cdc.gov/niosh/pdfs/hearloss.pdf].

NIOSH [in press]. NIOSH Hazard Alert on Firing Ranges.

Other Publications

Sweeney MH, Fosbroke D, Goldenhar L, Jackson L, Linch K, Lushniak B, Merry C, Schneider S, and Stephenson M [2000]. Health consequences of working in construction. Chapter 10, In: Coble R, ed. Construction safety and health management. Upper Saddle River, NJ: Prentice Hall, pp. 211-234.

Global Health

HHE Numbered Reports

NIOSH [1994a]. Pan American Health Organization, National smelting company. NIOSH Report No. HETA 1994-0109-2494.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1994-0109-2494.pdf].

NIOSH [1994b]. Evaluacion de peligros para la salud: Organizacion Panamericana de la salud, empresa nacional de fundiciones. NIOSH Report No. HETA 1994-0109-2494.

NIOSH [1994c]. Pan American Health Organization, Bogota, Colombia. NIOSH Report No. HETA 1994-0253-2451.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0253-2451.pdf].

Journal Articles

CDC [2003]. Cluster of severe acute respiratory syndrome cases among protected health-care workers - Toronto, Canada, April 2003. MMWR 52(19):433-436.

CDC [2005]. Health concerns associated with disaster victim identification after a tsunami - Thailand. MMWR 54(14):349-352.

Myers JE, Thompson ML, Niak I, Theodorou P, Esswein E, Tassell H, Daya A, Renton K, Spies A, Paicker J, Young T, Jeehbay M, Ramushu S, London L, Rees DJ [2003a].The utility of biological monitoring for manganese in ferroalloy smelter workers in South Africa. Neuro Toxicol 24:875-883.

Myers JE, Thompson ML, Ramushu S, Young T, Jeehbay M, London L, Esswein E, Renton K, Spies A, Boulle A, Niak I, Iregren A, Rees DJ [2003b]. The nervous system effects of occupational exposure on workers in a South African manganese smelter. Neuro Toxicol 24:885-894.

Other Publications

PAHO [2001]. La Higiene Ocupacional en America Latina: una Guia Para Su Desarrollo, Washington, D.C.: World Health Organization, Pan American Health Organization.

Indoor Environmental Quality

HHE Numbered Reports

NIOSH [1991a]. Library of Congress, Volume I, Washington, DC. NIOSH HETA Report No. 1988-0364-2102.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1988-0364-2102.pdf].

NIOSH [1991b]. Raymond W. Bliss Army Community Hospital, Ft. Huachuca, AZ. NIOSH HETA Report No. 1988-0369-2141.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1988-0369-2141.pdf].

NIOSH [1991c]. Library of Congress, Volume III, Washington, DC. NIOSH HETA Report No. 1988-0396-2104.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1988-0396-2104.pdf].

NIOSH [1991d]. Toledo Municipal Building, Toledo, OH. NIOSH HETA Report No. 1989-0065-2119.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1989-0065-2119.pdf].

NIOSH [1991e]. Andrew Jackson Junior High School, Cross Lanes, WV. NIOSH HETA Report No. 1989-0183-2101.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1989-0183-2101.pdf].

NIOSH [1991f]. Shamokin Elementary School, Shamokin, PA. NIOSH HETA Report No. 1990-0202-2116.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0202-2116.pdf].

NIOSH [1991g]. Northland Terrace Nursing and Rehabilitation Center, Columbus, OH. NIOSH HETA Report No. 1990-0252-2167.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1990-0252-2167.pdf].

NIOSH [1991h]. Pensacola City Hall, Pensacola, FL. NIOSH HETA Report No. 1990-0288-2113.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0288-2113.pdf].

NIOSH [1991i]. Department of Housing and Urban Development, Hato Rey, PR. NIOSH HETA Report No. 1990-0376-2106.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0376-2106.pdf].

NIOSH [1991j]. Berry Building, Birmingham, AL. NIOSH HETA Report No. 1991-0034-2114.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0034-2114.pdf].

NIOSH [1991k]. Oakland County Department of Social Services, Pontiac, MI. NIOSH HETA Report No. 1991-0056-2129.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0056-2129.pdf].

NIOSH [1991l]. University of Utah Medical Center, Salt Lake City, UT. NIOSH HETA Report No. 1991-0075-2122.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0075-2122.pdf].

NIOSH [1991m]. Social Security Administration, San Juan, PR. NIOSH HETA Report No. 1991-0078-2132.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0078-2132.pdf].

NIOSH [1991n]. Cocalico School District, Denver, PA. NIOSH HETA Report No. 1991-0118-2213.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0118-2213.pdf].

NIOSH [1991o]. State of Colorado Office of the State Public Defender, Denver, CO. NIOSH HETA Report No. 1991-0125-2125.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1991-0125-2125.pdf].

NIOSH [1991p]. Western Primary School, Russiaville, IN. NIOSH HETA Report No. 1991-0143-2136.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0143-2136.pdf].

NIOSH [1991q]. Immaculate Heart of Mary Church, Cincinnati, OH. NIOSH HETA Report No. 1991-0158-2161.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0158-2161.pdf].

NIOSH [1991r]. Garfield County Courthouse, Glenwood Springs, CO. NIOSH HETA Report No. 1991-0176-2168.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0176-2168.pdf]. NIOSH [1991].

NIOSH [1991s]. University of South Florida, Tampa, FL. NIOSH HETA Report No. 1991-0238-2162.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0238-2162.pdf].

NIOSH [1991t]. Hubert H. Humphrey Building, Washington, DC. NIOSH HETA Report No. 1991-0291-2151.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0291-2151.pdf].

NIOSH [1992a]. Hertz Car Rental Corporation, Chicago, IL. NIOSH HETA Report No. 1989-0220-2191.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1989-0220-2191.pdf].

NIOSH [1992b]. AMP Incorporated, Berwyn, PA. NIOSH HETA Report No. 1990-0264-2263.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0264-2263.pdf].

NIOSH [1992c]. J.M. Grasse Elementary School, Sellersville, PA. NIOSH HETA Report No. 1990-0287-2250.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1990-0287-2250.pdf].

NIOSH [1992d]. Somerset County Assistance Office, Somerset, PA. NIOSH HETA Report No. 1991-0065-2206.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0065-2206.pdf].

NIOSH [1992e]. Department of Veterans Affairs, Austin Finance Center, Austin, TX. NIOSH HETA Report No. 1991-0120-2286.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1991-0120-2286.pdf].

NIOSH [1992f]. Bethlehem-Center Elementary School, Fredricktown, PA. NIOSH HETA Report No. 1991-0188-2205.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0188-2205.pdf].

NIOSH [1992g]. Harold Washington Social Security Center, Chicago, IL. NIOSH HETA Report No. 1991-0253-2233.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0253-2233.pdf].

NIOSH [1992h]. Ropes and Gray Photocopy Center, Boston, MA. NIOSH HETA Report No. 1991-0254-2186.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0254-2186.pdf].

NIOSH [1992i]. Ohio Civil Rights Commission, Cincinnati, OH. NIOSH HETA Report No. 1991-0257-2184.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0257-2184.pdf].

NIOSH [1992j]. Social Security Administration District Office, Colorado Springs, CO. NIOSH HETA Report No. 1991-0351-2252.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1991-0351-2252.pdf].

NIOSH [1992k]. New York State Department of Taxation and Taxation, Albany, NY. NIOSH HETA Report No. 1991-0378-2242.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1991-0378-2242.pdf].

NIOSH [1992l]. Veterans Administration Medical Center, Los Angeles, CA. NIOSH HETA Report No. 1991-0395-2244.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0395-2244.pdf].

NIOSH [1992m]. University of Georgia Institute of Ecology, Athens, GA. NIOSH HETA Report No. 1992-0066-2216.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0066-2216.pdf].

NIOSH [1992n]. Western Primary School, Russiaville, IN. NIOSH HETA Report No. 1992-0107-2227.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0107-2227.pdf].

NIOSH [1992o]. Montpelier High School, Montpelier, VT. NIOSH HETA Report No. 1992-0108-2247.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0108-2247.pdf].

NIOSH [1992p]. South Junior High School, Morgantown, WV. NIOSH HETA Report No. 1992-0138-2258.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0138-2258.pdf].

NIOSH [1992q]. Ohio University Jennings Home, Athens, OH. NIOSH HETA Report No. 1992-0139-2274.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0139-2274.pdf].

NIOSH [1992r]. Mesa County Courthouse, Grand Junction, CO. NIOSH HETA Report No. 1992-0152-2214.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0152-2214.pdf].

