The NIOSH Surveillance Strategic Plan
Public health surveillance is the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practices, closely integrated with the timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to prevention and control. A surveillance system includes a functional capacity for data collection, analysis, and dissemination linked to public health programs.
To optimally develop comprehensive occupational safety and health surveillance, NIOSH needs to effectively partner and pool resources with States, other Federal agencies, and private organizations. Also, as the Nation's surveillance program becomes more complex, there is an increased need for strategic planning to guide surveillance efforts within NIOSH and to foster coordination of activities among agencies and other organizations.
Over the past quarter century, NIOSH has played a key role in the surveillance of occupational hazards, diseases, and injuries, complementing the important surveillance activities carried out by many States, the National Center for Health Statistics (NCHS) and other Federal agencies, including the Bureau of Labor Statistics (BLS), the Occupational Safety and Health Administration (OSHA), and the Mine Safety and Health Administration (MSHA). NIOSH began developing a program of national occupational health surveillance activities in the early 1970s. These initial efforts involved hazard surveillance and health effects surveillance.
The initial hazard surveillance efforts included the National Occupational Hazard Survey (NOHS) of general industry, conducted in the early 1970s. NOHS used a representative sample of 5,000 establishments and identified more than 9,000 potential workplace hazards. NIOSH conducted a second survey of potential hazards in general industry the National Occupational Exposure Survey (NOES) in the early 1980s, and a similar survey of potential hazards in the mining industry the National Occupational Health Survey of Mining (NOHSM) in the late 1980s. Competing priorities within the Institute, as well as cost considerations, have kept further surveys from being conducted on a regular basis. In recent years, NIOSH hazard surveillance efforts have also included dissemination of surveillance reports that incorporate results of OSHA and MSHA inspection sampling. Important hazard data have also been generated as a result of investigation activities carried out under various NIOSH programs.
Initial health surveillance efforts involved the analysis of data primarily from the National Center for Health Statistics (NCHS) National Health Interview Survey (NHIS), the Social Security Administration (SSA) disability award files, and the NCHS Vital Statistics Death Certificate Data files. Data were also analyzed from the NIOSH-administered Coal Workers' X-Ray Surveillance Program (CWXSP), a national program that has involved over 300,000 examinations of active underground coal miners since 1970.
In the early 1980s, NIOSH collaborated with NCHS and State vital statistics departments to develop the National Occupational Mortality System (NOMS), which enables the use of the national mortality statistics program for periodic surveillance of cause-specific mortality by decedents' usual industry and occupation. In the late 1980s, NIOSH established the National Surveillance System of Pneumoconiosis Mortality (NSSPM), providing annually updated information on all deaths in the United States with pneumoconiosis listed as a cause of death. In the 1990s, NIOSH began the periodic publication of the Work-Related Lung Disease Surveillance Report, which presents data from the NSSPM and other sources.
Collaboration between NIOSH and States related to occupational safety and health surveillance began with the Surveillance Cooperative Agreements between NIOSH and States (SCANS), a program that increased State health department capacities in the area of occupational safety and health.
Initial injury surveillance efforts within NIOSH began in the early 1980s with analyses of data collected by other agencies [e.g., BLS workers' compensation-based Supplementary Data System (SDS)] and other collaborative efforts [e.g., interagency agreement between NIOSH and the Consumer Product Safety Commission (CPSC) to collect work-related injury data in the National Electronic Injury Surveillance System (NEISS)]. NIOSH also developed the National Traumatic Occupational Fatalities (NTOF) Surveillance System to fill a gap in basic information on fatal occupational injuries, providing information on all work-related deaths in the United States based on death certificates. In 1993, NIOSH published a major surveillance report summarizing NTOF system data titled Fatal Injuries to Workers in the U.S., 1980-1989: A Decade of Surveillance.
