National Academies Report

Attachment C: HHE local health department survey, National Academies report

The Health Hazard Evaluation
Program at NIOSH
This report evaluates the National Institute for Occupational Safety and Health (NIOSH) Health
Hazard Evaluation Program for its relevance and impact in identifying and responding to
occupational health hazards. The report finds that the program has had a positive impact on
workforce conditions, responds well during public health emergencies, and offers excellent training
programs for occupational health professionals. The program could be further strengthened by
increasing its visibility, by expanding communication and outreach activities, and by expanding
its training programs.

E

xposure to chemical
or physical hazards
in the workplace
can lead to illness, injury, or
even death. These hazards can
also be costly to employers
due to loss of productivity
caused by lost days of work by
employees, increased workers’
compensation payments, and
legal costs. It is the unique
mission of the Health Hazard
Evaluation Program within
the National Institute for
Occupational Safety and Health
(NIOSH) to respond to requests
to investigate previously unknown potential
occupational health hazards and known health
hazards found in new occupational settings. In
contrast to other NIOSH programs, the Health
Hazard Evaluation Program is not primarily a
research program. Rather, it investigates and
provides advice to workplaces in response to
requests from employers, labor unions, and
federal agencies. The program also responds to
emergencies such as the 9/11 attacks and provides
training in field investigations to many health and
safety professionals.
The Health Hazard Evaluation Program
has been instrumental in identifying a wide
array of hazards such as potentially fatal latex
allergies associated with latex glove use in

medical facilities, and the
occupational transmission of
infectious diseases to workers
in swine processing facilities.
In a highly publicized case in
1999, the program responded
to a call to investigate
a microwave popcorn
manufacturing plant where
workers were becoming ill
with a rare lung disease.
The investigation showed a
link between occupational
exposure to a butter flavoring
and the illness, which became
widely known as “popcorn
lung” (see Box 1, p. 2).
As part of a series of reviews of NIOSH
programs, the National Research Council
assembled a committee to evaluate the NIOSH
Health Hazard Evaluation Program with respect
to its 1) relevance in addressing workplace
health hazards, 2) impacts on worker health and
safety as well as its impacts through outreach,
and 3) future directions to improve both
relevance and impact of the program.
ASSESSMENT OF THE PROGRAM’S
RELEVANCE AND IMPACT
The committee was charged with
evaluating the NIOSH Health Hazard Evaluation
Program and determining whether program

Attachment C: HHE local health department survey, National Academies report

activities resulted in improvements in workplace
practices and decreases in hazardous exposures
that cause occupational illnesses. The committee
assessed the relevance of the program in addressing
current and emerging workplace health hazards.
The committee also evaluated the impact of the
program on reducing worker risk and occupational
illness, transferring program-generated information
beyond the investigated workplaces, and whether
the program impacts research and policy decisions
within NIOSH and elsewhere.
The program was assessed on scales from 1-5,
with 5 as the top score (see Box 2). The criteria were
developed by a framework committee to evaluate
all NIOSH programs in a consistent manner. The
program received scores of 4 for both relevance
and impact. The evaluation committee notes that
the program actually performs between a 4 and 5 in
both categories, but that it was restricted to the use of
integers for the rating scale.
FINDINGS AND RECOMMENDATIONS
Even though the Health Hazard Evaluation
Program is very strong overall, the committee
makes several recommendations that could help
advance the program beyond its current strengths.
These recommendations are not provided in order
of importance. The committee recognizes that
implementation of the recommendations depends
on the availability of resources and encourages the
program to implement any of the recommendations
as resources are available.
Strategic Planning. The Health Hazard Evaluation
Program’s strategic plan, intermediate goals,
and performance measures are highly relevant to
its mission given its limited resources. If more
resources become available, the committee believes
performance measures could be improved by
being more specific and ambitious. The committee
recommends regular assessments of performance
measures to determine whether more ambitious goals
could be implemented with available resources.
Improving the Investigation Request Process.
The Health Hazard Evaluation Program responds
well to health hazard evaluation requests, but it
could reach a wider range of requesters. Outreach
could be improved by establishing formal
relationships with organizations that represent
underserved populations, and small businesses
and their employees. The function and activities of

