NIOSH eNews – November 2011

From the Director’s Desk

John Howard, M.D.
Director, NIOSH
November eNews 2011

Worker Health, Totally

We often speak of our personal and working lives as if they were mutually exclusive. We “go to work” or “come home.”

A similar perception of life divided by the company fence has traditionally driven public policy, business practice, and individual initiative for worker health. Typically, a corporate safety and health department is responsible for practices to prevent injuries or illnesses associated with the conditions of work. The human resources department handles insurance duties (including the administration of workers’ compensation insurance for injuries on the job after the fact) and provides assistance for health issues viewed as “life style” or “personal health” choices, such as smoking cessation and stress management.

As the U.S. economy undergoes revolutionary changes, as businesses try to adapt to new market forces, as CEOs seek to rein in spiraling insurance costs, and as scientists and doctors learn more about the nature and causes of illness and injury, the distinctions between work and home become less clear-cut. Our bodies do not compartmentalize exposures according to whether they occurred at work, on the street, or at home. When a child comes down with a mild cold and has to stay home from preschool, the frantic search to find backup day care is both a personal and a work-related stress point, as any working parent knows.

Earlier this year, NIOSH and its partners introduced the Total Worker Health program. This is our vision for identifying and promoting integrated health programs in the workplace and recognizing the multitude of factors that influence a person’s health, safety, ability to work, and well-being in every aspect of their lives. It recognizes that greater advances can be made by addressing the individual’s health and safety holistically-by eliminating hazards at work while also using the workplace as a platform for healthy life choices—than by looking at work and personal life in isolation.

A new article in the on-line edition of the American Journal of Public Health underscores the importance of understanding the interaction of occupational and personal risk factors in workforce health and safety. The paper by Drs. Paul Schulte, Sudha Pandalai, and HeeKyoung Chun of NIOSH, and their colleague, Dr. Victoria Wulsin, identifies eight personal health risk factors (genetics, age, gender, chronic disease, obesity, smoking, alcohol use, and prescription drug use). It presents 32 examples of the ways in which those factors may interact with occupational risk factors. The integration of occupational and personal risk factors has important implications for other initiatives related to improvements in 21^st century healthcare delivery, as Dr. Schulte and his colleagues note. One such initiative is the current effort by NIOSH and its partners to emphasize the need to regularly include occupational information in medical records, particularly as records systems transition from paper records to electronic records. The opportunities and challenges presented by the incorporation of occupational information into electronic health records were discussed by an Institute of Medicine (IOM) review panel in a recent study requested by NIOSH. The IOM report can be found at http://www.iom.edu/Reports/2011/Incorporating-Occupational-Information-in-Electronic-Health-Records-Letter-Report.aspx.

An upcoming NIOSH Science Blog will discuss the model described by Dr. Schulte and his colleagues. In the meantime, I invite you to read their paper at http://ajph.aphapublications.org/cgi/reprint/AJPH.2011.300249v1.

As we continue new research to identify and address opportunities for Total Worker Health, I am pleased that the program and the foundational research on which it is built are gaining wider attention. Dr. Casey Chosewood, NIOSH’s Total Worker Health coordinator, spoke recently on the Federal News Radio network about the importance of worker health protection and promotion for the federal government workforce. As more and more federal employees become eligible to retire and as agencies face tightening budgets, it is imperative that we maintain a capable, motivated work force to carry out the multitude of services that society depends on. You can read and listen to Dr. Chosewood’s comments at http://www.federalnewsradio.com/?nid=455&sid=2530513 .

In an article on the web-based news service Medscape, Dr. Chosewood discussed the importance of strategies for addressing age, health, and work. These approaches are critical for providing safe and healthful work today for “chronologically gifted” men and women who wish to remain in the workforce after traditional retirement age. They are also important for helping to sustain an able workforce over the coming decades, so that work-related injuries, illnesses, stress, and wear on the body do not compound the effects of aging as today’s 20-, 30-, and 40-year-old workers grow older. The article is available online at http://www.medscape.com/viewarticle/741559.

Today, individuals seek to stay healthier so that they can enjoy life to the fullest, companies look for ways to maintain a competitive advantage in the global market, and policy-makers increasingly recognize that preventing injury and illness is an essential part of economic recovery. Total Worker Health offers a wise business model to help attain those goals. Please learn more by visiting our web page at /niosh/TWH/, and please consider joining our diverse partnership if you have not done so already.

