Proceedings of the

Workshop on Needs

and Resources for

Occupational

Mortality Data

This report contains the proceedings of

the Workshop on Needs and Resources

for Occupational Mortality Data, January

21-22, 1987. The Workshop was

sponsored by the National Center for

Health Statistics, the Bureau of Labor

Statistics, and the National Institute for

Occupational Safety and Health. The use

of industry and occupation data from

death certificates and the history of

coding these data in mortality data bases

are reviewed. Options for future

occupational motiality data coding are

developed and discussed by agency

representatives and working groups of

Workshop participants. Evaluation of the

options include cdteria of timeliness,

geographic and occupational coverage

and detail, data quality, surveillance

capability, cost, and relevance to State

and national research.

Documents and Committee Reports

Series 4, No. 26

DHHS Publication No. (PHS) 88-1463

U.S. Department of Health and Human

Services

Public Health Service

Centers for Disease Control

National Center for Health Statistics

Hyattsville, Md.

August 1988
Copyright information

All material ●ppearing in this report is in the public domain and may

bc reproduced or copied without pemtiaaio~ citation aa to source,

however, is appreciated.

Suggested citation

National Center for Health Statistic. 1988. Proceedings of the

Workahopon Neadaand Resourcea for Occupational Mortality Data.

Vita/ ●nd Health Statistics. Series 4, No. 26. DHHS Pub. No. (PHS)

88-1463.

library of Congress Cataloging-in-Publication Dots

Workshop on Noeda and Resources for Occupational

MoRality Dsta (1 987: Washington, D.C.)

Proceedings of the Workshop on Needa and Resources

for Occupational Mortality Data, January 21-22, 1987.

(Vital & health statiatica, Series 4, ,Documents and

committee reports : no. 26) (DHHS publication ;

no. (PHS) 88-1463)

Supt. of Doca. no.: HE 20.6209 :4f26

Irrcludea bibliographies.

“’The workshop was sponsored by the National Center

for Health Statistics, Bureau of Labor Statistic, and

the National Institute for Occupational Safety and

Health.”

1. Occupational mortslity-Statistics-Congresses.

2. Death—Proof and certification-Congresses.

L National Center for Health Statistics (U. S.)

IL United States. Bureau of Labor Statistics.

HI. National Institute for Occupational Safety and

Health. IV. Title. V. Series Vital and heslth

statistics. Series 4, Documents and committee repons ;

no. 26. VI. Serie= DHHS publication; no. (PHS) 88-1463.

HA37.U1 693 no. 26 362.1 ‘0723 a 88-600196

[H81323.P6] [363.1 ‘12’0723]

ISBN 0-6406-0393-2

For sale by the Superintendent of Documents. U.S. Government Printing 0r3ce, Washington, D.C. 20402
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate DiwctorjbrAna@zk

and Epiiiemwlogy

Gail F. Fisher, PhJ3.,Asso&te Dihxtor for Planning ond

Extmmural l?mgm?ns

Peter L. Hurley, Associute Director forVi and HeaZth

Statistics Systems

Stephen E. Nieberdirg Associate Dktor for blan~ent

George A. S&m&Associate Diwctor forData Processing

and Se?w”ces

Monroe G. Sirken, Ph.D., Asswiate DiYvctoTfor Reseamh

and Methodology

Sandra S. Smith, Information O&w

Office of Analysis and Epidemiology

Jacob J. Feldman, Ph.D., Associate Dinxtor

Division of Epidemiology and Health Promotion

Ronald W. Wilsq Director

Patricia M. Golden, S’cialAssistant

Ronald W. Wilson, Acting Chiej Envibunental StudkY

Branch

Patricia M. Golden, Actikg Chie$ Health Status

Measurement Bnmch
Foreword

~“s report includes the proceedings of a Workshop

devoted to the improvement of statistical data related to

occupational safety and health. These activitieswere sponsored by the three agencies that entered into the formal

bipartite Memorandum of Understanding at this Workshop: the Bureau for Labor Statistic%the National Institute

for Occupational Safety and Health, and the National

Center for Health Statistics.

The Workshop was organized by the National Center

for Health Statistics. Special thanks go to Dr. Patricia

Buffler. Other members of the Workshop planning group

include Dr. Bruce (Xhen, Dr. Haq Rosenbe~ and Mr.

Jeffrey Maurer km the National Center for Health Statistic; Dr. Gilbert Beebe and Dr. Thomas Mason from the

National Cancer Institutq Mr. Harvey Hilaski from the

Bureau of Labor Statistic and Mr. Todd Frazier from the

National Institute for Occupational Safety and Health. The

Workshop proceedings were prepared under the direction

of Dr. Diane Wagener. Special thanks also are given to

Dr. Jacob Feldman for filling in for Dr. Manning Feinleib

who was suddenly hospitalized the day before the Workshop. In additioq we particularly appreciate the work of

Ms.Jane Schienle from the Bureau of Labor Statistics and

Ms. Madelyn Lane and Ms. Dorothea Donahue fkom the

National Center for Heiilth Statistics,who took care of the

many administrative details of the Workshop.

Finally,the role of the weather must be recognized.At

noon on the second day, the Workshop came to a premature end because of one of the heaviest snowstormsto hit

Washington D.C., in recent years. Therefore, most of the

discuAoxw pos-”ptsj and summary statements in these

proceedings are not from the transcript but from comments

prepared after the Workshop.

Ronald W. Wilson, Director

Divisionof Epidemiology and Health Promotion

Office of Analysis and Epidemiology

National Center for Health Statistic

iii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

... m

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter I. Plenary Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Greetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Needs and resources for occupational mortality data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reviewof activities National Institute for Occupational Safety and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Review of activities Bureau of Labor Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Review of activities and conference objectives:National Center for Health Statistic

Figure 1. U.S. Standard Certificate of Death

. . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tables

1. Deaths of men 20-64 years of age of races other than white with work experience,from selected causes of

death, by major occupation group, age, and standardized mortality ratiox United State%1950. . . . . . . . . . . . .

2. Observed numbers of deaths and standardized mortality ratios (SMR) for selected occupational groups

exhibitingexcessmortality from malignant and nonmalignant rcspirato~ disease for males aged 20-64 yearx

United States, 1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Growth in number of reporting areas adopting uniform occupation and industry coding procedures . . . . . . . .

Utah’s experience in building an occupational health surveillanceprogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

2

3

7

9

11

13

12

14

14

16

Chapter IL Review of options for producing ~upational mortality data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Option No. 1 Existing system:Occupational mortality coding at the National Center for Health Statisticsfor 20.

States (Annual) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Option No. 2. 13qxmdingthe existingsystem to all States (Annual) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Option No. 3. Data for all States in census years only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Option No. 4. Subsets of causes or subsets of States (Annual) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Option No. 5. Mortality followbacksumys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Option No. 6. Followup of general population surveysusing the National Death Index . . . . . . . . . . . . . . . . . . . . . . 23

Option No. 7. Followup of targeted National Center for Health Statistics surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Option No. 8. Cohort followup of national study groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Option No. 9. Records systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Option No. 10. Use of compressed vital statistics files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Table 4. Synopsisof options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Chapter III. Working group reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Objectivesfor working groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Figure 2. Data resources for occupational sumeillancc and research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Report from Working Group No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Report from Working Group No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Report from Working Group No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Report from Working Group No. 4

34

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Discussions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Summary of recommendations from participant questionnaires. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Chapter IV. Postscriptshorn sponsoring agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postscripfi Bureau of Labor Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Postscript: National Institute for Occupational Safety and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Figure 3. Sentinel event notificationssystem for occupational risks (SENSOR):-1987 . . . . . . . . . . . . . . . . . . . . . . . . 48

v
Table 5. Surveillance activities for occupational disease reported by health departments in 50 States, New York

City, and Washington, D.C.: 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Postscript: National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Appendixes

I. Memorandum of understanding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

IL Workshop participant questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

III. Workshop participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

VI
Proceedings of the

Workshop-on Needs and

Resources for

Occupational Mortality

Dataa

Introduction

On January 21, 1987, a Memorandum of Understanding (appendix I) was signed by the Bureau of Labor

Statistics (BLS), the National Center for Health Statistics

(NCHS), and the National Institute for Occupational Safety

and Health (NIOSH) to work collaboratively in the development of improved reporting systems and surveillance of

occupational illness and injuries. The occasion of the signing was used to convene a workshop (January 21-22, 1987,

in Washington, D.C.) to explore the needs and resources

for occupational mortality data. This volume includes the

proceedings of that Workshop.

Surveillance and research in the areas of occupationally

related illness and injury are important areas for health

poliq. According to Langmuir (1976), “good surveillance

does not necessarily insure the making of the right decisio~

but it reduces the chances of making the wrong one.” Ml

three agencies (MS, NCHS, and NIOSH) have been collecting data relevant to surveillance and research of occupationally related illness and injury. NIOSH has identified a

spectrum of Leading Work-Related Diseases and Injuries

‘Workshopsponsored byNationalCenterfor Health Ststisti~ Bureau of

Labor Statistics and National Institute for Ckupstional Safety and

Health.

that necessitates the collection of health data fkom early

symptoms of disease to clinical illness to death. The development of a coordinated national strategy to obtain these

data may require the use of several different complementary data systems.

The purpose of the Workshop was to review the collection and use of data regarding mortality risks by occupation

and industry and to develop recommendations regarding

future direction. A variety of options focusing on data

collected by NCHS and the States were reviewed, and the

participants then evaluated these options in working

groups. Evaluations included the following criteriz timeliness, geographic and occupational coverage and detail, data

quality, surveillance capability, cost, and relevance to State

and national research. The working groups then reported to

the Workshop. In addition, a questionnaire for the evaluation of each of the options was given to the participants, and

the comments that were returned were reviewed in these

proceedings.

Reference

Langmuir, A. D. 1976.WilliamFam Founder of modem concepts

of surveillance. h. J. Epidetm”ol.5(1):13-18.

1
Chapter 1.

Plenary session

Greetings

by Ronald Wilson, Director, Division of

Epidemiology and Health Promotion,

National Center for Health Statistics

I would like to weleome you to this first Workshop on

Needs and Resources for Occupational Mortality Data.

This Workshop is a collaborative effort among the National

Center for Health Statistics (NCHS), the National Institute

for Occupational Safety and Health (NIOSH), and the

Bureau of Labor Statistics (KS). We hope that it will be

the first of a number of such workshops dealing with issues

related to occupation and health. The immediate concern

of this Workshop is the issue of the coding of occupation

and industry on the death certificate and the fiture of this

activity at NCHS.

In 19S0, the National Cancer Institute and NIOSH

provided NCHS with the funds to implement coding of

occupation and industry on death certificates for a limited

number of States with the hope that this developmental

project would lead to producing occupational mortality

data from the death certificates on a routine basis. Later

this year, NCHS will make available mortality data tapes

with the occupation and industry codes for 16 States that

participated in this program during 19SS.

At this Workshop, we want to identify the needs

current and future use% and resources available for the

continued inclusion of occupational and industry information in the mortality data systems of NCHS. We have

partieipanta from the Federal Government, State govemmen~ industry, labor, and academia at this conference. It

is hoped that, with this broad participation, the Workshop

will develop recommendations that will identi& many needs

and eoncerna regarding these mortality data.

2
Needs and resources for

occupational mortality data

by BailusWalker,Jr., Ph.D., M.P.H.,

(%mmissioner, MassachusettsDepqtrnent of

PublicHeatth

At the outset, allow me to commend the Bureau of

Labor Statistics (BLS), the National Center for Health

Statistics (NCHS), and the National Institute for Occupational Safety and Health (NIOSH) for their continuing

efforta to prevent occupational disease and disability.The

dvities of these three Federal ageneies are reinforcing

our efforts at the State level. Their teehnical assistan~

grant%and other forms of help have enabled us to pursue

signiikant risk management programs, including worker

education, in our States and in local communities.

This is indeed an appropriate time to evaluate the

needs and the resources for developing ocwpational mortality data because we are recognizing at more frequent

intervalsthe numerous and complexissues surrounding the

identification and recognition of occupational diseases. At

the same time, we are constantly reminded that the prevention and control of workplace risk rquire that we have in

place comprehensive systemsto ‘&ptureoccupational morbidity and mortality data The development of suck systems

cannot proceed very far without sincere Federal and State

cooperation.

I want to offer a State perspective from the vantage

point of not only my Massachusetts public health portfolio

but also my membership on the National Academy of

Sciences and the Institute of Medicine’s Commission for

the Study of the Future of Public Health in the United

States. II& group was established last year by the Institute

of Me&ine to examine a broad range of public health

issues and problems and to make recommendations for

future positive directions for public health. It has held

public hearings and collected a significantvolume of information.

Even to the most casual observer, it is elesr that we

have made significantprogress in the prevention and control of occupational disease and dysfunctionsince 1910,the

year Alice Hamilton, one of the pioneers in occupational

health, was in Brussels attending a conference on occupational disease. At that conference, the Belgium delegate

walked up to her and said, “In the United States, occupational disease prevention and control activities do not in

fact exist.” According to Hamilton, she could not at that

time find papers published on industrial poisoning. Employers eager to improve conditions in the workplace could

find ve~ little advice from medical experts at that time

because little progress had been made in the area of

industrial hygieneand in the monitoring and sumeillanceof

occupationallyrelated diseases.

The literature is far more complete now, and it provides us with ample evidence that work-related diseases

must continue to be among our highest public health

priorities. Indeed, lle 1990Health Objectivesfor theNatkwx

A Midcourse Review (Public Health Semite, 19S6), published in late November of last year, underscores the fact

that the nearly 104 million men and women who make up

the workforce of the United States sustain an estimated 10

million traumatic injuries on the job each year.

It is important at the outset of this Workshop to

recognize that when we discuss occupational health and

safety, we are dealing with an expanded universe. In the

1%0’s and 1970’s many of us watched the field of health

and safety grow from one that was primarily concerned

about injuries and acute poisonings to one that included

concern for a broad spectrum of chronic diseases

dysfunctions-most notably, cancer. Today, we eontinu~d

confront mounting evidence of reproductive disorders

caused by workplace exposure% and we are increasingly

aware of clinical and subclinical necrologic dysfunctions

caused by workplace stressors. In addition, occupational

asthma and cumulative trauma disordera must be recognized as substantial occupational health problems.

On the horizon, but not yet fully acknowledgedin this

countxy,is the entire realm of stress-related health problems such as peptic uleer~ hypertension, and emotional

disorders, that can be attributed to working conditions.This

expandeduniverse of health problems is exph.incdby a new

awareness of longstanding concerns of health and work

conditions and by the changing nature of work and workplaces.

Indeed, entirely new technologies and materials are

being rapidly introduced without sufficient regard to their

potential impact on human health. Fm will debate that the

challenge to prevent work-related diseases is today a substantial one. I submit that sumeilkmee of health conditions

and the workplsee is an essential part of our prevention

effort. We m~ I believe, develop sensitive and timely

sumeillance systems to identify work-related health problems for targeting research and for intervention acclivities.

BUL here ag~ l’he 1990 Health Objectivesfor the

N&m A MiiicoumeReview (Public Health Sewi~ 19S6)

points to deficienciesin the system.For example,one of the

objectiveswas the elimination of occupational heavymetal

poisoning by 1990. Aczmding to the midcourse repo~ no

data are available to messur~ either directly or indirectly,

progress toward obtaining this objective. Because no data

are available, it is not posd%le to evaluate the likelihood

that this objectivewill be reached by 1990.

Another objective stated that .at least one question on

lifetime work history and known exposure to hazardous

substances should be added to all appropriate existing

health data reporting systems. This objective was not

achieved by 19S5. It k however, an important practical

measure that is now in effect in many States.

Sumeillsnce must not be limited to the monitoring of

health conditions with well-established occupational etiologies. It must also enable us to generate new hypotheses, to

ident~ newproblems, and to develop more effectiveinterventions. Omupational illness and injury surveilkum

should provide us with the numbers that we need to justify

our policies and programs and to carry them out.

3
But before we focus on the needs and resources of

omupational mortality dat~ we need to broaden our scope

here to note that there is a necessity to develop a comprehensive surveillance program utilizing a variety of information from different data sets.

There are many smveilhmce mechanisms that have yet

to be used. This year in Massachusetts, with NIOSH support, we have assembled an interagency task force to

identifj existing data sources that might be employed for

occupational illness, injury, and hazard surveillance at relatively low additional costs. We are, for example, evaluating

the utility of workers’ compensation records, clinical laboratory reports, health maintenance organization data bases,

and a broad array of data systems on the health of infants

and children and the general population in Massachusetts.

We are looking ve~ closely at right-to-know data and

pollution data for both indoor and ambient air. We are

scrutinizing vmy carefully the regional Occupational Safety

and Health Administration’s data and our own State inspection reports. And we are exploring the feasibility of

using the comparatively large number of occupational

health clinics in Massachusetts for the surveillance of workrelated lung disease and dysfunction.

We have also initiated, with NIOSH support, a pilot

program to assess the feasibility of occupational disease

reporting by sentinel physicians. It is within this broad

context that we must evaluate the need and the resources

available for gathering occupational mortality data.

In our enthusiasm for new and innovative sumeilhuxx

mechanism% however, we should not underestimate the

value of death certiikate information. Despite certain inaccuracies and limitations, death certificates remain one of

the major sources of data on the health status of the

population.

In Massachusett& we are fiiding that these certiflxtes

are reasonably reliable and that they are accurate as indicators of the occurrence of certain diseases that are significant in the context of the health effects of the environment,

including occupational environment.

Our experience indicates that death certificates can

provide the information required for defining death iiom

specified causes over time and idcntifjing variations between geographic sections of our State. These analyses are

most helpful in planning and in implementing programs for

prevention and control. “

Population-based occupation and industry data are

very difficult to obtain in a timely and inexpensive way.

Beeause of thi~ death certificate statements of usual occupation and industry would appear to be an attractive solution to this problem. Frazier and Wegman (1979), Frazier

(1982), and Beebe (1981) have emphasized the ptential

usefulness of an occupational health surveillance system

based on death certificates. Others have demonstrated that

the analysis of death certificates is a relatively simple and

low-cost means of generating leads about work-related

health problems.

In Massachusetts, we are currently coding the occupation and industry information contained on our death certificates and, again with NIOSH support, we are analyzing

these data to identi$ potential work-related health problems. We are concerned about occupational asthma and

chronic solvent poisoning and reproductive outcomes. But

we are also concerned about cancer and acute myocardial

infarction and fatrd injuries—outcomes that we can explore

using death-certificate data.

Today we should not be debating whether occupational

mortality data can be used, but rather, we should be asking

ourselves to what extent we should code and analyze available industry and occupation information. Before we can

answer this question, a series of preliminary questions

directed to the Federal agencies need to be addressed.

● Whathadth conditions can be monitomd by death cerh~

icates? Given these conditions, what alternative surveillance mechanisms an? mwdi/y available? What am the

companrtive costr?

For example, in Massachusetts, we are currently evaluating the use of cancer registry data for occupational

cancer surveillance. We know that the diagnostic information in the cancer registry is more accurate than deathcertificate diagnoses, but the occupational information is,

thus far, less complete and more highly dependent on the

medical community’s inclusion of the occupational data in

patients’ medical histories. Not all States have cancer registries and not all cancer registries include occupational

information.

