NIOSH Program Portfolio

Respiratory Diseases

Inputs: NIOSH Strategic Goals

The RDRP mission is to provide national and international leadership for the prevention of work-related respiratory diseases. RDRP uses a scientific approach to gather and synthesize information, create knowledge, provide recommendations, and deliver products and services to those who can effect prevention.

The RDRP Steering Committee provides leadership and coordination of respiratory disease research across NIOSH. The steering committee was established for RDRP in 2006. Members of this committee are drawn from all of the NIOSH divisions and laboratories, as well as from the NIOSH Office of the Director. A key component of the steering committee is representation from the NIOSH Office of Extramural Programs, to assure communication and coordination between intramural and extramural efforts. The steering committee is charged to review and rank competitive intramural NORA funding requests; to provide recommendations to divisions and laboratories about projects needed to maintain the program’s relevance and impact; and to engage in strategic planning for research in the area of occupational respiratory diseases. In addition, during 2006 and 2007, many of the steering committee members were active participants in a review of respiratory diseases research at NIOSH that was conducted by the National Academies. A key current activity is development of an Implementation Plan in response to the National Academies review document (http://www.nap.edu/catalog.php?record_id=12171). A list of committee members can be found in section 2.3 of the RDRP Evidence Package prepared for the National Academies’ review and at the end of this document.

NIOSH Program Portfolio Approach

NIOSH has been organizing research, guidance, information, and service efforts into specific programs that can be readily communicated and strategically governed and evaluated. Eight NORA Sector Programs represent industrial sectors, and twenty-four Cross-sector Programs organized around adverse health outcomes, statutory programs and global efforts.

The NORA Sector Programs intersect with Cross-Sector Programs in a matrix-like fashion. For example, an Agriculture, Forestry and Fishing Program goal of reducing farm-related deaths and injuries due to tractor rollovers and trucks would likely be a shared goal with the Transportation Program and if appropriate would be adopted by both programs. This approach provides an added advantage and will allow multiple Programs to work towards accomplishment of intersecting goals.

Each of the 32 programs in the NIOSH Program Portfolio has a Manager and Coordinator. Each of the 8 NIOSH Sector Programs facilitates the work of a NORA Sector Council to engage external stakeholders in the process of developing sector goals for the nation and methods to measure the short-term, intermediate and long-term outcomes arising from those goals. The NORA goals for the nation will be considered when choosing NIOSH sector program goals. Cross Sector programs have internal Steering Committees that develop program goals and monitor outcome measures.

These planning efforts will position NIOSH to align with the most current governmental approaches for evaluating program effectiveness, i.e., the Program Assessment Rating Tool (or PART). PART is a mechanism to hold governmental agencies accountable for accomplishing results. As part of our comprehensive approach to performance measurement, NIOSH has engaged the National Academies to independently evaluate our sector and cross-programs for relevance and impact.

Background

Work-related respiratory diseases are a problem of major magnitude. They cut across all industrial sectors and all elements of NIOSH, constituting ~70 percent of all occupational disease mortality and ~60% of total occupational mortality from diseases and injuries.¹

Airways Diseases

Airways diseases such as asthma and chronic obstructive pulmonary disease (COPD) are important occupational problems. In 2004, 11.4 million U.S. adults (aged 18 and over) were estimated to have COPD. In the interval from 1997-1999, an estimated 7.4 million people in the U.S. aged 15 and greater reported an episode of asthma or asthma attack in the previous 12 months. A 2003 statement by the American Thoracic Society estimated that 15 percent of COPD and adult asthma were work-related, with a conservative annual estimated cost of nearly $7 billion in the U.S. alone.^2,3,4

Interstitial Lung Diseases

Even though the capability has existed for many years to prevent pneumoconioses such as silicosis, coal workers’ pneumoconiosis (CWP), and asbestosis, pneumoconioses still cause or contribute to more than 2500 deaths per year. The threat of other interstitial lung diseases, such as chronic beryllium disease in beryllium processing or hypersensitivity pneumonitis in those exposed to metal working fluids, are also important concerns in specific industries.^5,6

