Roisman, Rachel MD, MPH; Materna, Barbara PhD, CIH; Beckman, Stella MPH; Katz, Elizabeth MPH, CIH; Shusterman, Dennis MD, MPH; Harrison, Robert MD, MPH
Public health surveillance, the ongoing systematic collection, analysis, and interpretation of health data for the purpose of improving safety and health, is an essential public health function.1,2 Occupational health surveillance is the tracking of occupational injuries, illnesses, fatalities, and hazards to monitor trends and progress over time and guide efforts to improve worker safety and health.1 State public health agencies have been recognized as critical partners in efforts to conduct public health surveillance since 1951 when the Centers for Disease Control and Prevention asked the Association of State and Territorial Health Officials to convene a group of state epidemiologists and have them develop a list of diseases that should be reported to the public health service.3 This group later became the Council of State and Territorial Epidemiologists, which currently recommends diseases and conditions for reporting within states and to the Centers for Disease Control and Prevention and develops recommendations for state-based public health surveillance.
The states are important partners in all aspects of public health surveillance, and they play a unique and well-described role in surveillance for work-related injuries, illnesses, fatalities, and hazards.4–8 The National Institute for Occupational Safety and Health (NIOSH) has recognized the role of state public health agencies in occupational health surveillance and has incorporated them as principal partners in the NIOSH surveillance strategic plan.9 NIOSH has fostered state capacity by providing funding for state-based occupational health programs since the 1970s. In 2010, NIOSH awarded 5-year cooperative agreements to 23 states (public health agencies and labor departments) to enhance state-based occupational health and safety surveillance capacity.10 Current NIOSH-supported state-based surveillance programs include both basic occupational safety and health surveillance (“Fundamental”) programs and in-depth (“Expanded”) programs. The Fundamental Program enables states to establish an occupational safety and health program and to carry out basic surveillance using existing data sets (eg, occupational health indicators11,12). The Expanded Program enables states to focus on one or more priority health conditions, injuries, hazards, or worker populations (eg, occupational pesticide illnesses,13 work-related fatalities14) in addition to conducting basic surveillance activities. These cooperative agreements serve the dual purposes of building state occupational health surveillance capacity and augmenting national surveillance of occupational conditions.
In July 2010, NIOSH and the Mountain and Plains Education and Research Center jointly sponsored the conference, Nanomaterials and Worker Health: Medical Surveillance, Exposure Registries, and Epidemiologic Research. Attendees discussed both the growing evidence that exposure to engineered nanomaterials may cause adverse health effects in workers and the need for occupational health surveillance of nanomaterial workers to better characterize the hazards and guide prevention efforts. The importance of helping societies “act in the face of uncertainty in a precautionary manner,” and the role that surveillance plays in these efforts, have been described elsewhere.15 Options for tracking workers exposed to engineered nanomaterials, including medical surveillance, exposure registries, and epidemiologic studies, were discussed at the conference and are described in this journal and in previous publications.15–17
As discussions about implementing new surveillance systems for this emerging hazard take place, it is important to remember that state public health agencies have been identified as uniquely able to (1) provide critically needed data on occupational diseases, (2) generate information necessary to evaluate the conventional occupational data sources, (3) actively link surveillance findings with intervention efforts at the state and local levels, and (4) integrate occupational heath into mainstream public health practice.6 This essay aims to characterize the occupational health surveillance that state public health agencies currently conduct, describe the limitations with existing systems for detecting the potential hazards associated with nanomaterial exposure, and demonstrate that state public health agencies should be included as essential partners in the development and implementation of nanotechnology worker surveillance programs.
STATE PUBLIC HEALTH AGENCY OCCUPATIONAL HEALTH SURVEILLANCE
The California Department of Public Health's (CDPH) authority to conduct surveillance of work-related injuries and illnesses was expanded in 1985 with legislation (Chapter 1394, Statutes of 1985) mandating the development of an occupational health and disease prevention program that includes data collection, investigations, technical assistance, prevention efforts, and other components of occupational health surveillance. Today, CDPH occupational health surveillance programs for several specific health endpoints are supported by cooperative agreements with NIOSH. The existence of a legislative mandate and the amount of state and federal support varies among states, and some states do not have any occupational health surveillance capacity, but many of the CDPH occupational health surveillance programs described below have counterparts in other states.