Box 1: Finding the Cause of “Popcorn Lung”
In 1999 and 2000, workers at a Missouri
microwave popcorn plant became ill with
bronchiolitis oblitans, a severe and sometimes
fatal lung disease. The workers’ doctors noticed
the heightened occurrence of this rare disease,
and contacted the state health department. The
plant was inspected for known respiratory health
hazards by both state and federal inspectors and
was determined to be in compliance with existing
standards. However, the cause of the workers’
illnesses remained unsolved.
The Missouri Department of Health then
contacted the Health Hazard Evaluation Program
to conduct an investigation of the plant. The
investigation revealed that rates of bronchiolitis
obliterans in plant workers and former workers were
significantly higher than in the general population,
and that the likely cause was occupational exposure
to an artificial butter flavoring. The program issued
recommendations to prevent exposure to the
flavoring in the future, and continued testing the plant
to ensure that the recommendations were effective.
The program then worked to inform workers at other
workplaces that use the artificial butter flavoring to
help prevent bronchiolitis obliterans, now commonly
referred to as “popcorn lung.”

the program need to be communicated to national,
regional, and state health and labor departments.
Cooperation between the program and these
departments could be improved.
Overall, the program’s current process of
prioritizing requests is effective. To improve the
process, requests could be prioritized using an
explicit written process that is more transparent
to requestors. The staff could further improve
the prioritization process by using scientific and
professional meetings, surveillance data, and
scientific literature to recognize emerging issues.
A formal technical assistance mechanism could be
implemented to help requestors formulate requests,
or in the case of requests that will not be addressed
by the program, referrals to another NIOSH
division or government agency.
Increasing Report Quality. Reports that result
from investigation requests tend to be well-written,

Attachment C: HHE local health department survey, National Academies report

exhibit a high level of expertise, and provide
important information and control solutions to
prevent occupational illness, but there is no evidence
of a formal quality-assurance program in place. An
external review of a subset of reports for scientific
content, report completeness, and appropriateness
of recommendation could help ensure consistency
in report quality. Quality of recommendations
made in reports is generally excellent. Additional
impact might be realized if the reports included
descriptions of the priority, relevance, feasibility
and impact of each recommendation. Assessment
of the effectiveness of investigations might benefit
from post-investigation debriefing in NIOSH to
systematically identify missed opportunities and
emerging hazards, and by improvement of postinvestigation of surveys to employers to assess
impacts.
Professional Training. The Health Hazard
Evaluation Program offers training opportunities
for occupational health professionals that are highly
effective. However, this training function could
be more effective if NIOSH relationships with

occupational health professionals were expanded.
Recruitment of personnel for temporary assignment
to participate in health hazard evaluations from
universities, government agencies, occupational
medicine residencies, and state and local health
departments could be increased. The program
could make use of educational and research centers
to increase collaborations with faculty and to
involve trainees in field investigations. Training
program alumni could also help develop program
opportunities through a program-level advisory
board, or assist in the maintenance of vital routine
program functions during deployment of key staff
responding to emergencies.
Reaching a Wider Audience. The Health Hazard
Evaluation Program uses a wide variety of tools
to disseminate its findings to the public, such as
the Internet, free CD-ROMS, articles in trade
publications, and presentations at trade and
scientific meetings. There is a concern that the
program is not reaching many who could benefit
from its services. The program could reach a wider
audience through innovative communications