Respiratory Infectious Diseases

Respiratory infectious diseases have become important occupational concerns. In the wake of the anthrax attacks of 2001, the potential for exposure to weaponized airborne microbiological agents has become a new reality for public service first responders and first receivers in health care facilities, as well as previously unanticipated at-risk groups such as postal workers. First responders and health care workers are also at risk for occupational exposure to naturally-occurring emerging infectious diseases. SARS-coronavirus (the causal agent of Severe Acute Respiratory Syndrome), avian influenza, and pandemic influenza have all emerged as important concerns. New drug resistant strains of tuberculosis (TB), such as extensively drug-resistant-TB, have also emerged as important concerns. A particularly troubling aspect of these emerging respiratory pathogens is their often poorly defined potential for airborne transmission, an issue of obvious importance in designing prevention strategies.^7,8

Respiratory Malignancies

Respiratory malignancies can also result from occupational exposures. In 1996, it was estimated that ~9,000-10,000 men and ~900-1,900 women developed lung cancer annually in the U.S. due to past exposure to occupational carcinogens. More than half of these lung cancers were attributed to asbestos. Mesothelioma, a malignancy involving the pleural and/or the peritoneal mesothelium and caused by inhalation of asbestos fibers, was responsible for more than 2650 deaths in 2004.^9,10

Emerging Issues

New occupational respiratory diseases continue to emerge. Examples investigated by NIOSH in the last decade include severe obstructive lung disease due to constrictive bronchiolitis in those exposed to artificial butter flavorings, interstitial lung disease caused by respirable particles of nylon flock, and acute respiratory distress syndrome caused by leather conditioning spray.^11,12 It is critically important for RDRP to maintain its ability to anticipate and rapidly respond to emerging problems. In this regard, the emerging issue of nanotechnology and associated exposure to engineered nanoparticles is one where anticipation may lead to prevention. Although occupational diseases have yet to be attributed to engineered nanoparticles, use of manufactured nanomaterials is projected to grow at an impressive pace with associated economic impacts. Laboratory-based RDRP studies already suggest that engineered nanoparticulate exposures represent potentially preventable occupational health hazards.¹³ Another potential emerging source of nanoparticle exposure is generation of combustion-related nanoparticles by newer, fuel efficient diesel engines.

Based on these considerations, RDRP has developed five Strategic Goals. Four are categorically based on diseases; and one is based on exposure, since it is currently unknown if engineered nanoparticles will induce respiratory or other work-related disease. The Strategic Goals are as follows:

• Prevent and reduce work-related airways diseases
• Prevent and reduce work-related interstitial lung diseases
• Prevent and reduce work-related respiratory infectious diseases
• Prevent and reduce work-related respiratory malignancies
• Prevent respiratory and other diseases potentially resulting from occupational exposures to nanomaterials

These goals are largely organized by disease and have a strong disease focus. However, a broad spectrum of activities is needed to effectively address them. Thus, a multidisciplinary research program that includes surveillance; research in exposure assessment methods, respiratory health assessment methods, epidemiology, engineering controls, respiratory protection, underlying disease mechanisms, and toxicology; development of authoritative recommendations; health communications; and training and education is of critical importance in the prevention and reduction of work-related respiratory disease. The most recent revision of these strategic, intermediate and output goals has been heavily influenced by the National Academies (NA) Report: Respiratory Disease Research at NIOSH.

Respiratory Diseases Research Program Strategic Goals

Strategic Goal 1: Prevent and reduce work-related airways diseases

It should be noted that surveillance is critical to the intermediate goals (IG) and output goals (OG) supporting the airways diseases strategic goal. Surveillance is needed to document baseline conditions and the impact of intervention and prevention efforts. Education, communication, information dissemination, and providing support to standard-setting and regulatory groups are also critical to achieving intermediate outcomes that demonstrate impact.

Intermediate Goal 1.1: Prevent and reduce the full range of work-related asthma (WRA), including work-exacerbated asthma; occupational asthma; and irritant-induced asthma.