● Am them &oes of industriesfor which death certificates

tae pen+aps the best available souxe of information?

Industries with small workplaces-for example, gas

stations and automobile repair shops-are diflicult to study

using cohort methods.

● What an the i%dtations in the accumqy of death certi~-

cate &ata? Am these limitations inherenb or am them

pmspect3for imprmementin data qudip?

That iq will the forthcoming 10th Revision of the

International Cktssification of Diseases enhance diagnostic

precision? Can we improve on the occupational information being prcAded, for example, by funeral directors?

I am very tempted to ask whether wc have the resources to follow up the leads generated by death certificate

analyses, but I hesitate to judge the long-range value of a

data system based on the short-run commitments to occupational health of some segments of the present administration.

. What m the alternatives to natbwidg routine codbg

and analysis of occupationalmatality data? What aw

theu cosfi, including oppo~nity costs?

One alternative that has been proposed is the analysis

of data only for years coinciding with the decennial census.

Will this approach provide sufficient data to analyze small

industries concentrated geographically, such as the jewehy

industry in Rhode Island? Who will code this information?

Clearly, it does not make much sense to mount coding

4
capabilities in the States on a sporadic or catchas-catch-can basis. Can these data be disaggregate back to

the States and used for State-specific studies? We have

approximately 55,000 deaths per year in Massachuse@,

and we estimate that we need, at a very minimunq 3 years

of occupational mortality data for meaningful analysis.

Another proposed alternative is to select a representative sample of States to provide data for nationwide statistic. Most certainly, in choosing only several States, we will

lose information on certain geographically concentrated

occupations and industries. Will sample dat% for example, ,

provide us with sufficient information to tiamine mortality

patterns in minority groups? I am constantly appalled by

the inadequacy of health data to provide meaningful information about minority health-information that will enable

us to develop policies and programs designed to address

minority health issues.

● Can we taget tidustries and occupd”ons of interest by

fwing on specifi geogmphic locations? And who will

decde what ir “of iittemt?”

How can we make use of NCHS survey data? he

survey samples large enough to allow for meaningful occupational morbidity analysis?

● At thti juncture, can we develop an automated systemfor

coding occupation and industty information accotiing to

the US. Bureau of the Census classification scheme? I

understand that it would be impossible to code 100

pexent of the data by compute~ but wouldn’t it be

possible to code a significant percentage?

k our view, an automated coding system would result

in more standardized information and would substantially

reduce long-term coding costs. Additionally, such a system

could be applied to multiple data sets used by a variety of

agencies, including many represented here today.

As we consider the prospect of nationwide coding it is

inappropriate to envision coding systems based on old

models—people in offices shuffling paper forms. It is 1987,

we are in the midst of an information processing revolution

with highly sophisticated technologies. Although previous

attempts to automate coding have been limited, perhaps

now wc can move forward. Whatever type of surveillance

system we consider, though, whether it involves death

certificates, survey data, clinical data, compensation claims,

or health maintenance organization data, we will certainly

need to code industry and occupation information.

. What are the roles of the vmious Federal agencies and

State governments?

Essentially, the options that we are considering require

additional data gathering and analysis by the Federal Government. And yet, I think that the bleak realities we face in

Federal budgeting make this somewhat difficult. I would

hope that history would not repeat itself. In the period of

concern about the Federal deficit, I cannot resist the temptation to quote from a letter Alice Hamilton wrote to her

sister in 1914 about the inability of the Bureau of Labor

Statistics to pay her for her occupational health studies.

Hamilton wrote: “They are so poor they cannot make a

contract with me for an investigation of rubber, but I mean

to do it anyway and trust to their making it in July, the new

fiscal year.”

I would hope that Janet Norwood’s Bureau of Labor

Statistics is more affluent today than it was when Alice

Hamilton was on its payroll.

But I think it is important that there be a kind of

collaboration. States are extremely hesitant to incorporate

any additional data components into the Vital Statistics

Cooperative Programs until the basic components have

been adequately funded for all States. ,States, however,

need to consider the value of coding occupational information for their own purposes as opposed to relying on

Federal statistics. Our experience in Massachusetts would

indicate that State-specific information provides more immediate direction for State research and intervention efforts. Clearly, it has a greater impact on our State

legislature.

In the last 6 months in Massachusetts, we have had

requests for occupational mortality data from unions, a

large number of requests from academicians, and an inordinate number of requests from health care providers. We

have used occupational data to elucidate the geographical

distribution of cancer, which we analyze routinely as part of

our environmental surveillance program.

Clearly, from our experience, there is a user constituency. By providing information and periodic report% we

increase that constituent, and in doing so, we gain support

for our programs.

In conclusion, let me stress the need for collaboration

between Federal agencies and the States. I commend the

joint efforts of the agencies represented here today. I

believe sincerely that these seminars and workshops are

extremely helpful. And I suggest that, until we have a

better, readily available source of information, the use of

occupational mortality data is an essential component of

any comprehensive effort in occupational medicine.

A 1986 report to Congress by its Committee on Government Operations was entitled Occupational Health Hazard Swveillance: 72 Years Behind and Counting (U.S.

Congress, 1986). The overriding question is not can we

afford to code occupational mortality data but can we

afford not to?

References

Beebe, G. W. 1981. Record linkage and needed improvementsin

existing data resources. Quantificationof OccupationalCancer.

Banbwy Report No. 9. Cold Spring Harbor Laboratory.

pp. 661-673.

5
Frazier, T. M.: 1982. The use of national and State data systems Public Health Service. 1986. 7he 1990 Health Objectives jbr the

for occupational health .swveilkmce. EnvinmnentaZ Epidenu”o@y, Nadon: A Midcowse Review. Washington: U.S. Government

edited by P. E. Leaverton. New York Praeger Publ. pp. 121-127. Printing Office.

Frazier, T. M., and D. H. Wegman. 1979. Exploring the use of U.S. Congress. 1986. House of Representatives. Occupational

death certificates as a component of an occupational health Health Hazard Surwillance: 72 Years Behind and Counting. House

surveillance system. Am. J. Public Health 6Ck718-720. report 99-979. Washington: U.S. Government Printing Offk.

*

6

.
Review of activities: National

institute for Occupational Safety

and Health

by J. DonaldMillar,M.D., Director,National

Institutefor OccupationalSafetyand Health

Introduction

It is a real pleasure for me to be here with you for this

Workshop on Needs and Resources for Occupational Mortality Data. I am proud to be associated k tiis wifi Dr.

Manning Feinleib and Commissioner Janet Norwm& who,

as true leaders in international statistical circles, have done

so much to provide this Nation with sophisticated data on

our health and work. Also, I appreciate the kind introduction by my good friend and colleagu~ Ronald Wilson.

Among his many duties is service with me on the Subcommittee on Environmental Health Risk Assessment of the

Public Health Service Committee to Coordinate Environmental Health Related Programs. In the Subcommittee, we

grapple with some tough issues in quantitative risk assessment, and we know well the need for sound data.

It is good to be here with many colleagues from the

State health and labor departments, where so much of the

real work in statistics is done. When I was serving as

Director of the Bureau of State Services, I heard from State

offickds a constant refrain-”We sure wish you Feds would

get your acts together and give us a consistent message!”

Well, the tripartite Memorandum of Understanding among

the National Center for Health Statistics (NCHS), the

Bureau of Labor Statistics (BUS), and the National Institute for Occupational Safety and Health (NIOSH) that will

be signed today is aimed’at that very purpose. We are vexy

intent on getting our acts together in, as is stated in the

Memorand~ “... improving occupational illness and injury reporting systems and surveys.”

It is grati@ing to me that the first highly visiile c0lh3borative action to be taken by us under terms of the Memorandum (paragraph II-8) is to bring together our partners

from the State& busine~ labor, and academia. & long as

we are getting things coordinated, it makes good sense for

us all to do it together. Please note that this Workshop

could be put fonvard as Workshop number one, suggesting

it is the first of many. I hope so. It is an important beginning

in making utilitarian sense out of a myriad of activities that

are rich in complexity and diversity, but not in unity.

The movement

This meeting and the formal collaboration of NCHS,

BLS, and NIOSH result from a growing national movement

of people who recognize the need for sound information on

the relationship of occupation and health-or, more precisely, the relationship of occupation to injury, disease,

disability, and death. Two congressional hearings on the

subject of the surveillance of occupational disease within

the last 18 months testify to the strength of this growing

awareness. Until recently, it would have been unthinkable

that a subject so seemingly esoteric and technical would

have attracted such congressional attention. For this we are

indebted to concerned activisb such as Eric Frumin of the

Amalgamated Clothing and Textile Workemj AFL-CIO,

who is here today. He and othera have pushed this idea of

occupational disease suweillance with enthusiq imaginatio~ and effectiveness.

Dreamscomingtrue

It would please me if this Workshop is seen in the

minds of some here as solid evidence of the incipient

realizadon of dreams long nurtured. Within NIOSH, for

example, I think of Todd Frazier, who has labored long

hard, and diligently over the past 15 years to encourage,

stimulate, and nourish the surveillance of occupational

diseases and injuries. Todd the seeds you planted have

begun to bear the fruit of national attention.

What NIOSH is doing

Within NIOSH, the surveillamx of occupational disease and injury is now proceeding across the organization.

Within five of our seven divisions-in both Cincinnati and

Morgantown-there are specMc surveillance programs. I

am proud of all this activity by NIOSH professional%

including those in attendance here John Sestito, Patricia

Honchar, Carol Burnett, Robert Mullan, Michael Moll,

David Brow and Dennis Bregman. Moreover, Dr. James

Meli~ whose Division of Surveillance, Hazard Evaluations and Field Studies is most visiily associated with

surveillance, will chair a portion of the Workshop.

Last week in Morgantown, we presented our annual

Program Review of NIOSH to Dr. James O. Mason,

Director of the Centers for Disease Control (cDC). In my

judgment, it was the best program review by NIOSH since I

first got involved with NIOSH as acting director in 1978.

Included in the review was a presentation by Dr. Moll of

preliminary resuks of a new surveillance effort. He presented an analysis of all death certificates for occupational

fatalities during the years 1980-84. Straightforward and

fairly simple preliminary analyses revealed striking evidence of a hitherto unidentified epidemic of occupational

deaths among female workers due to homicide in the

workplacq the results also showed that for most States in

this great hmd agriculture is the occupation associated with

the highest rates of occupational mortality. For whatever

r-n, I had not expected that. His presentation graphically contirnmd the point made earlier, that there still are

important “leads””to be had in the collection and analysis of

mortality data.

Because our surveillance activities in NIOSH have

become so widespread and varied, I recruited Dr. Edward

Baker from Harvard University onto our headquarters’

staff as Assistant Director of NIOSH. He is one of the

outstanding young figures in occupational medicine. I gave

him a spedc charge to develop a comprehensive plan for

surveillance activities in NIOSH and asked him to coordinate our activities in accord with the plan. That plan was

7
developed, many of you have had input into it, and we are

going about its implementation,

Surveillance in the national prevention

strategies

As many of you know, because you were there, NIOSH

convened two national symposia on the Prevention of Leading Work-Related Diseases and Injuries, one in Atlanta in

May 1985 and the secxmd in Cincinnati in October 1986.

Both were attended by 450-500 of the Nation’s top professionals in occupational safety and health. They came born a

wide variety of organizational settings. In these symposi~

we introduced for discussion and modification, by these

professionals, 10 proposed national strategies for preventing each of the 10 Leading Work-Related Diseases and

Injuries-one strategy for each entry on the list.

This process has been exhilarating to me personally,

and it has given rise to a unprecedentedly broad-based

understanding of what needs doing to reduce the burden of

the Nation’s most important occupational health and safety

problems. In all of these strategies-each 1 of the 10–the

Nation’s experts called specifically for epidemiologic surveillance of the target conditions. In 9 of the 10 strategk+

they also called specifically for environmental smveillance

of the causative agents associated with the condition.

In responding to this ringing endorsement of the need

for better surveillance, we have reinvigorated our notions of

.eventually having in this country a comprehensive system

that wotid result in the reporting of all significant health

problems associated with occupation. The concept also now

has a name, SENSOR, which is the acronym for

Sentinel

Event

Notification

System, for

Occupational

Risks

Many aspects of this concept await full elaboration, but

at least we have the dream and a name for it. You will hear

more about it horn Edward Baker.

The big question

Withall the national interest generated in surveillance

of occupational health problems, there is now a big and

somewhat scary question posed by our many interested

allies “Now that you have our attention, what are you

going to do about this thing called surveillance?” It is a

challenge we cannot afford to fumble.

Action–The reason for data

In the Statement of Purpose for this meeting there is a

quote by Dr. Alexander D. Langmuir, for many years the

Nation’s premier epidemiologist and Director of the Epidemiology Program, Centers for Disease Control (CDC). He

was my boss the first 5 years I was in the Public Health

SeAce. In epidemiologicrd circles, he is justifiably called

the “Father of Disease Surveillance in America.”

Beginning in the early 1950’s, under Dr. Langmuir’s

leadership, CDC and its components have pioneered effort

after effort in the suweillance of human health events.

These encompass a very wide array from classical infectious

diseases such as poliomyelitis and influenza to chronic

diseases such as lead poisoning and cardiovascular disease

to conditions that go beyond the definition of “disease” such

as abortion and sudden intknt death syndrome (SIDS). In

discussing surveillance, hc often said something akin to the

following

Surveillance is done for the sake of action-preventive

intervention if possiile-if not, at least analysis and

meaningful reporting back to those who collected the

data. Unless you are prepared to act on the dat~

surveillance is an unconscionable waste of resources.

We in NIOSH are interested in surveilkmce-sudllance for the sake of uction, surveillance for the sake of

pmventhfi and sumeillance for the sake of erutiicatt”on, if

possiile, of at least some occupational diseases and injuries. We, all of us here, now have the Nation’s attention to

the need for sumeilhmce of occupational diseases and

injuries. We have a priceless and probably fleeting opportunity to move forward briskly, intelligently, and together.

Let’s make the most of it!

8
Review of activities: Bureau of

Labor Statistics

by Janet L Norwood, Ph.D., Commissioner,

Bureauof Mm Statistics

Let me first say that I think that occupational safety

and health is probably the most imprtant issue in the labor

market today. Jobs are important. Income is important.

And there are a lot of other issues. But if we cannot have a

safe and healthy workplace, it really does not matter to

workers what happens otherwise.

Occupational safety and health information is essential

to bringing about a safer and healthier workplace and to

preventing the problems Dr. Millar was talking about. The

economy today is changing and I believe the changes are

going to make it harder, not easier, to get good data. Our

whole industrial economy is being restructured. Our manufacturing industries are becoming more efkient by removing from production many old, inefficient, and,

Perhapq unsafe and unhealthy plants. At the same time,

new technology is being put in place, and new substances

are being used in the manufacturing process. We are

creating a large number of jobs. In fact, in the past 49

months of reeovery, we have added 12 million new jobs to

the economy in different industries, activities, and occupations than before. We are, in fact, in the midst of change—

both industrial and omupational. We need to take these

changes into account if we are going to be looking at data

on occupational safety and health.

What does this mean to us who are here today? We

recognize the tremendous responsibility to develop information that can be used to establish public policy, to inform

our citizens, and, for those who have responsibility to do so,

to take preventive action. A number of these issues will be

discussed here today. At the Bureau of Labor Statistic

(BLS) we have had a program providing information on

safety and health for a long time. When the Occupational

Safety and Health Act was passed, the Secretary of Labor

delegated the statistical requirements of that act to the

Bureau of Labor Statistics. More than 10 years ago, we

began a system of recordkeeping in establishments and a

survey of business establishments-2S0,000 every year. We

have a Federal-State cooperative relationship to develop

consistent data from business establishments and from

administrative records. We have also started a series of

work injury surveys to provide data to the Department of

Labor for regulatory deeisions.

It is now more than 10 years since that work was begun.

As in all statistical programs, it is always good to reassess

where we are. For that reason, we have asked the Committee on National Statistics of the National Academy of

Sciences to setup a panel to review this work. We believe,

and I am very pleased to tell you that !lxreta~ William

Brock agrees, that rec.ordkeeping and data are essential to

the implementation of the Department of Labor’s responsibilities. The data systems BLS and the National Center

for Health Statistics (NCHS) maintain and the work that

the National Institute for Occupational Safety and Health

(NIOSH) is doing can help to sensitize both workers and

employers to these needs.

There are problems there can be no question about

that. There are problems with almost any statistical program. Some are harder to solve than others, but what we

need to do is to keep working at them.

We have got to learn more about what causes injuri+

Mn_ and fatalities in the workplace. By working together with NCHS and NfOSH, we ean learn and perhaps

develop a better data base for the population.

Many approaches can be taken to developing data in

the workplace. There are household sumeys, establishment

survey% and administrative records. Each data set has

problems and strengths. In the household survey are% in

addition to the NCHS sponsored surveys, there is the BLSS

Current Population Sumey that is basically a labor force

survey. This survey, conducted for us by the U.S. Bureau of

the Census is used to collect information on people from

60,000 households who work or look for work. It was not

designed to collect health, safety, or injury information. The

surveys qxmsored by NCHS are designed to collect health

and injury data. They were not designed to ecdhxt information on the workplace. We need to experiment in both

sumys to get additional information that will bring these

data systems together.

We would be remiss if we ignored the fact that the

existing household surveys were created for different purposes. There are a number of statistical issues that arise

when we add questions to a survey. Occupational data are

very difficult to collect. People do not always know what

their occupation is. I had an interesting experience visiting

the computer-assisted telephone installation of the U.S.

Bureau of the Census, where testing on the Current Population Survey was conducted. I listened to the questioning

of the respondents. One after the other, they stumbled on

the questions of industry and occupation, but particxdarly of

occupation. One respondent, when asked a question about

indus~ and then about his occupation, said: “I just told

you I worked in a bank. Why are you asking me my

occupation?” Now we have to recognize as survey specialists that some improvements need to be made, both for

survey purposes and also for administrative reeords. We

should not get earned away with the belief that all we have

to do is take a few questions and add them to the Current

Population Survey or the National Health Interview Sumey

or put some extra codes on the mortally records. It may get

us toward a more perfect data system, but it is not going to

do it by itself.

I do want to express my admiration for the leadership

that NCHS has taken in the whole area of cognition and

survey research. I think Monroe Sirken’s work is an example for the whole statistical system. It is an area that we at

BLS are moving into as rapidly as possible. For the kinds of

issues we are talking about today, cognitive testing is

tremendously important.

There are other ways of getting data besides household

surveys. Obviously establishment surveys are one way. At

9
BLS we have found that we get better occupational data

from business establishments than from household surveys.

Our occupational injuries and illnesses survey (interestingly

the only mandatory survey in BLS) is an establishment

survey based on a comprehensive rccordkeeping system.

We are working hard to improve the data from this survey.

But we recognize that problems remain. We have also been

looking at our other establishment surveys, such as the

Wage and Industrial Relations Surveys, that may form the

basis for further work. If we could find a way to get the

resources, we would like very much to begin collecting data

from business establishments and then surveying subsamples of employees at those establishments to get further

information.

