Qualified Safety and Industrial Hygiene Professionals in Healthcare

Note: A version of this post was originally published in in The Monitor, a technical publication of the American Society of Safety Engineers' Industrial Hygiene Practice Specialty, in August 2015.

Healthcare workers have the potential to experience a wide variety of occupational injuries. Under the Occupational Safety and Health Administration (OSHA) Healthcare Safety and Health Topics webpage, OSHA lists the following as potential hazards: blood-borne pathogens (BBP) and other biological hazards, chemical and hazardous drug exposures, waste anesthetic gas exposures, respiratory hazards, ergonomic hazards, laser, hazards, workplace violence, and radioactive and x-ray hazards.

Chemicals such as formaldehyde, glutaraldehyde, ethylene oxide, peracetic acid, ortho-phthalaldehyde (OPA), and environmental disinfectants are sources of potential hazardous exposure for healthcare workers (OSHA, 2015). There is insufficient guidance for healthcare safety personnel to evaluate the risks associated with the use of these chemicals. Research evaluating the potential for synergism among chemicals used in healthcare that may adversely affect healthcare workers is scarce. The heightened awareness of infectious diseases such as Ebola and Middle East Respiratory Syndrome (MERS) has led to increased use of environmental disinfectants throughout healthcare and other workplaces. More research and expertise is needed by qualified industrial hygienists and safety experts to properly recognize, evaluate, and control the hazards present in healthcare.

Despite the improved focus on patient safety, quality control and regulatory compliance, the injury and illness rate from healthcare workers are almost twice as high as the private industry rate. A news release from OSHA on June 25, 2015 explained that OSHA will be expanding enforcement activity in healthcare facilities. OSHA�s enforcement focus will be on preventable injuries, such as those from patient handling, BBP, workplace violence, tuberculosis, and slips, trips, and falls (OSHA, 2015).

OSHA has developed resources, checklists, and guidance for healthcare safety relating to building a culture of safety, injury and illness prevention programs and/or safety and health management systems, infectious diseases, safe patient handling, and workplace violence. The National Institute for Occupational Safety and Health (NIOSH) has also developed resources for healthcare safety relating to hazardous drug exposures, waste anesthetic gases, and latex allergies. Additional guidance is available from accrediting organizations such as The Joint Commission, DNV Healthcare, and Center for Improvement in Healthcare Quality(CIHQ), among others.

So, with all the resources and guidance available, why are the injury and illness rates so high among healthcare workers?

Some safety and health professionals might argue that the healthcare organizations are too focused on patient safety as opposed to employee safety, in order to improve their ratings and popularity. To combat this belief, The Joint Commission developed a monograph entitled �Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation� that explains the methods of coordinating quality improvement activities that will benefit both the patients and the workers. In the Foreword of the monograph, The Joint Commission explains that: �The organizational culture, principles, methods, and tools for creating safety are the same, regardless of the population whose safety is the focus. In fact, the same principles, methods, and tools may be separately used by different groups (clinical, human resource, and general liability personnel) within an organization� (The Joint Commission, 2012). This is not a surprise to healthcare safety personnel who came to the healthcare industry after training in other industries, but may be a pleasant discovery for healthcare safety personnel who were promoted into their position from other clinical or non-clinical jobs.

There is variability in the tasks performed by healthcare safety personnel. Depending on the size of the campus or healthcare organization, healthcare safety personnel may have many other responsibilities beyond occupational and patient safety. Some healthcare safety personnel serve as the Director of Materials Management, Director of Facilities, Risk Manager, or Director of Infection Prevention, and the safety management aspect of their job is only a small portion of their daily responsibilities. Others may also serve as the Compliance and Privacy Officer, Radiation Safety Officer, Laser Safety Officer, and other technical and regulatory required positions.

In a quick internet search of posted jobs for �healthcare safety officer� or �EOC safety officer,� the following job tasks and requirements were listed (not a comprehensive list):

�  Conduct training of staff	�  Know OSHA and EPA regulations	�  Radiation and laser safety knowledge	�  Chemical safety and proper disposal
�  Develop education modules	�  Know NFPA Life Safety Code	�  Emergency management	�  Chair the EOC Committee
�  Conduct fire drills	�  Process improvement	�  Work independently	�  Risk assessment
�  Consultation and assessment	�  Understand project management	�  HICS and HSEEP Exercises	�  5 to 7 years� experience in safety
�  Manage hazmat program	�  Familiar with ADA compliance	�  Act as community liaison	�  B.S. or M.S. in health sciences or safety
�  Conduct emergency spill response	�  Assist with laboratory safety	�  Provide regulatory oversight	�  Professional certification(s)

Healthcare safety personnel usually serve on a facility�s Environment of Care (EOC) Committee, which is an interdisciplinary team tasked with managing a facility�s physical environment in six functional areas: safety, security, hazardous materials and waste, fire safety, medical equipment, and utilities. The EOC Committee should have representation from clinical staff, security, healthcare administration, biomedical engineering, facilities engineering, infection prevention, employee health, laboratory, and other areas such as research administration that may be applicable to the facility.

Aspects of the Environment of Care are an integral part of the survey instruments used to score hospitals on sites such as Hospital Safety Scoreor the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS). The results of these surveys are supposed to be used by patients to select hospitals and health systems based on patient safety and outcomes. The HCAPHS survey asks two questions related to the physical environment of the hospital and patient safety (Centers for Medicare & Medicaid Services, 2015):

• During this hospital stay, how often were your room and bathroom kept clean?
• During this hospital stay, how often was the area around your room quiet at night?