NIOSH [1992s]. Ohio State Auditor's Office, Sharonville, OH. NIOSH HETA Report No. 1992-0180-2246.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0180-2246.pdf].

NIOSH [1992t]. Kenton County Department for Social Insurance, Covington, KY. NIOSH HETA Report No. 1992-0216-2239.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1992-0216-2239.pdf].

NIOSH [1992u]. National Labor Relations Board, Cincinnati, OH. NIOSH HETA Report No. 1992-0219-2266.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0219-2266.pdf].

NIOSH [1992v]. Food and Drug Administration, Cincinnati, OH. NIOSH HETA Report No. 1992-0261-2262.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0261-2262.pdf].

NIOSH [1993a]. Internal Revenue Service Appeals Office, Omaha, NE. NIOSH HETA Report No. 1991-0215-2293.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0215-2293.pdf].

NIOSH [1993b]. Internal Revenue Service McNamara Building, Detroit, MI. NIOSH HETA Report No. 1991-0308-2376.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0308-2376.pdf].

NIOSH [1993c]. Rhode Island Department of Education, Providence, RI. NIOSH HETA Report No. 1991-0349-2311.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0349-2311.pdf].

NIOSH [1993d]. Indiana Bell Telephone Company, Bloomington, IN. NIOSH HETA Report No. 1991-0402-2324.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0402-2324.pdf].

NIOSH [1993e]. New York Telephone Company, White Plains, NY. NIOSH HETA Report No. 1992-0009-2362.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0009-2362.pdf].

NIOSH [1993f]. Legi-Slate®, Washington, DC. NIOSH HETA Report No. 1992-0024-2285.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0024-2285.pdf].

NIOSH [1993g]. Loral Command and Control Systems, Colorado Springs, CO. NIOSH HETA Report No. 1992-0106-2313.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0106-2313.pdf].

NIOSH [1993h]. Lakeland Junior and Senior High School, Jermyn, PA. NIOSH HETA Report No. 1992-0126-2358.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0126-2358.pdf].

NIOSH [1993i]. Pennsylvania Department of Revenue, Harrisburg, PA. NIOSH HETA Report No. 1992-0166-2318.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0166-2318.pdf].

NIOSH [1993j]. Internal Revenue Service Office, Flint, MI. NIOSH HETA Report No. 1992-0217-2300.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0217-2300.pdf].

NIOSH [1993k]. Alaska Department of Environmental Conservation, Juneau, AK. NIOSH HETA Report No. 1992-0228-2280.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1992-0228-2280.pdf].

NIOSH [1993l]. Celebrezze Federal Building, Cleveland, OH. NIOSH HETA Report No. 1992-0269-2330.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0269-2330.pdf].

NIOSH [1993m]. Randolph County Schools Administration Building, Elkins, WV. NIOSH HETA Report No. 1992-0309-2306.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1992-0309-2306.pdf].

NIOSH [1993n]. Washington Metropolitan Area Transit Authority, Washington, DC. NIOSH HETA Report No. 1992-0316-2339.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1992-0316-2339.pdf].

NIOSH [1993o]. Hennepin County Health Services Building, Minneapolis, MN. NIOSH HETA Report No. 1992-0339-2323.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0339-2323.pdf].

NIOSH [1993p]. Anclote Elementary School, New Port Richey, FL. NIOSH HETA Report No. 1992-0347-2287.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0347-2287.pdf].

NIOSH [1993q]. OTIS Elevator Company, Alexandria, VA. NIOSH HETA Report No. 1992-0350-2292.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0350-2292.pdf].

NIOSH [1993r]. Hubert H. Humphrey Building, Washington, DC. NIOSH HETA Report No. 1992-0369-2322.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0369-2322.pdf].

NIOSH [1993s]. Oakland Sports Therapy and Work Hardening, Exton, PA. NIOSH HETA Report No. 1992-0389-2332.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0389-2332.pdf].

NIOSH [1993t]. Tri-County North School, Lewisburg, OH. NIOSH HETA Report No. 1993-0011-2309.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0011-2309.pdf].

NIOSH [1993u]. Blackshere Elementary School, Mannington, WV. NIOSH HETA Report No. 1993-0784-2350.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0784-2350.pdf].

NIOSH [1994a]. Internal Revenue Service, Brookhaven Service Center, Holtsville, NY. NIOSH HETA Report No. 1991-0174-2468.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1991-0174-2468.pdf].

NIOSH [1994b]. Patio Enclosures, Inc., Macedonia, OH. NIOSH HETA Report No. 1991-0394-2435.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0394-2435.pdf].

NIOSH [1994c]. Houghtaling Elementary School, Ketchikan, AK. NIOSH HETA Report No. 1992-0074-2452.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0074-2452.pdf].

NIOSH [1994d]. Kaiser Northlake Atrium, Atlanta, GA. NIOSH HETA Report No. 1992-0244-2373.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0244-2373.pdf].

NIOSH [1994e]. Kingwood Elementary School, Kingwood, WV. NIOSH HETA Report No. 1992-0362-2385.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0362-2385.pdf].

NIOSH [1994f]. Social Security Administration, Richmond, VA. NIOSH HETA Report No. 1992-0374-2402.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0374-2402.pdf].

NIOSH [1994g]. Goodwill Industries of America, Bethesda, MD. NIOSH HETA Report No. 1993-0351-2413.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0351-2413.pdf].

NIOSH [1994h]. Princeton High School, Cincinnati, OH. NIOSH HETA Report No. 1993-0737-2393.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0737-2393.pdf].

NIOSH [1994i]. Dauphin County Prison, Harrisburg, PA. NIOSH HETA Report No. 1993-0926-2472.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0926-2472.pdf].

NIOSH [1994j]. Sterling Van Dyke Credit Union, Sterling Heights, MI. NIOSH HETA Report No. 1993-1134-2400.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-1134-2400.pdf].

NIOSH [1994k]. Dr. Victor Gammuchia Dental Office, Apopka, FL. NIOSH HETA Report No. 1994-0017-2394.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0017-2394.pdf].

NIOSH [1994l]. Deerwood Place Office Building, San Ramon, CA. NIOSH HETA Report No. 1994-0051-2463.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0051-2463.pdf].

NIOSH [1994m]. Tri-County North School, Lewisburg, OH. NIOSH HETA Report No. 1994-0129-2397.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0129-2397.pdf].

NIOSH [1994n]. H.E. McCracken Middle School, Hilton Head Island, SC. NIOSH HETA Report No. 1994-0237-2446.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0237-2446.pdf].

NIOSH [1995a]. District of Columbia School of Law, Washington, DC. NIOSH HETA Report No. 1991-0160-2493.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1991-0160-2493.pdf].

NIOSH [1995b]. Sacramento Army Depot, Sacramento, CA. NIOSH HETA Report No. 1992-0102-2537.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0102-2537.pdf].

NIOSH [1995c]. Truman State Office Building, Jefferson City, MO. NIOSH HETA Report No. 1993-0154-2527.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1993-0154-2527.pdf].

NIOSH [1995d]. Hillsborough County Sheriffs Office Communication Center, Tampa, FL. NIOSH HETA Report No. 1994-0370-2511.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1994-0370-2511.pdf].

NIOSH [1995e]. Group Health Associates, Cincinnati, OH. NIOSH HETA Report No. 1994-0414-2492.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0414-2492.pdf].

NIOSH [1995f]. Tri-County North School, Lewisburg, OH. NIOSH HETA Report No. 1995-0026-2488.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0026-2488.pdf].

NIOSH [1995g]. Advanced Occupational Health Services, Elizabethtown, KY. NIOSH HETA Report No. 1995-0273-2525.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0273-2525.pdf].

NIOSH [1995h]. DeKalb County Board of Health, Decatur, GA. NIOSH HETA Report No. 1995-0333-2546.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0333-2546.pdf].

NIOSH [1996a]. Coe Manufacturing, Portland, OR. NIOSH HETA Report No. 1992-0176-2328.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0176-2328.pdf].

NIOSH [1996b]. Martin County Courthouse and Constitutional Office Building, Stuart, FL. NIOSH HETA Report No. 1993-1110-2575.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1993-1110-2575.pdf].

NIOSH [1996c]. National Center for Environmental Health, Cleveland, OH. NIOSH HETA Report No. 1995-0160-2571.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0160-2571.pdf].

NIOSH [1996d]. Jordan Hospital, Plymouth, MA. NIOSH HETA Report No. 1995-0362-2587.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0362-2587.pdf].