Another area of importance is the full use of administrative records. I am glad to see Fritz Sheuren here. He has

probably done more than anyone in the statistical area to

keep reminding us about the importance of administrative

records as a source of data. They reduce the burden on

respondents, and they usually cost less than direct surveys—certainly less than household surveys.

Our experience at the Bureau of Labor Statistics suggests that a great deal can be done through Federal and

State cooperation, We like to think that BLS has developed

one of the best Federal and State cooperative programs in

the statistical system. Perhaps NCHS might disagree with

us. We have, in the labor market area, tremendously good

relationships with the States. We are building on those

relationships in the safe~ and health area. The only way to

have an effective Federal and State cooperative relationship

is to make it truly cooperative. That means that there have

to be two parties to the system. Second, it has to be a

system in which both parties gain. You cannot go out to the

States and say, “You have got to do this because the Federal

Government wants you to do it.” Even if you pay them for

it, the States have to need the data that are collected.

In my experience, I have found the real work to be in

the rest of the country-not here in Washington. The data

that can be used by the States are usually the most practical

data for administering programs and even for informing the

general population. Our job in the Federal Government is

to try to provide leadership, to bring the States together,

and to develop quality standards and statistical approaches

to have data that can be matched or coordinated for the

States as well as for the Federal Government. The National

Center for Health Statistics has a great deal of experience

in working with public health authorities. At BLS we are

beginning to work more and more with public health

authorities in the States. Our major contacts have been with

the Departments of Labor in the States, in most cases with

the employment security agencies. All of the data collected

by these agencies are extremely important to the Nation as

a whole and to its people. Because we believe that these

issues are so important, we are devoting a great deal of

attention this year to a complete reorganization of our

Wage-Industrial Relations and Safety and Health Programs. George Stelluto and William Eisenberg are perhaps

spending more time with me than they would like, but when

we are through, we will have moved ahead a great deal.

This really underscores the importance of the work of

this conference. We were very pleased at the response we

got to the conference that BLS hosted with assistance from

NIOSH and NCHS on issues involving the measurement of

health statistics in Albuquerque. We hope to see more and

more of these kinds of cooperative endeavors. The problems are too large to be solved by any single statistical

agency. We have to remember that we are living in a period

of budget austerity, and the challenge is to find ways to

accomplish what we need to do at minimum cost. We have

to get large benefits with small increases in budget. I

believe that we can find ways to develop data from household surveys, from business establishments, and from administrative records. Sampling of administrative records is

extremely important because collecting comprehensive data

may not be possible.

We would like to draw from administrative data in a

more practical manner to develop estimates for the States

and the Nation as a whole. We believe that, by working

together, we can find ways to develop the information that

is needed to understand the kinds of issues that are facing

this country and to move forward to improve the conditions

in the workplace.

10
Reviewof activitiesand

conferenceobjectives:National

Centerfor HeaithStatistics

by Jamb Feldman, Ph.D., Direetor,Office of

Analysisand Epidemiology,National Center

for Health Statiatiea

It is a great pleasure for me to welcome our distinguished speakers and participants to this Workshop on

occupational health statistics. ~s Workshop, a joint effort

of the National Center for Health Statistics (NCHS), the

Bureau of Labor Statistics (BL8), and the National Institute for Occupational Safety and Health (NIOSH), will

serve several purposes. The Workshop will identifi gaps in

occupational health statistics that are needed for problem

identification and surveillance. It will help identi~ the role

of participating ageneieq particularly that of the NCHS,

which is the Federal agency responsible for collecting general purpose health statistics An~ finally, the Workshop

will help tG identi~ resources to support this effort.

This Workshop will foeus on occupational mortality

statisti~ an area in which NCHS and its predecessor

agencies have a long history. Our current developmental

activities are reaching a stage that makes today’s topic

particularly apropos. We are interested in determining how

vital statistics data can contribute to the development of a

national strategy for occupational mortality surveillance

and research.

Surveillance and research in the areas of oceupationdy

related illness and injmy are extremely important topics.

Indeed, the spectrum of the Leading Work-Related Diseases and Injuries identified by NIOSH (Centers for Disease Control, 1983) necessitates the collection of health

data from early symptoms of disease to ciinieal illness and

ultimately death. The development of a coordinated national strategy to measure these outcomes may require the

use of several different and complementary data systems.

I will digress briefly to discuss some alternative methods for eolkxting occupational mortality data. A study

published by Kitagawa and Hauser (1973) linked about

300,000 death certificates for the period May through

August 1960 with the U.S. Bureau of the Census’ schedules

on April 1 for those individuals. From the U.S. Bureau of

the Census questionnaire, the current occupation of the

individual could be determined. Because the death certificates and U.S. Bureau of the Census questionnaires represented information for the same population, the mortality

rates could be calculated for different occupational groups.

Unfortunately, even with the fairly large sample size, the

data base was not suftkiently large to do analyses on

speeific occupations or on highly specific causes of death.

In an ongoing study jointly sponsored by NCHS, the

U.S. Bureau of the Census, and the National Heart, Lung

and Blood Institute, a sample of about a million individuals

who had been participants in the Current Population Survey for 1978-83 are being tracked through the National

Death Index (Rosenberg and Feinleib, 1986). This study

links the Current Population Survey sample with death

reccmis in a prospective fashio~ providing a growing &ta

base similar to that of Kitagawa and Hauser (1973).

Mortality as an endpoint has certain methodologic

limitations for studies of occupational health. Death generally occurs late in the etiologicprocess. However, if morbidity measures ean be detected at an earlier poin~

interventions might be performed. At NCHS we are currently planning our third National Health and Nutrition

Examination Swey (NHANBS III) in close collaboration

with NIOSH and various other agencies. That survey will

have an occupational component, including assessments of

central nervous system and pulmonary functions., In addition, determinations of some trace metal concentrations in

blood and urine and, in a nonrandom sample of 20 to

59-year-old subject% volatile organic compounds in blood

and pesticide residues in urine will be used as indicators of

exposures to some toxic-ants.Two examination sumeys were

completed in the 1970’s. The f~st of these surv~

NHANES ~ is being followed up in collaboration with the

National Institutes of Health. This will provide information

on the course of occupationally-related diseases and on

diseases that developed after the initial suIvey. Finally, the

National Health Interview Sumy (NHIS) can also be used

for occupational morbidity analyses. NIOSH has used the

survey to publish differentials in a variety of conditions

according to industry and occupation (Kaminski and

Spirtas, 1980). We are trying to improve the measures of

occupational exposure in that survey. The 1988 NHIS will

include a special topic section on occupational health developed in collaboration with NIOSH and BLS. This survey

will include questions on longest joh symptoms of backpain

or hand discomfor~ work injuries skin eonditionq eye,

nose, and throat irritation; and chronic conditions.

In this Workshop, we would like to review the eolkction and use of data regarding mortality risks by occupation

and indust~ in order to develop recommendations regarding future directions. Of crucial concern to NCHS is the

continued implementation of coding of indus~ and occupation on death certificates. A variety of options that focus

on data collected by NCHS and the States will be reviewed.

These should be evaluated using criteria such as timeline+

geographic and occupational coverage and detail, data

quality, and surveillance capability (that is, sensitivity and

specificity of the compilations of the occupationally related

mortality data). The issues are

. How many relationships between occupational exposure and deaths are discovered based on coded ocqpational data horn death certificates?

. What proportion of all of the elevated standardized

mortality ratios or proportionate mortality ratios that

are identified turn out to ident@ hazardous situations?

. Could the information have been gotten by other

methods?

We anticipate that, by using existing data that include

coding occupation and industry from death certificates and

by implementing new data collection efforts in support of a

11
national strategy for occupational mortality surveillance

and research, the efforts of this Workshop will result in the

development of practical rcmmmendations and priorities.

Statistics compiled from death certificates have been

crucial historically to occupational health studies. Over two

centuries ago, Sir Percival Pott observed the association

between the occupation of chimney sweep and an elevated

risk of scrotal cancer, due to the exposure to soot. Since

that time, many countries have produced occupational

health data fkom death records. Great Britain has the best

record; they have produced an occupational mortality supplement almost every 10 years for the past century from

vital statistics in combination with their census data. The

record for the United States is much spottieq we published

national studies in 1870, 1880, 1890, 1900, 1930, and 1950.

Occupation and industry from information is obtained

from the funeral director’s entry on two items on the death

certificate (figure 1). Figure 1 is the U.S. Standard Certificate of Death that is being recommended by NCHS for use

in the States beginning in 1989. The Standard Certificate of

Death is revised about every 10 years to reflect changes in

the need for statistical data and to meet changing State

legal requirements. The Standard Certificate of Death that

will be used beginning next year differs from that used for

many years in the United States; however, the occupation

and industry items (12a and 12b) are unchanged from the

version of the death certificate currently in use. Almost all

States use items that are identical or very similar to those

recommended on the Standard Certificate of Death (Kaminski et al., 1981). Specifically, the information sought is

the decedent’s usual occupation, that is, the kind of work

during most of his or her working life, and his or her kind of

business or industry.

In the most recent national study for the United States

by Gurahtick (1962, 1963a, 1963b, 1963c), working with

Moriyama and Dom, occupational mortality was estimated

from death certificates for over 300,000 male decedents.

Table 1 provides illustrative data from this study for males

Table 1. Deaths of men 20-64 years of age of races ether thsn white with work experience, from selected causes of death, by major

occupation group, ●ge, ●nd standardized mortality ratiox United States, 1950

[Ferrnars and farm tabot’ers]

SLmdeKllrs+d morialny raw

m64 25’59

Cause of cbath Tofai m w

Allcausee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11,689 190 196

Tuberculosis, Cll fCMIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .001-019 752

Syphillsand ttssequelae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...020-029

259

251 E m

Malignant neoplasm, Including necplasms of tymphatio and hemato@etb thsues. . . ...140-205 889 m

Mal~MIMpl=mofWti=~Mdp_ . . . . . . . . . . . . . . . . . . . . . ...140-148

104

25 74 J’;

Maltgnent neoplasm of stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...151 225 201

MalJgnent neoplasm oflntastlneand rectum . . . . . . . . . . . . . . . . . . . . . . . . . ...152-154 29 72

Mallgnant neoplasm of tracheil md of bronchus and lung. . . . . . . . . . . . . . . . ...162.183

83

87 49

Mallgnantneoplesm ofprostrafe . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . ...177 100 3::

Malignant neoplasm of kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 ?!J

Maltgnant neoplasm of bladder and ether urhary crgsns

-lJ

. . . . . . . . . . . . . . . . . . . . ...181 2

Mallgnent neoplasm of brain andolherparte ofnervoussystem. . . . . . . . . . . . . . . . ...193 12 (’.’ (’)

Leukemia andaleukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...204 34

WM@WI=IIC ~ other IWO@SWW

63

of tym~k and harnefcpcietk ftseuss . . . .2004K13,205 37 88

Diabatesrnelllfus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...260

74

98 143 164

MajOf OCJdbVSSCUbWS* dbeaaea . . . . . . . . . . . . . . . . . . . ..330-334.4CI0-46S.892-594 5,555 187 190

Dlseasaa of cardiovascular system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330-334,4clo-4e8 5,170

Vascuiar lesions affecting central nervous system , . . . . . . . . . . . . . . . . . . . . . ...330-334 1,472 E ::

Dbeasas of ttaaff and rlwurnatk fever. . . . . . . . . . . . . . . . . . . . . . . . . . .400-402,410-443 3,406 m m

Rheurnaficfevarend chronic rheumatic heart cksease . . . . . . . . . . . . . . .4IW402,41O-418 156 118

~e~mtk~~d-~,hcludbgcom~d- . . . . . . . . . . . . . . . . . . ...420

107

1,184 71

Merbsclerctk heart disease so described . . .

73

. . . . . . . . . . . . . . . . . . . . . . ...420.0 245 94

Other diaeaseaof comnaryarleries. . . . . . . . . . . . . . . . . . . . . . . . . . ...420.1.420.2

103

939

Olhermycoardiel degeneratbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...422

69

407 z

~rfensbnwtlh heertcflsease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...440-443 1,066 m !%

Hypafensbn willwut menlbn of heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .444-447 151 m m

Genera! arlerbsclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4S0 es 35!

Chrorrio and unspecifbd nephriits end other renal solerosls . . . . . .

m

. . . . . . . . . . . ..se2.594 ~

Inftuenraand pneumonki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...460.493

—

451

Other diseeses otraspiratory system. . . . . . . . . . . . . . . . . . . . . . . . . . . ..470-475.500.527 71 % %

Ulcer IX stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...540 1s0 161

Ulcer of duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendices

541 z 88 (’)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 179

Hemki and Infeatlnal ebskuofbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .569,%E 88

Cinhoefscfllver . . . . . . . .

300

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 % =!B

Acclderlfe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .E8COE= 1,139 175 179

Whneafwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 108

Notwhlleat workand nctetated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

109

972 195

Sukide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .E96S,E97&E979 105

Homklde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .E984,E960-E98S —

8% i%—

SOum Gurdnick iea3a.

%t00rmuonc4con@od

12
U.S.SfANDW

FEs&N7

S4AcuELK

INn&%Dss

I aEEslsssmE

M HASM9X

i

-

ssEosnNImN

w oTNEnmc

EEmsnummN

IsomLm EAos

aiim

SEEFs!nNlmN

oNolNsssmE

Alm3

FIWT.W2

SEv. lMS

lDcumx — CERTIFICATEOF DEATH S7A7E m WJMun

1.DECEDENTS NAME fftiL~L4@ 2. SEx S. DATE W DSATIE~kov.v=)

6. SOCIALSECU_ *SER Sa.AOI?-I.UI ltintdmv M ~DfR 1 ‘=S I

k UNDER 1 DAY ●.DATEDFmm* 7. :~nll&Arv -d .-m w

InMsl MmElm ;Dw : Wwm OSV,YM?I

I I

10,MAWALSIAtUS-Mmnid, %%21FRWVINGSFouss 12s. O+CADENT% USUAL 0CCUPA710N ltiWOOF -ESSflNDLISTRY

tinw Mmi8d. ~. InWrc.,hvmdnbnm

Dwlud (sAuiivI

fGi8wh+ldcFmf2awwa+slmw dwfkiw&

cu@ Lu, *.1

I I I

1SS.RESIOHACE-SYA?E lilb. CDUFA?Y 1= m. TOWN, on LocAmoN 12s~ AFADWMGER

)

Z* MEINoo OF c4smEmoN Sah FLAcsoFLss?osllx4N /kwat~. OaNmv. m a I.OCATION-CAV e Tmal. SE9W

❑ sulld 13cmmEs0n c1 ~fmms8Ltc

mtmlkbli a-ih+ddomh,

iOsdFysswddm FIL mlnandTxAI”~ .

I

24. mME OF OEAYN 26. DATE ~DNDWCEO WAD IMalhDw.vur) 26. WAS CAGEFSFWIEO TO MEOICALSXAMINWCOWWR7

M

w- - ID/

27. w~L&wti ~,ww~ti ti_ti&ti. bw~ti&d~tia_umwMw

-hek. OrnNIYfAlum. &L OnkmD-rnmdtliu.

niMsDLa7E CAuss mid I

unJnare0r9mul + ,. I

MuKq h dusll GUSTO m AS A CONSEWENCE OFII I

1

Smwnwiv ELFml-dsbl-n.

II mm”. ISA-q 10h’armAm* CFWTOAGRASACONSEWEWEOFI: I

-. Enle Usm!sl.vmo I

CAusEinbamub?+utv ~.

LiuE Ilil!mod Owms I

mdEhshtihlun

GIETOMASACWSEDUE?ECEOFk

I

a

?ART9. wlumOnmcm! cadnbmamuAwmsmdsmhM1 —unNmlwm*m4slh+u -E&16 inFu L - WAS AN AU70UY - m AUTD?SY FwOINos

FE#omso? AVASASIS FRW TO

.#Ya * MA CGFM.STIONOF CAUSE

OF OEAIH? I% u w

1

32. REOLSTMR% SIGNAWTE Ss. DAYS wSO a4mm.Dw. YE

Figusu1, U.S. Standmd Csriiibsta of Datls
Table 2. Observed numbars of deaths ●nd standardlzecf mortslity ratios (SMR) for selected occupational groups exhibiting excess

mortality from malignant ●nd nonmalignant respiratory disease for males ●ged 20-64 year- Unked Ststes, 1950

A40kwny ilvm mal&tent Mnlmal@nent IBsp&stoly

~ oft~m dksnsa other than

bronchus, and lung kltluenza erldpmwrnnria

Gxl@aibnel group Oaa#s .SMR Deaths Sh4R

aarbers, etc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cooks,exeeptprivate hwseholct .,... . . . . . . . . . . . . . . . . . . . . . . . . . . .

Machinistsand job setters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Molders,melal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Paintets(construatbn)opepetlmngera,end glazier%. . . . . . . . . . . . . . . . . . . .

Tmdcabdriv asendchautfeurs... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IAxwers,wood pr uats,elc . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Laborers,primaryrnatslindustries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Laborers,transpxtatbn equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operatives,etc., plimelymelsl industrial . . . . . . . . . . . . . . . . . . . . . . . . . . .

9s

1:

34

212

77

414

62

30

77

*151

’165

1136

%27

’167

‘1ss

‘1s6

11s7

!200

~145

29

41

66

so

64

36

20

49

26

41

126

’195

125

%00

%3

’225

154

125s

1433

1195

‘SMRsignlfkdlystow 1~ u P <.01.

‘SMRsi@k.ndlyalmw 100a!PC .0s.

SOURC13Gurswck,1W3S.

of races other than white whose usual occupation at the

time of their death was farmer or farm laborer. The

underlined standardized mortality ratios (SMR’S) in the last

two columns represent significantly elevated risks for death

due to specific causes. The set of tables presented in the

report by Guralnick identified specific causes of death as

elevated in certain occupations and industries. Table 2 from

the same study shows another use of these data. SMR’S for

nonmalignant respiratory disease (basically chronic obstructive pulmonary disease) and for malignant neoplasms

of the trachea, bronchus, and lung were highly related, from

which it was inferred that nonmalignant respiratory disease

was probably an earlier indicator that might be used in a

morbidity study to identi~ types of exposures.

Since the 1950 study, NCHS has undertaken no fullscxde national study, but a number of States, including

California, Rhode Island, Wisconsin, Washington, and

Pennsylvani~ have produced periodic studieq Wisconsin

produces annual data from death certificates. A survey of

States in 1979, carried out by the Association of Vital

Records and Health StatistiW the voluntary organization

that represents the interests of State vital registration officials revealed that about a dozen States were coding

occupation and industry on the death certificate. Six of

these States coded both occupation and industry, five coded

occupation only, and one coded industxy only. However, the

different States did not use the same coding system, resulting in problems of comparability among State studies. Prior

to 1979, no national standards or procedures existed for

coding or chissi&ing the cause of death from the death

certificate.