The Hospital Safety Score provides patients with a score for each hospital in the U.S. on an A through F scale, measuring safe practices such as (The Leapfrog Group, 2015):

• Leadership structures and skills
• Culture measurement, feedback, and intervention
• Teamwork training and skill building
• Identification and mitigation of risks and hazards
• Hand hygiene
• Falls and trauma

In reviewing the job tasks and requirements listed previously for healthcare safety personnel, it quickly becomes apparent that individuals holding a Certified Industrial Hygienist (CIH) or Certified Safety Professional (CSP) designation already have much of the required knowledge, skills, and abilities. Individuals with CIH/CSP designation who have not worked in healthcare before may need to learn more about BBP and infectious diseases, hazardous drugs, medical terminology, ionizing radiation, patient safety, laboratory safety, and the accreditation process.

Having a qualified, certified, and well-trained person at the helm of health, safety, and environmental compliance activities may help healthcare facilities to improve their overall culture of safety � both for patients and employees. In an informal survey of hospitals located within Arizona, 23 hospitals were awarded an �A� or �B� designation by the Hospital Safety Score method in June 2015. After those hospitals were identified, a search of LinkedInprofiles was conducted to evaluate whether the hospital had a qualified and trained safety and health professional serving in a healthcare safety role at the facility.

If the individual held a professional certification such as CIH, CSP, Certified Healthcare Safety Professional (CHSP), Certified Professional in Patient Safety (CPPS), orCertified Healthcare Protection Administrator (CHPA), it was noted in the survey. If the individual had also completed a master�s degree in safety, environmental management, business administration, healthcare administration, or other applicable degree, it was noted in the survey. The size of the hospital � and associated complexity of environmental health and safety management � is indicated by the number of licensed patient beds.

Table 1 details the results of the informal survey of Arizona hospitals with a Hospital Safety Score of �A� or �B� � identifying details such as the hospital name and actual number of licensed beds have been replaced with an identification number and a size range. Hospitals included in this survey range from small hospitals with less than 100 licensed beds, to large hospitals with 700 to 750 licensed beds. If the individual serving as the �safety officer� did so in an ancillary capacity (i.e., job title was Director of Facilities), and did not have any formal safety training documented in their LinkedIn profile, the �Safety Professional� selection was �No.� If the individual performed safety functions as the primary role, the �Safety Professional� selection was �Yes.� An �X� indicates that the individual held the professional designation and/or had a relevant master�s degree. 

Table 1: Informal Survey of Arizona Hospitals with a Hospital Safety Score of A or B (June 2015)

The data from this informal survey has been summarized into Tables 2 and 3 below. Table 2 shows the number of Arizona hospitals with a �Safety Professional� (e.g., a �Yes� answer) as compared with the number of Arizona hospitals with a person who acts as safety officer in addition to their other job duties (e.g., a �No� answer). Table 3 shows the number of Arizona hospitals with a �Safety Professional� holding a CIH/CSP, CHSP/CPPS/CHPA, or relevant master�s degree. The hospital size ranges associated with these trained professionals is also provided in Table 3.

Table 2: Arizona Hospitals with  Dedicated Safety Professional (June 2015)

Table 3: Arizona Hospitals with a Qualified and Certified Safety Professional (June 2015)

Of the 23 Arizona hospitals with an �A� or �B� rating on the Hospital Safety Score site in June 2015, 13 (56.5%) had a dedicated safety professional. One of the smaller hospitals (AZ002) was not able to be included in the survey results due to the lack of information about the hospital�s safety officer responsibilities and lack of presence on LinkedIn. Of the 13 dedicated safety professionals, 10 (76.9%) had obtained a professional level certification or relevant master�s degree. Hospitals employing these trained and qualified safety professionals ranged from small (<100 beds) to large (600 beds). Only 3 (30%) of the trained and qualified safety professionals held a CIH or CSP designation. The remainder of the certifications (70%) were from organizations such as the International Board for the Certification of Safety Managers, the Certification Board for Professionals in Patient Safety, and the International Association for Healthcare Security and Safety.

                Although only 10 (43.5%) of the 23 Arizona hospitals earning an �A� or �B� rating on the Hospital Safety Score site had safety and EOC responsibilities performed ancillary to the individual�s other job responsibilities, many of the hospitals represented in this informal survey are part of regional health systems spanning multiple states. These health systems may have regional or corporate level occupational health and safety personnel who serve multiple healthcare campuses and provide technical support to the facility-specific staff.

                As part of the �Improving Patient and Worker Safety� monograph, The Joint Commission listed several topic areas for targeted interventions with the goal of improving safety. Individuals with CIH/CSP designation that are looking to foray into the world of healthcare safety should research strategies, solutions, and benefits associated with this list. Healthcare systems looking to hire safety officers, safety managers, and directors of safety are looking for healthcare-specific knowledge that is difficult to obtain if you have never worked in healthcare before. An abbreviated and modified list of these topics is included below (The Joint Commission, 2012).

• Safe patient handling (including use of lifts and slings)
• Fall prevention (both patient and staff)
• Sharps injury prevention
• Infection prevention (including hand hygiene and personal protective equipment)
• Assault and violence prevention and management
• Security management
• Emergency management (including the Healthcare Incident Command System)
• Exposure to hazardous drugs
• Surveillance and exposure assessment
• Environmental hazards
• Ergonomics and human factors engineering
• Improving safety culture throughout an organization
• Safer design of practices and the built environment

Qualified industrial hygienists and safety professionals are needed to take healthcare safety to the next level. With OSHA promising to increase enforcement action, and accreditation agencies like The Joint Commission requiring documented improvements in safety and quality measures, opportunities for solution-oriented and collaborative safety professionals are becoming available. Industrial hygienists are needed to evaluate acute and chronic exposures to workers that may be inadvertently passed on to patients. Safety experts are needed to bring the industry knowledge from manufacturing, aviation, power generation, and other high-risk industries into the healthcare arena.

As Dr. David Michaels, Assistant Secretary of Labor for Occupational Safety and Health, said in the news release from June 25, 2015: �[�] it�s time for hospitals and the health care industry to make the changes necessary to protect their workers� (OSHA, 2015). Let�s accept this exciting challenge and improve safety for all of the people that enter into, or are employed by, healthcare facilities. 