In Memoriam: John Palassis

NIOSH and CDC have lost a great colleague, mentor, friend, and respected researcher. John Palassis passed away on October 18. John retired from NIOSH in 2010. His efforts over his 33 years at NIOSH produced significant impacts through worker training, outreach to small businesses, and the development of consistent and comprehensive safety and health program standards. He was highly effective in developing solutions and providing joint guidance; this approach has served as a model for other CDC and NIOSH colleagues. In particular, John’s collaborations involving national programs to educate and protect young workers (e.g., National Skills Standards, School Chemistry Laboratory Safety) have addressed key issues for an important public health audience. His development and promotion of the NIOSH Safety Checklist Program for Schools is one of his legacies. The many persons who had the pleasure of working with John will remember him for his strong faith, his love of family, his tireless work ethic, his warm and friendly spirit, and a life of service to others.

Protecting Emergency Response Employees from Infectious Disease

NIOSH announces revised and updated resources to help prevent exposures of emergency response employees to potentially life-threatening infectious diseases in the line of duty. The action was taken as a result of provisions in the Ryan White HIV/AIDS Treatment Extension Act of 2009. For more information on these new resources go to /niosh/updates/upd-11-02-11.html

National Assessment of the Occupational Safety and Health Workforce Released

A national survey and assessment of the occupational safety and health workforce has been completed by Westat under contract with NIOSH. This effort was guided by a multidisciplinary advisory task force of occupational safety and health professional and practitioners. A key finding is that future national demand for occupational safety and health services will significantly outstrip the number of professionals with the necessary training, education, and experience to provide such services. Next steps include wide dissemination of the results and further analysis of the disparities in the supply and demand for safety and health professionals in the United States. NIOSH plans to make this unique database publicly available to help guide action and policy development in occupational safety. The final Westat report is available at /niosh/oshworkforce/.

Get Fired Up for New NIOSH Twitter Site

Follow NIOSH @NIOSHFiringRanges and get updates on NIOSH research and newest findings related to the evaluation, measurement, and control of noise and airborne lead exposures at indoor firing ranges. (https://twitter.com/#!/NIOSH_FirRanges)

Centers of Excellence to Promote a Healthier Workforce

NIOSH funded four extramural centers of excellence in fiscal year 2011. The three existing centers successfully re-competed and a new center at Oregon Health Sciences University (Portland) was funded. These centers were funded as part of the NIOSH Total Worker Health Program(/niosh/TWH/). More information on each center is located at the sites listed below.

• Center for the Promotion of Health in the New England Workplace (CPH-NEW), at the University of Massachusetts (http://www.uml.edu/centers/cph-new/) and at the University of Connecticut (http://www.oehc.uchc.edu/healthywork/index.asp)
• Harvard School of Public Health Center for Work, Health and Wellbeing (http://centerforworkhealth.sph.harvard.edu/)
• University of Iowa Healthier Workforce Center for Excellence (HWCE) (http://www.public-health.uiowa.edu/hwce/)
• Oregon Healthy WorkForce Center (ORhwc) (http://www.ohsu.edu/xd/research/centers-institutes/croet/oregon-healthy-workforce-center/index.cfm)

Celebrating 50 Years of MMWR

In October, the U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR) released a special supplement, Public Health Then and Now, which celebrates 50 years of MMWR. The supplement includes an article by NIOSH Director Dr. John Howard and Dr. William Halperin entitled “Occupational Epidemiology and the National Institute for Occupational Safety and Health.” The article discusses the rich history of occupational epidemiology in supporting NIOSH’s vital mission and the foundational role of health surveillance in providing the data through which job-related disorders can be identified, tracked, measured, and prevented. (https://www.cdc.gov/mmwr/preview/mmwrhtml/su6004a15.htm?s_cid=su6004a15_w)

HHE Program Annual Report

It’s a poster! It’s modern art! It’s a conversation starter! It’s an annual report? To access the 2010 Health Hazard Evaluation Program Annual Report, go to /niosh/hhe/resources.html! This unique format will keep this annual report up on your wall rather than collecting dust on your bookshelf for years to come. To request a paper copy of the 2010 Annual Report, send an email with your mailing address to SEvans2@cdc.gov.