The CDPH Occupational Lead Poisoning Prevention Program is supported both by a state-funded mandate and by NIOSH as the California component of the NIOSH Adult Blood Lead Epidemiology and Surveillance program.18 The California Health and Safety Code requires laboratory reporting of blood lead levels (Section 124130) and that CDPH develop and maintain an occupational lead poisoning prevention program (Sections 105185 to 105195); funding is provided by a fee on employers in industries where there is documented evidence of potential occupational lead poisoning. The Occupational Lead Poisoning Prevention Program staff maintain an occupational blood lead registry and track adult blood lead levels to determine who is exposed to lead in California, identify lead-poisoned workers and help them get proper medical care, assist employers to improve their lead safety practices, provide information to help health care providers care for lead-poisoned workers, and help clinical laboratories comply with adult blood lead reporting requirements.19 Lead is one of the few occupational hazards for which there is a state-funded mandate requiring a surveillance program. Lead is also one of a select number of occupational hazards for which the California Department of Industrial Relations, Division of Occupational Safety and Health (Cal/OSHA), has a comprehensive standard governing workplace exposures and medical surveillance. Also, lead is atypical in that it is one of the few exposures for which valid and reliable environmental and personal (biomonitoring) test methods are available. As a result of decades of research demonstrating, characterizing, and quantifying the hazards from lead exposure, occupational health surveillance programs benefit greatly from legislation that guides workplace activities and provides dedicated funding for surveillance efforts; few occupational surveillance programs have this sort of support.
California has been conducting multisource surveillance of work-related asthma (WRA) since 1993. The current CDPH program is partially funded by NIOSH and aims to identify primary and secondary causes of WRA, characterize exposures and disease, and devise prevention strategies.20 CDPH collects and analyzes mandatory physician reports of occupational injuries and illnesses, workers' compensation data, and hospital data and uses key word searches and International Statistical Classification of Diseases (ICD-9) and other codes to identify cases of WRA. Information from these reports is supplemented by telephone interviews and review of medical records. These data are used to generate state-based prevalences of WRA by industry and occupation to guide intervention activities. Interviews of workers with WRA also serve as an opportunity to provide individuals with educational materials and technical assistance related to their condition. When a review of the data reveals a high-risk worksite or industry, worksite visits and interviews with employees and other stakeholders are conducted to guide development of targeted interventions to prevent WRA. In contrast to lead surveillance where surveillance efforts are based on mandatory reporting of blood lead levels, state surveillance for WRA, and other disease-specific endpoints (eg, occupational carpal tunnel syndrome surveillance), relies on passive reporting using multiple secondary sources of data that are not primarily collected for the purpose of occupational health surveillance. Although there are limitations with these types of surveillance systems (eg, clinician recognition that the injury or illness is work-related is critical for detection), they are efficient, timely, cost-effective, and supply meaningful data.7
The unfolding story of diacetyl-related lung disease (“popcorn lung”) offers another example of the ways in which a state public health agency conducts occupational health surveillance and links data to public health interventions.21 Between 2004 and 2006, Cal/OSHA received reports of two index cases of bronchiolitis obliterans among California flavor manufacturing workers. CDPH collaborated with Cal/OSHA, NIOSH, employees, employers, and medical providers to initiate industry-wide medical surveillance based on lung function screening spirometry and respiratory health questionnaires. The information obtained was used to characterize the flavor manufacturing workforce, identify employees with obstructive lung disease, determine risk factors associated with obstruction, calculate the increased risk of obstruction associated with working in the flavor manufacturing industry, work with clinicians to ensure that employees received enhanced medical surveillance and proper medical care, and make recommendations regarding workplace interventions for primary and secondary prevention. In September 2010, an occupational diacetyl regulation was approved by the standards board responsible for promulgating Cal/OSHA regulations. The surveillance results provided important information establishing the need for a standard and outlining appropriate requirements. Distinct from the long-term surveillance systems for lead and WRA, in this case, two sentinel cases led to the recognition of an emerging hazard and prompted collaboration with Cal/OSHA to develop a new active surveillance system.