References

Centers for Medicare & Medicaid Services. (2015, March 20). HCAPHS Online. Retrieved from HCAPHS Survey: http://www.hcahpsonline.org/files/HCAHPS%20V10.0%20Appendix%20A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20March%202015.pdf

OSHA. (2015, June 27). Healthcare. Retrieved from Safety and Health Topics: https://www.osha.gov/SLTC/healthcarefacilities/

OSHA. (2015, June 25). OSHA adds key hazards for investigators' focus in healthcare inspections. Retrieved from News Release: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=28197

The Joint Commission. (2012). Retrieved from The Joint Commission: http://www.jointcommission.org/assets/1/18/TJC-ImprovingPatientAndWorkerSafety-Monograph.pdf

The Leapfrog Group. (2015, April). Scoring Methodology. Retrieved from Hospital Safety Score: http://www.hospitalsafetyscore.org/media/file/HospitalSafetyScore_ScoringMethodology_Spring2015_Final.pdf

New job, snow, and creativity

It's been a couple of months since my last post.

My reason? I took a new job! I'm now an Assistant Professor in the Safety and Health Management Program (Department of Engineering Technologies, Safety, and Construction) at Central Washington University. At the very end of August, we packed up our meager belongings and Alaskan Malamute and drove up to Ellensburg, WA.

This is Central Washington University (CWU):

Image credit CWU

The campus is gorgeous, with red brick buildings throughout, grassy areas, a canal, several bike paths, and my personal favorite location: a Japanese Garden (video tour on YouTube here). There is also a Starbucks on the edge of campus, so I can walk over within 10 minutes.

Ellensburg is also a spiffy college town - the weekend after we arrived, it was the annual Ellensburg Rodeo for all of Labor Day weekend. This rodeo started in 1923, so it is one of the oldest rodeos. Where we used to live, in Prescott, AZ, they have had a rodeo since 1888 and rock the "World's Oldest Rodeo" vibe throughout town. 

Ellensburg is a town of ~18,000 people and the speed limit around town ranges from 20-35 miles per hour. After our experiences in Phoenix the last few years, with a population of ~1.5 million people and some really aggressive drivers, this has been a nice change. Seattle is about 2 hours away, and Spokane is 2.5 to 3 hours away.

My colleagues and family keep asking how we are adjusting to life in the Pacific Northwest. My answer is usually congenial, something along the lines of: "It's ... fine?" We haven't explored around much and I have been working consistently long hours, as is expected when you are new faculty. Last week, when we had our first real snow, I freaked out a little bit, but have since learned how to drive in snow (with my fancy new snow tires), how to walk in snow (with my fancy new YakTrax), and learned the value of layered clothing. We raided the Columbia outlet in Anthem, AZ on our way out of Phoenix.

The Alaskan Malamute is deliriously happy, building himself little dens in the fresh snow, and bounding inside covered in snow flakes. We are deliriously happy to not have to answer the "How does he do in the summer? Do you shave him?" questions we were asked by everyone in Phoenix. (He did great, he's an inside dog).

Shadow practicing his best "stoic" look in the snow.

I'm preparing some exciting new content for the blog over winter break. But I'm also working on two academic research papers, one on construction project EHS budgets and the optimal budget amount for reduced injury and illness rates (co-writing with two excellent CWU professors), and one on "Practical Tools for Gender Equal Protection in OSH Programs" that will be presented at Safety 2017 in Denver, CO. 

On a professional note, I've had some fun new volunteer experiences arrive this fall/winter: (1) I was elected the Assistant Administrator of the Training and Communications Practice Specialty within ASSE, (2) I was asked to step in as Secretary of the Industrial Hygiene Practice Specialty within ASSE, and (3) I get to serve on the Editorial/Press Advisory Board for the National Safety Council. So things are very busy for the Industrious Hygienist, but as always, I am up for the challenge!

How to Study for and Pass the CSP Exam

Dear loyal readers,

Thanks for your patience during the long delay between posts. I have great news � I passed the Certified Safety Professional (CSP) exam yesterday! I�m working on a celebratory manga, but in the meantime, I�d like to pass along my study tips for this difficult exam.

I started studying for the exam in October 2015, when I took the Bowen EHS CSP Online Review Course. This course was immensely helpful in helping me identify where I needed to focus my self-study efforts. Based on the various topics and final exam, I identified my weak spots as: risk analysis, statistics, physics, radiation, and fire protection.

Reference sources that I reviewed and found useful:

• Safety and Health for Engineers (new 3rd edition just released May 2016)
• The Safety Professional�s Handbook
• Occupational Safety Calculations: A Professional Reference
• Concise Guide to Workplace Safety and Health
• Safety Management: A Human Approach
• Advanced Safety Management: Focusing on Z10 and Serious Injury Prevention
• Fundamentals of Fire Protection for the Safety Professional

A colleague also gifted me with her old (2011) CSP review course materials and a 2010 CSP Self-Assessment. Her course materials also had excellent problem sets and summary material ready for flash cards. I�ve taught Occupational Safety to graduate students for three years, so I thought I had a pretty solid grasp on the material � until I sat down to take the 2010 CSP Self-Assessment from BCSP about 10 days before my exam. Based on my, uh, lackluster score, I decided to redouble my efforts and really study.

The Bowen EHS CSP Online Review Course comes with an added bonus � a one-year membership to their �premium resources.� These resources include practice quizzes (by topic area) based on a bank of 675+ questions that they have developed since 2003. Each practice quiz contains a reference to the solution page, so you can go back on questions you missed to see how it was supposed to be solved. I went through about 200 questions on the practice quizzes and was able to narrow down my weak areas even further. Basically, my brain hates physics, mechanical engineering, statistics/probability, and risk analysis methodologies (FMEA, FTA, MORT, HAZOP, etc.). Maybe it�s the algebra. I may have arithmophobia specific to algebra. :) My brain just freezes up every time one of those questions flashes on the screen.

Some of the super-helpful practice quizzes in the Bowen EHS Member Center.

