I have nothing to disclose The findings and conclusions in this - - PDF document

3/8/18 1

Novel and Persistent Occupational Hazards: Are We Making Gains? Insights from NIOSH’s Health Hazard Evaluation Program

Bruce P. Bernard, M.D., M.P.H. Captain, USPHS Chief Medical Officer, Health Hazard Evalua>ons Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

I have nothing to disclose

“The findings and conclusions in this report are those of the

author(s) and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.”

Outline: Insights from NIOSH’s Health Hazard Evaluation Program

1. The Health Hazard Evaluation (HHE) Program

2. Refer to pages- HHEs: Persistent Occupational Hazards/ Novel

Occupational Hazards 3. Examples of HHEs

Persistent hazards: § A respiratory outbreak in the DR § Lead § Poultry & Musculoskeletal Disorders; Disinfectants Novel Hazards: § Diacetyl and Coffee § Opioids and Emergency Response Workers § Cannabis Growers § Electronic Waste § Robotics

• 4. Are we making Gains?

NIOSH’s Health Hazard Evaluation Program

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What is a NIOSH Health Hazard Evaluation?

Worksite medical / epidemiologic / industrial hygiene investigation in response to a request; right of entry same as OSHA Determine whether harmful exposures, processes, or conditions exist OR cause injuries or illnesses

Involves employees at every step (… along with managers…)

At no cost to the employer, unions, employees, etc. (your tax dollars at work)

Safety Physical Organizational Ergonomic Biological Chemical and Dust

The NIOSH HHE Program investigates ALL Hazards except “Safety”…

HHE= Health Hazard Evaluation

Who Can Request an HHE* at their worksite?

From the NIOSH HHE Website:

http://www.cdc.gov/niosh/hhe/request.html

3 current employees (can maintain confidentially) Union Employer Other gov’t agencies

177 HHE Requests in 2017 by Industry Sector

Services

Healthcare

Manufacturing

Transport T r a d e HHEs reflect the trend in the U.S. towards a Service Economy

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What is the Final Product from the HHE* Program?

A final report Plain language summary and recommendations Technical Appendices

• Methods
• Evaluation criteria
• Discussion/References

Must be posted for 30 days prominently at the worksite Also posted on the NIOSH HHE website

*HHE= Health Hazard Evaluation

https://www.cdc.gov/niosh/hhe/

Are we making GAINS in terms of protec6ng and improving the health of workers, and improving the science?

Repetitive & Forceful work; Bending and twisting, standing, vibration; patient handling

Persistent Occupational Hazards

Biological Safety

Chemical and Dust

Organizational Ergonomic Physical

Noise, UV light, artificial UV (welding, phototherapy, dye and paint drying), radon, solar radiation, heat, cold Confined space, falls, violence, fatigue, motor vehicles, disasters and emergency response; human error Stress, intimidation, sexism, job demands, work pace, job control, shift work, child labor, job insecurity, work-life imbalance Mineral dusts: silica, coal, asbestos; metals; solvents, gases, irritants, allergens, Carcinogens: diesel, PAHs, dioxins

Flu Virus, HIV, Hepatitis, Tuberculosis, molds, fungus, campylobacter, E coli, salmonella

Let’s look at a persistent biological hazard in a novel location

Severe Respiratory Illness In Tunnel Workers in the Dominican Republic

An Unexpected Respiratory Illness in the Dominican Republic

Management no*fied the HHE Program about § 17 temp workers c̄ unknown severe febrile illness; several were hospitalized Symptoms § : headache, fever/chills, malaise, cough, shortness of breath Ini*ally, Rx § for leptospirosis (endemic), but no response to penicillin A physician (luckily) no*fied § local health dept. about illnesses and common work at a hydroelectric dam

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An Unexpected Respiratory Illness in the Dominican Republic

§ A 36 member crew; working in previously closed access tunnels at the hydroelectric dam § Shoveling black muck & dry “mud”, knee-deep, out of tunnels into wheelbarrows and depositing it outdoors § Tunnels, built for access and maintenance of the dam, had not been cleaned in decades

§ The tunnel workers had been

provided with knee-high rubber boots, hard hat & headlamp, and shovels

§ A few were given paper surgical

masks; only 3 used them

§ Worked in oppressive heat;

reported difficulty breathing while wearing masks inside the tunnel

§ They worked a full shift, 5 days a

week

An Unexpected Respiratory Illness in the Dominican Republic

An Unexpected Respiratory Illness in the Tunnel Workers in the Dominican Republic

When § examined, the tunnels had a large number of bats flying in and out… around the workers We suspected § Histoplasmosis: although there had never been an

• utbreak in the DR

DR= Dominican Republic

Results of Investigation, Histoplasmosis in the Dominican Republic

§ 36 male workers; working median 24

days (range 1-25 days)

§ Median age: 32 yrs. (range: 18-62) § O/36 immunocompromised § All removed large amounts of earth

containing bat guano from tunnels

§ None wore respiratory protection

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Results of inves-ga-on, Histoplasmosis in 36 Tunnel Workers in the DR

§ Diagnosis on bronchoscopy: histoplasmosis § 30 (83%) met the case definition* for Histo

Ø28 (93%) hospitalized Ø 9 (30%) required intensive care Ø 6 (20%) required intubation Ø 3 (10%) died

§ Time from symptom onset to antifungal Rx was

~ 6 days (range: 1-11 days)

§ 22 (65%) had lab evidence** of histoplasmosis

*Fever and ≥2 symptoms consistent with histoplasmosis **Urine or serum for H. capsulatum anQgen using enzyme immunoassay

Histoplasmosis Investigation in Dominican Republic

§ Severe illnesses and death from exposure to

large inocula of Histoplasma capsulatum spores in an enclosed space

§ Lack of respiratory protection, delay in

recognition and treatment

§ No prior outbreaks of histoplasmosis in DR

What Did We Recommend for the Clinics and the Dam Regarding the Outbreak?