NIOSH Partners with Mexican Embassy, Consulates for Labor Rights Week Activities

The Mexican Embassy and its network of 50 consulates in the United States celebrated the Second Annual Labor Rights Week August 29 through September 5 with the theme of “Women in the Workplace.” NIOSH participated in a variety of activities hosted by the Embassy, the consular services office in Washington, DC, and the consulate general in Atlanta. NIOSH and the Mexican Government and other stakeholders have an ongoing partnership that aims to build capacity in both the consulates and in occupational safety and health institutions to improve the workplace safety and health of immigrant workers. For more information, contact Pietra Check at pcheck@cdc.gov.

WTC Health Program Updates

WTC Scientific/Technical Advisory Committee To Meet

On November 9 and 10, the World Trade Center Scientific/Technical Advisory Committee will hold its first meeting. The meeting will be held at the Jacob K. Javits Federal Office Building in New York, NY, and will be open to the public. For more information about the Scientific/Technical Advisory Committee and the WTC Health Program, visit the website at www.cdc.gov/niosh/wtc.

NIOSH Congratulates….

Kaori Fujishiro, Winner of CDC/ATSDR Science Award…
Dr. Kaori Fujishiro from the NIOSH Division of Surveillance, Hazard Evaluations and Field Studies received the CDC/ATSDR Behavioral and Social Science Working Group (BSSWG) award for Excellence in Behavioral and Social Science Research in Public Health at the BSSWG 6th annual awards ceremony in Atlanta in September. Dr. Fujishiro’s paper discusses various ways in which occupation can influence health, both positive and negative, and points out limitations in using occupational categories as a measure of socioeconomic status. The paper was published in Social Science and Medicine in December 2010 and is accessible at http://libproxy.cdc.gov:2073/science?_ob=MiamiImageURL&_cid=271821&_user=856389&_pii=S0277953610006908&_check=y&_origin=&_coverDate=31-Dec-2010&view=c&wchp=dGLbVlS-zSkzV&md5=a86ac4d135ba4d17debc527639b74f0f/1-s2.0-S0277953610006908-main.pdf.

Intervention Evaluation Contest Winners…
Winners of the of the NIOSH sponsored contest to recognize outstanding evaluations of interventions designed to prevent work injuries were announced in October at the National Occupational Injury Research Symposium (NOIRS) in Morgantown, WV. For the list of winners and more information on the contest go to /niosh/noirs/2011/contest2011.html.

Global Happenings

New Collaborating Centre Connection Available

The latest issue of Collaborating Centre Connection (CCC) is now available. CCC is a quarterly e-newsletter of the WHO Global Network of Collaborating Centres (CCs) in Occupational Health. It aims to communicate successes, opportunities, and developments in the Network while linking the various projects, CCs, project managers, and initiative leaders. For the most recent issue of the CCC newsletter and to subscribe, go to /niosh/ccc/.

News from Our Partners

New Published Findings From Massachusetts Show Decline In Sharps Injuries Rates

New findings showing the reduction of sharps injuries among employees in acute care hospitals have been published by the Massachusetts Department of Public Health. From 2002–2007, over 16,000 injuries among employees of 76 acute care hospitals were reported to the Massachusetts Sharps Injury Surveillance System. The annual sharps injury rate (injuries per 100 full-time employee equivalents) decreased by 22% over the 6 years, with significant declines in rates of injuries associated with both hypodermic needles and winged steel needles, two devices with injury prevention features that appeared to be increasingly used. The continued use of devices lacking sharps injury protections needs to be addressed, the authors said. (http://www.ncbi.nlm.nih.gov/pubmed/21558765)

OSHA Publishes New Safety Materials for Laboratory Managers and Workers

The Occupational Safety and Health Administration (OSHA) has published new educational materials for laboratory managers on protecting their workers from exposure to chemical, biological, and physical hazards. The materials include the document Laboratory Safety Guidance (http://www.osha.gov/Publications/laboratory/OSHA3404laboratory-safety-guidance.pdf), which describes how electrical hazards, fire, explosions, and falls, among other hazards, can be minimized or eliminated if employers use safety plans, worker training, engineering controls, and personal protective equipment. The materials also include fact sheets that each focus on a specific hazard related to laboratory environments. For more information, go to http://www.osha.gov/SLTC/laboratories/index.html.