After some intense studying for 3 days, I took the 2015 CSP Self-Assessment and scored a 90%. Since much of the content between the 2011 and 2015 CSP Self-Assessments is similar, I figured that a bit more studying was in order. I made two decks of flash cards for specific items that required memorization. But the thing I am proudest of is my �safety alchemy� drawing. Here it is:

The Industrious Hygienist's CSP Exam safety alchemy art!

When I passed the Certified Industrial Hygienist (CIH) exam in 2012, one of the most helpful things I did was create an abstract symbol and fill it with the things I needed to memorize (constants, equations not on the reference sheet, etc.). So my CSP exam �safety alchemy� drawing contained the items that I wanted to memorize.

The drawing has information about experience modification rates, total case incident rates, radiation exposure measures, the range of normal human hearing, radiation quality factors, sizes of particulates, potential vs. kinetic energy, respirator assigned protection factors, the NIOSH lifting equation, volume of a cylinder, types of hard hats, air changes per hour, eyewash flow rates, combustible metals, distance between a crane and a power line, specific gravity, guardrails, probability, ISO standards, ANSI standards, LOTO, risk management, process safety management, types of fires, and fire sprinkler placement. All in one handy piece of art.

When I sat down to take the test, I used the scratch paper to draw my safety alchemy art, which had a calming and centering effect since I drew it for several days prior to the exam. The most ironic part is that most of the items on my safety alchemy art were not even on the exam version I took. My exam (for double irony) was heavy on statistics/probability, training, risk analysis (FMEA, FTA, MORT, HAZOP, etc.), radiation, and system safety.

I found some extra sources for studying if you�re like me and have issues with the topics referenced below:

• Risk Analysis Methodologies
• CrashCourse Physics � video playlist on YouTube
• Probability 101 video from Hank Green
• Khan Academy Statistics � video playlist on YouTube

I also went through a bunch of OSH Academy courses where I needed a refresher. The OSH Academy website is easy to use and I am currently enrolled in (almost done!) the 132-Hour OSH Professional course. I found the narrative easy to read and the quizzes were helpful. I really liked the custom posters and infographics used in modules throughout the course. there's a healthcare-specific track that I am doing next. 

Other helpful (and free!) video sources for CIH/CSP studying:

• CrashCourse Anatomy & Physiology � video playlist on YouTube
• CrashCourse Biology � video playlist on YouTube
• CrashCourse Chemistry � video playlist on YouTube
• Safety Management System Fundamentals (from the FAA)
• Process Safety Management Training

Look for more frequent posts and some new manga in future weeks. I am excited to get back to my creative life now that this professional/analytical hurdle has been achieved.

Update: Industrial Hygiene and Safety Blogs I Follow

I figured it was time to update the published list of industrial hygiene and safety blogs I follow regularly. These blogs are written by practicing industrial hygienists and/or safety professionals and do not include curated blogs from large companies or industry publications.

• OSHA Training Services Blog 
• Industrial Hygiene in Construction
• The Young Occupational Hygienist Blog 
• Theatre Safety Blog (#theatresafety)
• Indoor Air Nerd

Take a look and consider adding some of these to your reading list. If I've missed any interesting bloggers, please leave a comment and I'll update the list.

What's an Exposome? Recent Research on Occupational Exposure Limits

The Journal of Occupational and Environmental Hygiene (JOEH) is the official publication of the American Industrial Hygiene Association (AIHA) and the American Conference of Governmental Industrial Hygienists (ACGIH). JOEH released a supplemental journal issue for 2015 entitled: �Special Issue: State of the Science of Occupational Exposure Limit Methods and Guidance.� 

This supplemental issue contains nine research articles and two introductory/summary articles detailing recent research in occupational exposure limits (OELs). Members of AIHA and/or ACGIH can log in to their respective member portals to view the research articles referenced below. This blog post is a high-level summary of each of the articles, including best practices that can be used by practicing industrial hygiene and safety professionals.

The Past and Future of Occupational Exposure Limits

This introductory article by Jonathan Borak and Lisa M. Brosseau about �The Past and Future of Occupational Exposure Limits� is a quick history of OELs and analysis of the barriers present in developing new OELs. The authors note that the ten articles �present a systematic approach that begins with an understanding of systems biology, mechanisms of action and the early (i.e., �pre-clinical�) effects of toxic exposures including genetic and epigenetic phenomena.� 

The most obvious barrier to developing OELs is the lack of data available that is relevant to human occupational exposure. Another barrier is the difficulty in establishing global exposure limits � since countries are at different stages of industrialization and the necessary controls may be infeasible. The third barrier mentioned by the authors is the lack of a formal, systematic approach to develop, establish, and update OELs.

Occupational Exposure Limit Derivation and Application

In a summary article titled �State-of-the-Science: The Evolution of Occupational Exposure Limit Derivation and Application� authors A. Maier, T. J. Lentz, K. L. MacMahon, L. T. McKernan, C. Whittaker, and  P. A. Schulte provide a review of the research articles provided in the JOEH supplement. The four-page summary article explains that the research articles in the JOEH supplement are not an exhaustive assessment of OELs, but they explain scientific advances to be considered for risk assessment and management of occupational hazards.

Historical Context for OELs

The first research article in this JOEH supplement is �Historical Context and Recent Advances in Exposure-Response Estimation for Deriving Occupational Exposure Limits� by M.W. Wheeler, R. M. Park, A. J. Bailer, and C. Whittaker. In the abstract of the article, the authors explain that most occupational exposure limits are not based on quantitative risk assessment (QRA), and provide examples of exposure-response modeling methods available for QRA. �The key step in QRA is estimation of the exposure-response relationship,� the authors state, recommending the use of statistical tools to properly characterize the risk.