NIOSH [1996e]. Bally's Park Place Casino Hotel, Atlantic City, NJ. NIOSH HETA Report No. 1995-0375-2590.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0375-2590.pdf].

NIOSH [1996f]. Acton Post Office, Acton, MA. NIOSH HETA Report No. 1996-0120-2608.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0120-2608.pdf].

NIOSH [1996g]. Roudebush Veterans Administration Medical Center, Indianapolis, IN. NIOSH HETA Report No. 1996-0129-2615.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1996-0129-2615.pdf].

NIOSH [1996h]. Greater Wheaton Chamber of Commerce, Wheaton, IL. NIOSH HETA Report No. 1996-0188-2605.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0188-2605.pdf].

NIOSH [1997a]. Cowlitz County Health Department, Longview, WA. NIOSH HETA Report No. 1997-0048-2641.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0048-2641.pdf].

NIOSH [1997b]. Albert Einstein Medical Center, Northern Division, Philadelphia, PA. NIOSH HETA Report No. 1997-0049-2650.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1997-0049-2650.pdf].

NIOSH [1997c]. Martin County Administrative Building, Stuart, FL. NIOSH HETA Report No. 1994-0422-2622.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0422-2622.pdf].

NIOSH [1997d]. Brigham and Women's Hospital, Boston, MA. NIOSH HETA Report No. 1996-0012-2652.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0012-2652.pdf].

NIOSH [1997e]. Santa Fe Indian Hospital, Santa Fe, NM. NIOSH HETA Report No. 1996-0207-2635.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0207-2635.pdf].

NIOSH [1997f]. Federal Express, Cincinnati, OH. NIOSH HETA Report No. 1997-0015-2639.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0015-2639.pdf].

NIOSH [1997g]. Blue Cross and Blue Shield, Grand Rapids, MI. NIOSH HETA Report No. 1997-0031-2656.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0031-2656.pdf].

NIOSH [1997h]. Valley High School, West Des Moines, IA. NIOSH HETA Report No. 1997-0189-2668.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0189-2668.pdf].

NIOSH [1998a]. J.L. Long Middle School, Dallas, TX. NIOSH HETA Report No. 1994-0265-2703.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0265-2703.pdf].

NIOSH [1998b]. Cle Elum-Roslyn High School, Cle Elum, WA. NIOSH HETA Report No. 1997-0045-2676.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0045-2676.pdf].

NIOSH [1998c]. Point Pleasant High School, Point Pleasant, WV. NIOSH HETA Report No. 1997-0068-2690.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0068-2690.pdf].

NIOSH [1998d]. Northwest Airlines, Wayne County Airport, Detroit, MI. NIOSH HETA Report No. 1997-0115-2718.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0115-2718.pdf].

NIOSH [1998e]. The Grand Experience Salon, Chicago, IL. NIOSH HETA Report No. 1997-0153-2694.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0153-2694.pdf].

NIOSH [1998f]. United States Postal Service, Omaha, NE. NIOSH HETA Report No. 1998-0017-2699.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0017-2699.pdf].

NIOSH [1999a]. Governor Juan F. Luis Hospital and Medical Center, Christiansted, VI. NIOSH HETA Report No. 1997-0010-2730.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1997-0010-2730.pdf].

NIOSH [1999b]. Social Security Administration, Batavia, OH. NIOSH HETA Report No. 1997-0177-2727.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0177-2727.pdf].

NIOSH [1999c]. University of Iowa Hospitals & Clinics, University of Iowa, Iowa City, IA. NIOSH HETA Report No. 1997-0224-2740.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/1997-0224-2740.pdf].

NIOSH [1999d]. Ronald McDonald House of Durham, Durham, NC. NIOSH HETA Report No. 1998-0026-2745.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0026-2745.pdf].

NIOSH [1999e]. Dollar General Store, Prestonsburg, KY. NIOSH HETA Report No. 1998-0300-2723.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0300-2723.pdf].

NIOSH [1999f]. United States Postal Service, Mail Processing and Distribution Center, Tampa, FL. NIOSH HETA Report No. 1998-0307-2761.
[http://www.cdc.gov/niosh/hhe/ reports/pdfs/ 1998-0307-2761.pdf].

NIOSH [1999g]. Lockheed Martin Aeronautical Systems, Marietta, GA. NIOSH HETA Report No. 1998-0347-2758.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0347-2758.pdf].

NIOSH [1999h]. Gwinnett Medical Center, Lawrenceville, GA. NIOSH HETA Report No. 1999-0090-2744.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0090-2744.pdf].

NIOSH [2000a]. Immigration and Naturalization Service, Salt Lake City, UT. NIOSH HETA Report No. 1999-0320-2791.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0320-2791.pdf].

NIOSH [2000b]. Southwest Airlines - Dallas Reservations Center, Grand Prairie, TX. NIOSH HETA Report No. 2000-0088-2809.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2000-0088-2809.pdf].

NIOSH [2000c]. Horry County Assessor's Office, Conway, SC. NIOSH HETA Report No. 2000-0091-2803.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0091-2803.pdf].

NIOSH [2000d]. Southwest Airlines, Dallas, TX. NIOSH HETA Report No. 2000-0268-2812.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0268-2812.pdf].

NIOSH [2001a]. Benefis Healthcare, Great Falls, MT. NIOSH HETA Report No. 2000-0255-2868.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0255-2868.pdf].

NIOSH [2001b]. DuPage County Judicial Office Facility, Wheaton, IL. NIOSH HETA Report No. 1992-0380-2302.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1992-0380-2302.pdf].

NIOSH [2001c]. North View Elementary School, Clarksburg, WV. NIOSH HETA Report No. 1999-0235-2836.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0235-2836.pdf].

NIOSH [2001d]. Virgin Islands Department of Health, Christiansted, VI. NIOSH HETA Report No. 2000-0092-2832.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0092-2832.pdf].

NIOSH [2001e]. The Phoenician Resort, Scottsdale, AZ. NIOSH HETA Report No. 2000-0176-2829.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0176-2829.pdf].

NIOSH [2001f]. Rehabilitation Services Commission, Columbus, OH. NIOSH HETA Report No. 2000-0283-2823.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0283-2823.pdf].

NIOSH [2001g]. Group Health Associates, Cincinnati, OH. NIOSH HETA Report No. 2000-0339-2852.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0339-2852.pdf].

NIOSH [2001h]. Oklahoma City Community College Bookstore, Oklahoma City, OK. NIOSH HETA Report No. 2001-0496-2866.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2001-0496-2866.pdf].

NIOSH [2002a]. Nassau Community College, Garden City, NY. NIOSH HETA Report No. 2000-0168-2871.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0168-2871.pdf].

NIOSH [2002b]. 26 Federal Plaza, New York, NY. NIOSH HETA Report No. 2002-0038-2870.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0038-2870.pdf].

NIOSH [2002c]. Jergens Road Adult Services Center, Dayton, OH. NIOSH HETA Report No. 2002-0218-2881.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0218-2881.pdf].

NIOSH [2003a]. Warren Occupational Technical Center, Lakewood, CO. NIOSH HETA Report No. 2002-0306-2911.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0306-2911.pdf].

NIOSH [2003b]. Fayette County Courthouse, Uniontown, PA. NIOSH HETA Report No. 2002-0343-2902.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0343-2902.pdf].

NIOSH [2003c]. Hilton Head Elementary School, Hilton Head Island, SC. NIOSH HETA Report No. 2003-0039-2914.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0039-2914.pdf].

NIOSH [2003d]. Norwin Middle School East, North Huntingdon, PA. NIOSH HETA Report No. 2003-0080-2905.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0080-2905.pdf].

NIOSH [2004a]. Private Residence, WV. NIOSH HETA Report No. 2004-0075-2944.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0075-2944.pdf].

NIOSH [2004b]. Teletech, Morgantown, WV. NIOSH HETA Report No. 2004-0195-2951.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0195-2951.pdf].

NIOSH [2005a]. Nye County Justice Court Building, Pahrump, NV. NIOSH HETA Report No. 2003-0368-2961.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0080-2905.pdf].

NIOSH [2005b]. Samuel Staples Elementary School, Easton, CT. NIOSH HETA Report No. 2004-0138-2967.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0138-2967.pdf].

NIOSH [2005c]. West Virginia University, Morgantown, WV. NIOSH HETA Report No. 2004-0344-2979.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0344-2954.pdf].

NIOSH [2005d]. Liberty Central School District, Liberty, NY. NIOSH HETA Report No. 2005-0033-2984.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0344-2954.pdf].