At the same time, there was a growing interest in

environmental and health issues. The NCHS (1977) report,

“Statistics Needed for Determining the Effects of the Environment on Health,” discusses many of these interests. The

convergence of interests and needs resulted in the cobboration of a number of Federal agencies (including NCHS,

NIOSH, NCI, and the U.S. Bureau of the Census) and the

States that has resulted in 32 States and the District of

Columbia coding occupation from data on the death certificates on a routine and uniform basis. The rapid growth in

14

the number of reporting areas that have adopted uniform

coding procedures for occupation and industry from the

death certificate is shown in Table 3. The number of States

that are providing the data to NCHS is now 20.

Let me brief& summarize our achievements to date.

In 1978, with the U.S. Bureau of the Census and

NIOSH, we conducted an evaluation study on the

completeness of reporting and codability of the occupational information on the death certificate. We found

that over 75 percent of the occupational entries in the

sample of 5,000 records were codable (Rosenberg et

al., 1979).

In 1983, we published a handbook for funeral directors

to promote accurate and complete reporting of occupation and industry information on the death certificate.

In 19S4, an instruction manual was first produced by

NCHS, IWOSH, and the U.S. Bureau of the Census for

uniform coding of occupation and industry on the

death certificates (NCHS, annual).

NCHS currently does quality control coding for the 20

States that submit coded occupational data to NCHS.

In 19SS, we plan to publish the first periodic report on

occupational mortality as a supplement to the-NCHS

publication Monthly VW Statistics Rq.xwt. This will

include data from about 270,000 deaths in 12 reporting

States.

Tabfe 9. Growth In number of reporting ●reas ●dopting uniform

oeeup8tIon ●d Industry oodlng procedures

~d

MnrSbwd sraes~

-=$- KHSwh

m ~~ ~~

M md~ bntwi?vars mms~

lea ......... 11 0

. . . . . . . . . : 13

;=,. . . . . . . .

o

ao 16 5

1W6, . . . . . . . . 22 19 7

19s7 . . . . . . . . . 34 w 11
In a word, we have made considerable progress with

the program of occupational mortality data eollectio%

which is now institutionalized in two out of eveg three

States.

NCHShasbeen able to make this progress in large part

&rough collaboration with NIOSH and NCIj who have

provided funding for the fist steps. NCHS is giving a great

deal of thought to the future of the occupational mortality

program. As part of our planning for fd year 1989, we

are, in fact, doing a rather full review of this program. It is

imperative that any request for new funds to carry forward

the occupational mortality program must be made only

after a careful review of the needs of the States for the datq

the uses to which it will be put, and the various options for

its collection. We hope that with your assistance, we ean

explore these issues andprovide a solid basis for developing

NCHS’ plans for occupational mortality.

References

Centers for Disease Control. 1983. Leadingwork-mkted diseases

andinjuries,United States.Modidify and M&afity WeeklyRepcm.

Vol.32, No. 2.

Guralni~ L. 1962,Mortalityby occupationandindustry among

men 20 to 64 years of a~ United Stat+ 1950. Hral Stathtics—

S’cial Repons, Vol. 53, No. 2. WashingtoIXU.S. Govemxnent

Printing Office.

Guralnick, L. 1963a.Mortality by occupation and cause of death

among men 20 to 64 years of age: United State+ 1950. 14tol

Statistics-Special Rep&, Vol. 53, No. 3. WashingtoIXU.S. Government Printing Office.

Gumlnic~ L. 1963b. Mortality by industry and cause of death

among men 20 to 64 years of agex United States, 1950. Vilal

Statistks-Spcia fRepmts, Vol. 53, No. 4. WashingtorxU.S. Government Printing Office.

~ L. 1963c. Mortality by occupation level and cause of

death amongmen 20 to 64 years of age United State+ 1950.Kral

Statistks-Speaaf R- vol.53, No. 5. Washington U.S. GovernmentPrintingOffice.

Kaminski,R,, J. Brocke~ J. Sestito, and T. Frazier. 1981. Occupational information on death certificates A survey of State

praetiees.Anz L Pubfic He& 71(5)KL89.

IG@nski, R, and R spirttm 1980.Ihdwttial Chmctenkics of

PeKons Reptxiing Mdidity Dwing theHealth Intem”ew Surveys

C2mduc&d in i?k%U974:An E@onatay Review. DHHS Pub. No.

(NIOSH) 80-123.Washington U.S. Government Printing Office.

Kitsgaw E. M., and P. M. Hauser. 1973.DiffmnfiafMomlity in

the United Stores. Cambridge, Mass Harvard UniversityPress.

National Center for Health Statistics. 1977.Statistics needed for

determining the effects of the environment on health. Report of

the Tedmical Consultant Panel to the United States National

Committee on Vital and Health Statistics.Wtaland Health Stark

tics. Series 4, No. 20. DHEW Pub. No. (PHS) 79-1457. Public

Health Serviee.Washington:U.S. Government Printing Office.

National Center for Health Statistics. (Annual). Indumy and

Occupation C2xiing for Death Certificates. NCHS Ihstrwtion

Manr@ Par W. HyattsviUe,Md.

Rosenbexg H. M., D. Burnham, R Spirtas, and V. Valdisera.

1979.Occupation and industry information horn the &ath eertificatex Assessment of the completenem of reporting. Statistical

Uses of Ahinisbndve Records w-h Emphasis on Mortality and

Disabifi~ l?ese~ edited by De@ B. L., and F. scheluren, U.S.

Department of Health, Education, and Welfare, social Security

Administration, Officeof Policy,Office of Research and Statistics.

Washington U.S. Government Printing Office.

Rosenber& H. M., and M. Feirdeib. 1986. Data bases for the

analysisof socioecmomic differences in mortality in the United

States. Pmceedhgs of the Ztiemadonaf Seminar on

Socio—Eeononw“ Aspects of Differential Mcxtafity. Zaraardi,

Hungary.

15
Utah’s experience in building an

occupational health surveillance

program

by John E. Brockert, Direetor, Bureau of

Health Statistics, Utah Department of Health

The initial impetus for the development of an occupational health program in Utah occurred in 1978 because of

the interest of Mark Nichols, M.D., then the Director of the

Chronic Disease Program. The Chronic Disease Program

provided resources for the manual translation of occupation from the death certificate to a listing of all deaths of

males 16 through 65 years of age, for the period 1959-68.

That experience demonstrated the extensive amount of

work involved in coding and keying occupation from the

death certificate. However, the results of that analysis did

identify a population potentially at high risk for myocardial

infarction, employed in the rocket industries located in

Utah. These results were reported in a master’s thesis by

Dr. Nichols.

In 1980 the National Institute for Occupational Safety

and Health (NIOSH) announced the Surveillance Cooperative Agreements between NIOSH and the States

(SCANS) projects and the staff in the Bureau of Health

Statistics realized they had a great advantage to compete

for one of these contracts. The Director of Health Statistics

was eoncemed that Federal funding might be obtainti, and

then after 2 years, the Department would either have to go

to the legislature for State funding or drop the program.

That concern was expressed to the Administration of the

Department, and the response was to apply for the contract

funds and worry about additional timding later. The Utah

proposal was one of six proposals that were subsequently

funded through the first SCANS awards by NIOSH.

The Occupational Health Program efforts by the Bureau of Health Statistics were particularly productive during the next 2 years. We successfully coded the occupation

and industry for all death certificates on file from 1957

through 1980. This was in excess of 150,000 deaths. We

were also successful in doing some preliminary coding of

occupation on the birtheertifieates. Proportionate mortality ratios (PMR’s) were prepared for 85 cause-of-death

categories and 85 occupation or industry categories. A

series of technical reports was prepared on coal miners,

farm workers, and wood workers in Utah that utilized the

PMR’s available from this large resource.

Several meetings were held with interested users from

the University of Utah, the Rocky Mountain Center for

Occupational and Environmental Health, the Utah State

University, the State Industrial Commission, and from Dr.

Mark Nichols (now director of a local health department).

There was widespread support and encouragement for

further analysis and publication of occupational health

data. The report on lung disease mortality in Utah miners

was printed in Utah Science, published by the Utah Agricultural Experiment Station at Utah State University. TWO

additional reports were presented, and they are part of the

proceedings of two national scientific meeting.

The Department of Health continued to be interested

in the occupational health program and, subsequently,

allocated resources to obtain an occupational health epidemiologist. A member of the department staff, Richard

Johns, M.D., was assigned to head up the department’s

epidemiology programs. He hired Dennis Perrott~ Ph.D.,

to work with him as an occupational health epidemiologist.

Subsequently, Dr. Johns left employment with the Department of Health to complete post-doctoral studies in occupational health. Dr. Perrotta continued to be active in

occupational health epidemiology with the department until

October 1986, when he transferred to a similar program in

the Texas Department of Health. While still in Utah, he

was the recipient of a 1984 NIOSH contract to study the

effect of anesthetic gas on reproductive outmmes of medical personnel.

The Bureau of Health Statistics was also a recipient of

a 1984 NIOSH contract to study occupational injuries in

Utah. This contract continued to build on the work that was

already completed, extending it to include mortality data

for 1981-84. Under this contract, we successfully linked the

injury information from the Industrial Commission with

our mortality files. This analysis provides preliminary confirmation that there were workers who were injury prone.

They appeared in the Industrial Commission injury files on

multiple occasions, and they had a higher probability of

being linked with the Utah mortality file of deaths due to

injuries than persons who appeared in the injury file only

once.

Starting in 1984, Utah was one of the States to contract

with NCHS for the provision of current mortality data

coded for occupation and indust~. That eontraet was to

provide 1985 dat~ and, subsequently, it has been renewed

for 1986 data. We have also been successful in reeently

completing the coding for 1984, and we will shortly be

providing NCHS with that data tape.

With funding from the original SCANS contract, Utah

has been developing an automated dictionary of occupation

and industry titles and codes. Currently, we have about

25,000 linked occupation and industry titles and codes in

our automated dictionary. Since 1978, we have keyed the

literal entry for occupation and industry on all death certificates. Monthly, the keyed Iiterals are matched with the

dictionary. Currently, we are getting a 60-percent match.

The balsnee are coded manually by our coding staff. The

codes are keyed, and the monthly death file is updated. The

automated dictionary is also updated.

Utah has approximately 800 deaths per month, and it is

able to complete the occupation and industry coding and

keying for a total cost of $500.00 per month. This includes

all of the activities deseribed above.

I believe the sueeess in the development of the Utah

Occupational Health Surveillance Program has been at

least partially the result of our willingness to involve other

parts of the department and other agencies outside the

department in our efforts. It is seen as a broad-range

program that will improve the health of Utah’s workers by

reducing injuries and illness that are occupationally related.

16
Chapter Il.

Review of options for

producing occupational

mortality data

The second session of the Workshop was devoted to a

review of 10 options for producing occupational mortality

data, focusing in particular on the existing system used by

the National Center for Health Statistics (NCHS). These

options (summarized in table 4) were suggested in discussions with several Workshop planners and participants in

preparation for the Workshop. They were presented at the

Workshop by representatives of the sponsoring agencies,

but they did not necessarily reflect the priorities of those

agencies.

The session was introduced by John E. Patterson,

Director, Division of Vital Statistics (DVS), National Center for Health Statistics. DVS operates the national vital

statistics program with the States under an administrative

arrangement called the Vital Statistics Cooperative Program (VSCP). Data from vital records filed in the States

are sent on data tapes to NCHS for consolidation into the

national vital statistics data base, which includes births,

marriages, divorces, fetal deaths, abortions, mid deaths.

Beginning in 1984, coded occupational and industry data

have been sent by some States, now numbering 20, to

NCHS along with other coded mortality information. A

more detailed description of this program is given later as

Option No. 1. Other options that were considered by the

individual working groups and the Workshop as a whole in

plenary session are also described. All of the cost estimates

discussed in Option Nos. 1-10 are expressed in 1986 dollars.

Option No. 1. Existing system:

Occupational mortality coding at

the National Center for Health

Statistics for 20 States (Annual)

Presented by Harry M. Rosenberg, National

Center for Health Statistics

Description

The purpose of this project, which is a collaborative

activity of NCHS, the National Institute for Occupational

Safc[y and Health (NIOSH), and the National Cancer

Institute (NCI), is to develop a data system—within the

context of VSCP—that can produce on a routine basis

occupational mortality data from the death certificate.

The death certificate asks for the usual occupation and

industry of the decedent. This information can be readily

coded using the existing coding and classification system

developed jointly by NCHS, NIOSH, and the U.S. Bureau

of the Census. The system is based on State utilization of

common coding procedures promulgated by NCHS and on

State acceptance of NCHS quality control standards for

coding. The system was initiated during 1978-79, when a

special study was undertaken by the U.S. Bureau of the

Census for NCHS to evaluate the codability from the death

certificate of the usual occupation and the usual business or

industry of decedent (Rosenberg et al., 1979).

As of 1987, this VSCP approach was well institutionalized. A total of 32 States and the District of Columbia code

this information from the death certificate, with partial

support to 11 States from the participating agencies. A total

of 20 of the 32 States are sending their coded data, including usual industry and occupation, to NCHS for quality

control and for incorporation into the multi-State data

base, which includes other routinely coded demographic

and medical information available for all other deaths in

the coded death records (including underlying and multiple

causes of death). Seed money for this program has been

primarily available on a reimbursable basis from NIOSH

and NCI. The substantial NCI contribution will end with

fiscal year 1988, at which time NCHS has indicated that it

will attempt to obtain appropriated funds to continue and

expand the program.

Uses

Occupational information from the death certificate is

one of the most accessible, routinely available, and geographically comparable sources of data for measuring occupational health effects over time and across geographic

areas. It can be used to identify possible problem areas

(geographic or occupational), to generate hypotheses, and

to monitor change over time. The usefulness of the vital

statistics files for occupational health studies has been

demonstrated over the years in the decennial reports of

Great Britain, in periodic reports for a number of Sta[cs

(for example, California, Pennsylvania, Wisconsin, Washington, and Rhode Island), and the United States in 1950.

Measures of risk based on the VSCP approach can include

standardized mortality ratios (SMR’S), at least on a decennial basis but possibly on an annual basis. In the absence of

population data, measures of relative risk (for example,

proportionate mortality ratios, or PMR’s) can be used.

17
Tabfe 4. Synopsis of options

Can

Ca; analysk

Number of analyWs be done by

Federal racorw be 00rre by detailed

Average cost~r number of Stalistlcal detailed i/O causes of ConfiderrtL31ify

Oplbn annual cod Ferbdwfy dealh deaths measures codes? death? an issue? Comments

Existklg system

Annual f/O coding for all States

f/O codfng fc+ all Stales for years

afound decennlai sensus

Annual data for subset of causes

and/cf Subsd of stares

Mofltdfly Folfowbask Survey

Fdfowup C4NHANES Ill for 10 years

Fofbwup of 3 consecutive years

C4NHIS fw 10 years

U= Natbnal Infant and Malemat

Health Survey

Use Nalbnal Longiiudual Morfaltty

study

Use Annual Survey (BLS)

$B91,000f

(NCHS

$294,m)

$3,850,000’

(NCHS

$I,450,0(N))

$4.4-7.42

mfllkxr

(NCHS

$4.4-724

mlllbn)

Varfabfe

$2&&rr

$wXX3\

S803,0004

$1.30

$0.75

S220-3.70

285,0001

285,G00

PMR

PMR

PMR, SMR

PMR

PMR, reles

SMR,

Yes Yes

Yes

Yes

No Provides for small aree analysis for reporting

areas Iimlled in coverage

1.

2

3.

4.

5.

6a

b.

7.

8.

9a.

2,000,000/

2,000,CO0

Yes

Yes

Selwted 1/0

codes

No

No

Yes

No

Yes

Induslry

only

Yes

No Maximizes stahstical power, geographk

coverage, and depth of 1/0 and cause of

death analysis

Doss not allow for development of ongoing

stale programs

Annual

Pertcensal

(for

3 years

every 10

years)

Annuaf

Every 5

yeara

1968-1994,

folknved

for 10

yeare

3 years,

folfowed

for 10

yeara

4 year

suNey

parbd

1979-1961

6J300,000/

6,000,1M0

No

Varfabfe No

No

Lower costs, limited analysis depending on

program design

Analysis for detail dependent on survey

deskgn; no small area analysis

$90

$2,870

$37

$53

$40

$9

$9

$.0GQ3

20,0001

20,000

No

28,000/ No

2,600

Yes 12denstve examinalbn findings useful for

. .

analylic sludies and prevalence estimates

based

$123,00@ 330,000/ Perhaps

33JIO0

Yes

“i)asad

$132,5006 20,000/

1o,ooo

PMR

SMR

Rates,

counls

Counls

SMR

Perhaps Yes POlenlial use for reproductive hazard

exposures

$2,800,DO07 1,ooo,ooo/

55,0Q0

No

Yes

Yea

No

Morlallly differentials by Industty and

occupation for current job and usual industry

and occupalbn from dealh carffiicate

.$2,500,0000 2,800,000 Limited by coverage

employeral

1,562 In

1EJ85

Variable/1,179

in 10 Slates

k-r1983

31,000,fxro/

Fatality

event or

source

$2,0C0,0000 Fatali

event or

Limited by coverage and lack of populatbn

base

Excellent for geographic and time trend

surveillance by underlying cause of death

b. Use SDS (8LS)

source

10.useofcompressed $IO$XKW

MorirdHyFMe

1986-63 No Yes

31 JXX3,000

%cbdss Sfab costs.

z~tis m stale chsrgesto NCHS forpurchasingdaethcerflflcsdas.

%s!s stfrltslsd10 owpationsl fxxtion of smey.

41m~ em ~ts f~ -paiim corrpnd s4metd $S,00J,OOO d $2S,rXKl NCi ah.

%cbdss S9C0,0W inter+w costs for 3 yearsforcccufdonsl ccmponsrdsndS?30,000 NU mslsfor 10years.

%30d onestimatedsurvsycosfof S480,0Wover4 yews foroccupslio+-rsl corqmmnt plus$50,0G0forW =dIng.

7ESIiMSlSdccds perdeslhbssedon 1972-19SSSSIWr’sS.

%udescustsofwccesshofbc4 hfalalsndrro rMalcases.

424s forfXocessir@falslCssesare notavailabrssaparar.siyfromnorialslcmes.

%tknsted ~sd~ d sacorzderydstacOIlOctiOnC051S.
costs

The projected cost of the program is as follows

. If the program were to continue at the present level (11

States), the pass-through funding requirement for FY

1989 would be about $176,000.

● If the program were to be expanded to the 20 States

currently sending data to NCHS, it would require an

estimated $375,000.

These figures represent only the Federal support to the

States for coding their data. The additional cost to NCHS

for processing, analyzing, and publishing these data is

estimated to be about $118,000 annually, bringing the total

NCHS cost to $294,000 annually for program continuation

at the present level (table 4). For NIOSH, the cost is about

$45,000 annually. Further, the States incur a cost estimated

to be about twice that for which NCHS reimburses them.

Altogether, then, the per record Federal cost of the existing

approach to fund 11 States is about $1.30. The per record

cost, including the State share, is $2.60. The cost of State

coding might ultimately be reduced somewhat if automated

coding of occupation and industV, being investigated by the

U.S. Bureau of the Census for the 19Xl Census, proves cost

effective.