BOX 2: Committee Scoring Criteria
Rating of Relevance
5 = Activities are in high-priority subject areas and NIOSH is significantly engaged in appropriate transfer
activities for completed projects/reported results.
4 = Activities are in priority subject areas and NIOSH is engaged in appropriate transfer activities for
completed projects/reported results.
3 = Activities are in high-priority or priority subject areas, but NIOSH is not engaged in appropriate transfer
activities; or activities focus on lesser priorities but NIOSH is engaged in appropriate transfer activities.
2 = Activities are focused on lesser priorities and NIOSH is not engaged in or planning some appropriate
transfer activities.
1 = Activities are not focused on priorities and NIOSH is not engaged in transfer activities.
Rating of Impact
5 = Activities have made major contribution(s) to worker health and safety on the basis of end outcomes or
well-accepted intermediate outcomes.
4 = Activities have made some contributions to end outcomes or well-accepted intermediate outcomes.
3 = Activities are ongoing and outputs are produced that are likely to result in improvements in worker health
and safety (with explanation of why not rated higher). Well-accepted outcomes have not been recorded.
2 = Activities are ongoing and outputs are produced that may result in new knowledge or technology, but
only limited application is expected. Well accepted outcomes have not been recorded.
1 = Activities and outputs do not result in or are NOT likely to have any application.
NA = Impact cannot be assessed; program not mature enough.

Attachment C: HHE local health department survey, National Academies report

techniques such as public service announcements
for truck drivers, or collaborations with centers
that work with immigrant workers. Resources
could be made available in multiple languages
and in multiple forms of media to address literacy
and cultural issues. To increase outreach, outside
resources such as community and small business
groups and federal agencies could be enlisted to
help translate report findings to their constituencies.
Influencing Policy and Research. Although
the Health Hazard Evaluation Program is not a
regulatory agency, it has substantially impacted
policies and regulations designed to protect
workers. Likewise, the program has had a profound
impact on research carried out by other NIOSH
divisions. In order to increase its impact on research
and policy within NIOSH and the Department
of Health and Human Services, the committee
recommends the program form more extensive
formal linkages with other NIOSH divisions, with
the Centers for Disease Control, and with the
Department of Health and Human Services.
Identifying Emerging Hazards. The Health
Hazard Evaluation Program is highly effective at

identifying emerging hazards. However, available
surveillance data (health-related events data that
have been systematically collected, analyzed, and
interpreted) have not been used sufficiently. The
program could establish a systematic approach
using surveillance data to more actively seek
opportunities for field investigations. This would
help to identify occupational health hazards that
are either unknown, known but found in new
circumstances, or known but are not regulated or
are under-regulated.
Responding to Emergencies. Staff of the Health
Hazard Evaluation Program have the unique ability
to formulate information needed to safeguard the
workforce during and following a disaster and
are well prepared to deploy during emergencies.
When public health emergencies arise, care should
be taken by the program to balance the immediate
needs of the crisis with the need to maintain essential
functions. A mechanism could be developed, perhaps
with the assistance of training program participants
and alumni, to ensure routine essential functions are
maintained while key staff are deployed.

Committee to Review the NIOSH Health Hazard Evaluation Program: Rogene F. Henderson (Chair),
Lovelace Respiratory Research Institute, Albuquerque, New Mexico; Joel Bender, General Motors Corporation,
Detroit, Michigan; Eula Bingham, University of Cincinnati, Ohio; James E. Cone, New York City Department
of Health and Mental Hygiene, New York; Monica Gaughan, University of Georgia, Athens; Clarion Johnson, ExxonMobil Corporation, Fairfax, Virginia; Franklin E. Mirer, Hunter College of the City University of
New York, New York; Barbara Silverstein, Washington State Department of Labor and Industries, Tumwater,
Washington; Rosemary K. Sokas, University of Illinois, Chicago; Michael J. Wright, United Steelworkers,
Pittsburgh, Pennsylvania; Sammantha L. Magsino (Study Director), National Research Council
This report brief was prepared by the National Research Council based on the committee’s
report. For more information, contact the Division on Earth and Life Studies at (202) 334-2500 or
visit http://dels.nas.edu. Copies of The Health Hazard Evaluation Program at NIOSH are available
from the National Academies Press, 500 Fifth Street, N.W., Washington, DC 20001; (800) 6246242; www.nap.edu.
This study was supported by funds from the National Institute for Occupational Safety and Health of the Centers
for Disease Control and Prevention.
Permission to reproduce this brief in its entirety with no additions or alterations.
© 2008 The National Academy of Sciences