NIOSH [2005e]. Taft Elementary School, Santa Ana, CA. NIOSH HETA Report No. 2005-0112-2980.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0112-2980.pdf].

NIOSH [2005f]. Indian River Memorial Hospital, Vero Beach, FL. NIOSH HETA Report No. 2005-0167-2983.
[http://www.cdc.gov/niosh/hhe/reports/ pdfs/2005-0167-2983.pdf].

NIOSH [2006a]. West Virginia Department of Health and Human Resources, Webster Springs, WV. NIOSH HETA Report No. 2003-0300-2993.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2003-0300-2993.pdf].

NIOSH [2006b]. The Spa at the Grove Park Inn, Asheville, NC. NIOSH HETA Report No. 2004-0005-3024.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0005-3024.pdf].

NIOSH [2006c]. International Marine Terminal, Scotia Prince Cruises and Department of Homeland Security, U.S. Customs and Border Protection, Portland, ME. NIOSH HETA Report No. 2005-0126-3004.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0138-3004.pdf].

NIOSH [2006d]. US Environmental Protection Agency, Research Triangle Park, Durham, NC. NIOSH HETA Report No. 2005-0290-2992.
[http://www.cdc.gov/niosh/ hhe/reports/pdfs/2005-0290-2992.pdf].

NIOSH [2006e]. Dixie Regional Medical Center, Saint George, UT. NIOSH HETA Report No. 2005-0346-3008.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0346-3008.pdf].

NIOSH [2006f]. DaimlerChrysler Jefferson North Assembly Plant, Detroit, MI. NIOSH HETA Report No. 2006-0059-3009.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0059-3009.pdf].

NIOSH [2006g]. West Virginia Department of Health and Human Resources, Fairmont, WV. NIOSH HETA Report No. 2006-0246-3023.
[http://www.cdc.gov/niosh/hhe/ reports/pdfs/2006-0246-3023.pdf].

NIOSH [2007]. Interfaith Medical Center, Brooklyn, NY. NIOSH HETA Report No. 2003-0205-3032.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0205-2905.pdf].

Journal Articles

Burr G, Malkin R [1996]. Investigations into the indoor environmental quality of a school: a two-year educational experience. Appl Occup Environ Hyg 11(6):513-521.

CDC [2004]. Investigation of a home with extremely elevated carbon dioxide levels - West Virginia, December 2003. MMWR 53(50):1181-1182.

CDC [2006]. Mold prevention strategies and possible health effects in the aftermath of hurricanes and major floods. MMWR 55(RR-8):1-51.

Cox-Ganser J, Rao C, Kreiss K [2002]. Work-related asthma symptoms correlate with environmental measures in a healthcare facility. Indoor Air 12(2):91-96.

Cox-Ganser J, White S, Jones R, Hilsbos K, Storey E, Enright P, Rao C, Kreiss K [2005]. Respiratory morbidity in office workers in a water-damaged building. Environ Health Persect 113:485-490.

Crandall M, Sieber W [1996]. The National Institute for Occupational Safety and Health indoor environmental evaluation experience. Part one: building environmental evaluations. Appl Occup Environ Hyg 11(6):533-539.

Hall R, Trout D, Earnest G [2004]. An industrial hygiene survey of an office building in the vicinity of the World Trade Center: assessment of potential hazards following the collapse of the World Trade Center buildings. J Occup Environ Hyg 1(5):D49-53.

Krake A, Worthington K, Wallingford K, Martinez K [1999]. Evaluation of microbiological contamination in a museum. Appl Occup Environ Hyg 14(8):499-509.

Malkin R, Wicox T, Sieber W [1996]. The National Institute for Occupational Safety and Health indoor environmental evaluation experience. Part two: symptom prevalence. Appl Occup Environ Hyg 11(6):540-545.

Malkin R, Martinez K, Marinkovich V, Wilcox T, Wall D, Biagini R [1998]. The relationship between symptoms and IgG and IgE antibodies in an office environment. Environ Res 76(2):85-93.

Martinez K, Rao CY, Burton NC [2004]. Exposure assessment and analysis for biological agents. Grana 43(4):193-208.

McCammon C, Martinez K, Bullock D, Sorensen B [1997]. An evaluation of biological and other exposures during an indoor stock show. Appl Occup Environ Hyg 12(5):315-322.

Mendell M, Fisk W, Kreiss K, Levin H, Alexander D, Cain W, Girman J, Hines C, Jensen P, Milton D, Rexroat L, Wallingford K [2002]. Improving the health of workers in indoor environments: priority research needs for a National Occupational Research Agenda. Am J Pub Health 92(9):1430-1440.

Mendell M, Brennen T, Hathon L, Odom J, Offerman F, Turk B, Wallingford K, Diamond R, Fisk W [2006]. Causes and prevention of symptom complaints in office buildings: distilling the experience of indoor environmental quality investigators. Facilities 24(11/12):436-444.

Morley J, Seitz T, Tubbs R [1999]. Carbon monoxide and noise exposure at a monster truck and motocross show. Appl Occup Environ Hyg 14(10):645-655.

Page E, Trout D [2001]. The role of stachybotrys mycotoxins in building-related illness. AIHAJ 62(5):644-648.

Page E, Biagini R, Beezhold D [2005]. Methodologic issues regarding Stachyhemolysin and Stachyrase-A as clinical biomarkers. Med Sci Monit 11(9):LE7-8.

Park J, Schleiff P, Attfield M, Cox-Ganser J. Kreiss K [2004]. Building related respiratory symptoms can be predicted with semi-quantitative indices of exposure to dampness and mold. Indoor Air 14(6):425-433.

Park J, Cox-Ganser J, Rao C, Kreiss K [2006]. Fungal and endotoxin measurements in dust associated with respiratory symptoms in a water-damaged office building. Indoor Air 16(3):192-203.

Rao C, Cox-Ganser J, Chew G, Doekes G, White S [2005]. Use of surrogate markers of biological agents in air and settled dust samples to evaluate a water-damaged hospital. Indoor Air 15(S9):89-97.

Rosenstock L [1996]. NIOSH Testimony to the U.S. Department of Labor on indoor air quality. Appl Occup Environ Hyg 11(12):1365-1370.

Shorr P [2005]. Breathe easy - what every school can do to improve indoor air quality. Am School Board J 192(6):35-37.

Sieber W, Stayner L, Malkin R, Petersen M, Mendell M, Wallingford K, Crandall M, Wilcox T, Reed L [1996]: The National Institute for Occupational Safety and Health indoor environmental evaluation experience. Part three: associations between environmental factors and self-reported health conditions. Appl Occup Environ Hyg 11:1387-1392.

Sieber W, Petersen M, Stayner L, Mendell M, Wallingford K, Wilcox T, Crandall M, Reed L [2002]. HVAC characteristics and occupant health. ASHRAE Journal 44(9):49-53.

Trout D, Decker J, Mueller C, Bernert J, Pirkle J [1998]. Exposure of casino employees to environmental tobacco smoke. J Occup Environ Med 40(3):270-276.

Trout D, Bernstein J, Martinez K, Biagini R, Wallingford K [2001]. Bioaerosol lung damage in a worker with repeated exposures to fungi in a water-damaged building. Environ Health Perspect 109(6):641-644.

Trout D, Seltzer J, Page E, Biagini R, Schmechel D, Lewis D, Boudreau A [2004]. Clinical use of immunoassays in assessing exposure to fungi and potential health effects related to fungal exposure. Ann Allergy Asthma Immunol 92(5):483-492.

Tubbs R, Seitz T [2000]. Evaluation of verbal communication problems and indoor environmental quality at a government service office. Appl Occup Environ Hyg 15(12)869-878.

Weber A, Page E [2001]. Renovation of contaminated building material at a facility serving pediatric cancer outpatients. Appl Occup Environ Hyg 16(1):1-30.

NIOSH Numbered Documents

NIOSH [2007]. NIOSH manual of analytical methods (NMAM®). 4th ed. DHHS (NIOSH) Publication 94-113 (August, 1994); 1st Supplement Publication 96-135, 2nd Supplement Publication 98-119; 3rd Supplement 2003-154.
[http://www.cdc.gov/ niosh/nmam/].

Other Publications

Biagini R, Trout D, MacKenzie B, Martinez K, Wallingford K [2001]. Antibodies to roridin A-hemisuccinate-human serum albumin in sera from workers exposed to stachybotrys chartarum in a water-damaged building (abstract). J Allergy Clin Immunol 107:S128.

