Concept: Health Hazard Evaluation Program
In July 2015, a municipal health department in Ohio received complaints of respiratory and ocular symptoms from patrons of an indoor waterpark resort. In response, the health department conducted an online survey in August 2015 through which 19 (68%) patron and employee respondents reported eye burning, nose irritation, difficulty breathing, and vomiting. On August 11, 2015, the health department requested a health hazard evaluation by CDC’s National Institute for Occupational Safety and Health to characterize the prevalence of symptoms among employees and determine the etiology of work-related symptoms. In January 2016, CDC investigators performed a cross-sectional epidemiologic study, environmental sampling, and ventilation system assessment (1). Findings suggested that chlorine disinfection byproducts and environmental conditions contributed to a higher prevalence of work-related respiratory and ocular symptoms among employees in the waterpark compared with employees in other resort areas. Recommendations included servicing the ventilation system, changing work practices to decrease the amount of disinfection byproduct precursors, and responding promptly to employee reports of symptoms.
In March 2014, a new disinfection product, consisting of hydrogen peroxide, peroxyacetic acid, and acetic acid, was introduced at a Pennsylvania hospital to aid in the control of health care-associated infections. The product is an Environmental Protection Agency-registered non-bleach sporicide advertised as a one-step cleaner, disinfectant, and deodorizer. According to the manufacturer’s safety data sheet, the product requires no personal protective equipment when it is diluted with water by an automated dispenser before use. On January 30, 2015, CDC’s National Institute for Occupational Health (NIOSH) received a confidential employee request to conduct a health hazard evaluation at the hospital. The request cited concerns about exposure of hospital environmental services staff members to the product and reported symptoms among persons who had used the product that included eye and nasal problems, asthma-like symptoms, shortness of breath, skin problems, wheeze, chest tightness, and cough.
Synthetic cannabinoids (SCs), commonly known by the street name “Spice,” are designer drugs of abuse that mimic the psychoactive effects of marijuana. Intentional SC use has resulted in multiple toxicities (1,2), but little is known about occupational SC exposure. After a federal agency’s law enforcement personnel in Nevada reported irritability and feeling “high” after raiding illegal SC laboratories and processing seized SCs, a request for a health hazard evaluation was made by the agency to CDC’s National Institute for Occupational Safety and Health (NIOSH) in 2014 to evaluate agents' occupational SC exposures. After making the request for a health hazard evaluation, federal agents conducted a raid of an illegal SC laboratory, with assistance from local law enforcement and Drug Enforcement Administration (DEA) personnel and with NIOSH investigators observing from a distance. After the raid, agents collected and processed material evidence. NIOSH investigators tested agents' urine for SC levels before and after the raid and measured SCs in the air and on surfaces after the raid. DEA determined that AB-PINACA (an SC compound) and mitragynine (a plant material with opium-like effects, also known as “kratom”) were present in the illegal laboratory. AB-PINACA, its metabolites, and mitragynine were not detected in agents' urine before the raid; however, one or more of these substances was found in the urine of six of nine agents after the raid and processing of the SC evidence. AB-PINACA was detected in one surface wipe sample from the SC laboratory; none was detected in the air in the laboratory or in the offices of the law enforcement agency where the materials were processed after the raid. No policies were in place regarding work practices and use of personal protective equipment (PPE) during raids and evidence processing. To protect agents from SC exposures, NIOSH recommended that the agency require agents to wear a minimum level of PPE (e.g., protective gloves and disposable clothing) and undergo training in PPE and in handling and storing of contaminated evidence from SC laboratory raids. Showers and locker rooms also need to be provided so that agents can reduce contamination and prevent take-home exposure.
During a health hazard evaluation, we investigated 29 cases of laboratory-diagnosed Campylobacter infection among workers at a poultry-processing plant. Most infected employees worked at the plant <1 month, worked as live hangers, and lived at a state-operated center. To lessen the infection risk, we recommended improvements to engineering and administrative controls at the plant.
Abstract Objectives: We present a re-analysis of a recent Health Hazard Evaluation (HHE) that was performed by the US National Institute for Occupational Safety and Health (NIOSH) regarding the pulmonary status of workers at a flavorings manufacturing facility. This facility has used acetaldehyde, acetoin, benzaldehyde, butyric acid, diacetyl and many other flavoring chemicals for many years. Methods: Ten years of spirometry testing and job descriptions data on 112 workers were analyzed by the authors and by NIOSH. Using NIOSH’s exposure assessment criteria, we compared the prevalence of restrictive findings (as determined by spirometry testing) in production workers to an internal control group that had reduced or no potential for exposure to flavoring chemicals. NIOSH used multiple linear regression to evaluate changes in pulmonary function by the exposure group. After our review of the NIOSH findings, we evaluated associations between longitudinal changes in pulmonary health and workplace exposures through the use of generalized estimating equations. We then compared our results to those obtained by NIOSH. Results: We found that the prevalence of pulmonary restriction was similar in production workers and internal controls. We found no relationship between the magnitude of exposure to flavorings chemicals and observed decrements in pulmonary function. Our findings were contrary to those reported by NIOSH, most likely because of how we accounted for the longitudinal nature of the spirometric data. Conclusion: Many years of exposures to flavoring chemicals in this workplace, including diacetyl, were not found to produce an increased risk of abnormal spirometric findings.