Ø Educate clinicians about histo risk Ø Improve lab capacity to dx fungal infections Ø For tunnel work:

§ Hire experienced environmental remediation firm for future work § Devise a worker safety and health plan § Train workers on health risks, protective measures (rabies vaccination) § Provide appropriate PPE (Tyvek coveralls, disposable gloves, boots, PAPRs) and train on use

Histoplasmosis Investigation: Environmental recommendations

Use § wet methods to remove waste, minimize dust Collect waste in § 6ghtly-sealed, plas6c biohazard bags in 55-gallon drums; transport to waste disposal site Do § not decontaminate tunnels with formaldehyde or other chemicals Cover waste pile § with agricultural lime and re-cover with addi6onal soil

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Histoplasmosis Outbreak among Tunnel Workers: Were We Making Gains? Ø Made small inroads regarding previously unrecognized

• ccupational disease in a foreign country & defining global

burden

Ø Using the Hierarchy of Controls, prevented new cases Ø Changed the way the larger CDC involved the NIOSH HHE

Program– now there is a new algorithm to ask an intro question “Are there workers involved?”…then CDC contacts NIOSH (never before has that worked… usually person- dependent)

§ Led to our involvement in 12 more recent CDC

Investigations (Epi-Aids)

Repetitive & Forceful work; Bending and twisting, standing, vibration; patient handling

Persistent Occupational Hazards

Biological Safety

Chemical and Dust

Organizational Ergonomic Physical

Noise, UV light, artificial UV (welding, phototherapy, dye and paint drying), radon, solar radiation, heat, cold Confined space, falls, violence, fatigue, motor vehicles, disasters and emergency response; human error Stress, inKmidaKon, sexism, job demands, work pace, job control, shiN work, child labor, job insecurity, work-life imbalance Mineral dusts: silica, coal, asbestos; metals; solvents, gases, irritants, allergens, Carcinogens: diesel, PAHs, dioxins

Flu Virus, HIV, HepaKKs, Tuberculosis, molds, fungus, campylobacter, E coli, salmonella

Let’s look at Lead Exposure

A Persistent Occupational Health Problem: Lead Exposure

The NIOSH HHE Program has evaluated Lead Exposure in workplaces 533 times in the last 30 years, of these 16 were in the last year. Direct + indirect costs of ALL occupational lead work in 2017: ~$392 million Worker lead levels have been steadily decreasing….

* Per 100,000 employed adults aged ≥16 years.

Na8onal Prevalence of Lead Toxicity 1984-2016

BLLs≥ 5 ug/dl BLLs≥ 10 ug/dl BLLs≥ 25 ug/dl

BLL= blood lead level; ug/dl= micrograms per deciliter

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But Lead has No Safe Level, And is Worse than we Thought!

lead exposure Ø has been linked to epigene3c changes: associated with changes in DNA methyla3on and expression of specific genes*

* Shefa, Toxicology Letters 2017, vol 232-237

Long linked Ø to morbidity: GI, neuro, neuromusc, renal Ø Nervous & renal system effects at 2 μg/dL; with no detectable threshold* Ø IARC and NTP: lead a possible carcinogen

Almost All 533 NIOSH HHEs on lead

Addressed employee exposure to lead during activities -- in shooting ranges, lead battery plants, munitions manufacturers, rolled and extruded metal plants, paints and coatings manufacturers Made Recommendations based on the Hierarchy of Controls, and emphasized ventilation and hygiene….

But we have VERY Outdated Federal Government Lead OELs

Since ~1980, NIOSH has assigned Ø personnel to work on a new lead REL… Ø OSHA and NIOSH have PEL and REL from 1978, respectively: 8-hour TWA of 50 (µg/m3) in air Ø Accordingly, action is not required until workers blood lead levels are 40, 50, and 60 mg/dl

OELs =occupaXonal exposure limits

NIOSH Even Takes “Accountability” for its Out-dated REL

The current NIOSH LEAD website states:

“ Some studies suggest that the current OSHA PEL

and NIOSH REL may be too high to protect against certain health effects.”

REL= Recommended Exposure Limit BLL=blood lead level

Certain States have been more responsive

CA and WASH working on more stringent requirements BLL medical removal

• AcNon Levels
• Permissible Exposure Limits

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Look Closely at the Lead Literature

Steenland et al., 2017*, in multi-country cohort of 88,000 workers exposed to lead Found significant (p<0.05) positive trends between log of maximum worker’s blood lead levels and lung cancer, COPD, stroke, and heart disease. (not what you normally think of lead exposed health outcomes…) But then the authors reveal they had little or no data on

smoking among the cohort!

A cohort mortality study of lead-exposed workers in the USA, Finland and the UK. Steenland K et al. 2017, Occ Env Health

Within NIOSH, how do we respond to workers’ lead levels? Ø Currently, the NIOSH HHE Program uses a

worker’s BLL >5 ug/dl, the ABLES definition, to recommend further workplace assessment... and medical removal at 20 ug/dl) –

Ø This is not official NIOSH policy…

• ABLES= Adult Blood Lead Epidemiology and

Surveillance

• BLL= blood lead level
• ug/dl= micrograms per deciliter
• HHE= health hazard evaluation

Any GAINS? Lead exposure: A Persistent Occup Problem

Ø NO: Federal OELs should be updated in accordance

with the scientific evidence.

Ø Yes: State-specific actions (WA and CA), ACOEM,

CSTE, the NIOSH HHE Program

Ø How low do we go? Ø Should we still be investigating shooting ranges,

lead battery plants, munitions manufacturers, rolled and extruded metal plants, paints and coatings manufacturers?