Brightman H, Moss N [2001]. Sick building syndrome studies and the compilation of normative and comparative values. In: Spengler J, Samet M, McCarthy, eds. Indoor air quality handbook. New York: McGraw Hill, p. 3.27.

EPA/NIOSH [1991. Building air quality - a guide for building owners and facility managers. Washington DC: U.S. Environmental Protection Agency. EPA Publication No. 400/1-91/033.

EPA/NIOSH [1998]. Building air quality action plan. Washington DC: U.S. Environmental Protection Agency. EPA Publication No. 402-K-98-001.

Kreiss K [2005]. Building-related illness. In: Levy B, Wagner G, Rest K, Weeks J, eds. Preventing occupational diseases and injury. 2nd ed. Washington, DC: American Public Health Association, p. 134.

Kreiss K [2006]. Sick building syndrome and building-related illness. In: Rom W, Markowitz S, eds. Environmental and occupational medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1373.

Martinez K, Thorne P [2003]. Biological agents-control in the occupational environment. In: Perkins J, ed. Modern industrial hygiene. Vol. 2. Cincinnati, OH: American Conference of Governmental Industrial Hygienists, p. 329.

Menzies D, Kreiss K [2006]. Building-related illnesses. In: Bernstein I, Chan-Yeun M, Malo J, Bernstein D, eds. Asthma in the workplace and related conditions. 3rd ed. New York: Taylor and Francis Group, p. 737.

Rao C [2000]. Toxigenic fungi in the indoor environment. In: Samet J, Spengler J, McCarthy J, eds. Indoor air quality handbook. New York: McGraw-Hill Publishers, p. 46.1.

Sieber W, Wallingford K, Allen J [1998]. Carbon dioxide levels in the indoor office environment. Proceedings of the American Statistical Association Annual Joint Statistical Meeting. American Statistical Association, Dallas, Texas.

Woods J, Petrisek R, Granger R, Wallingford K, Martinez K, Morey P [2000]. A procedure for evaluating the effectiveness of mold remediation. Proceedings of the Healthy Buildings 2000 Conference. International Society of Indoor Air Quality and Climate, Espoo, Finland.

Woods J, Petrisek R, Granger R, Wallingford K, Martinez K, Morey P [2000]. Case-specific criteria for evaluating the scope and intensity of mold impaction and remediation effectiveness. Proceedings of the Healthy Buildings 2000 Conference. International Society of Indoor Air Quality and Climate, Espoo, Finland.

Metalworking Fluids

HHE Numbered Reports

NIOSH [1996]. Martin Sprocket and Gear, Inc., Fort Worth, TX. NIOSH HETA Report No. 1996-0020-2610.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0020-2610.pdf].

NIOSH [1997a]. Remington Arms Company, Inc., Ilion, NY. NIOSH HETA Report No. 1997 0118-2664.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0118-2664.pdf].

NIOSH [1997b]. Woodward Governor Company, Fort Collins, CO. NIOSH HETA Report No.1997-0084-2669.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1997-0084-2669.pdf].

NIOSH [1997c]. Dana Corporation, Spicer Axle Division, Fort Wayne, IN. NIOSH HETA Report No. 1995-0293-2655.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0293-2665.pdf].

NIOSH [1998a]. R. H. Sheppard Company, Hanover, PA. NIOSH HETA Report No. 1998-0246-2747.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0246-2747.pdf]

NIOSH [1998b]. Meritor Automotive, Inc., Heath, Ohio. NIOSH HETA Report No. 1998-0050-2733.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0050-2733.pdf].

NIOSH [1998c]. Ford Electronics and Refrigeration Corporation, Connersville, IN. NIOSH HETA Report No. 1996 0156-2712.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 1996-0156-2712.pdf].

NIOSH [1998d]. Pratt and Whitney TAPC, North Haven, CT. NIOSH HETA Report No. 1998 0030-2697.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0030-2697.pdf].

NIOSH [1999]. Met-Tech Industries, Inc., Cambridge, OH. NIOSH HETA Report No. 1996-0232-2776.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0232-2776.pdf].

NIOSH [2000a]. DaimlerChrysler Transmission Plant, Kokomo, IN. NIOSH HETA Report No. 1999-0311-2790.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0311-2790.pdf].

NIOSH [2000b]. Case Corporation, Burlington, IA. NIOSH HETA Report No. 1999-0144-2797.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0144-2797.pdf].

NIOSH [2001a]. Southern Supply & Manufacturing Company, Inc., St. Petersburg, FL. NIOSH HETA Report No. 2000-0262-2833.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2000-0262-2833.pdf]

NIOSH [2001b]. Boeing Commercial Airplane Group, Oak Ridge, TN. NIOSH HETA Report No. 99-0177-2828.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0177-2828.pdf].

NIOSH [2001c]. Campbell Hausfeld, Harrison, OH. NIOSH HETA Report No. 2000-0356-2851.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0356-2851.pdf].

NIOSH [2002]. TRW Automotive, Mount Vernon, OH. NIOSH HETA Report No. 2001-0303-2893.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0303-2893.pdf].

NIOSH [2003]. DaimlerChrysler Indiana Transmission Plant, Kokomo, IN. NIOSH HETA Report No. 2002-0155-2886.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0155-2886.pdf].

NIOSH [2006]. NTN-Bower Corporation, Hamilton, AL. NIOSH HETA Report No. 2004-0399-3007.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0399-3007.pdf].

Journal Articles

Freeman A, Lockey J, Hawley P, Biddinger P, Trout D [1998]. Hypersensitivity pneumonitis in a machinist. Am J Industr Med 34:387-392.

CDC [1996]. Biopsy-confirmed hypersensitivity pneumonitis in automobile production workers exposed to metalworking fluids - Michigan. MMWR 45(28):606-610.

Pretty J, Glaser R, Jones J, Lunsford RA [2004]. A technique for the identification and direct analysis of hexahydro-1,3,5-tris(2-hydroxyethyl)-s-triazine in metalworking fluids using electrospray-mass spectrometry. Analyst 129(11):1150-5.

CDC [2002]. Respiratory illness in workers exposed to metalworking fluid contaminated with Nontuberculous Mycobacteria - Ohio, 2001. MMWR 51(16):349-352.

Trout D, Weissman DN, Lewis D, Brundage RA, Franzblau A, Remick D [2003]. Evaluation of hypersensitivity pneumonitis among workers exposed to metal removal fluids. Appl Occup Environ Hyg 18(11):953-960.

Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ, Kreiss K, Kunkel S, Lynch D, Quirce S, Rose C, Schleimer RP, Schuyler MR, Selman M, Trout D, Yoshizawa Y [2005]. Needs and opportunities for research in hypersensitivity pneumonitis. Am J Respir Crit Care Med 171(7):792-798.

NIOSH Numbered Documents

NIOSH [1998a]. Criteria for a recommended standard: occupational exposure to metalworking fluids. DHHS (NIOSH) Publication No. 98-102.
[http://www.cdc.gov/ niosh/pdfs/98-102.pdf].

NIOSH [1998b]. What you need to know about occupational exposure to metalworking fluids. DHHS (NIOSH) Publication No. 98-116.
[http://www.cdc.gov/niosh/pdfs/98-116.pdf].

Other Publications

Martinez K, Trout D, Kanwal R [2002]. Bioaerosols in Industrial Settings. In: Bitton G, ed. Encyclopedia of Environmental Microbiology, John Wiley and Sons, Inc., New York, pp. 416-425.

OSHA [1999]. Final report of the OSHA metalworking fluids standards advisory committee.
[http://www.osha.gov/SLTC/metalworkingfluids/mwf_finalreport.pdf].

Washington State Department of Labor and Industries [1997]. SHARP Program: Metal Working Fluids: A Resource for Employers and Health and Safety Personnel in Washington State. Technical Report #46-2-1997 (888-66-SHARP).
[http://www.lni.wa. gov/Safety/Research/files/mwf_man.pdf].

Flock-Related Lung Disease

HHE Numbered Reports

NIOSH [1998]. Microfibres, Inc., Pawtucket, RI. NIOSH HETA Report No. 1996-0093-2685.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1996-0093-2685.pdf].

NIOSH [2000a]. Claremont Flock Corporation, Claremont, NH. NIOSH HETA Report No. 1998-0212-2788.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0212-2788.pdf].

NIOSH [2000b]. Spectro Coating Corporation, Leominster, MA. NIOSH HETA Report No. 1998-0238-2789.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0238-2789.pdf].