• Output Goal 1.1.1: Assess the extent, severity, burden, and risk factors for WRA and approaches to prevention across a broad range of industries and occupations.
• Output Goal 1.1.2: Develop improved tools for detection of WRA by questionnaire or ambulatory spirometry.
• Output Goal 1.1.3: Develop improved tools for detection of allergic sensitization to low molecular weight allergens such as isocyanates or high molecular weight allergens such as mold allergens.
• Output Goal 1.1.4: Identify, document, and characterize emerging causes of WRA, including novel host factors, novel occupational exposures, and irritant inhalation exposures encountered during natural or man made disasters.
• Output Goal 1.1.5: Evaluate the impact of indoor air quality on WRA and the effectiveness of building remediation in preventing WRA associated with poor indoor air quality.
• Output Goal 1.1.6: Develop and implement demonstration projects that address the role of screening and surveillance for WRA in occupational settings.
• Output Goal 1.1.7: Conduct basic research to better define the mechanisms of action of low molecular weight sensitizers and irritants capable of inducing WRA and to better characterize high molecular weight occupational allergens and their health effects.

Intermediate Goal 1.2: Prevent and reduce work-related COPD.

• Output Goal 1.2.1: Conduct surveillance and epidemiological studies to assess the extent, severity, and burden of work-related COPD and identify industries and occupations associated with COPD.
• Output Goal 1.2.2: Conduct systematic population-based studies to better define groups of workers at greatest risk of COPD and guide development of preventive strategies.
• Output Goal 1.2.3: Improve tools such as longitudinal spirometry and respiratory questionnaires for early detection of occupationally-related COPD.
• Output Goal 1.2.4: Develop and improve methods for collecting, analyzing, and responding to the results of longitudinal pulmonary function testing to optimize identification and secondary prevention for individuals at risk of developing severe COPD.
• Output Goal 1.2.5: Promote the implementation of longitudinal pulmonary function testing in the workplace for surveillance and intervention in populations at risk for fixed airways obstruction.
• Output Goal 1.2.6: Study associations between irritant inhalation exposures during disasters, such as dust at the site of the World Trade Center (WTC) collapse, and development of obstructive lung disease (this objective overlaps with asthma prevention, since many affected individuals have reactive airways disease; and potentially will overlap with other long-term effects of WTC-related exposures).

Intermediate Goal 1.3: Prevent and reduce flavorings-induced obstructive lung disease, including bronchiolitis obliterans.

• Output Goal 1.3.1: Conduct surveillance, epidemiological studies, and field studies to identify the full range of food production industries at risk for flavorings-induced lung disease.
• Output Goal 1.3.2: Develop and improve sampling and analytical methods for assessing exposure to diacetyl and other artificial flavorings.
• Output Goal 1.3.3: Develop protective recommendations for exposure assessment and engineering controls in work settings using artificial flavorings; disseminate information to improve recognition of flavorings-induced lung disease by a range of groups, including clinical practitioners, public health officials, facilities using artificial flavorings, and workers using artificial flavorings; disseminate information and encourage health care providers to report cases of flavoring-induced lung disease to state health departments and NIOSH.
• Output Goal 1.3.4: Provide regulators with information needed to address current requests for Emergency Temporary Standards for diacetyl and the data and risk assessments they will need for worker protection over the long term.
• Output Goal 1.3.5: Conduct basic toxicology research, including inhalation toxicology studies, to better characterize the toxic potential and mechanisms of toxicity of diacetyl and other potentially toxic artificial flavorings.

Strategic Goal 2: Prevent and reduce work-related interstitial lung diseases.

It should be noted that surveillance is critical to the IG and OG supporting the interstitial lung diseases strategic goal. Surveillance is needed to document baseline conditions and the impact of intervention and prevention efforts. Education, communication, information dissemination, and providing support to standard-setting and regulatory groups are also critical to achieving intermediate outcomes that demonstrate impact.

Intermediate Goal 2.1: Prevent and reduce coal mine dust-induced respiratory diseases, with primary focus in this intermediate goal on CWP and PMF.