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Repetitive & Forceful work; Bending and twisting, standing, vibration; patient handling

Persistent Occupational Hazards

Biological Safety

Chemical and Dust

Organizational Ergonomic Physical

Noise, UV light, artificial UV (welding, phototherapy, dye and paint drying), radon, solar radiation, heat, cold Confined space, falls, violence, fatigue, motor vehicles, disasters and emergency response; human error Stress, intimidation, sexism, job demands, work pace, job control, shift work, child labor, job insecurity, work-life imbalance Mineral dusts: silica, coal, asbestos; metals; solvents, gases, irritants, allergens, Carcinogens: diesel, PAHs, dioxins

Flu Virus, HIV, Hepatitis, Tuberculosis, molds, fungus, campylobacter, E coli, salmonella

Let’s look at a persistent hazard in a known risky environment

Feb 2018, U.S. Sec of Agric Sonny Perdue addressed the Poultry Market Intelligence Forum

§ He thanked universities, research teams

and USDA APHIS, as “partners” to help the poultry industry be more productive and profitable.

§ “Work must be based on sound science

and not on political decisions.”

§ But then said “the USDA wishes to

partner with the industry to address burdensome regulations.”

APHIS: Animal and Plant inspection Service

How do you talk about 1) productivity, 2) profitability, and 3)burdensome regulations ---And NOT base things on POLITICAL DECISIONS???

NIOSH HHEs has long been dealing with line speeds and disinfectants which are regulated in the Poultry Industry

We have seen poultry using more mechanized processes

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New Issues with Poultry Processing

In Fall 2017, the National Chicken Council petitioned the USDA to waive all poultry line speed limits (after failure to get 175/min) and allow workplaces to maintain their own process control January 31, 2018, the USDA DENIED this request…and limited the slaughter line speed to 140 birds/min.

The “Catch” in Current Regulations in Poultry Processing

The chicken slaughter line speed is currently limited to 140 birds/min and is mostly automated.

The “Catch” in Current Regulations in Poultry Processing

However, there are no regulations which limit the line speed for processing the chickens, where birds are cut and deboned, and turned into sold products. PROBLEM: The more chickens delivered to the line, the more meat that must be processed…

When Slaughtering 140 birds/min and processing them…

An employee can process more than 14,000 chickens on the line each day Depending on the job, each worker then processes around 35-45 birds/min This means ~ 2,000 chickens/hour or ~ 1 chicken/2 secs

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NIOSH has already Identified MSD* Risk to Poultry workers

In HHEs*, our docs and IH’s found that > 30% workers were found to have carpal tunnel syndrome (by symptoms and nerve conduction testing) in the highly repetitive, forceful jobs

• n the lines in poultry

processing

MSD=musculoskeletal disorder HHE=health hazard evaluation *NIOSH 2014, 2015

In HHEs, NIOSH also documented most poultry processing jobs over the ACGIH Recommended Limits for Hand Activity Level 81% of jobs*, including all jobs in evisceration, involved levels of hand repetition and force over the (ACGIH) Action Limit

*NIOSH 2014, 2015 AACGIH =American Conference of Governmental Industrial Hygienists’

Are we making Gains in MSDs in the Poultry Industry?

• In areas of mechanization, where automation has

eliminated workers: a limited YES

• In areas of processing requiring highly repetitive, high

force, intensive manual labor: NO

MSDs=musculoskeletal disorders

In January 2018 GAO* Asked NIOSH to Study Poultry Disinfectants

Specifically peracetic acid's (PAA) use, as well as other chemicals in meat and poultry plants

*GAO=U.S. Government Accountability Office

Another NEW issue in Poultry we are dealing with:

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Peracetic Acid

Routinely used as a disinfectant in food processing, a sterilant cleaning endoscopes and medical devices, and as a bleaching agent Formed from a sulfuric acid-catalyzed chemical reaction between acetic acid and H2O2 Highly reactive, unstable, and volatile; decomposes to acetic acid, oxygen, and water Sprayed directly on the meat or to clean machines Relatively low cost compared to other disinfectants

Disinfectant Process in Poultry

Procedures vary, but high-powered nozzles shoot disinfectants along its surface and into the interior of a bird. Bird moves through one or two spray cabinets, where it is showered with disinfectants. Then the carcass is chilled and soaked, usually in chlorine and water. Finally, chilled carcasses have a dip treatment

Health Hazards of Peracetic Acid and

• ther chlorine disinfection processes

PAA is a primary irritant NIOSH HHEs* have repeatedly found employees report respiratory, eye, and skin irritation, coughing and shortness of breath in departments that use chlorine- based disinfectants* High exposure has been found to cause pulmonary edema and may affect liver and kidneys. In health care, PAA associated with occup asthma

*NIOSH 2017, 2012, 2007, 2006, 2003

Regulatory Environment of Peracetic Acid (PAA) Is Changing

2014, ACGIH released a STEL of 0.4 ppm. 2010, EPA issued 8 hour TWA AEGL: irreversible health effects: 0.52 ppm Late 2017, NIOSH has proposed an IDLH level of 0.55 ppm based on sensory irritation. 2017, due to concerns about poor quality data and objections about overprotection, NIOSH reevaluating…requested info from stakeholders regarding health risks of PAA to establish a final IDLH and REL.