NIOSH [2006a]. Hallmark Cards, Inc., Lawrence, KS. NIOSH HETA Report No. 2004-0013-2990.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0013-2990.pdf].

NIOSH [2006b]. Claremont Flock Corporation, Leominster, MA. NIOSH HETA Report No. 2004-0186-3011.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2004-0186-3011.pdf].

Journal Articles

Antao V, Piacitelli C, Miller W, Pinheiro G, Kreiss K [2007]. Rayon flock: a new cause of respiratory morbidity in a card processing plant. Am J Ind Med 50(4):274-284.

Atis S, Tutluoglu B, Levent E, Ozturk C, Tunaci A, Sahin K, Saral A, Oktay I, Kanik A, Nemery B [2005]. The respiratory effects of occupational polypropylene flock exposure. Eur Respir J 25:110-117.

Barroso E, Ibanez M, Aranda F, Romero S [2002]. Polyethylene flock-associated interstitial lung disease in a Spanish female. Eur Respir J 20:1610-1612.

Boag A, Colby T, Fraire A, Kuhn C, Roggli V, Travis W, Vallyathan V [1999]. The pathology of interstitial lung disease in nylon flock workers. Am J Surg Pathol 23:1539-1545.

Burkhart J, Piacitelli C, Schwegler-Berry D, Jones W [1999]. Environmental study of nylon flocking process. J Toxicol Environ Health 57(1):1-23.

Castellan R, Burkhart J, Jones W, Porter D, Eschenbacher W [1999]. A newly recognized respiratory illness among workers at a flocking plant in the USA: results of NIOSH investigations. Flock 6:1-30.

CDC [1997]. Chronic interstitial lung disease in nylon flocking industry workers - Rhode Island, 1992-1996. MMWR 46:897-901.

Daroowalla F, Wang M, Piacitelli C, Attfield M, Kreiss K [2005]. Flock workers' exposures and respiratory symptoms in five plants. Am J Ind Med 47:144-152.

Eschenbacher W, Kreiss K, Lougheed D, Pransky G, Day B, Castellan R [1999]. Nylon flock-associated interstitial lung disease: clinical pathology workshop summary. Am J Respir Crit Care Med 159:2003-2008.

Porter D, Castranova V, Robinson V, Hubbs A, Mercer R, Scabilloni J, Goldsmith T, Schwegler-Berry D, Battelli L, Washko R, Burkhart J, Piacitelli C, Whitmer M, Jones W [1999]. Acute inflammatory reaction in rats after intratracheal instillation of material collected from a nylon flocking plant. J Toxicol Environ Health 57:25-45.

Warheit DB, Hart GA, Hesterberg TW, Collins JJ, Dyer WM, Swaen GMH, Castranova V, Soiefer AI, Kennedy GL [2001]. Potential pulmonary effects of man-made organic fiber (MMOF) dusts. Crit Reviews in Toxicol 31:697-736.

Washko R, Day B, Parker J, Castellan R, Kreiss K [2000]. Epidemiologic investigation of respiratory morbidity at a nylon flock plant. Am J Ind Med 38:628-638.

Flavorings

HHE Numbered Reports

NIOSH [2003a]. Agrilink Foods Popcorn Plant, Ridgway, IL. NIOSH HETA Report No. 2002-0408-2915.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0408-2915.pdf].

NIOSH [2004a]. American Pop Corn Company, Sioux City, IA. NIOSH HETA Report No. 2001-0474-2943.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2001-0474-2943.pdf].

NIOSH [2004b]. ConAgra Snack Foods, Marion, OH. NIOSH HETA Report No. 2003-0112-2949.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0112-2949.pdf].

NIOSH [2006]. Gilser-Mary Lee Corporation, Jasper, MO. NIOSH HETA Report No. 2000-0401-2991.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2000-0401-2991.pdf].

NIOSH [2007a]. Carmi Flavor and Fragrance Company, Inc., Commerce, CA. NIOSH HETA Report No. 2006-0303-3043.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0303-3043.pdf].

NIOSH [2007b]. Yatsko's Popcorn, Sand Coulee, MT. NIOSH HETA Report No. 2006-00195-3044.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0195-3044.pdf].

Journal Articles

Akpinar-Elci M, Stemple K, Elci O, Dweik R, Kreiss K, Enright P [2004a]. Exhaled nitric oxide measurement in microwave popcorn production plant workers. Int J Occup Environ Health 24:298-302.

Akpinar-Elci M, Travis W, Lynch D, Kreiss K [2004b]. Bronchiolitis obliterans syndrome in popcorn plant workers. Eur Resp J 24:298-302.

Akpinar-Elci M, Stemple K, Enright P, Fahy J, Bledsoe T, Kreiss K, Weissman D [2005]. Induced sputum evaluation in microwave popcorn production workers. Chest 128:991-997.

Boylstein R, Piacitelli C, Grote A, Kanwal R, Kullman G, and Kreiss K [2006]. Diacetyl emissions and airborne dust from butter flavorings used in microwave popcorn production. J Occup Environ Hyg 3:(10)530-535.

CDC [2002]. Obstructive lung disease in workers at a microwave popcorn factory - Missouri, 2000 - 2002. MMWR 51:345-347.

CDC [2007]. Fixed obstructive lung disease among workers in the flavor-manufacturing industry - California, 2004 - 2007. MMWR 56(16):389-393.

Kanwal R, Kullman G, Piacitelli C, Boylstein R, Sahakian N, Martin S, Fedan K, Kreiss K [2006]. Evaluation of flavorings-related lung disease risk at six microwave popcorn plants. J Occup Environ Hyg 48(2):149-157.

Kreiss K, Gomaa A, Kullman G, Fedan K, Simoes E, Enright P [2002]. Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant. N Engl J Med 347:330-338.

Kreiss K [2007]. Flavoring-related bronchiolitis obliterans. Allergy Clin Immunol 7(2):162-167. Kullman G, Boylstein R, Jones W, Piacitelli C, Perdergrass S, Kreiss K [2005]. Characterization of respiratory exposures at a microwave popcorn plant with cases of bronchiolitis obliterans. J Occup Environ Hyg 2(3):169-178.

NIOSH Numbered Documents

NIOSH [2003b]. NIOSH alert: preventing lung disease in workers who use or make flavorings. DHHS (NIOSH) Publication No.2004-110.
[http://www.cdc.gov/niosh/docs/ 2004-110/pdfs/2004-110.pdf].

Severe Acute Respiratory Syndrome

Journal Articles

Booth TF, Kournikakis B, Bastien N, Ho J, Kobasa D, Stadnyk L, Spence M, Paton S, Henry B, Mederski B, White D, Low DE, McGeer A, Simor A, Vearncombe M, Downey J, Jamieson FB, Tang P, Plummer F [2005]. Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units. J Infect Dis 191(9):1472-1477.

CDC [2003]. Cluster of Severe Acute Respiratory Syndrome cases among protected health-care workers - Toronto, Canada. MMWR 52(19); 433-436.

CDC [2004]. Enhancing environmental microbiology capacity at CDC. A report of the CDC Environmental Microbiology Working Group to the CDC Director, July 30, 2004.

Christian M, Loutfy M, McDonald L, Martinez K, Ofner M, Wong T, Wallington T, Gold W, Mederski B, Green K, Low D [2004]. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 10(2):287-292.

Esswein EJ, Kiefer M, Wallingford K, Burr G, Lee LJ-H, Wang J-D, Wang SC, Su I [2004]. Environmental and occupational health response to SARS, Taiwan. Emerg Infect Dis 10(7):1187-1194.

NIOSH [2007]. Institute of Occupational Safety and Health: inflatable negative pressure isolation chamber.
[http://www.iosh.gov.tw/iosheng/index.htm].

Yassi A, Bryce E, Moore D, Janssen R, Copes R, Bartlett K, Fitzgerald M, Gilbert M, Bigelow P, Danyluk Q, Gamage B, Hon C, Perry T, Saunders S, Svirchev L, Thiessen R [2004]. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Report to Change Foundation, March 2004.

Silica Exposure in the Roofing Industry

HHE Numbered Reports

NIOSH [2006a]. Diversified Roofing Inc., Phoenix, AZ. NIOSH HETA Report No. 2003-0209-3015.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2003-0209-3015.pdf].

Journal Articles

Eisenberg J, Sollberger R [2005]. Respirable silica: a health hazard for roofers working with cement tiles. Professional Roofing 35(8):36-41.

Eisenberg J, Sollberger R [2006]. Respirable silica: a health hazard to coatings professionals. Coatings Pro 6(1):16-17, 105.