• Output Goal 2.1.1: Improve technologies for dust assessment and dust control in coal mining. Provide technical guidance for the use of a personal dust monitor for real-time assessments of dust exposure.
• Output Goal 2.1.2: Identify state-of-the-art technologies for controlling coal mine dust exposures and transfer this information to industry through a series of regional dust control workshops by October 2012.
• Output Goal 2.1.3: Perform x-ray surveillance for CWP to monitor the extent and severity of the problem. Investigate the nature and causes of geographic "hot spots" of pneumoconiosis, in part by completing a comprehensive program of mine-site sampling to assess the impact of geology, control technology and mining practices. Survey mines in hot-spot and non-hot-spot areas of the coal fields to assist in identifying factors associated with rapid disease development and progression.
• Output Goal 2.1.4: Engage Mine Safety and Health Administration (MSHA) in a dialogue with the aim of adopting the NIOSH – REL¹⁴ (1.0 mg/m³) as the actual PEL for coal mine dust exposure. As the enactment of such a PEL would be solely the domain of MSHA, we have no control over the process or timeframe.
• Output Goal 2.1.5: Perform studies and develop updated recommendations for chest imaging of pneumoconiosis that allow implementation of digital imaging for classification of chest radiographs using the International Labour Office classification system. Transition NIOSH’s mandated surveillance activities, including the B reader certification program, to use of digital chest imaging.

Intermediate Goal 2.2: Prevent and reduce silica-induced respiratory diseases, with primary focus in this intermediate goal on silicosis.

• Output Goal 2.2.1: Conduct hazard surveillance to track silica exposures and seek new or overlooked sources of silica exposure to workers.
• Output Goal 2.2.2: Reduce hazards associated with abrasive silica sand blasting by evaluating the relative respiratory toxicities of silica vs. abrasive blasting alternatives such as coal slag, garnet, steel grit, crushed glass, and specular hematite.
• Output Goal 2.2.3: Develop, improve and validate sampling and analytical methods for assessing exposures to silica.
• Output Goal 2.2.4: Develop mining control technologies to reduce or eliminate silica exposure, which would include dust reduction or particle coating. Transfer information on these silica control technologies to the metal/non-metal mining industry through a series of regional workshops.
• Output Goal 2.2.5: Develop and improve control technologies to reduce or eliminate silica exposures across a range of occupational settings where silica is a known problem (mining, construction, abrasive blasting, foundries, dental laboratories, etc.) and in new occupational settings where silica exposure may appear as an emerging problem.
• Output Goal 2.2.6: Develop and validate approaches to early detection for silicosis such as new approaches to chest imaging and assessment of biomarkers associated with silica exposure and interstitial lung disease.

Intermediate Goal 2.3: Prevent and reduce “fiber”-induced respiratory diseases.

• Output Goal 2.3.1: Obtain public and stakeholder comment and finalize a document that identifies current research gaps and priorities in the area of respiratory diseases caused by inhalation exposure to asbestos and other elongated mineral particles (“Asbestos and other mineral fibers: a roadmap for scientific research”).
• Output Goal 2.3.2: Develop improved sampling and analytical methods for assessing exposure to asbestos and other elongated mineral particles.
• Output Goal 2.3.3: Conduct hazard surveillance to document workers, job tasks, and industries in which workers are exposed to various types of elongated mineral particles, including elongated cleavage fragments of amphibole minerals.
• Output Goal 2.3.4: Conduct epidemiological investigations to better characterize the relationships between exposures to asbestos and other elongated mineral particles, including elongated cleavage fragments of amphibole minerals, and health effects such as interstitial lung disease, lung cancer, and mesothelioma.
• Output Goal 2.3.5: Perform basic toxicologic research to elucidate the important determinants of toxicity for asbestos fibers and other elongated mineral particles and to improve the ability to predict the toxic potential of natural and man-made inorganic fibers.
• Output Goal 2.3.6: Develop and publish a NIOSH Alert on flock and the flock workers’ lung.

Intermediate Goal 2.4: Prevent and reduce beryllium sensitization and chronic beryllium disease.