To help guide future surveillance of occupational injury deaths, NIOSH and BLS are currently collaborating on a comparative analysis of the NTOF system and a more recently developed, multi-source occupational injury mortality surveillance system maintained by BLS. Further, NIOSH has recently collaborated with the United States Department of Agriculture and the Department of Labor on new approaches to gather information on agricultural workers, a population under-represented in occupational injury surveillance systems. A recent example of targeted analyses has identified previously unrecognized high injury rates among youth less than 18 years of age who are working in agriculture.
To complement population-based occupational surveillance, NIOSH has developed programs to supplement surveillance data with information from in-depth, case-based investigations of selected diseases and injury deaths. The State-based Sentinel Event Notification System for Occupational Risks (SENSOR) Program is intended to carry out surveillance, investigation, and preventive intervention for specific occupational conditions, including work-related carpal tunnel syndrome, work-related asthma, and pesticide poisoning, among others. Operating in 13 States, SENSOR has recently been supplemented with funding from the Environmental Protection Agency for enhanced pesticide poisoning surveillance.
The Fatality Assessment and Control Evaluation (FACE) program has expanded from an internal program of fatality investigations to include cooperative agreements with 15 States. In addition to the SENSOR and FACE Programs, current major collaborative surveillance-related activities between NIOSH and States include the Adult Blood Lead Epidemiology and Surveillance (ABLES) Program, which has grown from 4 States in 1987 to 28 States in 1999.
NIOSH established an overall Institute strategic plan for 1997 through 2002 that complements goals set by the Department of Health and Human Services (DHHS) and the Centers for Disease Control and Prevention (CDC). Representing the broad spectrum of the Institute's work, the NIOSH Strategic Plan consists of four goals that focus on research, surveillance, prevention, and information dissemination and training. The NIOSH strategic goal for surveillance is to "Develop a system of surveillance for major occupational illnesses, injuries, exposures and health hazards." The 1999 objective for this goal was to "undertake a comprehensive surveillance planning process with NIOSH partners at the State and Federal levels to establish surveillance priorities." The intended purpose of this planning process was to ensure that NIOSH builds effectively on progress in occupational surveillance achieved to date and moves closer to achieving the Institute's overall vision of "Delivering on the Nation's promise: Safety and health at work for all people through research and prevention."
The process for developing this NIOSH Surveillance Strategic Plan for occupational illnesses, injuries, and hazards began in 1998 with input from two groups: the NIOSH-States Work Group and the NIOSH Surveillance Coordination Group. Together, these groups represent public health leaders, surveillance specialists, and other public health professionals from within and outside of NIOSH.
The NIOSH-States Work Group performed the following:
The NIOSH Surveillance Coordination Group performed the following:
Over one year was committed to the development of this plan with input from over 400 health professionals.A total of 65 recommendations were generated by these two groups. After a critical review by NIOSH Senior Staff, the list was consolidated and narrowed to 20 draft objectives. To obtain additional input and comment on these draft objectives, several internal and public meetings were held during the summer of 1999. Representatives of States provided input at a meeting in Madison, Wisconsin, which was held in association with the national meeting of the Council of State and Territorial Epidemiologists (CSTE). A public meeting was held in Washington, D.C., and internal NIOSH meetings were held in Cincinnati, Ohio, and Pittsburgh, Pennsylvania. Input was also obtained from the National Occupational Research Agenda (NORA) Surveillance Research Methods Team, Federal partners, including BLS, OSHA, and NCHS, and non-governmental organizations, including worker and employer representatives. Table 1 provides a summary of the NIOSH surveillance strategic planning process. Overall, approximately 400 health professionals contributed to the development of the NIOSH Surveillance Strategic Plan.
The NIOSH Surveillance Strategic Plan is based on a long-range vision of a comprehensive occupational surveillance program involving a coordinated set of complementary surveillance systems. The plan seeks to achieve an appropriate balance between national and State-based activities, as well as an appropriate balance among health, injury, and hazard surveillance. Because no single Federal agency has an exclusive mandate to promote and conduct occupational health and safety surveillance, surveillance at all levels will benefit from increasing coordination and information exchange. Since new issues in occupational health will undoubtedly emerge in the next decade, the Surveillance Strategic Plan incorporates flexibility and the capacity to respond to them.