STEL= 15 minute Short Term Exposure Limit AEGL= Acute Exposure Guidelines IDLH= Immediately Dangerous to Life and Health REL= recommended Exposure Limit

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Other Disinfectants Used in Poultry Processing

Alternatives to Chlorine and PAA: acidified sodium chlorite, cetylpyridinium chloride, chlorine dioxide, gamma irradiation,

• zone, sodium hypochlorite, and trisodium phosphate

Most disinfectants have been limited due to: § chemical residues & potential health effects, § discoloration of chicken (causes avoidance by consumers), § corrosiveness to equipment, § high cost, § limited effectiveness

NIOSH HHEs have evaluated air methods for PAA and finds the method is poor

NIOSH has measured chlorine solutions* using high- performance liquid chromatography using in-house methods based on the Hecht et al. method [2004] But the Hecht et al. method is known to underestimate exposures when peracetic acid is applied as a spray. Due to method problems, Georgia Tech is measuring acetic acid and H2O2 simultaneously…

*NIOSH 2017, Hecht et al, 2004 PPA= Peracetic Acid

Are we making Gains? Stay tuned…

Well, NIOSH Has Proposed a New Peracetic Acid Research Initiative

Complete epi and field studies Complete animal tox studies on acute, sub-chronic, and chronic effects Develop risk assessments to characterize workplace exposure Evaluate workplace controls Develop better methods to collect/analyze air samples under various conditions (e.g., task-based, full-shift, and real-time monitoring) NIOSH requested more information through Fed Register

Novel Occupational Hazards

Biological Hazards Safety Hazards Chemical and Dust Hazards Organizational Hazards Ergonomic Hazards Physical Hazards Novel Avian Flu, Middle East Respiratory Virus, Hemorrhagic fevers, Newer vector borne (Chikungunya, Zika, etc.) Human-machine interaction, robotics, drones, distraction and inattention Aging workers, nonstandard work arrangements, workload intensification, worker rights and benefits Nanoparticles; biotechnology causing sensitizers, non-allergic asthma, low molecular weight pesticides; diacetyl; opioids Climate change, Energy (oil and gas), noise, heat Nonstandard work Environments; exoskeletons, Sit-stand issues Electronic medicine; e tools, simulation technology; automated vehicles, hazard banding, sensors, total worker exposure

Novel Exposure with Controversial REL? Diacetyl in Coffee Roasters and Baristas

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NIOSH Has Identified Coffee Workers to be at Risk for Lung Disease

Roasting and grinding coffee beans produces Diacetyl and 2,3-pentanedione linked to occup lung morbidity 2013, Univ of Texas, Tyler dx’d Bronchiolitis Obliterans (BO) in 5 workers at a coffee processing facility NIOSH concluded “Workers at coffee processing facilities at risk of decreased pulmonary function (decreased FEV1/FVC & % predicted FEV1), and increased risk of BO

BO= Bronchiolitis Obliterans

Bronchiolitis Obliterans as Work-related

Bronchiolitis Obliterans (BO) is a rare inflammatory lung disorder recognized as occupationally related Inflammation and fibrosis lead to narrowing or occlusion

• f bronchioles.

BO was previously identified in those manufacturing flavorings, popcorn, and cookie dough; exposed to diacetyl or 2,3-pentanedione NIOSH studies have used both symptoms of “exertional shortness of breath” as “suspect BO” or PFT abnormalities to define BO

For workers exposed to Diacetyl, NIOSH set a Very Low REL

NIOSH set an REL at 5 ppb -- risks of 1:1,000 for lung disease

• ver a working lifetime (45 years)

NIOSH also proposed a 15-minute STELs: 25 ppb for diacetyl; 31 ppb for 2,3-pentanedione NIOSH has found >7,000 ppb diacetyl – as well CO2 and CO – in coffee storage bins that contained roasted beans.

REL= recommended exposure limit ppb=parts per billion STEL= short term exposure limit

NIOSH Published Best Practices for Occup Exposure to Diacetyl and 2,3-Pentanedione

Guidance was provided in a variety of areas to reduce workers’ exposures through:

• Engineering controls,
• Best work practices,
• Techniques for monitoring airborne exposures.
• Recommendations for flavors industry, not

coffee

Publication Number 2015-197

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Recently, Questions Have been Raised Concerning the Diacetyl REL at 5 ppb in Coffee Roasters Bruce Fern, attorney, Feb 2018, Washington Times:

“The industry opposes the (NIOSH REL) as unnecessarily stringent. It has funded studies by Cardno ChemRisk suggesting that much higher exposure levels are common but nevertheless

• safe. Who is right? “

Questions Have been Raised Concerning the Diacetyl REL at 5 ppb in Coffee Roasters

NIOSH used the same cut-point as the American Thoracic Society for its risk assessment models NIOSH had evidence in animals and people which found decreases lung function. Challenges to risk assessment models for a 45- year exposure of a worker… Is the NIOSH REL a “bright line” versus a “target” or “starting point?”

Are we making gains with Diacetyl and Coffee

Are our assumptions for risk assessment models achievable in small coffee shops? Are we over-reacting …or… unwilling to face the hard consequences of new scientific findings? Novel Occupational Hazards

Biological Hazards Safety Hazards Chemical and Dust Hazards Organizational Hazards Ergonomic Hazards Physical Hazards Novel Avian Flu, Middle East Respiratory Virus, Hemorrhagic fevers, Newer vector borne (Chikungunya, Zika, etc.) Human-machine interaction, robotics, drones, distraction and inattention Aging workers, nonstandard work arrangements, workload intensification, worker rights and benefits Nanoparticles; biotechnology causing sensitizers, non-allergic asthma, low molecular weight pesticides; diacetyl; opioids Climate change, Energy (oil and gas), noise, heat Nonstandard work Environments; exoskeletons, Sit-stand issues Electronic medicine; e tools, simulation technology; automated vehicles, hazard banding, sensors, total worker exposure

Novel Exposure? Occupational Opioid Exposures Among First Responders

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Occupational Opioid Exposures Among First Responders

§ NIOSH has received multiple HHE requests about exposure to fentanyl & opioid analogues from: – Pre-hospital Patient Care – Law Enforcement Officers – Investigators and Evidence Handlers – Special Operations and Decontamination – Medical personnel

HHE=health hazard evaluation

Occupational Opioid Exposures Among First Responders

5X increase in synthetic opioid overdose deaths in U.S. since 2013 Emergency responders and investigators are concerned about:

Potential routes of exposure: Inhalation, mucus membrane contact, ingestion, and percutaneous exposure (e.g., needlestick) Symptoms they suspect might be caused while working around opioids, including stress reactions

Knowledge gaps about occupational opioid exposures among first responders

What are common scenarios for opioid exposures? Which routes of exposure are the most relevant?