Creating Healthy Organizations: Promising Practices in Kentucky

A new report by the University of Kentucky’s Institute for Workplace Innovation (iwin) highlights best practices in health and wellness initiatives that are taking place in Kentucky. The report documents 23 promising practices from Kentucky-based employers that aim to promote worker health and presents and describes the “HealthIntegrated Workplace” Model. This model illustrates the key dimensions and business processes necessary to create a workplace that promotes an integrated approach to worker health. The report was sponsored by NIOSH, CVS Caremark, and UK HealthCare. For more information, go to http://www.uky.edu/Centers/iwin/workplace_research/HealthyOrgReport.pdf.

Study Links Fast Food Dining to Work Hours

A study by the University of California, Davis, found that fast-food dining is most popular for those with middle incomes rather than those with lowest incomes. The study also found that people who worked more hours were more likely to go to both fast-food and full-service restaurants. Based on these findings, the authors say that policymakers and researchers may need to look beyond restaurant type for reasons for and solutions to the obesity epidemic. The study is available at online at http://www.liebertonline.com/doi/pdfplus/10.1089/pop.2010.0071 and will also be published in the December print edition of Population Health Management. The research was funded in part by the National Institute of Occupational Safety and Health.

New Health Hazard Evaluation Reports Now Available

Chemotherapy Drug Evaluation at a Medical Laboratory

HHE Program investigators evaluated concerns about potential adverse health effects associated with working with chemotherapy drugs at a medical laboratory. Investigators found that none of the employees interviewed reported chronic health problems related to their work. The work practices used for handling chemotherapy drugs were appropriate. Investigators did note that the chemotherapy drug and health effects training should be more specific to the work, and managers should provide employees with more information about chemotherapy drugs and reproductive health. HHE Program investigators recommended that employees follow all recommended work practices and personal protective equipment procedures.

Multiple Sclerosis Cluster Evaluation in an Inpatient Oncology Ward

Investigators from the HHE Program evaluated workplace exposures to acrolein, carbon monoxide, and chemotherapy drugs in a university hospital’s inpatient oncology unit. Employees were also concerned about recent diagnoses of multiple sclerosis in three nurses. Investigators found no association between the cases of multiple sclerosis and the work environment. Very small amounts of cyclophosphamide and ifosfamide, two chemotherapy drugs used in the unit, were found on some surfaces. This finding could indicate breaches in the handling of chemotherapy agents and the potential for hazardous drugs to contaminate the family area of the hospital. Levels of carbon monoxide were found to be well below occupational exposure limits, but investigators did determine that helicopter exhaust could enter the hospital ventilation system.

Links to the full reports from these investigations can be found at /niosh/hhe/whats_new.html.

New Fatality Assessment and Control Evaluation (FACE) Program Reports Now Available

New FACE Reports Available

Municipal Solid Waste Collector Dies after Falling from Solid Waste Vehicle Hopper Area
NIOSH investigators identified the following factors that led to the death of a municipal solid waste collector: failure to perform daily post-trip safety checks on waste collection vehicles and having timely repairs being performed, ensuring employees are never riding on the waste trucks’ rear steps when the trucks are traveling faster than 10 miles per hour or traveling more than 0.2 miles, the lack of a communication device that employees can use during emergency situations, the need for a job hazard analysis and a written safety program that includes safety training, providing an alcohol/drug free workplace for employees, and the need to consider the feasibility of implementing automated processes for solid waste collection. (/niosh/face/stateface/ky/10KY006.html)

Rigging Slinger Killed by Swinging Log in Yarding Turn
NIOSH investigators concluded that the contributing factors that led to the death of a rigging slinger were failure to get in the clear before any lines are moved and the lack of follow-up on training and supervision for safe practices, even with experienced workers. (/niosh/face/stateface/or/08OR007.html)

Logger Killed Under Rigging When Carriage Drops
NIOSH investigators provided the following recommendations based on the investigation findings: ensure machine anchors are rigged correctly, remove rigging hang-ups, stay clear of rigging, closely supervise new workers, and be aware of the effects of alcohol even many hours after consumption. (/niosh/face/stateface/or/06OR024.html)

Report from Annual FACE Meeting

The annual FACE meeting was held last month in Boston. Topics focused around green energy, worker impairment, immigrant/foreign born workers, and the great work and impact of the nine FACE states. Specifically highlighted was a Michigan FACE program case study related to bathtub refinishers and deaths occurring due to overexposure of methylene chloride while stripping bathtubs. This Michigan FACE investigation revealed an emerging issue and led to OSHA involvement. The next State FACE meeting will be held in Morgantown in the fall of 2012.