McCleery R [2007]. Silica hazard found in the cement tile roofing industry. The Synergist. Am Ind Hyg Assoc 18(3):38-39.

NIOSH Numbered Documents

NIOSH [2006b]. Silicosis - working with cement roofing tiles: a silica hazard. DHHS (NIOSH) Publication No. 2006-110 (available in English and Spanish).
[http://www.cdc. gov/niosh/docs/2006-110/].

Other Publications

LSS [2006]. Cement roofing tiles and silicosis. Lab Safety Supply.
[http://www.labsafety. com/refinfo/saftnews06/stn218.htm#article2].

NIOSH [2006c]. Engineering and Physical Hazards Branch Report: EPHB 06-133; In-Depth Survey Report of a Local Exhaust Ventilation Device for Suppressing Respirable and Crystalline Silica Dust from Powered Saws at Revelation Roofing, Denver, Colorado.

NIOSH [2006d]. Engineering and Physical Hazards Branch Report: EPHB 317-11a; In-depth survey report of a demonstration and evaluation of roofing tile saws and cutters controlling respirable and crystalline silica dust. Newark, California.

NRCA [2006]. Silica: clearing the air on a cloudy issue. Ask the Expert (ATE) Webinar. National Roofing Contractors Association.
[https://www.nrca.net/rp/education/nrca/ate/ archive.aspx].

NSMS [2006]. Fact Sheet: Silica Hazards in Working With Cement Roofing Tiles. National Safety Management Society Digest.
[http://www.nsms.us/pdf/0604NSMS.pdf].

Carbon Monoxide and Houseboats

HHE Numbered Reports

NIOSH [2004a]. Lake Havasu Municipal Employees, Lake Havasu City, AZ. NIOSH HETA Report No. 2002-0393-2928.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0393-2928.pdf].

NIOSH [2004b]. Evaluation of Two Exhaust Stack Configurations on Two Houseboats at Table Rock Lake, MO. NIOSH HETA Report No. 2003-0318-2936.
[http://www.cdc. gov/niosh/hhe/reports/pdfs/2003-0318-2936.pdf].

NIOSH [2005]. Glen Canyon National Recreation Area (GCNRA), UT and AZ. NIOSH HETA Report No. 2000-0400-2956 & 2002-0325-2956.
[http://www.cdc.gov/niosh/hhe/ reports/pdfs/2000-0400-2956.pdf].

Other Publications

California [2004]. Anthony Farr and Stacy Beckett Safe Boating Act of 2004. The People of the State of California, Bill Number: AB 2222, February 18, 2004.

CSBC [2001]. Quiet Death On The Lake: Boat-Related Carbon Monoxide Poisonings. Canadian Safe Boating Council, Videocassette.

CSBC [2002]. Carbon Monoxide - Where Do We Stand? One year later. Canadian Safe Boating Council, Videocassette.

DBW [2004]. 2004 California Boating Safety Report. State of California, Department of Boating and Waterways.
[http://www.dbw.ca.gov/BSRs/2004/html/section_5.html].

House of Representatives [2001]. Baron R. Testimony, Recreational Boating Safety: Hearing before the Subcommittee on Coast Guard and Maritime Transportation of the Committee on Transportation and Infrastructure, 107th Congress, 1st Session. Washington DC: U.S. Government Printing Office.

LHC [2004]. Codes and Ordinances. Ordinance No. 04-735, Title 8 (Health and Safety), Section 16 (Watercraft), 210 (Idling While Beached Prohibited). Lake Havasu City, AZ.

LHC [2004]. Codes and Ordinances. Ordinance No. 04-736, Title 8 (Health and Safety), Section 16 (Watercraft), 220 (Discretionary Enforcement Actions). Lake Havasu City, AZ.

NASBLA [2005]. Model Act for Safe Practices for Boat-towed Watersports. National Association of State Boating Law Administrators, Committees on Law Enforcement and Boats and Associated Equipment, 21 September 2005.

Nevada [2004]. NAC 488.435 Prima facie evidence of reckless or negligent operation. Chapter 488 (Watercraft). Nevada Administrative Code, Legislative Counsel, State of Nevada. October 28, 2004.

Oregon [2005]. Relating to boating safety; creating new provisions; and amending ORS 830.990. Senate Bill 56. 73rd Oregon Legislative Assembly - 2005 Regular Session. February 14, 2005.

Pennsylvania [2004].105.3 Unacceptable boating practices. Chapter 105 (Operational Conditions), Title 58 (Recreation). Commonwealth of Pennsylvania. August 13, 2004.

Sumerset [2001]. Exhaust retrofit voluntary recall. Sumerset Custom Houseboats, Somerset, KY.

USCG [2001a]. MEDIA ADVISORY: Coast Guard recalls houseboats due to carbon monoxide hazard and cautions owners/operators on dangers. USCG Headquarters Public Affairs, Press Release, 28 February 2001. Washington, D.C.

USCG [2001b]. SAFETY ALERT: The United States Coast Guard advises boaters not to "Teak Surf." U.S. Coast Guard News, Press Release, 2 August 2001. Washington, D.C.

USNPS [2001a]. Public Alert. potentially deadly carbon monoxide poisoning from swimming off the rear deck of houseboats. U.S. National Park Service, Washington D.C.

USNPS [2001b]. SAFETY ADVISORY: 2001-02: Carbon monoxide and watercraft use. Press Release, 27 April 2001. Intermountain Region - Risk Management Office.

Washington [2006]. Jenda Jones and Denise Colbert Safe Boating Act. An act relating to the regulation of recreational vessels. Senate Bill Report, SB 6364. State of Washington, 59th Legislature, 2006 Regular Session. March 6, 2006.

Surface Wipe Methods for Chemical Detection and Decontamination

HHE Numbered Reports

NIOSH [1996]. Standard Industries, San Antonio, TX. NIOSH HETA Report No. 1994-0268-2618.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/1994-0268-2618.pdf].

Journal Articles

Martyny J, Arbuckle S, McCammon C, Esswein E, Erb N, VanDyke M [in press]. Chemical exposures associated with clandestine methamphetamine laboratories. J Chem Health Saf.

Other Publications

Esswein E, Boeniger M [2005]. Preventing the toxic handoff. Occup Hazard Sep 1:53-61.

Martyny J, Arbuckle S, McCammon C, Esswein E, Erb N [2004]. Chemical exposures associated with clandestine methamphetamine laboratories. Denver, CO: National Jewish Medical and Research Center.
[http://www.njc.org/pdf/Chemical_Exposures.pdf].

Anthrax

HHE Numbered Reports

NIOSH [2004]. Trenton Processing and Distribution Center, Trenton, NJ. NIOSH HETA Report No. 2002-0109-2927.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0109-2927.pdf]

Journal Articles

Biagini RF, Sammons DL, Smith JP, Page EH, Snawder JE, Striley CA, MacKenzie BA [2004]. Determination of serum IgG antibodies to Bacillus anthracis protective antigen in environmental sampling workers using a fluorescent covalent microsphere immunoassay (FCMIA). J Occup Environ Med 61(8):703-708.

CDC [2001a]. Evaluation of Bacillus anthracis contamination inside the Brentwood mail processing and distribution center - District of Columbia, October 2001. MMWR 50:1129-33.

CDC [2002a]. Suspected cutaneous anthrax in a laboratory worker - Texas, MMWR 51(13):279-281.

CDC [2002b]. Public Health Dispatch: Update: cutaneous anthrax in a laboratory worker - Texas, MMWR 51(22):482.

CDC [2002c]. Occupational health guidelines for remediation workers at Bacillus anthracis-contaminated sites - United States, 2001-2002. MMWR 51(35):786-9.

CDC [2004]. Responding to detection of aerosolized Bacillus anthracis by autonomous detection systems in the workplace. MMWR 53(RR-7):1-11.

CDC [2006]. Inhalation anthrax associated with dried animal hides---Pennsylvania and New York City, 2006. MMWR 55(10):280.

Greene C, Reefhuis J, Tan C, Fiore A, Goldstein S, Beach M, Redd S, Valiante D, Burr G, Buehler J, Pinner R, Bresnitz E, Bell B [2003]. Epidemiologic Investigations of Bioterrorism-Related Anthrax, New Jersey, 2001. Emerg Infect Dis 8(10)1048-1055.

Holtz TH, Ackelsberg J, Kool JL, Rosselli R, Marfin A, Matte T, et al. [2003]. Isolated case of bioterrorism-related inhalational anthrax, New York City, 2001. Emerg Infect Dis 9(6):689-696.