Inhalational, mucous membrane contact, ingestion, percutaneous? dermal?

What are best methods to prevent exposure and adverse health effects? (including stress) What should the occupational exposure limits for fentanyl or its analogues? NIOSH’s ongoing investigations about opioid exposures involves: Understanding the exposure

§ Interview first responders about possible exposures, symptoms, and concerns § Review reports about incidents § Blood or urine sampling, if needed § Air and surface sampling, if needed § Evaluate ventilation system and other controls (e.g., field detection devices)

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In the interim, NIOSH has Recommendations for possible workplace exposure to fentanyl and its analogues

§ Initial Step:

–Conduct an on-scene health risk assessment to determine the level of risk and warranted protection

NIOSH has Defined Fentanyl Exposure Risk Levels

Minimal: fentanyl may be present but not visible Moderate: small amounts of fentanyl is visible High: liquid fentanyl or large amounts of fentanyl are visible (like storage or distribution facilities, milling operations or production labs) NIOSH has Recommendations for Possible Exposure to Fentanyl and Analogues

Use standard safe operating procedures (e.g., avoid aerosolizing tasks) https://www.cdc.gov/niosh/topics/fentanyl/risk.html). Train employees Communicate with law enforcement prior to entering drug/death scenes Minimize the collection of substances Reduce # investigators on-scene For Moderate exposure level, wear PPE, including N or P-100 respirator Report exposures to supervisors

www.cdc.gov/niosh/topics/fentanyl/risk.html

NIOSH has PPE Recommendations Against Fentanyl by 4 Potential Exposure Groups § Pre-hospital Patient Care § Law Enforcement Routine Duties § Investigations and Evidence Collection § Special Ops and Decon

https://www.cdc.gov/niosh/topics/fentanyl/risk.htm

For Moderate exposure (where small amounts of fentanyl are visible) All Groups above wear: § Respiratory Protection: N or P-100s § Eye Protection/goggles § Nitrile Gloves § Arm/wrist protection

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Are we “Making Gains” with Worker Health and Safety regarding exposure to opioids ?

§ Yes – NIOSH is collaborating with First Responder

Groups, FBI, others § AIHA is asking for “thoughts on worker issues”

https://www.aiha.org/government-affairs/Pages/Newsletters/Opioids- %E2%80%93-A-Worker-Health-and-Safety-Issue.aspx

§ NO: NIOSH not addressing worker use issue…

§ ACOEM has not published the subject as a Worker Health and Safety Issue (Only addressing the physician prescribing issue and patient addiction issues…)

Novel Occupational Hazards

Biological Hazards Safety Hazards Chemical and Dust Hazards Organizational Hazards Ergonomic Hazards Physical Hazards Novel Avian Flu, Middle East Respiratory Virus, Hemorrhagic fevers, Newer vector borne (Chikungunya, Zika, etc.) Human-machine interaction, robotics, drones, distraction and inattention Aging workers, nonstandard work arrangements, workload intensification, worker rights and benefits Nanoparticles; biotechnology causing sensitizers, non-allergic asthma, low molecular weight pesticides; diacetyl; opioids Climate change, Energy (oil and gas), noise, heat Nonstandard work Environments; exoskeletons, Sit-stand issues Electronic medicine; e tools, simulation technology; automated vehicles, hazard banding, sensors, total worker exposure

Novel Exposure? Occupational Exposure to Cannabis..at the Federal Level It’s challenging to study the work- related exposures and health effects of marijuana at the Federal level because of recent doings from Jeff Sessions and the Justice Department.

Cannabis under the Trump Administration

www.justice.gov/opa/pr/justice-department- issues-memo-marijuana-enforcement

We have responded to Cannabis Growers Concerns in the HHE Program

q HHE #1: Harvesting and Processing

Cannabis at an Organic Farm (2015)*

q HHE #2: Medicinal Cannabis Grow

and Processing Facility (ongoing)

*www.cdc.gov/niosh/hhe/ reports/pdfs/2015-0111- 3271.pdf

3/8/18 19

Cannabis Industry and Occupational Health Risks

Grow/Cultivation Operations Processing/Manufacturing Operations Retail Operations NIOSH has also identified multiple risks of exposure and safety … NIOSH has identified many occupational health risks similar to other agricultural / horticultural activities…

Occupational Health Risks

Grow/Cultivation Operations

§ Indoor environmental quality

• Ozone; VOCs
• Humidity, temp

§ Ergonomic issues § High intensity grow lights – UV § Electrical safety/wet environs § Pesticides § Nutrient/corrosive chemical use § Working from heights Processing/Manufacturing Operations: § Repetition/force from tools § Flammable/explosive extraction chem: Butane § CO2 use (extraction/ enriching air) § Microbial exposures

• Airborne endotoxins?

Diacytyl exposures? § Safety hazards

• Lack of guards, Pinch

points, Wiring § Noise

Gains with Marijuana and the Workplace?