FACE Releases Report Using Digital Storytelling

The California FACE program recently released its first FACE Report using digital storytelling. View the video related to preventing wood chipper deaths at http://www.youtube.com/watch?v=7NKZM9IISEk.

New Fire Fighter Fatality Investigation and Prevention Program Reports Available

New Reports Available

Volunteer Fire Fighter Killed From Water Tank Explosion
NIOSH investigators concluded that the following factors contributed to the death of a volunteer fire fighter: use of a self-made water delivery system without an over-pressurization safety relief or other safety mechanism and inappropriate system components, limited written operating procedures and policies, inappropriate pressure gauge on the water delivery system for its intended use, and limited training in the use of the equipment. (/niosh/fire/reports/face201032.html)

Fire Apparatus Operator Suffers Fatal Heart Attack During Annual Medical Evaluation
The incident occurred while the Fire Apparatus Operator (FAO) participated in the Fire Department mandatory annual medical evaluation program that was scheduled while the FAO was on duty. NIOSH investigators concluded that the physical exertion involved in the exercise stress test probably triggered a heart attack resulting in the FAO’s death. (/niosh/fire/reports/face201104.html)

Fire Fighter Suffers On-Duty Sudden Cardiac Death
The incident occurred while the career fire fighter was working a 24-hour shift as the driver/operator of the tanker. During the shift he responded to two emergency calls. During the remainder of the shift, the fire fighter performed about 2 hours of physical fitness training. NIOSH investigators concluded that the physical stress of fire suppression activities and physical fitness training triggered a fatal heart arrhythmia. (/niosh/fire/reports/face201111.html)

Volunteer Fire Fighter Dies after Falling From a Rope
NIOSH investigators identified key contributing factors that led to the death of a volunteer fire fighter during a rope rescue training session: the lack of a designated safety officer, the lack of personal protective equipment, and an excessive student-to-instructor ratio. (/niosh/fire/reports/face201112.html)

NORA

Agreement Focuses on Safety for Wholesale Retail Trade Workers

In October, NIOSH and the Ergonomic Assist Systems and Equipment Council (EASE), a part of the Material Handling Industry of America (MHIA), signed a letter of agreement representing a commitment between the two organizations to help ensure the safety and health of workers in the wholesale and retail community. Under the agreement, the two organizations will collaborate and share information on occupational safety and health issues and promote appropriate engineering solutions to manual material handling jobs (see Manual Materials Handling Workshop). For more information on the agreement go to http://www.mhia.org/news/mhia/11085/ergonomics-assist-systems—equipment-council-signs-letter-of-agreement-with-the-national-institute-for-occupational-safety—health. For more information on Wholesale Retail Trade (WRT) Sector, contact the WRT coordinator, Vern Anderson, at vep1@cdc.gov.

r2p Corner

NIOSH and Loss Prevention Foundation Renew Partnership

NIOSH and the Loss Prevention Foundation (LPF) recently signed a new agreement to continue their partnership, which started in 2009. LPF is a trade organization serving the retail loss prevention industry in the United States. Since the initial agreement was signed, hundreds of retailers and wholesalers have received advance training under their certification program. The program has prepared LPF to address workplace safety issues with information supplied by NIOSH and other credible sources. For additional information, contact Vern Anderson at VAnderson@cdc.gov or visit http://www.losspreventionfoundation.org/.

Respiratory Protection Patent Issued

The U.S. Patent office has issued a patent for a new technology that can be used for respiratory protection. The technology—incorporating an optical fiber-mounted porous photonic crystals and sensors—was developed jointly by NIOSH and researchers at the University of California at San Diego. This technology enables remote sensing of environmental toxins and volatile organic compounds. It can be used for environmental sensing and as an end-of-service-life indicator in respiratory protection devices. For more information contact Jay Snyder at jsnyder@cdc.gov.