• Output Goal 2.4.1: Evaluate the effectiveness of a comprehensive preventive program that includes reduction of skin exposures at a copper-beryllium alloy in reducing immunological sensitization to beryllium and chronic beryllium disease.
• Output Goal 2.4.2: Evaluate the effectiveness of a comprehensive preventive program that includes reduction of skin exposures at a beryllium manufacturing facility in reducing immunological sensitization to beryllium and chronic beryllium disease.
• Output Goal 2.4.3: Perform a cohort study assessing the longitudinal development of immunological sensitization to beryllium and chronic beryllium disease in workers at a beryllium oxide/ceramics plant over an eleven-year follow-up period.
• Output Goal 2.4.4: Develop, refine and validate improved methods to assess exposure to beryllium; and determine whether complex exposure metrics taking estimated dissolved beryllium dose and dermal exposure into account are better predictors of adverse health effects than simple mass-based exposure metrics.
• Output Goal 2.4.5: Perform epidemiological and laboratory studies to elucidate mechanisms of beryllium-induced disease, including studies that clarify the role of genetic susceptibility in developing immunological sensitization to beryllium and chronic beryllium disease; and the role of gene-environment interactions.

Strategic Goal 3: Prevent and reduce work-related respiratory infectious diseases

It should be noted that surveillance is critical to the IG and OG supporting the respiratory infectious diseases strategic goal. Surveillance is needed to document baseline conditions and the impact of intervention and prevention efforts. Education, communication, information dissemination, and providing support to standard-setting and regulatory groups are also critical to achieving intermediate outcomes that demonstrate impact.

Intermediate Goal 3.1: Develop improved approaches to detect and quantify exposures to airborne infectious agents and settled infectious agents with the potential to cause respiratory infection.

• Output Goal 3.1.1: Develop database of methods for anthrax exposure assessment.
• Output Goal 3.1.2: Develop and validate novel sampling and analytical methods for assessing exposures to airborne infectious agents such as influenza virus.
• Output Goal 3.1.3: Develop, improve and validate direct-reading methods for assessing exposures to airborne and settled infectious agents with the potential to cause respiratory infection.

Intermediate Goal 3.2: Elucidate pathogen and host factors underlying susceptibility to transmission of occupational respiratory infectious diseases.

• Output Goal 3.2.1: Evaluate the impact of occupational exposures on susceptibility to respiratory infection, including underlying mechanisms. Occupational exposures of current concern include welding fume and its constituents; diesel exhaust; residual oil fly ash (ROFA); silica; and potentially others, if evidence suggests that exposure increases risk of respiratory infection.
• Output Goal 3.2.2: Evaluate the impact of pathogen characteristics on airborne disease transmission, including aerosol size distribution; impact of factors such as temperature, humidity and UV irradiation on aerodynamic properties, viability and infectivity; and pathogen/environmental factors that affect re-aerosolization of settled agents. Use these findings to develop approaches for predicting the relative importance of airborne and contact disease transmission.
• Output Goal 3.2.3: Apply available basic and epidemiologic data to developing approaches to risk assessment for airborne transmission of occupational infectious agents.

Intermediate Goal 3.3: Reduce exposure to airborne occupational infectious agents through engineering controls.

• Output Goal 3.3.1: Develop and disseminate information to improve engineering controls applicable to TB and other agents, including ventilation and modeling of air flow, air filtration, and disinfection via UV germicidal irradiation.
• Output Goal 3.3.2: Develop, demonstrate, and disseminate methods for “expedient airborne isolation” that can be deployed in settings such as epidemics where there is high demand for airborne isolation rooms.

Intermediate Goal 3.4: Reduce exposure to airborne occupational infectious agents through respiratory protection.

• Output Goal 3.4.1: Develop respirators with better sealing characteristics through improved anthropomorphic facial panels; develop a total inward leakage standard that would provide consumers with an assessment of the fitting characteristics of respirators; and perform research to assess the optimal methods and frequency of fit-testing.
• Output Goal 3.4.2: Perform research to assess the possibility of decontamination and re-use of disposable N95 filtering face piece respirators under conditions of respirator shortage.
• Output Goal 3.4.3: Complete the development of Chemical, Biological, Radiological, and Nuclear respirator certification standards
• Output Goal 3.4.4: Develop and disseminate information products to improve the use of respirators

Intermediate Goal 3.5: Reduce the burden of airborne occupational respiratory infectious disease through improved medical screening methods.

• Output Goal 3.5.1: Develop and evaluate new methods in medical screening and surveillance for TB infection as an alternative to tuberculin skin testing.
• Output Goal 3.5.2: Develop improved strategies for early identification and isolation of infectious cases.