Ø Federal law versus state laws differ

widely

Ø CDC has webpage about marijuana and

public health

Ø NO content for worker safety and health

growing or processing – has been “in clearance” more than 1 ½ years

Ø NIOSH hasn’t yet addressed workplace

issues and marijuana use (such as medical marijuana)

https://www.cdc.gov/marijuana/index.htm

Gains: ? Is the CDC Marijuana website up-to-date and current with what is happening in the States? e.g., “Does marijuana use lead to other drug use?”

More research is needed to understand if marijuana is a “gateway drug” - a drug that is thought to lead to the use

• f more dangerous drugs

(such as cocaine or heroin).

3/8/18 20

§ Addiction. § Increased risk for psychosis or

schizophrenia.

§ Increased risk for some types

• f cancer.

§ Increased risk for heart attack

and stroke.

§ Decreased IQ—and this change

in IQ can last a long time and may even be permanent.

§ Less academic and career

success.

• Lower income.

From the Current CDC Marijuana website: Novel Occupational Hazards

Biological Hazards Safety Hazards Chemical and Dust Hazards Organizational Hazards Ergonomic Hazards Physical Hazards Novel Avian Flu, Middle East Respiratory Virus, Hemorrhagic fevers, Newer vector borne (Chikungunya, Zika, etc.) Human-machine interaction, robotics, drones, distraction and inattention Aging workers, nonstandard work arrangements, workload intensification, worker rights and benefits Nanoparticles; biotechnology causing sensitizers, non-allergic asthma, low molecular weight pesticides; diacetyl; opioids Climate change, Energy (oil and gas), noise, heat Nonstandard work Environments; exoskeletons, Sit-stand issues Electronic medicine; e tools, simulation technology; automated vehicles, hazard banding, sensors, total worker exposure

Novel Exposure? Electronic Waste

3 HHEs at Electronic Waste Facilities

• Evaluated metals and flame

retardants in personal air monitoring, dermal wipe sampling, and biomonitoring (urine and blood)

• Collected surface wipe samples and

serial hand wipes samples in processing and non-processing areas.

Results: Electronic Waste HHEs

47 Employees participated in biomonitoring for lead and cadmium Results: 4 employees with BLL > 5 ug/dl 0 employee with cadmium > 5 ug/dl. Flame retardants pending No air results exceeded ACGIH for

• cadmium. (No OELs for respirable lead,

nickel, and chromium) Surface samples + for lead and cadmium in both processing and non-processing areas.

OEL= occupational exposure limits

3/8/18 21

Lead Found in Unexpected Areas

Positive visual colorimetric results for lead* on 12/13 uniforms, 8/12 “clean hands,” and inside respirator in employees working with shredder and glass breakers

• Immediate visual result

high impact for workers regarding lead exposure

• Opens the conversation

for need for workplace controls

*The Lower limit of visual identification is 18 μg of lead

HHE in E-Waste Facility

Gains in Electronic Recycling?

Working with EPA and E-stewards (Basel Action Network) to increase prevention Found lead exposure among workers Found metals tracked outside production areas, on skin and clothing). We are evaluating hand wipes and quantification of results, flame retardants We are also evaluating other exposures – noise and musculoskeletal disorders

Novel Occupational Hazards

Biological Hazards Safety Hazards Chemical and Dust Hazards Organizational Hazards Ergonomic Hazards Physical Hazards Novel Avian Flu, Middle East Respiratory Virus, Hemorrhagic fevers, Newer vector borne (Chikungunya, Zika, etc.) Human-machine interaction, robotics, drones, distraction and inattention Aging workers, nonstandard work arrangements, workload intensification, worker rights and benefits Nanoparticles; biotechnology causing sensitizers, non-allergic asthma, low molecular weight pesticides; diacetyl; opioids Climate change, Energy (oil and gas), noise, heat Nonstandard work Environments; exoskeletons, Sit-stand issues Electronic medicine; e tools, simulation technology; automated vehicles, hazard banding, sensors, total worker exposure

Novel Exposure? Robotics

Robotics in Industries: Forecast 2025*

Will be replacing 16% of jobs in US Creating nearly 9,000,000 (9%) new jobs in new fields like robot monitoring, data science and content curation Net value: Impacting 7% of jobs

*Forrester Research

3/8/18 22

Robotics in Industry: The Good Will improve material handling, challenging working conditions:

Handling heavy loads Performing dirty or dangerous work Tasks requiring difficult extreme postures, repetitive movements, forceful exertions Working at elevation Work at fast speeds Viewing work for defects

Robotic claw for bricklaying

How Good is our Surveillance about Injuries from Robotics?

Early as 1987: 32 reported robot injuries Robot-related injuries usually not identified; lack of standard classification codes NIOSH identified 61 robot-related deaths 1992- 2015, using keyword searches of BLS and CFOI data NIOSH’s Fatality Assessment and Control Evaluation (FACE) Program investigated 4 robot- related deaths

BLS=Bureau of Labor Statistics CFOI=Census of Fatal Occupational Injuries OSHA Investigations of Robot Deaths

Employee Is Struck By Axis Arm< Later Dies Maintenance Worker Is Struck And Killed By Robot Robot Crushes And Kills Worker Inside Robot Work Cell Employee Is Killed By Robotic Palletizer Employee Dies After Being Struck By Robotic Arm Employee Is Killed When Crushed By Robot Employee Dies When Struck By Robotic Equipment Employee Was Killed By Industrial Robots Employee Is Killed When Caught In Robotic Arm Employee Is Killed When Crushed By Equipment Employee Killed When Robot Pinned His Neck Employee Killed When Crushed In Robotic Welding Unit Employee Crushed And Killed When Run Over By Alvey Machine Employee Killed In Robotic Weld Cell Employee Killed When Crushed By Robot Against Conveyor Employee Killed When Crushed By Robot Arms Employee Struck By Material Handling Equipment Crushed By Robot Arm During Machine Cycle