Advantagesand disadvantages

Option No. 1, the existing system, is on line and

working effectively in 32 States, of which 20 States are

sending NCHS data on a routine basis for inclusion on data

tapes and reports, the first report of which will be produced

in 1988. The data are produced as an integral part of the

ongoing vital statistics system at the State and Federal

levelq neither technical nor administrative problems have

been encountered that have not been overcome in a routine

fashion. Option No. 1 can provide for the full range of

occupation and cause-of-death detail for areas as small as

counties and for State% a distinct advantage where surveillance is sought for detailed occupations and for small

@graphic areas. Second, all death certificates within these

States are covered, not just a sample of deaths. And, third,

as a State-based system, this approach can be used by the

States in support of State-administered occupational health

programs.

An advantage of the State-based approach is that

questionable information reported on the death certificate

can be queried by the State vital statistics offices, much as

other questionable entries are often queried as part of the

regular vital statistics program at the State level. Querying

at the national level is no longer possible because the

Federal Government is not a repository of actual death

certificates, which are fikxl in the States, nor does it routinely receive copies of certificates. Increasingly, State vital

statistics offices are making preceded information available

to NCHS on data tapes. NCHS has copies of only a small

number of records that are independently coded each

month for quality control purposes, as well as an additional

10-percent sample of records used by NCHS to produce

current estimates of mortality by cause of death, published

in the NCHS Monthly Htal Stah”sticsRepoz

A further advantage of Option No. 1 is that it is

relatively inexpensive per record, even when compared with

Option No. 3, which is a special study around the time of

the decenm”rdcensus.

The disadvantages of the system are related to developing meaningful measures of risk. In particular, the absence of denominator data on a routine and continuing

basis can present a problem. Even with census-based datrq

there are differences between the nature of the occupational information collected through the vital statistics system and that collected by means of censuses and sumeyx

the death certificate asks for “usual occupation” whereas

the Census asks for “current occupation.” The absence of

annual denominator data means that reliance for measures

of risk has to be placed on frequencies or PMR’s, which in

many cases may serve well. Another disadvantage is the

present limited number of States that participate. These

States may not be representative of the United States as a

whole or even of areas with occupational mortality patterns

that merit attention.

Questionsand Answers

During the brief question-and-answer period, the following points were made

. The coverage of the ongoing system, with participation

of 20 States, includes about 584,000 death records per

year, or 28 percent of all U.S. deaths annually.

● The participating States are coding occupation and

industry on all records that report this information, that

is, there is no arbitrary age cutoff.

● Quality control on medical items and on demographic

items, including occupation and industry, is carried out

on a continuous basis by NCHS by coding a sample of

records monthly that NCHS receives from the States

and by comparing the NCHS-assigned codes with those

sent to NCHS by the States. If the State coding does

not achieve a pre-established level of quality, the batch

of records that the sample represents has to be recuded

by the State.

Option No. 2. Expanding the

existing system to all States

(Annual)

f?resented by Harry M. Rosenberg, National

Center for Health Statistics

Description

Option No. 2 is similar to Option No. 1 except that

coverage would be rapidly expanded to include all 54

registration areas (that is, all States, the District of

Columbia, Puerto Rico, Guam, and the Virgin Islands),

rather than the estimated 20 States in the program for

1987.

19
Uses

Occupational information from the death certificate is

one of the most accessible, routinely available, and geomaphically comparable sources of data for measuring oc- .

cupational health effects over time and across geographic

areas. It & be used to identify possible problem areas

(geographic or occupational), to generate hypotheses, and

to monitor changes over time.

costs

The estimated annual Federal support to the States

under this approach is $1.2 million. The additional cost to

the Federal Government for processing, analyzing, and

publishing these data is estimated to be about $250,000.

Further, the States incur a cost estimated to be about Wice

that for which NCHS reimburses them. The per record

Federal cost is estimated to be about $.75 and $1.90 for the

total cost (table 4), including the State share.

Advantages and disadvantages

The advantages of national coverage are the ability to

produce national counts of deaths by occupation and industry and, in contrast to the 1950 national study (GuralnicR

1962, 1963a, 1963b, 1963c), there would be a sufh~ient]y

large number of cases to provide estimates of occupational

mortality for detailed occupations and causes of death. A

larger data base also would permit occupational mortali~

analysis for small geographic areas.

Option No. 2 has all the advantages cited for Option

No. 1. It is State based, and thus it can tie into occupational

health programs at the State level. It can have a querying

component at the State level to improve quality. Further, as

a larger data base, it can provide estimates and measures of

greater statistical reliability and it can provide a sampling

frame for followback surveys,

Disadvantages are related to the absence of denominator data except for census years, although some limited

population estimates by occupation and industry are available from the Current Population Survey, conducted

monthly by the U.S. Bureau of the Census. Another disadvantage of Option No. 2 is the cost, about $1.4 million

annually. However, this cost is not considerable by comparison with some other Federal data collection activities.

Questions and answers

A question was raised regarding the quality of the

information reported on the death certificate. In his answer,

Dr. Rosenberg stated that the demographic information on

the decedent is supplied by the funeral director based on

information from an informant, often a family member.

What is known about the quality of this information is

largely from special studies, including a 1960 NCHS study

that compared vital record information (excluding occupation and industry) with census information for the same

individuals (NCHS, 1969). Similar comparisons were made

in the 1950 national occupational mortality study produced

by the National Office of Vital Statistic& the predecessor

20

agency to NCHS (Guralnick, 1962, 1963a, 1963b, 1963c).

In the 1950 study, individual death certificates were

matched with census records for the same individuals; and

comparisons were made of the occupation and industry of

the decedent, as reported on each record. Those results

showed a generally good correspondence, despite the different types of questions asked on the two sources, but a

lower match rate on an individual record-by-record basis.

Another approach to studying the validity of information on

the death certificate is the followback survey (see Option

No. 5).

Option No. 3. Data for all States in

census years only

Presented by Harry M. Rosenberg, National

Center for Health Statistics

Description

An alternative to the VSCP approach of Option Nos. 1

and 2 would be to produce national occupational mortality

data once every 10 year% the approach used for many

decades in Great Britain. This approach was used in the

United States for 1950, though the coverage of the U.S.

study excluded females. By focusing on the 3-year period

around the 1990 census (that is, 1989-91), such a study

could take advantage—as did the 1950 study—of denominator information from the 1990 Census of Population. By

adding together the 3 years of mortality data, numerator

information would include more cases and would therefore

have greater statistical stability and reliability, which would

allow for more detailed geographic and occupational analysis than a single calendar year of data. Occupational data

from the death certificate could be coded either at NCHS

by the existing trained coding staff or under contract by the

U.S. Bureau of the Census. The latter was done in a 1979

NCHS pilot study on the quality of occupational data on the

death certificate (Rosenberg et al., 1979).

Uses

Occupational information from the death certificate is

one of the most accessible, routinely available, and geographically comparable sources of data for measuring occupational health effects across geographic areas. It can be

used to identify problem areas (geographic and occupational) and to generate hypotheses.

costs

The costs of producing occupational mortali~ data

under Option No. 3 would be high. Although it would

appear that the cost would be a simple multiple of the

annual cost under Option No. 2, there is an additional

substantial cost because, in a once-a-decade study, one

could not depend on States doing the coding as under

Option Nos. 1 and 2. It is believed that States would be

unwilling and unable to participate in a data program that

operates for only 1, 2, or 3 years in a decade. States prefer
to operate a continuous system, like the vital records

system, m“th constant processing. In contrast, under Option

No. 3, the coding would have to be handled in an entirely

different way, either by contracting coding out to an experienced Federal organization, like the U.S. Bureau of the

C&w or to a private organization. This would probably

cost more per annum than an establishe~ ongoing State

system.

In addition, it would be necessary to purchase death

certificates from Stat+ an estimated $1.50 to $3.00 per

record. Therefore, for the estimated 6 million deaths during

tie 3-year period, an additional cost of $9-$18 million for

records and $4 million for coding would bring the per

record cost to $2.20 to $3.70 (table 4).

Advantages and disadvantages

The principal advantage of this approach, like that of

Option No. 2, is having a large number of cases for detailed

geographic and occupational mortality analysis. The disadvantages are that it does not develop a State capacity to

code occupation and industry or to query records that cotdd

enhance the quality of reporting or promote better reporting by funeral directors through training. It also abandons

the idea of occupational surveillance on a continuing basis

and the possibility of relating occupational health sumeillance at the State kvel with occupational health programs

administered by the States. A formidable obstacle to this

approach is the cost, which was understated in a recent

Congressionalreport (the Weissreport) that suggested this

as a feasible and desirable option (U.S. Congress, 1986).

Under Option Nos. 1 and 2, the States absorb two-thirds of

the production costs under Option No. 3, they do not.

Option No. 4. Subsets of causes or

subsets of States (Annual)

Presented by Harry M. Rosenberg, National

Center for Health Statistics

Description

Under this option, only selected death certificates

would be coded for occupation and indust~. The selection

could be made on the basis of cause of death, such as

cancers or accidents, or on the basis of geographic areas,

such as States with cancer registries.

Uses

Occupational information from the death certificate is

one of the most accessible, routinely available, and geographically u)mparable sources of data for measuring occupational health effects over time and across geographic

areas. It can be used to identify possible problem areas

(geographic or occupational), to generate hypotheses, and

to monitor changes over time.

costs

The per record costs are estimated to be about the

same as in Option No. 1, unless records have to be purchased from the States.

Advantages and disadvantages

The advantage of this approach is cost reductions

roughly in proportion to the reduced number of records

from Option Nos. 1 and 2. However, a major disadvantage

of this approach is that it would have to rely on poststratification. That is the national mortality data would

have to be processed annually by NCHS in cooperation

with the States as it does now. After the data are processed, the sample of remrds, based on cause of death or

State, would be selected and separately coded for occupation and industry, either by the States or by a third party. As

a two-stage process, it would be cumbersome compared

with Option Nos. 1 and 2, where occupation and industry

are coded on line with other items. Dr. Walker earlier

raised the excellent question of who would decide which

areas would be included among the representative areas.

OptionNo. 5. Mortalityfollowback

surveys

Presentedby Gail S. Poe, National Center for

Health Statistics.

Description

The mortality followback survey method is a #owerful

one and can be used to accomplish many objectives. Target

groups, such as persons dying from certain types of cancer,

can be oversampled for epidemiologic investigations. Furthermore, historic information can be captured, such as

whether the decedent worked at any time for a particular

type of industry or was exposed to certain types of substances.

NCHS is currently sponsoring a major national followback smvey–the 1986 National Mortality Followback Survey (NMFS). In this survey, a sample of 18JO0 death

certificates of persons aged 25 years and over who died in

the United States in 1986 was selected. A next of kin

identified on the death certificate or some other knowledgeable person will serve as the respondent. The survey is

designed to supplement the information on the death certificate. Additional questions are asked about usual occupation, indust~, family income, and education. Other

major topics are the use of health care resources in the last

year of life, disability prior to death, and health habits, such

as smoking and drinking alcoholic beverages. The survey

has a number of sponsors, including NCHS; the Health

Care Financing Administration; the National Cancer Institute; the National Heart, Lung and Blood Institutq the

National Institute of Child Health and Human Development the Indian Health Servicq the Alcohol, Drug Abuse,

and Mental Health Administration, the National Institute

on Aging, and the Veterans Administration.

21
A major purpose of the 1986NMFS was to examine

the reliability of items reported on the death certificate by

comparing these items with the same items reported by the

survey respondent. Items that will be compared include

age, race, and veteran status. The present survey is also

being used to examine the reliability of occupation and

industry reported on death certificates. Considerable debate focused on the types of questions to be asked about

occupation and industry. Initially, consideration was given

to asking adaptations of the questions used on several other

major national surveys, including the Current Population

Survey; but, to save time and to more closely parallel the

death certificate items, the number of questions on occupation was limited to two. About 5 percent of the original

respondents are reinterviewed within 2 weeks of the original interview and asked a set of five additional questions on

occupation and industry related to the job longest held.

With two sets of questions, possible comparisons can be

made to the information on the death certificate and to the

information obtained from the more traditional surveys of

employment and the labor force, An additional feature of

the 1986 survey was that the 1986 National Health Interview Survey (NHIS) provided information relevant to the

estimation of denominator data. The 1986 NHIS included

questions on the longest held occupation and industry that

complement those in the NMFS.

Instead of using the final mortali~ file of all deaths in

the United States as a sampling frame, the 10-percent

national sample of deaths, called the “Current Mortality

Sample: was used in the 1986 survey. This file is used by

NCHS to produce current cause-of-death estimates for the

United States on a monthly basis, published in the Month/j

Mta/ Std.stiesReport,in contrast to the final mortality file,

which is not available until about 20 months after the

calendar year of occurrence. Past followback surveys have

underscored the importance of using the most current

mortality file to reach persons familiar with the decedent

because death is often followed by family dissolution and

relocation that make followup difficult.

With the followback surveys, it is possibleto oversimple certain groups who would ordinarily be represented by

very small proportions of national sample. The 1986 survey,

for example, included oversampling of younger persons,

black persons, American Indians, and persons dying from

selected causes, including ischemic heart disease and selected cancers.

The survey is conducted by sending out questionnaires

about 6 to 8 months after the death. If there was no

response after two mailings of the questionnaires, information was obtained either by telephone or personal visit. The

1986 survey was conducted by the U.S. Bureau of the

Census under contract with NCHS.

The 1986 NMFS contained 158 response items that

required approximately 30 minutes to administer. The sample design was totally uncluttered, resulting in increased

interviewer travel costs for those interviews that cannot be

obtained by mail or by telephone.

Uses

Mortality followback surveys can provide information

on industry and occupational exposure and on other variables to supplement cause-of-death information obtained

from the death certificate. These surveys can be used for

hypothesis-generating or hypothesis-testing studies related

to risk factors ascertained from responses to the questionnaire.

costs

The total field cost includes forms design, interviewing

management of data collection, quality control, data keying,

and computer edits. For a survey focusing only on occupation and industry, the costs would be approximately $90 per

case, assuming 20,000 cases, with a response of at least 90

percent over a 5-year period (table 4).

Advantages and disadvantages

Some advantages of the followback technique include

the ability to use extensive questioning to better measure

desired concepts; oversimple certain demographic and occupational groups or causes of death; collect historic information on a decedent’s work history, for example, rather

than relying only on a single question of usual occupation;

and have probing questions about exposure to hazardous

substances on the job.

Among the disadvantages of the followback method for

occupational mortality studies are that it is not linked to

general population surveys; the sample is generally too

small to provide information for occupational mortality

analysis unless specifically designed for that purpose; and

the sample is too small for geographic analysis of small

areas. Because of the periodicity and geographic coverage

problems associated with such followback surveys, this is

not a technique for surveillance.

Questions and answers

Discussion after the presentation covered the

following

Ms. Poe estimated that response rates of the present

survey would be at least 90 percent, based on an

unweighed response rate of 89 percent from returns of

the first quarter.

Costs per agency go down when the survey serves

multiple purposes rather than having a single focus

because of multiple agency sponsorship.

Responses on these occupational and industry items

have been very complete, in contrast to the expressed

concern that incomplete reporting of occupation and

industry would result because an informant, rather

than the person who is the focus of the questions,

responded to the survey.

22
. There was a question as to whether validation of

responses with information from the Social Security

Administration could be done, to which Ms.Poe indicated that this might not be possible because of confidentiality considerations.

OptionNo. 6. Followupof general

populationsurveysusingthe

NationalDeathIndex

Presentedby Bruce Cohen and

Jeffrey Maurer, National Centerfor Health

Statistics

Description

TWo major population surveys sponsored by NCHS–

the National Health Interview Smvey (NHIS) and the

National Health and Nutrition 12mnination Survey

~)–wdd be used for occupational surveillance

and research. The purpose of NHIS is to provide national

data on the incidence of acute illness and injuri~ the

prevalence of chronic conditions and impairment% the

extent of disability, the utilization of health care servi~

and other health-related characteristics. Each calendar year

data are collected from approximately 50,000 households,

yielding about 135,000 persons. In addition to the standard

questions that are asked every year, special questionnaires

on current health topics are added each year. For instance,

information will be collected during the 1988 survey on

longest job and symptoms of occupationally related

conditions.

Information is collected during NHANES on a national

sample through physical examination, clinical and laboratory tests, and related measurement procedures as well as

questionnaires. Prevalence data are collected for specifically defined diseases or conditions of ill healtly and normative health-related data are collected that show total

population distributions of particular characteristics, such

as visual acuity, pulmonary function, or blood pressure. In

NHANESI, 14,407 adultswere examined; the NHANES

HI survey (whichwillbegin in 1988) will yield examinations

of approximately 28,000 adults.

Uses

Questions about current and longestjob and symptoms

of occupationally related illness (and direct examination

findings in NHANES) make these surveys potentially useful for occupational research. Certainly, they can yield

normative data for comparison with specific studies performed by others. The possibility also exists to link the

respondents with later death certificates using the National

Death Index (NIX) in order to examine mortality by occupation and industry. In fact, searches of mortality records

have yielded over 2,000 deaths for the NHANES I cohort

as part of the NHAN123 I Epidemiologic Followup Study.

For these, questions in the followup included occupation

longest held. Other occupational information includes results of rereading x-rays, which have revealed some evidence of asbestosis. For the NHANES IrI study, an

estimated 10 percent of the effort will be related to occupation.

A possible scenario for using NHIS would be to gather

basic industry and occupation information on longest job

for a 3-year period (perhaps supplemented by additional

questionnaire information) and then follow thii cohort

using the NDI for a lo-year period. Followup of th~ sample

eventually would yield over 30,0(XIdeaths.

Both NHANES and NHIS could be developed to

routinely include longitudinal effortssuch as the NHANES

I Epidemiologic Followup Study, which is a longitudinal

reintewiew with the NHANES I adult cohort originally

examined from 1971 through 1974. Longitudinal designs

would expand the capabilities of these surveys to collect

occupational information. In both instances, the number of

cases would be relatively small for detailed occupation and

industry analysi~ the NHIS would have a larger number of

cases ultimately ascertained by the NIX, but would include

no examination data.

costs

Assuming a 10-year period of followup of NHANES

III using the NIX, resulting in about 2,800 deaths identified

over that period, the estimated cost (including the exam

costs) per ascertained case would be about $2,870 (table 4).

An alternative approach would follow up the NHIS samples

at 110,000 a year for 3 consecutive year& this would result

in a larger database, about 33,000 deaths identified over 10

years, for analysis and a lower cost, an estimated $37 per

case.

Advantages and disadvantages

The advantages of this approach are the availability of

detailed measures of covariables, symptoms, and examination findings; the potential for questioning indtilduals directly for exposure information and morbidity histo~, and

the potential for longitudinal followup. The disadvantages

include small sample sizes that cannot support detailed

analysis and suweillance activities by occupation or industry

for specific causes of death or small geographic areas.

OptionNo. 7. Followupof targeted

NationalCenterfor Health

Statisticssurveys

Presentedby Bruce Cohen, National Center

for Health Statistics

Description

In addition to the NHIS and NHANES programs,

NCHS performs several surveys aimed at specific populations, two of which—the National Survey of Family Growth

(NSFG) and the National Maternal and Infant Health

Survey (NMIHS)-may be useful for occupational

research.