The three state-based occupational health surveillance systems described earlier are quite successful, but different occupational health conditions require different surveillance systems and not one system described earlier could be easily adapted for nanomaterial worker surveillance. Lead surveillance is based on mandatory blood lead testing and reporting, but nanomaterial biomonitoring methods are in too early a stage of development to be used as the basis for a surveillance program. WRA surveillance depends on clinician awareness and reporting of the work-relatedness of a particular condition, but nanomaterial-related health effects are just beginning to be recognized and no pathognomonic sign or symptom has yet been identified. In the absence of clinician recognition and documentation of a particular nanomaterial-related health outcome, neither the passive surveillance for WRA, nor the active surveillance for obstructive lung disease in flavor manufacturing workers, would be applicable for nanomaterial workers.
POTENTIAL PUBLIC HEALTH CONTRIBUTIONS TO NANOMATERIAL WORKER SURVEILLANCE
Surveillance of nanomaterial workers presents many challenges, and state public health agencies have much to offer these efforts. Nevertheless, state public health capabilities are of little use in the absence of dedicated staff and resources. New legislation that requires medical surveillance and/or industry participation in an exposure registry, establishes a role for public health, and provides a funding mechanism would improve the success of a new project. Our experience establishing a new surveillance program for flavor manufacturing workers demonstrated the challenges of operating in the absence of a funded mandate and compulsory industry participation. In this section, we will describe some of the ways in which states could contribute to nanomaterial worker surveillance, assuming the infrastructure for occupational health surveillance, and the resources to support such programs, are available.
An initial challenge that medical surveillance programs, exposure registries, and epidemiologic studies face is the identification of exposed employees. The nanotechnology workforce crosses many industry and occupation sectors and has been difficult to characterize.16 Nanotechnology applications are already used for soil remediation, personal care products, paints, electronics, fabrics, sports equipment, and energy technologies, and research is underway for applications in agriculture, medicine, and many other sectors. The workforce is quite variable across states depending on the nanomaterial resources, research, manufacture, use, disposal, and regulations in each state. State public health agencies can work with academia, regulatory agencies, trade associations, and employee groups to characterize the nanomaterials workforce. For instance, the California Environmental Protection Agency's Department of Toxic Substances Control (DTSC) has taken an active interest in nanotechnology and has developed partnerships with relevant industries in an effort to develop an “industrial ecology of manufacturing” that will protect public health and the environment.22 DTSC has used California legislation (Chapter 699, Statutes of 2006) to request information relevant to determining environmental fate and transport from manufacturers who produce or import carbon nanotubes, nanometals, and nanometal oxides in California. In doing so, DTSC has made significant inroads into identifying these companies and establishing a dialogue with them, both useful first steps in the development of an occupational health surveillance program such as an exposure registry. DTSC and CDPH are in the process of establishing a memorandum of understanding to address collaboration and data sharing. As was the case with the flavor manufacturing worker surveillance program, state-based characterization of the nanomaterial workforce is necessary and state public health agencies can work with relevant partners to accomplish this first step.
Once the relevant workplaces have been identified, state public health agencies have several mandates that enable them to work with employees, employers, and medical providers to ensure cooperation with medical surveillance, exposure registries, and epidemiologic studies. State public health agencies are vested with the legal authority to require disease reporting and the authority to request health data including medical records. In many states, including California, there is required reporting of occupational injuries and illnesses to public health agencies. While there is no specific legal authority to require reporting of nanomaterial-associated injuries or illnesses, the legislature, or OSHA, could enact requirements for reporting illnesses associated with nanomaterial exposure. Even in the absence of a nanomaterial-specific reporting requirement, state public health agencies can play a key role as a repository of individual data. Nanomaterial worker medical surveillance and exposure data will be collected at the level of a particular workplace, but state public health agencies could serve as central reporting sites where information from all relevant workplaces could be collected and compiled, sentinel cases could be identified, and trends could be established. State public health agencies are familiar with accessing individual-level data and are experienced with the human subjects review and confidentiality issues that arise when tracking ill workers. Perhaps most importantly, state public health agencies, by virtue of their enduring presence in state government, can develop and sustain ongoing injury and illness surveillance systems to track nanomaterial workers, if adequate and long-term resources are made available to support this work.