OSHA keeps a running tally

• f Robot

deaths on its website

https://www.osha.gov/pls/ imis/AccidentSearch.searc h?acc_keyword=%22Robot %22&keyword_list=on

There are Already Existing Guidelines for Safe Designs & Protective Measures for Robots ANSI/RIA R15.06-2012: Industrial Robot and

Robot Systems – Safety Requirements

ISO 10218-1:2011— Safety requirements for

industrial robots

Part 1: Robots Part 2: Robot systems and integration

ISO now working on revision ISO/CD 10218

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NIOSH has a New Center for Occupational Robotics Research

Surveillance of injuries Evaluate robotic interventions for workplace injuries and illnesses Identify research needs/conduct Develop/support consensus safety standards Develop/communicate best practices, guidance and training

Robot Injuries Are Likely to Increase Due to Burgeoning Use

Unintended and unexpected movements Electrical hazards (contact with live parts or exposure to arc flash) Thermal Hazards (hot surfaces or extreme temperatures) Noise Hazards Vibration, Radiation, Chemicals

Two Types of Injuries:

Engineering errors due to programming bugs Human Errors due to programming, interfacing

Are we making Gains in Health and Safety and Robotics?

No specific OELS for Robotics OSHA and NIOSH have several case studies on-line dealing with Robotics Both ANSI and ISO have existing documents dealing with Safety of Robots NIOSH DSR is interested in gaining access to sites using Robotics!

Summary of Today’s Presentation

1. The Health Hazard Evaluation Program 2. HHE: Persistent/ Novel Occupational Hazards

• 3. Are we making gains?

Persistent hazards: § Histo outbreak in the DR § Lead § Poultry & Musculoskeletal Disorders; Disinfectants Novel Hazards: § Diacetyl and Coffee § Opioids and Emergency Response Workers § Cannabis Growers § Electronic Waste § Robotics

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Thank you for your attention! QUESTIONS?

Bruce P. Bernard, M.D., M.P.H.

Captain, USPHS Chief Medical Officer Health Hazard Evaluations and Technical Assistance Centers for Disease Control and Prevention National Institute for Occupational Safety and Health BPB4@cdc.gov

Question #1

• A. Recommend actions to reduce hazards and

improve health and safety B. Assess fines to particular workplaces that have egregious exposures that place the health of workers at risk C. Provide a list of consultants that NIOSH has recognized as reputable to do remediation

• D. Provide solutions based on economic feasibility

NIOSH Health Hazard Evaluations Regulations demand that the investigators (please choose the best answer):

Question #1

• A. Recommend actions to reduce hazards and

improve health and safety B. Assess fines to particular workplaces that have egregious exposures that place the health of workers at risk C. Provide a list of consultants that NIOSH has recognized as reputable to do remediation

• D. Provide solutions based on economic feasibility

NIOSH Health Hazard Evaluations Regulations demand that the investigators (please choose the best answer):

Question #2

• A. 2 ug/dl of whole blood
• B. 5 ug/dl of whole blood
• C. 10 ug/dl of whole blood
• D. 25 ug/dl of whole blood
• E. 40 ug/dl of whold blood

The NIOSH HHE Program uses this defined elevated blood lead level in a non-pregnant worker in the U.S. to recommend further workplace assessment:

Ug/dl= micrograms per deciliter

3/8/18 25

Question #2

• A. 2 ug/dl of whole blood
• B. 5 ug/dl of whole blood
• C. 10 ug/dl of whole blood
• D. 25 ug/dl of whole blood
• E. 40 ug/dl of whold blood

The NIOSH HHE Program uses this defined elevated blood lead level in a non-pregnant worker in the U.S. to recommend further workplace assessment:

Ug/dl= micrograms per deciliter

Question #3

• A. Surgical mask to prevent inhalation of powder
• B. N-95 respirator because the majority of health care

workers are already fit-tested for these

• C. N- or P-100 respirator to protect from > 0.3 microns
• D. SCBA because you don’t know what’s really going on
• E. Air supplied respirator- because we can get you a

long enough hose… Regarding Emergency Response workers dealing with Opioids, with a Moderate Risk Exposure Level, NIOSH recommends that workers should use this respiratory protection (choose the best answer)

Question #3

• A. Surgical mask to prevent inhalation of powder
• B. N-95 respirator because the majority of health care

workers are already fit-tested for these

• C. N- or P-100 respirator to protect from > 0.3 microns
• D. SCBA because you don’t know what’s really going on
• E. Air supplied respirator- because we can get you a

long enough hose… Regarding Emergency Response workers dealing with Opioids, with a Moderate Risk Exposure Level, NIOSH recommends that workers should use this respiratory protection (choose the best answer):

Question #4

A. Identifying hazards, assessment of risks at a particular workplace B. Recommending actions to reduce hazards and improve health and safety C. Assessing fines to particular workplaces that have egregious exposures that place the health of workers at risk D. Providing a list of consultants that NIOSH has recognized as reputable to do remediation E. Providing solutions based on economic feasibility

The impact of NIOSH Health Hazard Evaluations to a workplace includes (please choose all that apply):

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Question #4

A. Identifying hazards, assessment of risks at a particular workplace B. Recommending actions to reduce hazards and improve health and safety C. Assessing fines to particular workplaces that have egregious exposures that place the health of workers at risk D. Providing a list of consultants that NIOSH has recognized as reputable to do remediation E. Providing solutions based on economic feasibility

The impact of NIOSH Health Hazard Evaluations to a workplace includes (please choose all that apply):