23
Cycle IV of the NSFG was scheduled to start in May

1987. (Editor’s note The revised date for implementing

his cycle is early 1988.) This sample of approximately

12,000women was originally interviewed in the 1986 NHIS.

f’he survey will include interviews with a national sample of

women 15-44 years of age, regardless of marital status or

>regnancy history. They will be interviewed in person. The

nterviews will include the woman’s marital history, preglancy history, contraceptive history, data on social and

;conomic characteristics, and such risk factors as smoking,

.lrinking, pelvic inflammatory disease, and certain sexually

ransmitted diseases.

Information will be collected for the current or most

-ecent occupation and industry of employment for the

.voman (and her husband if she is married). Occupational

lata will be coded according to the 3-digit U.S. Bureau of

.he Census classification. Information regarding infertility,

reproductive patterns, and birth intervals will be available

hat can be assessed by employment patterns and labor

force participation. The NSFG currently includes some

questions requested by BLS that pertain to employer contribution to maternity benefits.

The 1988 NMIHS will be equivalent to the three

surveys that were previously conducted separately—the

National Natality, Fetal Mortality, and Infant Mortality

Followback Surveys-with information collected for three

national samples of vital recorcls: 10,000 live births, 4,000

fetal deaths, and 6,000 infant deaths. Thus, a total of 20,000

.leliveries will be surveyed to include information obtained

from the mothers, hospitals, and medical attendants. It will

De possible to corroborate information obtained on vital

records with that obtained by use of a detailed interview

questionnaire for those States that code industry and occupation on their vital records.

NMIHS staff plan to include the following

work-related items in the 1987 pretest of the 1988 NMIHS

questionnaire: industry and occupation of employment for

‘ather at time mother became pregnant (coded to 3-digit

U.S. Bureau of the Census codes), including dates of

:mployment and average number of hours worked per

.veek, and industry and occupation for mother at three time

>oints—prior to pregnancy, during pregnancy, and at time

~f interview (approximately 5 months after delivery) (coded

to 3-digit U.S. Bureau of the Census codes). These data will

also include dates of employment and average number of

hours worked per week. Examination of reproductive hazards may be possible with these data.

Other NCHS survey programs, such as the National

Health Care Utilization Survey, should be examined for

their potential usefulness for occupational research.

Uses

These are examples of special surveys that deal with

reproductive history and outcomes. Because reproductive

Jisorders were identified by NIOSH as one of the 10

leading work-related diseases, these data sources should be

examined for their utility to address specific hypotheses

and/or generate prevalence estimates of potentially workrelated conditions.

costs

The estimated cost for the NMIHS occupationally

related component is $480,000. The coding of industry and

occupation will cost an additional $50,000. Therefore, the

estimated cost per respondent is $26 and the cost per death

is $53 (table 4).

Advantages and disadvantages

NMIHS includes 4,000 fetal and 6,000 infant deaths

with enormous potential to examine occupational risk factors for both parents. The format could provide the opportunity for detailed and specific followback. Among the

disadvantages of the NSFG is that it will likely contain

information on very few deaths if the study population is

followed with the NDI for subsequent adverse pregnancy

outcomes. The NMIHS has information on a large number

of fetal and infant deaths but not enough for most analyses

by detailed occupation and industry or for small geographic

areas.

Questions and answers

To the question of whether the information from the

NMIHS could use occupational information currently being coded by the States, the reply was that the NMIHS

decedents were infants (without occupations), and the State

coding was for adult decedents. Unfortunately, no linkage

between the two sets of records is feasible, but information

on the occupation and industxy of parents could be obtained in followback surveys such as the NMIHS to link

occupational exposures of parents to health outcomes for

their infants.

Another suggestion that was made was for coding

occupation and industry of the parents on the report of the

fetal death or on the birth certificate in those States in

which data files of matched infant death and live birth

records are being developed. (Editor’s notti The occupation and industry of both parents are included in the U.S.

Standard Report of Fetal Death, but they are only recommended for the U.S. Standard Certificate of Live Birth.)

That may link enviroflmental and occupational exposures to

the outcomes of pregnancy. Some discussion ensued about

the problems associated With linking infant death and live

birth records. NCHS is currently exploring that possibility

in a major multiyear evaluation project. A pilot study

conducted jointly by NCHS and nine States in 1985 and

1986 generated a more than 95-percent match rate between

these two vital statistics source records, suggesting that

establishing an ongoing national data base of this type may

be feasible.

24
Option No. 8. Cohort foiiowup of

nationai study groups

Presentedby Gilbert Beebe, National Cancer

Institute

Description

In recognition of the need for a nationai system of

information on occupational mortality, consideration has

been given to using administrative record systems and

special study groups. The decennial census, the Current

Population Suwey (CPS), the Qmtinuous Work History

Sample (CWHS) of the Social Security Administration

(SSA), and State unemployment insurance files have all

been examined as potential sources of information on

differential mortality associated with employment. Despite

strong encouragement of the National Institutes of Health,

the U.S. Bureau of the Census has been unwilling to permit

the use of any part of the decennial census in this way

because of confidentiality requirements, but has agreed to

the substitution of the Current Population Survey for the

purpose. This has resuited in the National I.mngitudinai

Mortality Study, a collaborative undertaking of the National

Heart, Lung and Blood Institute, the U.S. Bureau of the

Census, and NCHS, with an expanding sample currently at

1.2 million individuai$ about 40 pereent of whom have

bepn in the labor force.

The CWHS of SSA consists of 1percent of all those in

the social security program since 1937. Beginning in 1957,

thefile contained a longitudinal history of employment with

Standard Industrial Classification (SIC) codes and also

reasonably complete information on the fact, but not the

cause, of death. The National Cancer Institute (NCI) is

funding SSA to obtain cause of death for the period

1973-77 in order to test the usefulness of the SIC information in this file. SSA, the Internal Revenue Semiee (IRS),

and NCI have all been interested in the potential value of

the occupational entries on the IRS Form 1040 and have

supported a project to develop a partially computerized

approach to Standard Occupational Classification (SOC)

coding. One goal is the transfer of IRS occupational data to

SSA for the CWHS.

Another source of nationwide data on occupational

mortality is the Dom smoking study of nearly 300,000

veterans surveyed in the mid-1950’s. Data through 1970

have been published by occupation and by industry, and

data through 1979 are being analyzed now. An additional

possibility would be to follow up a clearly identified occupational population, such as ail members of a particular

union or all employees of a particular company, with the

NDI in order to identi~ potential excesses in mortality if

appropriate comparison populations are available.

Uses

Each speciai study cohort presents a different mix of

information on demographic characteristics, mortality, industry of employment, and specific occupation, but all of

them provide the basis for erdculating mortality rates with

consistency between numerator and denominator as to

employment coding.

costs

The costs of the National Longitudinal Mortality Study

have been estimated to be $48 per death for 1973-83

samples. Other national studies would have similar costs

per death (table 4).

Advantagesand disadvantages

Dr. Beebe discussed the advantages and disadvantages

of Option No. 8 in relation to Option No. 2 (coding death

certificates annually for all States). He characterized Option No. 2.as the “Cadillac” and as a goai for a data source

on nationai and local occupational mortality trends and

patterns. Dr. Beebe felt that use at the local level is perhaps

an even more important consideration than national use, as

studies by Samuel Milham, for Washington State, have

demonstrated over the years.

The strength of the Current Population Survey (CPS)

as a data base for occupational mortality studies, as in the

National Longitudinal Mortality Study, is that it includes

information on lifestyle as well as occupation. Lifestyle

differences may account for a share of the differential

mortality that now is attributed to occupation. The major

drawback of the CPS is its small size. In addition, to

ascertain mortali& one has to go through three steps at

presenti (1) use the NDI to identi& the deaths to the CPS

cohort, (2) purchase copies of the death certificates of the

identified individuals from the States, and (3) code the

cause of death from these certificates.

The CWHS has good identi@g information, some

demographic variables, the fact of death, and SIC code for

the industry of the decedent. But it lacks occupational

information, and one needs to go through the same steps as

with the CPS to obtain the death certificate from the States

to codecause of death. A further disadvantage is its small

sample size.

Questionsand answers

A question was asked about the status of a bill designed to create “statistical enclaves” (Beebe, 1981). Statistical enclaves would allow certain Federal agencies to link

and pool reeords for statistical purposes, overcoming existing restrictions related to confidentiality that either completely or severely limit such information sharing. Dr.

Beebe indicated that the legislation was defeated.

It was pointed out that the vital records were not

subject to the Paperwork Reduction Act, implemented by

the U.S. Office of Management and Budget, because vital

records are State rather than Federal records but other

data sources of NCHS are subject to the act.

The information proposed for the 1990 census was

discussed. The questions for the 1990 census are likely to

be similar to those in 1980, including asking most recent

occupation if the respondent had worked within the past 5

25
years(in the 1970 census, it was asked for respondents

having worked in the past 10 years). The change reflects the

continuing pressures on the census to reduce respondent

burden.

Option No. 9. Records systems

Presented by William Eisenberg, Bureau of

Labor Statistics, and John Sestito, National

Institute for Occupational Safety and Health

Description

The Bureau of Labor Statistics is involved in two major

Federal-State cooperative programs that collect information on occupational injuries and illness from record

sources the Annual Survey of Occupational Injuries and

Illnesses (ASOII) and the Supplementary Data System

(SDS), based on State workers’ compensation reports. The

annual survey is a mandatory sample of 280,000 employers

concerning the private sector. Surveyed employers report

all occupational fatalities, illnesses, and injuries, except first

aid cases. The fatality cases that are reported in the survey

are followed back to obtain general causal information

about the fatal event. Fatality cases are then classified into

1 of about 15 different categories, such as highway vehicle

accidents, fires, or electrocutions.

The other general source of information is the State

workers’ compensation systems, on which the SDS is based.

Information provided in tl]is program includes the industry

and occupation of the affected worker, the nature and

source of injury or illness, the part of the body affected, the

accident or exposure type, the associated object of substance, and the sex and age of the worker. Thirty-two States

provide this information voluntarily. Of these, 12 States

provide information on fatalities. Ten States provide fatality

information on “closed cases,” that is, cases that have been

settled. Two States provide information on fatalities on a

“current basis: that is, cases for which claims are pending

but have not yet been closed.

In the past, more traditional approaches to the definition of occupationally related illness and injury have limited

the utility of workers’ compensation files for studying certain occupational diseases. However, in some cases, legal

and legislative initiatives have resulted in the compensation

system expanding its coverage to other chronic health

conditions.

Uses

The annual survey can provide national and State

estimates of the numbers and incidence rates of occupational fatalities by general industry and causal categories. It

can be used for trend analysis and interindustry comparisons.

The potential exists for followback of workers’ compensation files at the State level or through SDS although it

may be more useful for morbidity rather than mortality

surveillance.

costs

These surveys include morbidity, as well as mortality,

records. If the total cost of the surveys were amortized over

the death records only, the costs to maintain these two

surveys is currently about $1,600 (for ASOII) and about

$1,700 (for SDS) per death ascertained. The large cost per

death reflects the fact that a majority of the records processed in these surveys are not death related.

Advantages and disadvantages

The annual survey has the potential for followback by

industry or source and has detailed industry identification.

Although information on the demographic characteristics

of workers is not currently collected, this information is

available and could be obtained through followback. In

addition, demographic characteristics for facilities are calculated for employers with 11 or more employees. The

survey excludes agricultural employers with less than 11

employees and the government sector, and it captures

mostly traumatic fatalities due to accidents rather than

chronic illness and may exclude fatal injuries when the

death occurs in a different calendar year than the injury.

The SDS and workers’ compensation files have excellent information on demographic characteristics, on factors

relating to the event, and detailed industry and occupation

information. In addition, there is potential for followback at

the State level. SDS files are, however, lirnitcd by inconlplete coverage of workers, incomplete participation from all

State programs, variations in claims processing proccdurcs,

and lack of denominator information. The legal nature of

the system affects its ability to serve occupational health

and mortality surveillance. Being an insurance system,

some diseases are not recognized as work-related, and,

therefore, are not covered by the system. In addition, the

confidential nature of some of the information contained

on workers’ compensation tiles may limit its ability to be

used in a record linkage system.

Questions and answers

Among the questions asked of Mr. Eiscnbcrg was

whether his agency had given thought to establishing studies based on the Occupational Safety and Health Administration’s (OSHA) Form 101, which is a supplemental

record to the establishment survey that includes additional

information on the demographic characteristics of the injured workers. A pilot study is being developed to test the

feasibility of collecting the information on the OSHA Form

101. Also, BLS will explore the use of the standard ICD

codes (the International Classification of Diseases recommended by the World Health Organization) that are used

to code morbidity and mortality information.

Mr. Sestito noted that his colleagues in the Morgantown, West Virginia, office of NIOSH are developing a

national fatality registration system, which is an attempt to

link information from the mortality statistics system with

26
information from the workers’ compensation system.

Mr. Sest{to feels that there is considerable potential in

some of the State information systems, such as workers’

compensation, particularly States such as California that

arc beginning to establish compensation funds for certain

occupationally related diseases, such as asbestosis. The

costs of workers’ compensation is on the order of $22 to

$23 billion per year.

Option No. 10. Use of compressed

vital statistics files

Presentedby Bruce Cohen, National Center

for Health Statistics

Description

The detailed vital statistics files can be compressed for

rapid, easy use by investigators. An example of this type of

file is a county-level national mortality and population file

developed at NCHS that spans the years 1968-83, referred

to as the Compressed Mortality FiIe (CMF). These files can

be used to identi~ geographic areas with excess mortality

rates that may be related to occupational exposures.

The CMF files are stored on only three reels of tape,

hvo for the mortality data and one for the population data.

Differential mortality trends can be easily and efficiently

examined because of the compact nature of this file. AII

earlier version of this system, which covered the years

1968-78, was developed by Dr. Alan Gittelsohn (Department of Biostatistics, Johns Hopkins University School of

Hygiene and Public Health) under contract with NCHS.

The compressed vital statistics files are derived from

the 31 million U.S. microdata death records for this period.

The 159-160 byte records were condensed to 23-byte

records by reducing the number of variables included on

each record. The variables included on the condensed file

are county of residence, year of death, race (white versus all

other), sex, age group at death (divided into 15 age groups),

and underlying cause of death (4-digit ICD code). The 31

million records were reduced to 13 million records by

counting records that were identical with respect to these

variables, and then adding a count field.

The compressed population file is derived from annual

estimates for each U.S. county by 5-year age groups, race

(white versus all other), and sex. These estimates reflect

adjustments based on the 1980 census, and they were

prepared by the U.S. Bureau of the Census with modifications by NCHS, The compressed mortality files and the

corresponding population data from the U.S. Bureau of the

Census are now available as tapes from the National Technical Information Service for $300 for the first 10 years and

$900 for the next 5 years.

Uses

This approach would be used to identi~ geographic

areas (at the county level or greater) with excess causespecitic mortali~ rates that maybe related to occupational

exposures. It would also examine time trends and geographic variations in cause-sprzific and possibly occupationally related mortality.

costs

The costs to develop this data base are minimal because the source data are currently available through

VSCP. The costs for processing and secondary data collection are estimated to be $0.0003 per death (table 4).

Advantages and disadvantages

This approach is simple to use, and it can provide

inexpensive, comprehensive cause-of-death information

with broad geographic coverage over an 18-year span.

However, it provides neither industry or occupation information nor exposure information; it provides only ecolo~”c

datq no individual-level variables are available.

References

Beebe, G. W. 1981.Record linkage and needed improvementsin

existing data resources. Quantification of Occupational CanceZ

Banbury Report No. 9. Cold Spring Harbor Laboratory.

pp. 661-673.

Guralnic~ L. 1962.Mortality by occupation and industry among

men 20 to 64 yerus of age: United States, 1950. Htal Statistz”cs—

Special Repo~8 Vol. 53, No. 2. Washington: U.S. Government

Printing Office.

Guralnic~ L. 1963a. Mortality by occupation and cause of death

among men 20 to 64 years of a% United States, 1950. Hfal

Statktics-S’cial Reports, Vol. 53, No. 3. Washington U.S. Government Printing Office.

Guralniclq L. 1963b. Mortality by industq and cause of death

among men 20 to 64 yearn of agti United States, 1950. V7tal

Statistics+ecial Repents, Vol. 53, No. 4. Washington:U.S. Government Printing Office.

Guralnic~ L. 1963c.Mortality by occupation level and cause of

death amongmen 20 to 64 yems of age: United States, 1950.J4tal

Stat&tics-Speciaf Repo~, Vol. 53, No. 5. Washington:U.S. Government Printing Office.

National Center for Health Statistics, T. Z. Hambright. 1969.

Comparability of mm-tat status, race, nativity, and country of

origh on the death certificate and matchingcensusrecord: United

States, May-August1960.P7taland Health Statktics, Series 2, No.

34. PHS Pub. No. 1000.Public Health SeMce. Washington U.S.

GovernmentPrinting Office.

Rosenbe~ H. M., D. Bumham, R. Spirtas, and V. Valdisera.

1979.Occupation and industry information from the death certificate: Assessment of the completeness of reporting. Statistical

Uses of Administrative Records with Emphasis on Monality and

Disability Research, edited by L. Del Bene and F. Scheuren.

Washington SocialSecurityAdministration.

U.S. Congress. 1986. House of Representatives. Occupational

Heaith Hazard Surveiknce: 72 YearsBehind and Counting. House

Report 99-979.Washington: U.S. Government Printing Office.

27
Chapter Ill.

Working group reports

Objectives for working groups

by Bruce Cohen, Ph.D., Office of Analysis and

Epidemiology, National Center for Health

Statistics

There are many data resources that can be used for

occupational surveillance and research as depicted in figure

2. This figure is intended to represent the many interlocking

parts of a puzzle. The National Institute for Occupational

Safety and Health has several data bases that evaluate

exposures and health hazards. The Bureau of Labor Statistics collects information on work-related health events in

their annual survey. Obviously, State government and

university-based research play an important role in understanding the risks. Also, the National Cancer Institute

conducts many industry-wide studies of cancer. In addition,

there are studies sponsored by unions and industries. The

National Toxicology Program performs laboratory research

on toxic agents that are found in the workplace. The

National Center for Health Statistics (NCHS) has surveys

that address morbidity issues. The central location of

NCHS mortality data in the puzzle is meant to focus our

attention for this Workshop, not to imply that these data

2 C?5 .em

Workers

Compensation

I

NIOSH

Health

?’=jV”

L

Hazard

Evaluations

3

?sw.ti-~

T-

~y

% (+” ‘- n

University

Research

u

NCHS

Morbidity

w!@Vlw

National

Toxicology

Data Program BLS

Annual

suNeys

NOTE ELS is Bureau of Lnbor Statistics, NCHS ia National Center for Hadth Statistic, NCI ia National Cancer Institute, and NIOSH ia Nauonal lnwtute for

Occupational Safety and Health.

Fgure 2. Data Resourms for Occupatia+tal Survoill.ence sandReasmrch

28
areanymore central than other data sources to the overall

occupational health surveillance issue.

The visual display in figure 2 emphasizes several

points occupational health surveillance and research are a

real puzzle. Further, there are many pieces that provide

information relevant to the activity. How these pieces fit

together is not being addressed at this Workshop, but the

focus is on how NCHS might assist others in their research

activities. We all work on different pieces of this puzzle, so

I think that it is valuable that we view the NCHS mortality

data in the context of all of the other pieces of the puzzle.