State occupational health staff can also work with other public health partners and utilize other public health data for the purpose of nanomaterial worker surveillance. Several innovative projects integrating occupational health into mainstream public health have been described8 and new collaborations may be helpful for nanomaterial worker surveillance. For instance, public health agencies maintain cancer registries and conduct statewide population-based cancer surveillance. Partnerships with cancer registries and use of their data represent a potential way of identifying individual cases, or using data for epidemiologic studies, assuming that robust industry and occupational data are collected and coded. Efforts are currently underway, by NIOSH and others, to make improvements in industry and occupation data and to develop software that will make coding feasible and cost-effective.
State public health agencies also have unique relationships and experience communicating with health care providers. Communication is particularly important in the setting of an emerging hazard where there is potential for the emergence of a new occupational disease. Occupational health staff can alert health care providers to an emerging hazard through state medical boards, occupational medicine clinics, and other networks. This sort of outreach also serves as an opportunity to encourage health care providers to report cases to the state health department so that sentinel cases can be detected and trends can be identified. State occupational health physicians and nurses can also provide technical assistance to providers regarding appropriate medical treatment and follow-up.
Any new nanomaterial worker surveillance program must include mechanisms for acting on the information that is obtained. As mentioned above, states consolidate individual data into trends that can be used to identify and prioritize high-risk industries, occupations, and populations. This information can be used to aid enforcement actions by regulatory agencies and to develop public health prevention strategies. Many state public health agencies have the authority to investigate workplaces if a problematic worksite or high-risk work practices are identified from individual reports. State public health agencies have experience referring identified workplaces and/or employers to OSHA for technical assistance or enforcement actions and are well positioned to collaborate with other state agencies (eg, state environmental agencies) in efforts to reduce or eliminate hazards.
Several state public health agencies have the multidisciplinary staff, including health educators, occupational physicians and nurses, industrial hygienists, epidemiologists, and toxicologists, needed to design and implement prevention programs. States typically network with the employee groups, employers, trade associations, community groups, health and safety professionals, academics, and environmental and occupational regulatory agencies necessary to develop and disseminate feasible and effective interventions to prevent workplace injuries, illnesses, fatalities, and hazards. Occupational health staff can also work with partners in other areas of public health on prevention efforts. For instance, state public health departments are taking a lead role in developing worksite-based wellness programs. These programs sometimes tend to focus on behavioral changes to improve general health, but the recognition of a new occupational hazard would provide further impetus to ensure that injury and illness prevention efforts are integrated into workplace wellness activities. States participating in NIOSH cooperative agreements currently collaborate to standardize data, thus demonstrating that state-based information can be transmitted to national partners to help establish national trends and to serve as the basis for national intervention programs.
The role of state public health agencies in occupational health surveillance has been well described. Many states have significant and relevant experience and bring unique capacities to the surveillance of occupational injuries, illnesses, fatalities, and hazards. Other states, without existing occupational health programs, will require resources for capacity building in order for them to participate in these efforts. The legal authority afforded to state public health agencies to require disease reporting, obtain individual-level data, and investigate workplaces aids their ability to detect sentinel cases and monitor trends. The use of multidisciplinary staff and experience working with a variety of stakeholders supports enforcement activities and promotes prevention efforts. Individual employers and industries may conduct medical surveillance or contribute to an exposure registry, but this information should be tracked and evaluated by states for consolidation, evaluation, and action. State public health agencies can also work to support legislation and regulations that support occupational health surveillance and protect workers. For these reasons, information from new surveillance programs should not bypass state public health agencies on their way from workplaces to national partners, rather state public health agencies should be included as critical partners from the beginning.
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©2011The American College of Occupational and Environmental Medicine