Question #5

A. OSHA’s PEL B. NIOSH’s REL C. ABLES/NIOSH/CDC D. California DPH Medical Guidelines E. Council of State and Territorial Epidemiologists F. CDC (as a Nationally Notifiable Condition)

The Case Definition for an elevated blood lead level for a non- pregnant worker in the U.S. is defined as 5 ug/dl* by which of the following Agencies’ Guidelines/Regs? (Choose all that Apply)

Ug/dl= micrograms per deciliter

Question #5

A. OSHA’s PEL B. NIOSH’s REL C. ABLES/NIOSH/CDC D. California DPH Medical Guidelines E. Council of State and Territorial Epidemiologists F. CDC (as a Nationally Notifiable Condition)

The Case Definition for an elevated blood lead level for a non- pregnant worker in the U.S. is defined as 5 ug/dl* by which of the following Agencies’ Guidelines/Regs? (Choose all that Apply)

Ug/dl= micrograms per deciliter

Question #6

• A. Tyvex suit
• B. Surgical mask for

respiratory protection

• C. N- or p-100 for respiratory

protection

• D. Eye Protection/goggles
• E. Nitrile Gloves
• F. Arm/wrist protection

Regarding Emergency Response workers dealing with Opioids, with a Moderate Risk Exposure Level, NIOSH recommends that workers should use (choose all that apply):

3/8/18 27

Question #6

• A. Tyvex suit
• B. Surgical mask for

respiratory protection

• C. N- or p-100 for respiratory

protection

• D. Eye Protection/goggles
• E. Nitrile Gloves
• F. Arm/wrist protection

Regarding Emergency Response workers dealing with Opioids, with a Moderate Risk Exposure Level, NIOSH recommends that workers should use (choose all that apply):

What types of HHE Projects are we doing Now Around the U.S.?

Indoor air quality, mold at multiple sites Chemical exposures from flavorings and nicotine in vape shops Chemical and ergonomic concerns among nail salon workers Heat Stress among structural and wildland Firefighters Chainsaw exhaust, ergonomics, vibration in wildland firefighters Cancer clusters among labor and delivery health care personnel Other projects, I will mention today….

States on Lead

§ CDPH guidance

– BLL <10 μg/dL. Women pregnant or considering pregnancy < 5 ug/dl – Worker removal with 2 BLLs > 20 mg/dL or 1 BLL >30 mg/dL; – BLL testing based on lead hazard activities not air monitoring – PEL to 0.5–2.1 mg/m3 over 8-hr

§ WASH L & I draft regulation in 2017:

– same medical removal as CDPH; – AL of 10 mg/m3, a PEL of 20 mg/m3, ACOEM Task Force on Blood Lead Levels

Workplace Lead Exposure Holland, M; Cawthon, D. JOEM 58(12), Dec 2016, p e371–e374

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Ergonomic Assessment

q Two ergonomists assessed job tasks using the ACGIH TLV for

Hand Activity Level

§ Hand Activity Level scale: rate repetitiveness for right and left hands during at least five complete work cycles. § Force: rate peak exertion of the right and left hands using the modified Borg CR-10 scale.

1 2 3 4 5 6 7 8 9 10

• Nothing

Very weak Weak Moderate Strong Very Strong Extremely Strong Maximal

Statistical Analyses

q SAS Version 9.3 q Descriptive statistics: demographics q Bivariate analyses: associations between risk factors and

carpal tunnel syndrome

q Log-binomial regression used to evaluate relationship

between CTS and exposure groups

§ Adjusting for sex, age, body mass index, and diabetes mellitus § Prevalence ratios and 95% confidence intervals

There have been previous Histoplasmosis Outbreaks in the Caribbean

Caribbean/year/ref # Tested/population Histoplasmin skin test positivity % Cuba/ 19921 392/Poultry farmers 28.8 Barbados/19812 NR 4 Trinidad/19812 NR 42 Martinique & Guadeloupe/19723 454/Residents 7 Martinique; 4 Guadeloupe

• 1. Cermeno JR et al. [2005] Trop Med Int Health.;10(3):216–219.
• 2. Pedroza-Seres M, et al. [1994] J Med Vet Mycol. ;32(2):83–92.
• 3. Taylor ML et al. [1997] Mycopathologia.138(3):137–142.

What makes a robot?

q Autonomous, to some extent: capable of making decisions. § An electric drill, is not capable deciding on the best speed to rotate the drill bit for maximum drilling efficiency. Robots can. q Has sensors: light sensors, touch sensors (an ultrasonic

sensor for motion detection, even color sensors.

§ NASA's Mars Rover has 4 hazcams -hazard avoidance cameras, akin to eyes, to prevent it from getting lost or crashing into large boulders.

q Artificial Intelligence: can use data collected from its sensors

to detect when a state has changed and then take appropriate actions.

§ E.g., with a rain detector, it can activate a head umbrella when rain begins to fall.

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q Artificial Intelligence q A robot can use data collected from its sensors to detect

when a state has changed and then take appropriate actions. For example, if a robot had a rain detector on its head, it could activate a head umbrella when rain began to fall. The Massachusetts Institute of Technology (MIT), a world authority on the subject, believes this kind of response is artificial intelligence rather than real intelligence, yet concedes some robots are much better than humans at some things.

2016 Washington’s Proposed Airborne Exposure Limits

q • Biokinetic modelling in CA:

§ – PEL of 0.5 μg/m3: 95% workers BLL < 5 μg/dL over 40- year working lifetime § – PEL of 2.1 μg/m3: 95% workers BLL < 10 μg/dL over 40- year working lifetime

q • Public Health’s recommendation:

§ – Permissible Action Limit: 10 μg/m3 § – Action Level: 2 μg/m3

q • Based on stakeholder feedback in CA