What’s new on the NIOSH Science Blog?

The Continuing Persistence of Silicosis

We invite your feedback on silicosis and other chronic work-related diseases that take years to develop, often showing up after retirement. Should more be done to determine how often these diseases occur? Or on prevention and treatment for people who have these diseases? We look forward to your comments. (/niosh/blog/)

Federal Register Notices

Public Comment Period Extension: Draft Diacetyl/2,3-Pentanedione Criteria Document

NIOSH is extending the public comment period on the draft document, Criteria for a Recommended Standard: Occupational Exposure to Diacetyl and 2,3-pentanedione, to Friday, November 18. Written comments were to be received by October 14. NIOSH received requests to extend the comment period to permit the public more time to gather and submit information.

Buy Quiet Workshop Public Meeting Announced

NIOSH will hold a Buy Quiet Workshop November 9–10 at the NIOSH Taft Laboratory in Cincinnati, OH, to determine feasibility and functionality of Buy Quiet programs and to explore proactive steps to ensure successful implementation. For more information or to register, go to http://edocket.access.gpo.gov/2011/2011-26867.htm.

Public Meeting to Discuss NIOSH Carcinogen and RELs Policies

As an important part of the NIOSH effort to review its cancer (carcinogen) and related policies on recommended exposure limits (RELs), a public meeting will be held Monday, December 12, in Washington, DC, at the Hubert Humphrey Building. The meeting will allow stakeholders and other interested parties to ask questions and provide comments to NIOSH. A Federal Register notice will be published in November announcing the meeting with details and instructions for registering to attend. A link to the FRN will also be posted when it’s available on the web topic page: NIOSH Evaluation of Its Cancer and RELs Policies. (/niosh/topics/cancer/policy.html)

For a full listing of NIOSH official publications for rules, proposed rules, and notices for 2011, go to /niosh/fedreg.html.

New Communication Products

Use of Non-Conforming Rock Dust in Underground Coal Mines Found!

In September, NIOSH determined that rock dust not conforming to the requirements for particle size and caking properties is being used in underground coal mines in the United States. The use of non-conforming rock dust reduces the protection from potential dust explosions. NIOSH provides information for mines and rock dust suppliers to help ensure that only rock dust conforming to the requirements is used in underground coal mines. (https://www.cdc.gov/niosh/mining/pubs/pubreference/outputid3622.htm)

Preventing Worker Deaths from Trench Cave-ins

Workers are at risk of death from cave-ins during trenching and excavation activities. NIOSH recommends engineering controls, protective equipment, and safe work practices to minimize hazards for workers (/niosh/docs/wp-solutions/2011-208/). Also available in Spanish (https://www.cdc.gov/spanish/niosh/docs/wp-solutions/2011-208_sp/).

Reducing Noise Hazards for Call and Dispatch Center Operators

NIOSH provides recommendations for prevention to workers at call and dispatch centers who may suffer health risks associated with high noise levels from their headsets, including sudden spikes in noise and stress. (/niosh/docs/wp-solutions/2011-210/)

Call for Papers

2012 National Health Promotion Summit: Prevention. Promotion. Progress.
Call for Abstracts. Deadline for submission extended through November 9th. (http://www.aptrweb.org/2012summit.html)

XXXth International Symposium of the ISSA Construction Section on Occupational Safety and Health in the Construction Industry
Call for papers. Deadline for submission is January 15, 2012. http://www.issaboston2012.org/callforpapers.html

Upcoming Conferences & Workshops

5th International Entertainment Education Conference (EE5)
November 17–20, New Delhi
http://www.ee5conference.org/home

The 16th Annual Safety Seminar for Underground Stone Mines
December 6–7, Louisville, KY
/niosh/mining/calendar/images/Brochure-508.pdf

Engineered Solutions for Manual Handling Jobs
February 8–9, 2012, Atlanta, GA
http://www.modexshow.com/education/mmhWorkshop.aspx?ref=attendees

Association of periOperative Registered Nurses 59th Annual Congress—Look for us Booth 6053!
March 24–29, 2012, New Orleans, LA
http://www.aorncongress.org/

A comprehensive list of upcoming conferences can be found at /niosh/exhibits.html.

Word of the Month

Total Worker Health — Total Worker Health is a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being. More information on the program is available at /niosh/TWH/