One of the best takeaways of the article is found in Table 1: �Common Impediments to Inference When Developing an Exposure-Response Relationship from Epidemiological Studies.� This table presents issues such as confounding bias, selection bias, the healthy worker effect, reverse causation, and variable susceptibility, and provides the consequences and fixes for these issues when working on exposure-response relationships. Table 1 is a helpful summary for industrial hygienists or safety professionals who are just starting their education into epidemiology.

Another helpful element of the article is found in Table 7: �OEL Estimation Methods,� which sets forth the data requirements, considerations for use, epidemiological considerations, and caveats for estimation methods such as the no observed adverse effect level (NOAEL), traditional benchmark dose (BMD), and biologically-based methods. In the conclusion of the article, the authors recommend that risk managers select the proper �statistical methodology to estimate risks and quantify relevant uncertainties� in occupational risks.

Dosimetry Modeling for Occupational Risk Assessment

An article by Eileen D. Kuempel, Lisa M. Sweeney, John B. Morris, and Annie M. Jarabek explains the �Advances in Inhalation Dosimetry Models and Methods for Occupational Risk Assessment and Exposure Limit Derivation.� This article introduces the basic concepts of dosimetry, explains the hierarchical model selection criteria, considers agent-specific dosimetry and model selection with agent-specific examples, and discusses challenges to implementing dosimetry models and methods in risk assessment and OEL derivation.

When introducing the basic concepts of dosimetry, the authors explain that dosimetry involves determining the amount, rate, and distribution of a substance in the body. They also introduce the development and use of risk-based exposure estimates including the NOAEL, the lowest observed adverse effect level (LOAEL), and the benchmark dose (BMD), which is �the dose associated with a specified risk (e.g., 10%) of an adverse health effect (or benchmark response) as estimated from modeling the dose-response relationship.�

The authors explain that dosimetry is essential for understanding the relationship between exposure and the body�s response. Dosimetry can improve the accuracy of risk assessment by reducing the level of uncertainty in the calculated estimates. Reliable estimates of the internal dose at the target organ or tissue are accomplished by specific measurements or predictive models. 

The article focuses on inhalation dosimetry since it is a significant route of occupational exposure. Detailed mechanisms and models are provided for the respiratory tract, deposition of particles of fibers, clearance and retention of inhaled particles and fibers (including an interspecies comparison), and gas uptake factors. The interspecies comparisons discuss that similar clearance pathways are used by both humans and laboratory animals, but that extrapolation of animal data for human exposure estimates has changed due to an improved understanding of the differences between animal and human respiration.

Using Systems Biology and Biomarkers

The third research article in this JOEH supplement presents the use of �Systems Biology and Biomarkers of Early Effects for Occupational Exposure Limit Setting� as written by D. Gayle DeBord, Lyle Burgoon, Stephen W. Edwards, Lynne T. Haber, M. Helen Kanitz, Eileen Kuempel, Russell S. Thomas, and Berran Yucesoy. As provided in the abstract of the article, this article discusses �systems biology, biomarkers of effect, and computational toxicology approaches and their relevance to the occupational exposure limit setting process.� In the introduction, the authors mention the dearth of toxicity information known at present about tens of thousands of chemicals in use in industry today.

The authors note that complex exposure scenarios, where workers are �exposed to complex mixtures that may have additive, synergistic, or antagonistic actions� makes it difficult to conduct thorough risk assessments. Useful portions of this article include Table 1: �Glossary of Key Terms.� Table 1 provides definitions for key terms used in the article, including: benchmark dose (BMD), benchmark response (BMR), biomarkers, computational toxicology, metabolomics, proteomics, systems biology, and uncertainty factors.

A biomarker is an �[i]nternal [measure] or [marker] of exposures or effects for a chemical or agent in the body.� Research into biomarkers involves an assessment of which biomarkers can be quantitatively linked to human adverse outcomes from occupational exposure. The authors explain that �[e]nvironmental exposures can directly or indirectly cause alterations in gene expression at either the transcriptional (gene expression) or the translational level (proteomics).� Table 4: �Different Types of Biomarkers� shows the type of biomarker (exposure, effect, or susceptibility), its characteristics, and examples.

In the conclusion, the authors explain the advantages of using biomarkers, since they can be used to �establish more appropriate OELs to protect individuals who are at high risk.� They caution that the �whole field of computational toxicology and systems biology is still evolving and results have not been validated in human populations� and that interpretation of biomarker results is not yet available. These challenges need to be overcome before biomarkers can be used routinely in human occupational risk assessment.

Scientific Basis of Uncertainty Factors

An article by D. A. Dankovic, B. D. Naumann, A. Maier, M. L. Dourson, and L. S. Levy discusses �The Scientific Basis of Uncertainty Factors Used in Setting Occupational Exposure Limits.� The abstract of the research article explains that �[t]he use of uncertainty factors is predicated on the assumption that a sufficient reduction in exposure from those at the boundary for the onset of adverse effects will yield a safe exposure level for at least the great majority of the exposed population, including vulnerable subgroups.�

Of interest to practicing industrial hygienists and safety professionals, Table 1: �UFs Used in OEL-setting, and the Rationale for Their Use� explains the types of uncertainty factors, which area of uncertainty they are used for, and the basic principles when rationalizing their use in risk assessment and OEL setting. For example, UF_A is used for animal to human uncertainty, and is used to adjust for differences in sensitivity between animals and the average human (not the occupationally exposed human). Figure 5 shows the hierarchy of approaches that are available when incorporating chemical exposure data into the risk assessment process, in order to improve scientific certainty.