Surface wipe sampling in the occupational environment is a technique widely used by industrial hygienists. Although several organizations have promulgated standards for sampling lead and other metals, uncertainty still exists when trying to determine an appropriate wipe sampling strategy and how to interpret sampling results. Investigators from the National Institute for Occupational Safety and Health (NIOSH) Health Hazard Evaluation Program have used surface wipe sampling as part of their exposure assessment sampling strategies in a wide range of workplaces. This manuscript discusses wipe sampling for measuring lead on surfaces in three facilities: (1) a battery recycling facility, (2) a firing range and gun store, and (3) an electronic scrap recycling facility. We summarize our findings from the facilities and what we learned by integrating wipe sampling into our sampling plan. Wiping sampling demonstrated lead in non-production surfaces in all three workplaces and that the potential that employees were taking lead home to their families existed. We also found that the presence of metals such as tin can interfere with the colorimetric results. We also discuss the advantages and disadvantages of colorimetric analysis of surface wipe samples and the challenges we faced when interpreting wipe sampling results.
A case can be made that much common ground exists between pharmacovigilance and pharmaceutical manufacturing. Of the 8 major US statutes that shaped the pharmaceutical industry since early in the 20th Century, 7 followed fatally catastrophic events related to the use of a manufactured product, and 1 followed the discovery of a counterfeit product. To facilitate an understanding of the interplay between pharmacovigilance and manufacturing, it is convenient to divide manufacturing into 3 categories: (1) upstream sourcing of materials: pharmacovigilance plays an important role when adverse event clusters are seen during routine vigilance detection processes and the suspicion turns to possibly contaminated source material, (2) the manufacturing process itself: pharmacovigilance may be called on to conduct a health hazard evaluation if a manufacturing deviation is detected after product release (the assessment can inform the depth of a recall), and (3) downstream distribution and product use: there is only light regulation of the interval between product distribution after manufacturing release and just before administration to patients, a time during which product may be subject to an out-of-specification determination for environmental controls or subject to malfeasant activities, such as counterfeit substitution or product diversion. Recently introduced statutory remedies, including the FDA Safety and Innovation Act and the Drug Supply Chain Security Act in the United States and the Falsified Medicines Directive (directive 2011/62/EC) in the European Union, can provide capabilities to support pharmacovigilance signal management activities that have the potential to reduce the risk to patients of experiencing adverse events caused by counterfeit, diverted, or tampered product.
An aircraft seat manufacturing company requested a NIOSH health hazard evaluation to help identify a strong odor that had persisted throughout the facility for over a year. Employees reported experiencing health effects thought to be related to the odor. We collected and analyzed area air samples for volatile organic compounds, endotoxin, bacterial and fungal metagenome, and metalworking fluid aerosol. Bulk metalworking fluid samples were analyzed for endotoxin, bacterial and fungal metagenome, and viable bacteria and fungus. We also evaluated the building ventilation systems and water diversion systems. Employees underwent confidential medical interviews about work practices, medical history, and health concerns. Based on our analyses, the odor was likely 2-methoxy-3,5-dimethylpyrazine. This pyrazine was found in air samples across the facility and originated from bacteria in the metalworking fluid. We did not identify bacteria known to produce the compound but bacteria from the same Proteobacteria order were found as well as bacteria from orders known to produce other pyrazines. Chemical and biological contaminants and odors could have contributed to health symptoms reported by employees, but it is likely that the symptoms were caused by several factors. We provided several recommendations to eliminate the odor including washing and disinfecting the metalworking machines and metalworking fluid recycling equipment, discarding all used metalworking fluid, instituting a metalworking fluid maintenance program at the site, and physically isolating the metalworking department from other departments.
Work-related asthma is asthma that is caused or exacerbated by exposure to specific substances in the workplace. Approximately 10%-16% of adult-onset asthma cases are attributable to occupational factors, and estimates of asthma exacerbated by work range from 13% to 58%. During 2008-2012, the Massachusetts Department of Public Health received nine reports of work-related asthma among workers at a facility that manufactured syntactic foam used for flotation in the offshore oil and gas industry. These reports and a request from facility employees led to a CDC health hazard evaluation during 2012-2013 in which CDC reviewed records, toured the facility, and administered a questionnaire to current employees. Investigators found that workers' risk for asthma increased substantially after hire, possibly because of known asthma triggers (i.e., asthmagens) used in production. The company has since initiated efforts to reduce employee exposures to these substances. This cluster of work-related asthma was identified through CDC-funded, state-based surveillance and demonstrates complementary state and federal investigations.
In February 2014, CDC’s National Institute for Occupational Safety and Health received a request for a health hazard evaluation from a union representative in an office building. A female employee reported the onset of symptoms involving multiple organ systems upon returning to work after a prolonged absence. The employee searched the Internet for descriptions of symptoms matching hers, found a laboratory offering “toxic mold testing” direct to consumers, and submitted a urine sample, despite the absence of musty odors and signs of fungal growth in her office. The laboratory reported “positive” concentrations of two mycotoxins: ochratoxin at 2.8 parts per billion (ppb) and tricothecenes at 0.4 ppb. The laboratory cutoff for “positive” was ≥2.0 ppb for ochratoxin and ≥0.2 ppb for tricothecenes. The interpretation accompanying the laboratory report said the results “revealed that you have an unusual level of that mycotoxin(s) present in your body.”