The first goal of this Workshop is to review the coUection and use of data regarding mortality risk by occupation

and industry. The 10 options that were elucidated do not

preclude consideration of other options or modification of

the options that were proposed. The second objective is to

make recommendations regarding the implementation of

coding occupation and industry on death certificates. Certainly, in terms of the needs of NCHS for planning, this is

the key objective. A third objective of the working groups is

to discuss recommendations regarding the use of other

NCHS data sources or data from other agencies for occupational surveillance. This last objective is a secondary goal

of the Workshop.

29
?eport from Woricing Group No. 1

ienry Anderson,W-nsin Diviin of

ieaith

~articipants of Working Group No. 1

ncluded:

+emy Anderson, Rappxteur

Nisconsin Division of Health

2dward Baker

National Ihstitute for occupational Safety and Health

%aron Blair

National Cancer Institute

?red Blosser

occupational Safety and Health Reporter

me Bureau of National Affair% Inc.

3reg Bond

Dow Chemical Company

David Brown

National Institute for occupational Safety and Health

Harvey Chezkoway

University of North Carolina

Bruce Cohen

Sational Center for Health Statistic

Gwendolyn Doebbert

Gditbmia State Health Department

Joseph DuBois

kcupational Safety and Health Administration

Jacob Feldman

National Center for Health Statistics

John Froines

University of Californi% Los Angeles

Eric Frumin

%nerican Clothing and Textile Workers Union

George Gay

National Center for Health Statistics

David Lilienfeld

Mt. Sinai School of Medicine

Melvin L. Myers

National Institute for Occupational Safety and Health

Earl Pollack

National Academy of Sciences

Charles J. Rothwell

North Carolina State Center for Health Statistics

George Stelluto

Bureau of Labor Statistics

George VanAmburg

Michigan State Registrar

Diana Zuckerman

U.S. Congress, House of Representatives

Government Operations Committee

Review of options

The approach taken by this working group was to

temporarily ignore the options outlined for the group and

all of the existing data sets and then ask the question What

would we design as a system for a-g occupationally

related mortality? Alter that long proc~ the group agreed

that Option No. 2, the annual industry and occupation

coding for all States, represented the ideal situation. If one

already has an existing vital statistics data system, such as

currently exists in the Vital Statistics program at the National Center for Health Statistics (NCHS), despite all of

the problems that anybody can identify, it is worth extending that system to include industry and occupation coding

from as many of the States as possible on an annual basis.

The group felt that industry and occupation could not

be viewed as a single, isolated entity. They have to be

viewed as part of the vital recor@ specifically the mortali~

records. Therefore, the other data portions of those records

should be considered in the analyses. There is a lot of other

information available on the death certificate that is valuable for the analyses of occupationally related mortali~.

With regard to whether a national data system was

needs we could come up with no sound arguments for not

having a national system. Although a national system has

problems, any system that does not cover the entire country

has additional problem$ such as incompleteness of data

and limited application to other regions of the county due

to regional characteristics. Another imprtant aspect of a

national data system is that problems of bias because of

migration can be avoided. It was pointed out that, although

some people may retire to northern Stat% a substantial

proportion of the retired population tends to move to

warmer States in the south. Hence, estimates of mortality

for occupationally related causes at a State or regional level

would be misleading. The only way to capture information

relevant to an occupation or indushy category, or to capture information relevant to speciilc industrial settings, is to

have a national system.

Uses of a national data system

The working group summarized some of the important

uses of a national system. At the national level, these

include monitoring trends over time in mortality for particular occupations and industries, early identification of

health problems, and hypothesis generation. The number of

causes of death would necessarily have to be focused. For

instancc, the use of the sentinel health events (occupational) (lWtstein et al., 1983) would be key to causes of death

to study. At the State level, one of the key issues would be

the utilization of the data system to target prevention and

industrial hygiene assistance programs. This would also be

true for the Occupational Safety and Health Administration’s sponsored activities.

Key issues in implementing the system

The working group discussed several issues that they

considered central to the implementation of a high quality,

30
comprehensive data system. There needs to be national

leadership and encouragement for this system. Now that

the three agencies (the Bureau of Labor Statistics, NCHS,

and the National Institute for Occupational Safety and

Health) have signed a memorandum of understanding it is

hoped that new cooperation will engender greater attention

and provide greater assistance and direction to the States.

There is a need to use the information that has already

been collected and publish it so it can be used to inform the

States of the utility of this information. However, the States

should be involved in discussions of how the data should be

analyzed and summarized to avoid unilateral decisions by

the Federal Government regarding such aspects as age

brackets and grouping of other coded information.

The working group wished to stress the need to develop an automated coding system. This would assist the

additional States to begin the coding and would help reduce

escalating costs.

Clearly, the key to the program is quality control. We

found that everyone seems to have a different definition of

what quality control is. However, there was a consensus

that quality control must go beyond simple verification of

the coded information. There is a need for folIowback

studies (Option No. 5) to assess the information that is

coded, both for disease and for occupation and industry

information. Option Nos. 6 and 8 would also be useful in

assessing data quality.

We felt that Option No. 4 was the best approach for

States in transition to comprehensive coding.

Funding of the program

The working group thought that this program could not

be accomplished by shifting support from ongoing activities

at NCHS. There needs to be a total increase in the dollar

support for the whole program because the other aspects of

the vital statistics program should not be diminished. We

felt that the best way to fund the program would be as a

direct appropriation from Congress. It was felt that the

program should not be funded on a partial basis. The

importance of the issues of occupational and industry

coding for death certificates needs to be recognized so that

this system will be maintained in the future.

References

RutStein,D. D., R. J. Mullan, T. M. Frazier, et al. 1983.Sentinel

health events (occupational): A basis for physician recognition

and publich health surveillance.Am. J. Public Health 73:1054-

1062.

31
Report from Working Group No. 2

Todd Frazier, National Institute for

occupational Safety and Health

Participants of Working Group No. 2

included:

Todd Frazier, Rapporteur

National Institute for Occupational Safety and Health

Gilbert Beebe

National Cancer Institute

Warren Buckler

Social Security Administration

Km-en M. Deasy

National Institute for Occupational Safety and Health

William Eisenberg

Bureau of Labor Statistics

William Fayerweather

E. I. duPont deNemours and Company

Edward Hunter

National Center for Health Statistics

Deborah Keimig

National Academy of Sciences

Carl A. Keller

National Institute of Environmental Health Sciences

Barbara Kerr

National Center for Health Statistics

Karl Kroncbusch

Office of Technology Assessment

Philip Landrigan

Mt. Sinai School of Medicine

Samuel Milham

Washington State Department of Health

Michael MoI1

National Institute for Occupational Safety and Health

Robert Mullan

National Instilute for Occupational Safely and Health

Patricia Potrzebowski

Pennsylvania Division of Health

Statistics and Research

Harry Rosenberg

National Center for Health Statistics

Michael Silverstein

United Auto Workers Health and Safety Department

Elsie Stanton

National Center for Health Statistics

Janice Windau

Bureau of Labor Statistics

Review of options

The consensus of the working group was to concentrate

on Option Nos. 1 through 4. Option No. 2, annual coding

for all States, was selected as the goal for the program. The

other three options were viewed as special cases of the

preferred option and represented logical stages in the

evolution of a national program.

The working group recognized that fiscal constraints

would affect the speed with which Option No. 2 could be

implemented. It was proposed, therefore, that a modification of Option No. 4 should be implemented. Specifically, a

program should be developed that includes industry and

occupation coding in selected States plus demonstration

project funding designed to increase States’ ability to develop occupational disease intervention programs.

Uses of a national data system

The discussion of the group identified three important

uses of this data system: description of trends in occupationally related mortality; hypothesis generating capability

of mortality data with coded occupation and industry; and

use of sentinel events (preventable deaths due to work

injuries or diseases) that should result in effective intervention. At this point, it became clear that there were understandable, but major, differences in the uses made of the

mortality data systems by Federal agencies and by the

States. For some users, the purpose of the data is mainly

descriptive for others, the data represent a necessa~ first

step toward intervention.

Issues of data quality, coding, and

accessibilityy

The concept of an information chain in these data

systems includes the flow of information from the attending

physicians, to the informant, to the funeral director, to

nosologists, to epidemiologists. All have a part in providing

aeeurate information. The need for raising the awareness of

physicians to the possible role of workplace hazards was

noted. The work of the National Institute for Oeeupational

Safety and Health (NIOSH) and the National Center for

Health Statistics (NCHS) in publishing the Funeral Director Handbook was discussed. Mention was made of Dr.

Milham’s work developing industry aud occupation codes

that meet specific State needs but remain generally within

the taxonomy of a national industry and occupation classification system. The role of NIOSH in training nosologists

to code industry and occupation was credited, in part, for

the increase from 6 to 32 States plus the District of

Columbia now making use of the industxy and occupation

information on death certificates. Surveillance Cooperative

Agreements between NIOSH and States (SCANS) and the

NIOSH-funded State Capacity Building Agreements also

helped enhance the value of the death certificate for occupational health surveillance.

Key issues in implementing the system

It was recognized that there are different goals, that is,

that the needs of the National Center for Health Statistics

(NCHS) or the Bureau of Labor Statistics (BLS) to make

national estimates could not necessarily meet other Federal

32
or State Health Department needs. Clearly the current

status, Option No. 1, that is, the collection of information

from a limited number of States, is necessary but not

sufficient.

The group recommended that emphasis be placed on

the development of automated coding of industry and

occupation, that is, keying the literal descriptors from death

certificates and using the computer to code the industry and

occupation,

Funding of the Program

code occupation and industry on mortality records, there is

no assurance that such increases in the NCHS budget

would be possible. Without an increase, non-NCHS sources

would have to be sought to support the program. The group

urged NCHS to aggressively seek funding, and also urged

the National Cancer Institute to continue funding for industry and occupation coding beyond fiscal year 1988 if new

NCHS appropriations were not forthcoming.

Some concern over current funding plans was discussed. Although NCHS would plan to seek funding to

33
Report from Working Group No. 3

PatriciaHonchar, National Institutefor

Occupational Safety and Heafth

Participants of Working Group No. 3

included:

PatriciaHonehar, Rapporteur

National Institute for Occupational Safety and Health

Faye Aziz

Social Security Administration

Patricia Buffler

National Center for Health Statistics

Carol Burnett

National Institute for Occupational Safety and Health

John A. Cooper

National Cancer Institute

Deborah Dawson

National Center for Health Statistics

Ralph Frankow@

University of Texas, Houston

Frank Frodyma

U.S. Department of Labor

Lillian Guralnick

Consultant, formerly with National Center for Health

Statistics

AlIan Hoskin

National Safety council

Jay Lubin

National Cancer Institute

Jeffrey Maurer

National Center for Health Statistics

Dennis Perrotta

Texas State Department of Health

Gail Poe

National Center for Health Statistics

John Priebe

Bureau of the Census

Linda Rudolph

California Department of Health Sewices

Alice Stark

New York Department of Health

William Stewart

Johns Hopkins School of Hygiene

Lacola Washington

National Center for Health Statistics

Review of options

The consensus of the working group was for continued

effort to move toward Option No. 2, the industry and

occupation coding by all States. It was noted that Option

Nos. 1,3, and 4 are included in Option No. 2. The group

preferred to modi& Option No. 2, however, to be an

eventual goal, not a goal for rapid implementation. Rather,

the group recommends an aggressive but realistic implementation of Option No. 2.

The group did not review Option Nos. 5 through 10

because of time restrictions, not priorities. The group did

feel that there were many important options in this latter

group and would encourage the careful consideration of

these options at another time.

Uses of a national data system

The group discussed examples of industry and occupation presented by representatives from several States and

found a wide range of applications. Nonetheless, the issue

of development of further uses of the data beyond the

currently understood potential uses was felt to have a high

priority.

Uses of the data that were identified included trend

surveillance, program and policy evaluation and development, and hypothesis generation. We feel that consideration should be given to providing support and assistance to

States to continue to develop creative uses and evaluation

of the indushy and occupation coded mortality data. This

could be conducted through demonstration projects to

some states it should also include exploration of use by

States as well as usage for national level analyses.

Issues of data quality, coding, and

accessibility

Because the quality, validity, and accuracy of other

death certificate information is relevant in the analyses of

the industry and occupation data that will be coded, the

working group recommends that filrther attention be given

to appropriate estimates of error, or to qualifications of the

dat% for all information collected on the death certificate in

the process of reviewing the industry and occupation coding. There should be incentives provided to States to become part of the coding system. In most States, the effort

required to develop industry and occupation coding could

divert energy, time, and people away from other occupationally related activities.

Key issues in implementing the system

As noted before, the working group felt that an orderly,

rapid implementation of the national system is required,

There were two distinct approaches suggested for the

implementation of the system. One approach would be to

initiate the coding in one new State at a time. Another

approach would be to begin coding with subsets of certificates from all States, with the eventual movement toward

complete coding in each State. The group did not reach a

clear consensus on the relative value of these alternative

approaches.

The development and sharing of automated coding will

be very important to the implementation of Option No, 2. If

such software were available, the problem noted above of

34
diverting resources away from other occupationally related

activities could be minimized.

Questions were raised about the States that are currently not involved in the industry and occupation coding of

death certificate information sent to NCHS. &e these

States using the information? Among the States that do

colleet industry and occupation information on the death

certificate, what are the procedures and what is their

experience in assessing data quality? The group urged that

all of the States be involved early in the review of the

implementation of a national system.

Funding of the program

The funding issue is related to the relative usefulness of

the information. The working group recognized that the

funds are limited at the national as well as State levels.

Funding of this activity might mean the lack of funds for

related activities. The group did reeommend that the funding should be a multiagency activity. Involvement of severaI

agencies is important both from a teehnical, as well as

financial, point of view.

35
Reportfrom WorkingGroupNo. 4

Thomas Mason, National Cancer Institute

Participants of Working Group No. 4

inciuded

.Thomaa Mason, Rapporteur

National Cancer Institute

Robert Biigrad

National Center for Health Statistics

Dennis Bregman

National Institute for Oeeupationai

Safety and Health

John E. Broekert

Utah Department of Health

Elizabeth Delzell

University of Aiabama at Birmingham

Harvey Hilaski

Bureau of Labor Statistics

Robert Israel

National Center for Health Statistics

James M. Melius

National Institute for Oeeupationai

Safety and Health

John Pattersm

National Center for Health Statistics

Wiiiiam G. Phiiiips

Consultant

David Savitz

University of North Carolina

Fritz Scheuren

Internal Revenue Sewice

Joseph Schwerha

U.S. Steel Corporation

Thomas Scopp

U.S. Bureau of the Census

John Sestito

National Institute for Occupational

Safety and Health

Robert Spirtas

National Cancer Institute

Sabrina Sturba

National Center for Health Statistics

Diane Wagener

National Academy of Sciences

James Weeks

United Mine Workers of America

Review of options

The working group unanimously a~eed that Option

No. 2 was the goal to be sought. Any of the other options

would be compromising the potential utility of the data.

Therefore, at this stage of the process, Option No. 2 should

be the focus of the program.

Uses of a nationai data system

The first question asked of the working group was

whether anyone felt that we should not persist in coding

industry and occupation on death certificates. No one in the

group felt that the coding should stop. The group feit that

the coding should continue not beeause the continued

activity would facilitate answering important occupational

health risk questions but because continued coding wiil

stimulate use of the eoliected records and thought on

alternative uses of the data. Scientists are opportunist they

take advantage of what is avaiiable. Therefore, it is important that the coding continue so additional data are available and so continued emphasis ean be focused on the best

way to use industry and occupation data. The group felt

that the other uses for a national data system pale in

comparison to the utility of these data to drive the research

field of occupational health.

Key issues in implementing the system

One of the key i~ues not mentioned by the previous

working group reports is the timely dissemination and

reduced cost of obtaining the tapes. The working group felt

that the National Center for Health Statistics (NCHS) has a

good reeord in preparing and releasing data and, therefore,

NCHS should continue to have the primary responsibility in

collecting these data.

Funding of the program

The working group recommended that new funding

sources be sought. In particular, the group noted the

relevance of these data to the Agency for Toxic Substances

and Disease Registry (ATSDR). The group felt that the

reeent Super Fund reauthorization legislation had broadened the mandate of ATSDR to provide for their participation in collecting environmental hazard data to be included

in the registxy. Most of the high-dose exposures to toxic

substances occur in the workplace. Therefore, industry will

probably be one of the largest users of the registry. Obviousiy, death is an extreme health effeet of exposure, but the

causes of death can give important information regarding

the nature of toxic effects, The working group felt that

ATSDR anti other agencies involved in the assessment of

toxic exposures and their effects should be informed about

the work that is ongoing at NCHS and the need for

additional funding.

3e
Discussion

by Charles Rothwell, formerly the Director,

North Carolina State Center for Health

Statistics

This Occupational Mortality Data Workshop has

brought together a diverse group of participants from

various State and Federal agencies, private industry, and

academia. The Workshop has provided a good forum for

discussion of wide-ranging efforts relating to the collection

and analysis of health-related industry and occupation

(1/0) statistics, The tripartite agreement signed among the

Bureau of Labor Statistics (BLS), the National Center for

Health Statistics (NCHS), and the National Institute for

Occupational Safety and Health (NIOSH) will eneourage

joint ventures in this field and considerable discussion has

centered on the needs for various forms of 1/0 data.

However, the primary purpose of the Workshop has been

to discuss and then propose the most appropriate options

that NCHS should implement to produce occupational

mortality statistics.

The participants have considered 10 options for the

collection of 1/0 data. The first four options related to I/O

coding on death certificates; the next two options concerned

the use of NCHS surveys for followup in the collection of

1/0 data; and the remaining four options related, for the

most part, to the use of administrative data collection

systems, The participants, although representing agencies

of diverse responsibilities, were of one mind in their recommendation to NCHS. Both through open discussion and by

questionnaire, they strongly urge NCHS to place primary

emphasis on the collection and utilization of 1/0 coding on

death certificates, Specifically, they propose that NCHS

attempt to establish national coverage of I/O data on death

certificates while first seeking firm funding for the States

now involved in a pilot venture supported by short-term

funding arrangements.

Summary

Although many options were discussed, emphasis has

been placed on those alternatives that pertain to existing

data sets of NCHS that utilize NCHS’ strengths. Unlike

NIOSH and other centers in the Centers for Disease

Control, NCHS has not been involved with development of

State or county level disease surveillance systems. The

primary role of NCHS has been the creation of national

data systems for research of national issues and for producing national estimates to aid in formulating and evaluating

national policy. The exception to this national focus at

NCHS has been the vital statistics system that is a cooperative effort at the local, State, and Federal levels. Although

vital statistics can provide estimates at all three governmental levels, rates can be unstable for small-area estimates of

rare events. Thus, the most prudent use of I/O data derived

from death certificates for small-area estimation and survedlance should be a combmed r~spol]~itil,.i~ L,.

.>:.. ,.

:.;;.:.

and NCHS. For example, the refinement of the iist of

sentinel health events that are occupationally related

(Rutstein et al., 1983) is currently under way by NIOSH.