Mackey TA, Page EH, Martinez KF, Seitz TA, Bernard BP, Tepper AL, Weyant RS, Rosenstein, NE, Perkins BA, Popovic, T, Holmes, HT, Shepard, CW [2002]. Suspected cutaneous anthrax in a laboratory worker - Texas. Arch Dermatol 138:1111-1112.

McKernan JL, Taylor L, McCammon JB, Hartle RW, Gressel MG [2003]. Cross-contamination issues during a biological emergency response effort: lessons learned. Intl J Emerg Mgt 1(4):363-373.

Sanderson WT, Hein MJ, Taylor L, Curwin BD, Kinnes GM, Seitz TA, Popovic T, Holmes HT, Kellum ME, McAllister SK, Whaley DN, Turpin EA, Walker T, Freed JA, Small DS, Klusartiz B, Bridges JH [2002]. Surface sampling methods for Bacillus anthracis spore contamination. Emerg Infect Dis 8(10):1145-1151.

Sanderson, WT, Stoddard RR, Echt AS, Piacitelli CA, Kim D, Horan J, Davies MM, McCleery RE, Muller P, Schnorr TM, Ward EM, and Hales TR [2004]. Bacillus anthracis contamination and inhalational anthrax in a mail processing and distribution center. J Appl Microbiol 96:1048-1056.

Teshale EH, Painter J, Burr GA, Mead P, Wright SV, Cseh LF, Zabrocki R, Collins R, Kelley KA, Hadler JL, Swerdlow DL [2002]. Environmental sampling for spores of Bacillus anthracis. Emerg Infect Dis 8(10):1083-1087.

Valiante D, Schill DP, Bresnitz EA, Burr GA, Mead KR [2003]. Responding to a bioterrorist attack: environmental investigation of anthrax in New Jersey. Appl Occ Env Hyg 18(10):780-785.

NIOSH Numbered Documents

NIOSH [2002b]. Protecting workers from anthrax infection. Response from the National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication No. 2002-142. [http://www.cdc.gov/niosh/02-142.html].

Other Publications

CDC [2001b]. Trip report: Epidemiologic and environmental evaluation of Bacillus anthracis, Stamp Fulfillment Center, Kansas City, MO. November 2001. (NIOSH HETA No. 2002-0452).

CDC [2001c]. Protecting investigators performing environmental sampling for Bacillus anthracis: personal protective equipment.
[http://www.cdc.gov/niosh/unp-anthrax-ppe.html].

CDC [2001d]. CDC Interim Recommendations for Protecting Workers from Exposure to Bacillus anthracis in Work Sites Where Mail Is Handled or Processed.
[http://www.cdc.gov/niosh/unp-mailrecs1.html].

CDC [2002d]. Comprehensive procedures for collecting environmental samples for culturing Bacillus anthracis (revised April 2002).
[http://www.bt.cdc.gov/agent/anthrax/ environmental-sampling-apr2002.asp]
[http://www.cdc.gov/niosh/unp-envsamp.html].

CDC [2002e]. Technical assistance report: Environmental sampling for Bacillus anthracis in selected New York City postal facilities, New York City, NY, October and November 2001. (NIOSH HETA No. 2002-0450).

Farb D [2005]. Bioterrorism Anthrax Guidebook. University of Healthcare, Los Angeles, CA
[http://www.uohc.com/courseentry.htm]. ISBN 1594912653.

Martinez K [2003]. Congressional testimony to the U.S. House of Representatives before the U.S. House of Representatives; Committee on Government Reform Sub-committee on National Security, Emerging Threats, and International Relations, May 19, 2003. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.
[http://www.hhs.gov/asl/testify/t030519a.html]. Date accessed: June 2007.

Sandia National Laboratories [2006]. Joint Sandia/NIOSH exercise on aerosol contamination using the BROOM tool.
[http://www.prod.sandia.gov/cgi-bin/techlib/access-control.pl/2006/063784.pdf].

Irradiated Mail

HHE Numbered Reports

NIOSH [2002]. United States Senate and House of Representatives, Washington, DC NIOSH HETA Report No. 2002-0136-2880.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2002-0136-2880.pdf].

Natural Disasters

HHE Numbered Reports

NIOSH [2005]. Hurricane Katrina Response, New Orleans, LA. NIOSH HETA Report No. 2005-0369-3034.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0369-3034.pdf].

NIOSH [2006a]. New Orleans Fire Department, New Orleans, LA. NIOSH HETA Report No. 2006-0023-3003.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0023-3003.pdf].

NIOSH [2006b]. New Orleans Police Department, New Orleans, LA. NIOSH HETA Report No. 2006-0027-3001.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2006-0027-3001.pdf].

Journal Articles

Achutan C [2007]. Occupational noise levels during emergency relief operations in the aftermath of Hurricane Katrina. J Occup Environ Hyg 4(4):D33-D35.

Other Publications

NIOSH [1996]. Safety and Health Topic: Carbon monoxide hazards from small gasoline powered engines.
[http://www.cdc.gov/niosh/topics/co/].

World Trade Center

HHE Numbered Reports

NIOSH [2002].26 Federal Plaza, New York, NY. NIOSH HETA Report No. 2002-0038-2870.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0038-2870.pdf].

NIOSH [2005]. Metropolitan Transit Authority of New York, NY. NIOSH HETA Report No. 2002-0095-2955.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/2002-0095-2955.pdf].

NIOSH [2006]. Buildings in the Vicinity of the World Trade Center, New York. NY. NIOSH HETA Report No. 2002-0101-3208.
[http://www.cdc.gov/niosh/hhe/reports/pdfs/ 2002-0101-3028.pdf].

Journal Articles

CDC [2002]. Injuries and illnesses among New York City Fire Department rescue workers after responding to the World Trade Center attacks. MMWR 51:1-5.

Edelman P, Osterloh J, Pirkle J, Caudill S, Grainger J, Jones R, Blount B, Calafat A, Turner W, Feldman D, Baron S, Bernard B, Lushniak B, Kelly K, Prezant D [2003]. Biomonitoring of chemical exposure among New York City fire fighters responding to the World Trade Center fire and collapse. Environ Health Perspect 111:1906-1911.

Herbert R, Moline J, Skloot G, Metzger K, Baron S, Luft B, Markowitz S, Udasin I, Harrison D, Stein D, Todd A, Enright P, Stellman JM, Landrigan PJ, Levin SM [2006]. The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program. Environ Health Perspect 114(12):1853-1858.

Tapp LC, Baron S, Bernard B, Driscoll R, Mueller C, Wallingford K [2005]. Physical and mental health symptoms among NYC transit workers seven and one-half months after the WTC attacks. Am J Ind Med 47(6):475-483.

Trout D, Nimgade A, Mueller C, Hall R, Earnest GS [2002]. Health effects and occupational exposures among office workers near the World Trade Center disaster site. J Occup Environ Med 44(7):601-605.

Wallingford KM, Snyder EM [2001]. Occupational exposures during the World Trade Center disaster response. Toxicol Ind Health 17:247-253.

Other Publications

Bascetta CA. GAO testimony before the Subcommittee on National Security, Emerging Threats, and International Relations, Committee on Government Reform, House of Representatives. September 11 - Monitoring of World Trade Center Health Effects has progressed, but program for Federal responders lags behind. GAO-06-481T, February 28, 2006.

Jackson BA, Peterson DJ, Bartis JT, LaTourrette T, Brahmakulam IT, Houser A, Sollinger JM [2002]. Protecting Emergency Responders: Lessons Learned from Terrorist Attacks, Volume 1. RAND Corporation. Jackson BA, Baker JC, Ridgely MS, Bartis JT, Linn HI [2004]. Protecting Emergency Responders, Volume 3: Safety Management in Disaster and Terrorism Response. RAND Corporation.

LaTourrette T, Peterson DJ, Bartis JT, Jackson BA, Houser A [2002]. Protecting Emergency Responders, Volume 2: Community Views of Safety and Health Risks and Personal Protection Needs. RAND Corporation.

Porter D. Testimony by Diane Porter, Deputy Director, National Institutes for Occupational Safety and Health, Centers for Disease Control and Prevention, Department of Health and Human Services to the Subcommittee on National Security, Emerging Threats, and International Relations Committee on Government Reform, United States House of Representatives, Field Hearing in New York, New York, October 28, 2003.

Willis HH, Castle NG, Sloss EM, Bartis JT [2006]. Protecting Emergency Responders, Volume 4: Personal Protective Equipment Guidelines for Structural Collapse Events. RAND Corporation. 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.