Using Genetic and Epigenetic Information

The fifth article in the JOEH supplement by P. A. Schulte, C. Whittaker, and C. P. Curra is an introductory evaluation of �Considerations for Using Genetic and Epigenetic Information in Occupational Health Risk Assessment and Standard Setting.� The authors note that genetic and epigenetic data have not been widely used in risk assessment for occupational health. However, the authors envision that �genetic and epigenetic data might be used as endpoints in hazard identification, as indicators of exposure, as effect modifiers in exposure assessment and dose-response modeling, as descriptors of mode of action, and to characterize toxicity pathways.�

When evaluating the use of epigenetics in occupational health, the authors mention that using �epigenetics in epidemiologic studies of occupational disease may help explain the relationship between the genome and the work environment; however, other environmental exposures outside of work� also will need to be controlled for. Practicing industrial hygiene and safety professionals may be interested in Table 1: �Guide to Assessing Genetic and Epigenetic Data for Risk Assessment,� which is a 4 � 4 matrix showing the types of risk assessment functions (hazard identification, dose-response modeling, exposure assessment, and risk characterization) and the questions associated with using genetic or epigenetic data (both inherited and acquired) that may be asked.

Table 2: �Framework for use of genetic and epigenetic data in occupational and environmental risk assessment� is also interesting, since it uses the same 4 x 4 matrix and risk assessment functions with the recommended or estimated use of genetic and epigenetic data. For example, for the exposure assessment function, acquired genetic data can show deviations from normal pattern of gene expression, whereas inherited epigenetic data can be used as an indicator of exposure.

In the conclusion, the authors state that: �It is not far-fetched that a worker�s �Right to Know� might someday extend to the worker�s right to know their genetic susceptibility to workplace toxicants.� This is an intriguing idea for future research.

Setting OELs for Chemical Allergens

In an interesting article about �Setting Occupational Exposure Limits for Chemical Allergens�Understanding the Challenges� by G. S. Dotson, A. Maier, P. D. Siegel, S. E. Anderson, B. J. Green, A. B. Stefaniak, C. D. Codispoti, and I. Kimber, the authors discuss establishing exposure limits for low molecular weight (LMW) chemical allergens. The definition of chemical allergy is explained as �immune-mediated adverse health effects, including allergic sensitization and diseases, caused by exposures to chemicals.�

LMW allergens that are recognized occupational hazards include: diisocyanates, organic anhydrides (i.e., maleic anhydride) and some metals (i.e., beryllium and nickel). Table 1: �ACGIH Threshold Limit Values (TLVs) Based on Immune-mediated Health Endpoints� provides a list of chemical allergens with OELs already developed. These chemical allergens include beryllium, flour dust, natural rubber latex, various diisocyanates, and piperazine.

The article also provides an explanation of the biology of chemical allergens, including the difference between sensitization and elicitation, and forms of chemical allergy. The authors note that the two forms of chemical allergy of most interest to occupational health professionals are skin sensitization (resulting in allergic eczema and contact dermatitis) and respiratory tract sensitization (resulting in asthma and rhinitis). Specific challenges associated with development of OELs for chemical allergens are also discussed.

Exposure Estimation and Interpretation of Occupational Risk

The seventh article in the JOEH supplement provides a detailed analysis of �Exposure Estimation and Interpretation of Occupational Risk: Enhanced Information for the Occupational Risk Manager� by Martha Waters, Lauralynn McKernan, Andrew Maier, Michael Jayjock, Val Schaeffer, and Lisa Brosseau. The authors explain the risk characterization process for occupational exposures, including the regulatory basis for OELs, describing exposures and the exposed population(s), intrinsic variability and how to reduce uncertainty in exposure estimation, and methods for estimating exposures.

Table 1: �Occupational Exposure Limits (OELs) Developed by Various Organizations� shows the various OELs, which organization has set them, and whether they were developed based on a health basis, analytical feasibility, economic feasibility, and engineering feasibility. The authors provide an example of the compliance approaches used by the Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH). OSHA and NIOSH�s �[approach] include[s] collecting samples from the worst case exposure scenario or randomly from a defined similar exposure group of interest. The measurement is compared to the OEL and is classified into one of three decision categories: clearly below the limit, clearly above the limit, or too close to the limit for an immediate decision.�

The authors also provide an explanation of the AIHA exposure assessment strategy, which �recommended that [time-weighted average (TWA)] OELs be interpreted as upper limits of exposure (e.g., 95th percentile) for each similar exposure group (SEG) and that the exposure distribution profile of each SEG should be controlled so that the 95th percentile exposure is less than the OEL over time.� Following the discussion of SEGs, a short section on Bayesian methods is provided.

Aggregate Exposure and Cumulative Risk Assessment

In this research article about �Aggregate Exposure and Cumulative Risk Assessment�Integrating Occupational and Non-occupational Risk Factors,� T. J. Lentz, G. S. Dotson, P. R.D. Williams, A. Maier, B. Gadagbui, S. P. Pandalai, A. Lamba, F. Hearl, and M. Mumtaz evaluate the benefits of considering non-occupational exposures as part of the occupational risk assessment. The authors debate using a �combined risk from exposure to both chemical and non-chemical stressors, within and beyond the workplace,� with the understanding that �such exposures may cause interactions or modify the toxic effects observed (cumulative risk).�

Like previous articles in this OEL series, the authors provide a glossary of key terms in Table 1, including aggregate risk, exposome, and total worker health. Exposome is defined as �the measure of all the exposures of an individual in a lifetime and how those exposures relate to health.� Exposomics is defined as �the study of the exposome, which relies on the application of internal and external exposure assessment methods.�

Figure 2 of this article will be of special interest to practicing industrial hygienists and safety professionals. It is an illustration of the relationship between the key factors that must be considered in a cumulative risk assessment. The primary factors are divided into three categories: occupational factors, non-occupational factors, and individual factors. The occupational and non-occupational factors are further divided into settings, sources, pathways, dominant exposure routes, key stressors, and effects. Using the illustration in Figure 2, the authors provide an illustrative case study in Figure 3 to assess the cumulative risk for hearing loss.