Intermediate Goal 3.6: Reduce the burden of airborne occupational respiratory infectious disease through coordination and collaboration with other elements of CDC.

• Output Goal 3.6.1: Continue to work with other elements of CDC in the implementation of the Federal Interagency TB Prevention Plan.
• Output Goal 3.6.2: Continue to work with other elements of CDC in the development and implementation of a pandemic influenza prevention plan including outreach to multiple industries.
• Output Goal 3.6.3: Continue to work with other elements of CDC in the development and implementation of a cross-CDC environmental microbiology research program.

Strategic Goal 4: Prevent and reduce work-related respiratory malignancies.

The lead program for work-related cancer research, including research related to work-related respiratory cancers, is the NIOSH Cancer, Reproductive, and Cardiovascular Diseases (CRC) program. As noted in the NA report on NIOSH respiratory diseases research, respiratory cancers are best approached within the context of a comprehensive cancer program. This is because a single type of carcinogenic exposure may cause many types of cancer. Also, many research and prevention approaches and issues are common to many types of cancer. The goals specified in this section are those of special interest to the RDRP. Investigators should be sure to also refer to the cancer goals within the NIOSH CRC program. It should be noted that surveillance is critical to the IG and OG supporting the work-related respiratory malignancies strategic goal. Surveillance is needed to document baseline conditions and the impact of intervention and prevention efforts. Education, communication, information dissemination, and providing support to standard-setting and regulatory groups are also critical to achieving intermediate outcomes that demonstrate impact.

Intermediate Goal 4.1: Reduce the incidence of work-related cancer through research, promotion of carcinogen-free workplaces, and international collaborations.

• Output Goal 4.1.1: Develop a national research plan for fiber-induced lung cancer by obtaining public comment, completing, disseminating and implementing priorities described in the document, “Asbestos and Other Mineral Fibers: A Roadmap for Scientific Research.”
• Output Goal 4.1.2: Complete a reanalysis of respiratory malignancies in a cohort of chrysotile asbestos textile workers, previously studied only by light microscopy, whose exposures will be reanalyzed by EM. This will allow modeling of exposure-response that takes into account the vast majority of fibers that cannot be seen by the light microscopy-based methods previously used to study the cohort.
• Output Goal 4.1.3: Conduct epidemiological investigations to better characterize the relationships between exposures to asbestos and other elongated mineral particles, including elongated cleavage fragments of amphibole minerals, and health effects such as interstitial lung disease, lung cancer, and mesothelioma (same as 2.3.4).
• Output Goal 4.1.4: Elucidate mechanisms of silica-induced lung cancer and reduce silica exposures (exposure reduction is discussed in the interstitial lung diseases section).
• Output Goal 4.1.5: Evaluate a cohort of workers at three beryllium processing facilities to assess the association between lung cancer mortality and quantitative metrics of cumulative, average and peak exposures.
• Output Goal 4.1.6: Continue to follow the Colorado Plateau uranium miners’ cohort to assess lung cancer risk associated with radon exposure 20 to 40 years after exposure, as well as interactions between radon exposure and smoking.
• Output Goal 4.1.7: Prevent and reduce respiratory diseases associated with exposure to diesel particulate matter (DPM), including lung cancer by: a) improving technologies for DPM assessment and control in underground mining; b) providing technical guidance, through workshops and intervention studies, for the use of control technologies and monitoring to reduce DPM exposure in miners; c) evaluating the relationship between a miner’s exposure to DPM and mortality, including lung cancer mortality, in a large cohort study.
• Output Goal 4.1.8: Evaluate the ability of single-walled and multi-walled carbon nanotubes to cause chromosomal abnormalities in target cell populations in vitro and in vivo.

Intermediate Goal 4.2: Reduce mortality from work-related cancer by developing, testing, and implementing methods for early detection of work-related cancer.