Many Federal agencies engage in surveillance activities related to occupational fatalities, injuries, and illnesses. Although communication and collaboration among agencies has improved in recent years, there is a need for better coordination and collaboration of surveillance activities at the Federal level. The Surveillance Strategic Plan recognizes the importance of working with Federal partners to identify and fill data gaps, improve dissemination and use of surveillance information, expand public access to surveillance data, and encourage the inclusion of standardized coding of occupation and industry information in national data systems.
The Surveillance Strategic Plan recognizes that States have a vital role to play in the surveillance of occupational injuries, illnesses, and hazards. Under the Surveillance Strategic Plan, State-based surveillance systems and activities will provide a vital foundation for several Federal surveillance systems and will augment other Federal surveillance systems. In the long-range vision of an improved comprehensive nationwide occupational health surveillance program, all States will have the core capacity to conduct surveillance of occupational injuries, diseases, and hazards that will contribute to State and local prevention efforts, as well as to national data concerning magnitude, trend, and distribution. In addition, States will also have the capacity to conduct focused in-depth surveillance, follow-up investigations, and intervention for selected, targeted conditions (diseases, injuries, or hazards). Given inevitable resource constraints, it is not realistic to expect all States to conduct in-depth surveillance for all occupational conditions at the present time.
This Surveillance Strategic Plan recognizes that many day-to-day occupational health monitoring and surveillance activities are, and should be, conducted by employers, health care professionals and institutions, and unions. New technologies and changes in health care delivery offer new opportunities for surveillance activities. There is a tremendous amount of work outside of occupational health being done to develop health information/surveillance systems, and NIOSH recognized the importance of this work in designing its strategic plan. In fact, one goal in this Surveillance Strategic Plan is to identify those private sector individuals, institutions, groups, and organizations that are involved in successful surveillance programs, to learn from them, and to share their tools and effective prevention activities.
The Surveillance Strategic Plan seeks to continue to enhance a focus on high-risk industries and occupations, such as construction, agriculture, mining, and health care. In addition to maintaining surveillance of traditional concerns of continuing importance, the Plan seeks to increase surveillance relating to the use of protective technologies, as well as to work organization issues such as shift work.
Occupational safety and health surveillance presents a host of methodologic and other challenges. Research is needed to evaluate existing surveillance systems and approaches. New approaches must be developed to capture the experience of special populations and the growing number of workers who participate in non-traditional work arrangements, such as contingent, temporary, and contract workers, as well as part-time workers and multiple-job holders. The use of non-traditional data sources may be especially helpful for these surveillance efforts, but they are virtually unexplored. Recognizing these needs, the Surveillance Strategic Plan specifically includes a goal to enhance occupational safety and health surveillance research in the coming years.
Finally, the goals of the Surveillance Strategic Plan cannot be achieved without strengthening NIOSH partnerships with other Federal, State, and non-governmental organizations. The goals also cannot be achieved fully without identifying additional resources to carry out such a plan. To accomplish the long-range vision of a nationwide occupational health surveillance system, NIOSH and its partners must formulate a concrete plan to marshal those resources. At the Federal level, available NIOSH surveillance funding and staffing need to be complemented by effective collaboration and pooling of resources with other Federal agencies. For State-based occupational surveillance programs, NIOSH needs not only to collaborate with States, but also to assist States in accruing funding at levels of support consistent with other public health arenas. NIOSH also needs to work closely with colleagues in non-governmental agencies and with those in other health disciplines to identify new, non-traditional sources of funding for occupational health surveillance. These additional efforts can help ensure that occupational safety and health surveillance can be fully integrated into an overall public health surveillance system. Through this comprehensive strategy, NIOSH and its partners can fully participate in widespread efforts to build a comprehensive, integrated, electronic public health surveillance system operational at the local, State and national levels.