The Global Landscape of OELs

In this ninth and final research article from the JOEH supplement, �The Global Landscape of Occupational Exposure Limits�Implementation of Harmonization Principles to Guide Limit Selection� is discussed by M. Deveau, C-P Chen, G. Johanson, D. Krewski, A. Maier, K. J. Niven, S. Ripple, P. A. Schulte, J. Silk, J. H. Urbanus, D. M. Zalk, and R. W. Niemeier. The article�s abstract notes that an occupational hygienist seeking to determine the proper OEL to apply in an international setting will encounter a �confusing international landscape for identifying and applying such limits in workplaces.�

Practicing industrial hygienists and safety professionals may be interested in Figure 1, which is a reprint of the hierarchy of risk-based occupational exposure benchmarks as developed by AIHA in their publications on control banding and SEGs. The authors note that the goal of international harmonization for OEL derivation and development has been under much debate and discussion, and explains the existing harmonization initiatives in place.

Conclusion

As occupational health and safety professionals, industrial hygienists can have access to new and exciting research by academic, governmental, and other groups through journals such as JOEH. In their supplemental issue about OELs, JOEH has selected nine research articles that provide the current state of occupational exposure science. This blog post has summarized the contents of each article and provided takeaways and interesting quotes from the articles, to allow practicing industrial hygiene and safety professionals to focus their continuing safety education on the articles that will most interest them.

2015 Holiday Manga Preview

(The following is a lightly edited and dramatized build-up to the awesome holiday card I made for a colleague at Apex Environmental Safety and Health Consulting Inc.)

Industrious Hygienist: "Hmmm, let's pop into LinkedIn for a few minutes and see what everyone is doing. A message? I rarely get messages!"

Nira (Message): "Hi Morgan, thought I'd take advantage of your artistic talent and see whether you can design us a Christmas card for Apex with an IH theme. We can have Shutterfly print it for us. Love the blog. Mahalo, Nira."

Industrious Hygienist: Holy fudge muffins, somebody actually reads my blog? No way! Wait, a Christmas card that other people will actually see? Keep it together and sound professional, dang it.

Industrious Hygienist (Message): "Hi Nira! I'd be happy to - how soon are you wanting it? Did you want something like the elves from last year's holiday blog, and do you want it to be a cartoon (I assume so)?"

Nira (Message): "A cartoon. Probably by November 15th."

Industrious Hygienist (Message): "Ok, I'll send you two sketches this weekend and you can let me know which one you like more."

The 2014 Holiday Manga was distributed in four parts: Part 1, Part 2, Part 3, and Part 4. But a Christmas card requires a more focused approach. Thus commences a furious couple hours of thinking, pondering, hemming and hawing about how to do an industrial hygiene themed Christmas card that wasn't incredibly nerdy.

I sent her the following mock up to get approval for the design and content.

Mock up of the Christmas card for Apex Environmental.

Approval obtained, I went to work inking and coloring the manga with special care, since it would be printed and needed to be as crisp as possible. The main character was designed to look like the Principal Hygienist of Apex Environmental, Nira Cooray. The final version is shown below.

Happy Holidays from the Industrious Hygienist and her colleagues at Apex Environmental!

The inside reads:  "Join us in sharing random acts of kindness during the holidays. Mahalo from Apex Environmental." We're excited to see how Apex's clients and colleagues respond to the colorful cartoon. More Holiday Manga coming up in 2015!

The Revenge of the Christmas Tree

Ah, the joyous Holiday Season begins � a time for rampant illness (cue flu season), unsportsmanlike behavior* (never step foot in malls and big box stores), and increased levels of non-work-related injuries and illnesses (decorating and getting the house ready for guests).

I�ve come to one iron-clad conclusion about the whole holiday thing: the Christmas trees are getting revenge. It could be because the trees are fed up with only being associated with this winter holiday hoopla, or because they resent having to die and be used as decoration, or because they don�t want to spend their last living weeks laden with lights and tinsel and heavy ornaments. 

I�ll give the disclaimer that I don�t decorate for the holidays anymore, except for a smallish wooden wreath placed somewhere in the front room and three stockings, one for me, one for the Exceptional Spouse, and one for the dog. I will admit that having a 100+ pound Alaskan Malamute with a penchant for gnawing on ornaments was the original reason we stopped decorating.

So, why are the Christmas trees trying to get revenge?

Let�s start with the tree itself � do you purchase a real live tree, or an artificial one? Here�s the pros and cons of each related to safety and indoor air quality.

Real Live Tree

Pro:

• You get that pine-like smell to enjoy
• Can be recyclable (i.e., turned into mulch)
• Many trees come from local �plantations� so you�re likely buying local

Con:

• Many people find the pine-like odor to be irritating
• Someone had to grow and then kill a tree that is only used for 4 weeks or so
• Trees dry out and can contribute to the overall fire hazard of the holidays
• Trees harbor allergens like pollens, herbicides, fertilizers, mold, and pests

Artificial Tree

Pro:

• Usually listed as �flame resistant� and boughs made of polyvinyl chloride (PVC)
• Can be re-used year after year if they are put away and stored correctly
• Do not inherently contain allergens like pollens, herbicides, fertilizers, mold, and pests

Con:

• The flame resistant nature can also be from addition of flame retardant chemicals
• Are not recyclable � just end up in the landfill when you buy a new one
• Can easily accumulate heavy dust, pests, mold, etc. if not put away and stored correctly
• Will emit dioxins and other chemicals if they catch on fire
• Some studies also show that the trees release dioxins over time
• Some of the trees may also contain phthalates, lead, and other hazardous chemicals

According to Rodale�s Organic Life: �Real trees win. Why pollute your Christmas with toxic plastics and hazardous heavy metals? The durability and convenience of fake Christmas trees may make them more attractive than the alternative of buying a new tree every year, but a life-cycle analysis conducted in Canada found that you'd need to use your fake tree for 20 years for it to be considered more environmentally friendly than your yearly evergreen.�

Regardless, the cons seem to outweigh the pros in either case. Solution? Maybe move past this �essential� aspect of the holiday season and choose not to buy a tree, live or otherwise.

For a pretty interesting history of Christmas trees, see this video and article from The History Channel.