• Output Goal 4.2.1: Develop and test improved biomarkers for early detection of occupational carcinogenesis. Via a Cooperative Research and Development Agreement, assess the applicability of using alterations in gene expression and gene copy number that have been identified as important in the development of murine lung adenocarcinoma as aids in the early detection and diagnosis of occupationally-induced human lung cancer.
• Output Goal 4.2.2: Develop and validate biomarkers of exposure to occupational carcinogens or biomarkers for early detection of occupational respiratory cancer that address the needs of specific occupational groups at high lung cancer risk. Examples include evaluation of mdig¹⁵ expression for the early detection of silica-induced lung cancer and the used of blood biomarkers such as serum osteopontin or soluble mesothelin-related peptide for the early detection of mesothelioma.

Strategic Goal 5: Prevent respiratory and other diseases potentially resulting from occupational exposures to nanomaterials

It should be noted that surveillance is critical to the nanomaterials strategic goal. Ongoing hazard surveillance will be needed to document emerging exposures and ongoing health surveillance will be needed to document if any type of occupational respiratory disease becomes associated with exposure to nanomaterials. Education, communication, information dissemination, and providing support to standard-setting and regulatory groups are also critical to achieving intermediate outcomes that demonstrate impact.

Intermediate Goal 5.1: Determine the potential respiratory toxicities of nanomaterials.

• Output Goal 5.1.1: Perform basic in vitro and in vivo toxicology studies to evaluate for respiratory toxicity of nanoparticles and, if present, to characterize nanoparticle characteristics and mechanisms of action underlying toxic effects.

Intermediate Goal 5.2: Characterize respiratory exposures and measures used to reduce exposures, including engineering controls and respiratory protection, in work settings where engineered nanomaterials are produced or used.

• Output Goal 5.2.1: Develop partnerships and conduct field evaluations of facilities where nanomaterials are produced or used.

Intermediate Goal 5.3: Develop guidance for facilities that produce or use nanomaterials.

• Output Goal 5.3.1: Complete guidance documents on medical surveillance and use of control banding in facilities where nanomaterials are produced or used.

Resources

1. Dying for work: the magnitude of U.S. mortality from selected causes of death associated with occupation
   Am J Ind Med 2003 May; 43(5):461-482.
2. American Lung Association [2006]. Chronic obstructive pulmonary disease fact sheet,
   External link: http://www.lungusa.org/site/apps/nlnet/content3.aspx?c=dvLUK9O0E&b=2058829
   &content_id={EE451F66-996B-4C23-874D-BF66586196FF}&notoc=1.
3. Case-by-case assessment of adult-onset asthma attributable to occupational exposures among members of a health maintenance organization
   J Occup Environ Med 2006 Apr; 48(4):400-407.
4. American Thoracic Society Statement: Occupational contribution to the burden of airway disease.
   Am J Respir Crit Care Med 2003 Mar; 167(5):787-797.
5. CDC/NIOSH/DRDS/SB. WoRLD Surveillance Report pp, 2008.
6. Beryllium: a modern industrial hazard
   Annu Rev Public Health 2007 Apr; 28:259-277.
7. Luksamijarulkul et al. SE Asian J. Tropical Med & Public Health 35:1005-1011, 2004.
8. Fennelly et al. Emerging Infectious Diseases 10:996-1002, 2004.
9. Review of Occupational Lung Carcinogens
   Am J Ind Med 1996 May;29(5):474-490.
10. CDC/NIOSH/DRDS/SB WoRLD Surveillance Report pp, 2008.
11. Evaluation of flavorings-related lung disease risk at six microwave popcorn plants
    J Occup Environ Med 2006 Feb; 48(2):149-157.
12. Epidemiologic investigation of respiratory morbidity at a nylon flock plant
    Am J Indust Med 2000 Dec;38:628-638.
13. Progress towards Safe Nanotechnology in the Workplace
    DHHS (NIOSH) Publication No. 2007-123 (June 2007)
14. A NIOSH REL is a recommended exposure limit (not enforceable), a PEL is an enforceable permitted exposure limit set by MSHA or OSHA.
15. Mineral dust induced gene.

NIOSH Program:

Respiratory Diseases

Program Description
Inputs
• Economic and Surveillance Data
• NIOSH Strategic Goals
• Partners
• NIOSH Contacts
Activities
• NIOSH Research Projects
• NIOSH Funded Research Grants
Outputs
• Publications
• Topic Pages
• Web Pages
• Products
Outcomes
Review & Evaluation
• Program Review
• National Academies Evaluation