Putting Up Your Tree, a.k.a. Tree Torture

Let�s move on to the process of putting up your Christmas tree. In the case of real live trees, you either go to a lot and find one that suits you, or go chop one down yourself. Then you find a way to plop it into or on top of your car, drive it home, and wrangle it into the chosen room.

Some hazards:

• Fighting with your fellow humans (verbal or otherwise) over the �perfect tree�
• Impairing your visibility (front and rear) from tree boughs akimbo atop or inside your car
• Lifting injuries (from lot to car, from car to house, etc.)
• Not properly securing your tree atop your car, resulting in the tree careening down the road when it breaks loose of the cheap bindings you used

If you put the tree inside your vehicle, you have likely released all the allergens (pollen, mold spores, pests) into your car, such that the allergens coat the seats and sides of the vehicle. This means that every time you or your kids get into the car, you�ll re-disturb all the microscopic particles, releasing them into the air. Pine is a well-established sensitizer as well, so you�ll roll into work feeling crummy and sneezy, wondering why it is that you �always feel sick at work� during the holidays. Don�t be that person. :)

The same issue arises when you�re wrangling the tree through your front door or garage and into whichever room you designated. You�re getting a nice face full of needles, pollen, mold, and whatever else is on that tree while shaking and dragging the tree into position. The particles are released into the room and will be there long past the time you recycle your tree.

So, now you have the tree in the designated room. You�re likely going to take the somewhat heavy tree and put it into a tree torture device tree stand, where there is just enough water to keep it alive (provided you remember to refill it) and large screws are applied to the trunk to keep it upright. However, these tree stands are usually made of cheap plastic or metal and may not be hardy enough for the tree you�ve selected. The tree may not be secure in its base and fall over. The stands usually state something like �for 10-foot trees, ideal for 6-inch trunk� rather than indicating the weight limit the stand can effectively support.

Keeping your tree well-watered during the holidays is important for fire safety and aesthetics. NFPA has a dramatic video showing the difference in fire spread between a dry tree and a well-watered tree. An alternate version of the NFPA video has other safety ideas for holiday decorating.

Your tree is up, installed in its stand, and is ready to be decorated. The anthropomorphized tree is chuckling to itself (when it isn�t wincing from the liberally applied steel screws at its base) as it watches you try to set up your too-short ladder to place the hideous tree-topper your son made 24 years ago. The chuckles turn to nervous laughter as you wrap the tree in cheap strands of lights � it wonders if you understand that heat + electrical malfunctions + combustible material = fire. The nervous laughter turns to a whimper when you load it down with heavy ornaments and garlands. The whimper turns to despair as you spray the tips of its boughs with artificial snow from an aerosol can.

CDC�s Fall-Related Injuries During the Holiday Season details the types and causes of fall-related injuries:  �The majority of falls were from ladders (e.g., while hanging holiday lights), followed by roofs (e.g., while mounting an artificial Christmas tree on the roof), furniture (e.g., while standing on a table decorating a Christmas tree, standing on a chair hanging holiday decorations, or standing on a step stool when hanging a tree topper), stairs, and porches. Other falls were caused by tripping over or slipping on holiday-related objects (e.g., tree skirts or ornaments). Among 46% of injured persons, injuries occurred to the extremities (i.e., arm/hand and leg/foot); most persons (88%) examined in EDs were treated and released, and 12% were hospitalized. Fractures were the most commonly reported injury (34%); approximately half (51%) of the fractures were caused by falls from ladders. Of those who fell from ladders, nearly half (47%) were hospitalized.�

NFPA also has some safety-related information associated with Christmas trees and holiday lights.

The strands of lights you install on the tree should be UL-listed and inspected prior to installation, checking for burnt out or broken bulbs, nicks in the electrical insulation, and other potential issues. Remember that older strands of lights frequently have lead coatings and are made of PVC. The ornaments you select may have heavy dust (you meant to clean them last year but became too busy), and may also contain irritating or dangerous metals (lead and nickel) and chemicals, either in the paints or in the ornament itself.

Garlands and tinsel are also frequently made with PVC and are excellent collectors of dust and other potential allergens. On to the artificial snow, which usually comes in an aerosol can. There is a silicone-based artificial snow spray that looks pretty intriguing, and it has a less-scary list of chemicals in its Safety Data Sheet.  A common type of artificial snow spray is this: �Santa� brand snow.

Image courtesy of The Home Depot - showing 18 oz "Santa" Brand Spray Snow

A quick perusal of the Safety Data Sheet for the �Santa� brand snow shows the following:

• Contains butane, propane, and calcium carbonate (to give it that nice white color)
• Ingestion is �possible, but considered unlikely� (manufacturer has not met children or dogs)
• �Not recommended for use by anyone with history of asthma or other respiratory problems, or anyone who is ultra-sensitive to airborne particles.� (ultra-sensitive? Would love to see that definition) 
• �Keep away from heat, sparks, flame, and other sources of ignition� (so, don�t spray on your tree if it has lights?)
• �When using indoors, keep windows and doors open until fumes dissipate.� (this is unlikely in winter)
• Toxicological Information: �No Data Available�� (ellipses are theirs, not mine)

Not a chemist? Butane is the liquid inside your lighter (vapor catches fire easily) and propane is used as fuel in stoves, heaters, and barbecues (vapor also catches fire easily).

If you�re thinking that perhaps you�ll just try an artificial tree instead, just remember that the trees are currently not recyclable, they are made of PVC (and so are many of the items decorating your tree), and can catch on fire just like real live trees. The artificial trees with built-in lights are also potentially dangerous since it is difficult to inspect the tree and lights for electrical safety before putting the tree up.

Underwriters Laboratories has a �Christmas Tree Safety� video if you�re still bound and determined to do the holiday tree thing. The Industrious Hygienist has done a risk assessment and determined the inherent risks of Christmas trees outweigh the short-lived benefits.

More holiday-themed safety posts and the traditional Industrious Hygienist Holiday Manga coming soon!

* Fezzik in The Princess Bride (1987): �My way is not very sportsmanlike.