The use of these codes may be the most appropriate

method for utilization of I/O mortality data for small-area

surveillance.

The appeal of expanding the capabilities of a welldeveloped and highly utilized data system to serve as the

primary national data system to measure the extcut and

impact of occupationally related disease is considerable.

Nevertheless, the utilization of 1/0 information from cIMII1

certificatees is not devoid of problems. The quality of the

data is of paramount importance. Da[a quality CALLJILIS

beyond the standardization of coding procedures anti [k

verification of State coding. Financial support to States for

the coding and provision of 1/0 data should be prcdic.tt cd

on an active State-based query system to resolve ill-dcfinecl

or improper 1/0 entries. Unfortunately at this time, mosi

States collecting 1/0 information have not enacted a query

system. The bulk of financial support will be needed m

collect and code these data and assure their timeliness and

quali~, however, funding should not be directed solely m

States. At this time, NCHS does not have the ncccssmy

capacity to internally support a national 1/0 mortalily

system. NCHS will need adequate staff to train Slate

coders, to respond to daily questions from States on coding

conventions, and to verify State coding in timely fashion.

Also, given additional resources, the National Ivlormli[y

Followback Survey could serve as a quality control mechanism for cause-of-death information and for 1/0

information.

Another concern regarding the development of a national system relates to the appropriate analysis and display

of 1/0 mortality data. Central to this problem is the lack of

denominator data. States and researchers have used various

methods to depict differences in mortality outcome for

selected occupations and industrial settings. Years of life

lost and mean age at death have been used; yet, these

measures may reflect differences in the age distributions of

employees in selected occupations and not mortality differentials. Proportionate mortality ratios and odds ratios have

also been used; however, they may provide an unacceptable

level of false negative findings. Standardized mortality ratios and age-adjusted rates have been used successfully for

years immediately surrounding the census when denominator data are available.

A more intractable, yet related, issue is that cerlain

occupations or industries may attract employees with very

distinct lifestyle attributes and economic pressures. Thus,

the measurement of seemingly direct relationships between

occupation and mortality and certain diseases may instead

be the measurement of the relationships of certain diseases

and a select group of people who seek and hold such

employment. Unfortunately, many such lifestyle factors

cannot be handled statistically because data for the factors

are missing. For example, death certificates do not contain

37
smoking history, and it is well known that physicians severely underreport cause-ofdeath entities that relate to

smoking. A similar statement can be made about the

reporting of alcohol related mortality. Ye~ even with adequate cause-of-death reporting it cannot be assumed that

smoking and the utilization of stimulants and depressants

are uniformly distr]%uted over industry and occupation

groups. Here again, the National Mortality Followback

Survey may be of some help. Much analyticwork needs to

be done on the proper methods of data analysis and NCHS

should provide such leadership.

Still another problem relates to the comparability of

coding that willtake place at the State level.The training of

nosologists on standati methods of determining the underlyingcause of death led to automated means of determining

the underlying cause. In a similar fashion, NCHS should

review efforts at the U.S. Bureau of the Census and at the

Utah State Health Department to automate I/O coding.

With this as a basis NCHS may then be able to develop an

automated means of coding of I/O data from literal entries.

Funding will be needed to develop such a comprehensive

automated coding system.

Strategy

Even with the problems previously mentioned, the

most viable option for NCHS is to seek funding of a

national effort to collect I/O data from death certificates.

Funding should not be an “all or nothing” proposition.

However, if there is no hope for expansion, the money for

continued funding of pilot States should be placed elsewhere. Bythemselvesthe States currently providingdata do

not provide enough information for national estimates. The

minimum level of commitment should be for funding of

pilot States as well as neccssmy support functions within

NCHS, coupled with a good chance for future expansionto

the remaining States. If, for whatever reason, this strategy

does not entice funding support, NCHS should re-examine

the options relating to the utilization of linkagesbetween its

surveys and administrative data systemsto provide national

I/O mortality estimates. Although not recognized by this

Workshop as the most appropriate set of option% these

other options may generate more funding interest.

The future

Although a national I/O mortality system will take

years to develop, NCHS should continue to examine future

options. The problem of long latency periods from exposure to a diagnosed occupationally related disease is well

known. Now with improved treatment leading to delayed

mortality or death due to other causes, mortality data

become even more removed as a measure of a current

exposure problem. Several future possibilities exist.

In 1989, States will begin to collect I/O information on

all fetal deaths of greater than 20 weeks’ gestation. For

infant deaths, a change in procedure could be established

by States to either collect the I/O data of the mother on all

infant death certificates or to follow back on all infant

deaths for the mother’sI/O information. With the existence

of a national linked birth and infant death file,considerable

information is available surrounding conditions at birth.

Combining I/O data from fetal death certitlcates and linked

birth and infant death certificates could provide a vexy

sensitive and low-costsurveillance system for occupational

exposures by women. Such a systemwould not suffer from

the problem of long latency periods between exposure and

outcome. This project is also of interest because general

mortality I/O data may not be useful for the female population in the near future. Women have only recently become employedin some occupations.The risks of mortality

for women in these occupationalsettings can be expectedto

be underestimated. Yet we cannot, even temporarily, turn

our backs on measuring the risks of adverse occupational

exposure to women. Measuring reproductive outcome relative to occupational setting should be considered. The

fetal and infant death file is relatively small, and it should

be inexpensiveto maintain. There are approximately30,000

fetal deaths and 40,(XKlinfant deaths in the United States

each year. Even if each State paid $2.00 per record for

additional I/O dat% the cost of data collection would be

only $140,000 per yea~ and internal NCHS su~rt requirements beyond the general mortality I/O requirements

would be minimal.

Population-based registries are now being created in

many States. These morbidity registries include birth defects, cancer, trauma, and end-stage renal disease patients.

Few registries collect I/O data. It would be most helpful if

the National Committee on Vital and Health Statistic+ as

well as agenciesthat help support these registries such as

the National Cancer Institute, the Health Care Financing

Administration, and CDC, would emphasize the utility of

collectingI/O data.

Many States are creating data bases for health care cost

containment purposes. The agencies responsible for these

data systems am seldom found in State health departments.

Therefore, the emphasis of these data systems is not preventive health. There is a national organization, the National Association of Health Data Organizations

(N&IDO), that encourages information transfer between

these evolvingState systems.Again, the National Committee on Vital and Health Statistics should work with these

State agencies through NAHDO to sponsor discussion of

such issues as the collection of ICD E codes, I/O data, and

single-patient numbers. The data bases are of considerable

interest because they coversuch areas as hospital inpatient

care, ambulatory surgical centers, and outpatient services.

Conclusion

The conclusions of the Workshop are specific and

heartenin~ yet, the identified challengesare many.There is

a clear demand for a national systemto measure the impact

and extent of occupationallyrelated disease. There is complete agreement where that effort should begin and that it

should not create a new reporting system with substantial

reporting burdens. An existing system, the vital statistics

38
system, was selected for this purpose and its viability has References

been documented through a pilot project with States. Fund- Rut.stein, D. D., R. J. Mullan, T. M. Frazier, et al. 1983. Sentinel

ing will be needed to build capacity at the Federal and State

levels and research will be needed on analytic issues relating

health events (occupational): A basis for physician recognition

and public health surveillance. Am. J. Public Health 73(9):1054-

to the utilization of this information. 1062.

39
Discussion

by Harry M. Rosenberg, Ph.D., Chief, Mortality

Statistics Branch, National Center for Health

Statistics

It has been most grati@ing to have participated in this

landmark Workshop, which is the first systematic and

comprehensive review of alternatives for producing occupational mortality data. I am particularly grateful to Dr.

Manning Feinleib, Direetor of the National Center for

Health Statistics (NCHS), for convening this meeting. Dr.

Feinleib has sought, and I believe to a large degree received, a balanced description, critique of options, and

recommendations for producing occupational mortality statistics. Like many here, I admit to considerable surprise at

the degree of consensus regarding the direction in which

NCHS should proceed in this area that is, that NCHS

should exercise leadership in occupational mortality statisthrough the vital statistics system by

Adding to the existing reporting area of reimbursed

States.

Exploring automated coding of occupation and industry from the death certificate.

Undertaking research in methodologies, measurement,

and analysis of occupational mortality.

Promoting the quality of reporting occupation and

indust~ on death certificates.

Seeking appropriated funds for the NCHS budget to

support State coding.

I would like to use this opportunity to do three thingx

toprovide, for the record, some additional historic perspec-

~ive on the program; to raise some new issues and to

comment on the remarks of the rapporteurs and the other

discussants.

Some history

The current occupational mortality reporting system is

the outgrowth of one decade of sustained collaborative

effort by a handful of staff from four Federal agencies, with

the support of the individual participating States, as well as

the Association of Vital Records and Health Statistics.

Since 1978, the following Federal agencies have worked

together with dedication and a high degree of professionalism to develop a national occupational mortality data base

through the vital statistics system (Rosenberg et al., 1984):

The U.S. Bureau of the Census has provided standards

for classifying and coding occupation and industry,

developed materials for and carried out training for

State and Federal coders, and served as a continuing

focus for coding problem referrals and as a source of

coding expertise for these items.

The National Institute for Occupational Safety and

Health (NIOSH) has provided financial support

through funds to NCHS and through demonstration

grants to the States in the Surveikmce Cooperative

Agreements between NIOSH and States (SCANS)

●

c

programs. It has provided assistance to NCHS in many

operational aspects of the program, including programming assisting in developing tabulation lists, and conducting training of State coders.

The National Cancer Institute (NCI) has assisted

NCHS in many aspects of the program and provided

the core funding to the States for fiscal years 1985-88 to

demonstrate the feasibility and usefulness of the program. It is an understatement to say that NCI’Ssupport

has been crucial in institutionalizing the program

within the States and at NCHS.

The National Center for Health Statistics has administered the program with the State$ carried out quality

ecmtrol on the data received from the States; developed

instructional and training materials; developed, with

NIOSH and NCI, tabulation lists for cause of death

and for occupation and industry to be used in presentation and publication of these datw and has developed

the publication specifications for the NCHS program.

The occupational mortality program was initiated in

1978 with a study to evaluate the codability of the occupation and industxy entries on the death certificate (Rosenberg et al., 1979). The study, directed by NCHS staff, was

carried out, under an interagen~ agreement, by the U.S.

Bureau of the Census. The results demonstrated a high

level of eodability of these items and established cost and

production parameters for the coding, which could be used

as a baseline or standard by the States and NCHS.

The status of occupational mortality coding among the

States as of the late 1970’s was documented in a sumy

carried out jointly by NIOSH and the association representing State vital registration officials (Kaminski, 1981). At

that time, only a handful of States were coding these items

and were using a variety of classification and coding

schemes that were neither readily comparable nor amenable to being organized into a single multi-State data base.

The situation is vastly different today. Over 30 States

are using a single coding and classification system through

which high quality data from 20 States are being routinely

transmitted to NCHS as essentially a component of the vital

statistics data system.

Principal staff contributing to this deeade-long effort

include Thomas Scopp and John Priebe from the U.S.

Bureau of the Censuq John Sestito, Carol Burnett, and

William Crouse from MOSH; Gilbert Beebe and Robert

Spirtas from NC~ and Drusilla Bumham, Glenn Flinchum,

Jeffrey Maurer, and Harry Rosenberg from NCHS.

Issues

A large number of issues associated with implementing

occupation and industry coding have been identified. I

would like to comment on a number of those from the point

of view of the program at NCHS that has had a major

responsibility for this activity.

Institutionalizing the program—There is a consensus

among the working groups that NCHS should move toward

a continuous program of coding occupation and industry

40
from the death certificate at the State level through the vital

statistics system. To achieve this requires predictable, stable, and adequate funding and staff for the States and

NCHS. It must be emphasized, however, that this support

has to be for not only the occupational mortality program,

but also for the basic vital statistics program to which

occupation and industry coding are being added. Occupational data from the death certificate is of little value if the

other data from the death certificate—such as cause of

death, age, race, sex, and place of residence—are not

available or of good quality.

The advantages of Option No. 2 are not only that it is

economically competitive with other options that have been

discussed but that it draws on the strengths of State and

national vital statistics activities, which have been institutionalized for over 50 years, Vital statistics programs, which

exist in all of the States, provide an administrative

framework for ensuring uniform procedures, equitable

reimbursement, quality control, data processing, and contact with data providers. These programs are also adaptable, which is essential in a statistical system, as concepts,

classifications, and data requirements change over time. In

the vital statistics system, changes in data production are

institutionalized through the annual issuance of instruction

manuals to each State for coding and processing vital

statistics data and through the decennial revision of the

standard certificates and reports.

Funding strotcgies—Principal funding support for the

NCHS occupational mortality program was made on a

demonstration basis by NCI only through fiscal year 1988.

The funding strategy to continue the program that appears

to have emerged from this Workshop is a proposal that

NCHS pursue a multi-pronged approach with the ultimate

objective of implementing Option No. 2 for an ongoing

national program involving the vital statistics systems of all

States.

The multi-pronged strategy would involve simultaneously exploring several potential sources: (1) expanded

funding from NCI on a demonstration basis (2) funding

from the Agency for Toxic Substances and Disease Registry; and (3) funding through direct appropriation to NCHS.

Clearly, the last of these is preferable to institutionalize this

activity as an enduring and integral component of the

national vital statistics program. I agree with the suggestion

of Mr. Rothwell that a review of the program in 5 to 10

years would be desirable to ensure that the value and

utilization of the data for surveillance and analysis warrants

the expenditure.

I believe that we must approach the issue of resources

in terms of both adequacy and stability. AM]ough I agree

that the magnitude of resources required for implementing

Option No. 2 are quite modest compared with other

federally supported activities, it should be noted that an

occupational mortality coding program budgeted at $1

million annually would be a nontrivial change in the NCHS

budget, which is about $50 million annually.

If the occupational mortality program is implemented

even at a slightly expanded level from the 11-13 currently

funded States, NCHS must also be provided with the staff

and budget resources for processing the greater volume of

data, and, importantly, for the analyses of these data. With

assistance of other knowledgeable agencies such as NIOSH

and NCI, it is crucial that NCHS demonstrate how these

data can be used at the national and subnational levels to

show associations between occupation and cause of death.

Demonstration projects—Demonstration projects supported by grants to the States can develop creative ways to

produce, analyze, and use the data in support of occupational health activities at the State level. There may be

advantages to having such grants administered by program

agencies, such as NIOSH and NCI.

Automated coding—The possibilities of automated coding should be explored as part of a continuing occupational

mortality statistics program. NCHS already has experience

implementing a pilot project in several States for an automated system for encoding of cause of death from the death

certificate with the goal of ultimately having the capability

to automatically convert English language entries directly

into codes of the International Classification of Diseases. It

is clear that the required internal dictionary in such a

system must accommodate a large number of entries including synonyms and misspellings. The system will still

require a manual component to awommodate the entries

that cannot be automatically handled. It is unlikely that an

automatic system can completely replace experienced coders for complex data items, such as cause of death and

occupation and industry.

The U.S. Bureau of the Census is developing a system

of this type for automatically coding occupation and industry in preparation for the 1990 census. In earlier discussions, U.S. Bureau of the Census staff indicated that,

although the system is likely to work for a substantial

proportion of cases, perhaps 50-70 percent, a large remaining number may still have to be manually coded. Perhaps,

over time, this residual will be diminished. I strongly agree

that automated occupational mortality coding should be

explored by NCHS, possibly using l-percent evaluation

funds.

Mecwrement problems-The Workshop did not widely

discuss measurement problems; but these should be noted

and be explored thoroughly in an ongoing program. Briefly,

measures of mortality risk usually have a numerator representing the occurrence of an event over a stated period of

time, along with a denominator representing a population

at risk to experience the event. The problem for occupational mortality statistics is the paucity of routinely available

information on the denominator. Because denominator

data are often not readily available, occupational mortality

analyses must be carried out in terms of numerators only,

that is, using proportional mortality analysis. The growing

literature on numerator analysis needs to be tapped and

explored to make effective use of occupational mortality

data (e.g., Kupper et al. 1978).

Data quaMy-NCHS is cognizant of concerns in this

area and is addressing these in several ways, beginning with

reporting and extending through data processing to data

. 41
analysis. It is recognized that occupational mortality data

can be no better than the information reported on the death

certificate. Thus, efforts must be directed by State vital

statistics offices to funeral directors to provide occupation

and industry of decedents in sufficient detail and validity to

be useful for analysis. To facilitate this, NCHS has worked

with NIOSH to produce a handbook that provides funeral

directors with guidelines on reporting occupation and industry of decedents (NCHS, 1983).

It has been suggested by Rothwell and others that

additional efforts need to be made to improve the quality of

occupational mortality data. In particular, it is suggested

that States que~ incomplete and imprecise I/O information

reported on death certificates. This is an excellent idea, and

it should be part of a national strategy to improve the

quality of this information repted through the vital statistics system. For other items on the death certificate, NCHS

has developed a set of guidelines for State querying of

demographic items on vital recmls (NCHS, 1982). Full and

sustained querying and training programs at the State level

will be costly but they are crucial to improving the quality

of occupational information on vital records.

A firther suggestion is using followback surveys to

assess the validity and reliability of occupational information on death certificates. NCHS is undertaking such an

effort by including a number of occupation questions on the

1986 National Mortality Followback Survey.

Data use—National leadership in this program has

been emphasized in the discussions of several groups. This

would take several forms, including producing reports that

can serve as models to the States for data analyses and data

dissemination. It would include standardized tabulation

lists, and it would recommend analytical methods. Accepted, standardized measures and analytical approaches are

needed in an area where, because of potentially sensitive

implications, absence of ambiguity in measurement and

analysis is essential. A program at the national level would

investigate measurement methodologies examine issues of

quality, reliability, and validity of reported information;

develop resource materials for States to train funeral directors on reporting these items and for querying incomplete

or ambiguous entries on death records; and identi& resources to States for demonstration activities, including

data use in support of occupational health programs.

Reseaxh oppo~nities—I would like to elaborate on a

point made by Dr. Anderson regarding the nature of

occupational information from the mortality data system; I

call it the “baby bath syndrome” or “statistical myopia.” It

is the unfortunate tendency to denigrate not only occupational information but vital statistics information more

generally because of known and obvious data imperfections

and limitations. The challenge to all of us is to exploit this

accessible, highly standardized data set.

Statisticians and epidemiologists working in the area of

occupational health, accustomed to working with specialized surveys or with study cohort data, have to recognize

and to creatively overcome the limitations of the vital

statistics data base, which reflects a data collection instrument—the death certificate-that serves both legal and

statistical purposes. The vital statistics system is grounded

not in a survey statistician’s constructs but rather in the

legal and statistical needs of State health departments.

Problems of occupational mortality data identified in this

Workshop can provide a research agenda for occupational

mortality. Among the areas to be explored are

● The absence of denominator data for some years.

● The difference between occupation elicited on the

death record (“usual” occupation) and on census and

U.S. Bureau of the Census sumeys (“current” occupation).

. The lag between time of exposure to an occupational

hazard and related onset of death, especially for some

cancers.

. The problem of migration for subnational areas, which

may contaminate observed geographical associations

between occupation and mortality.

● The problem of confounding variables that may partially account for relationships between occupation and

cause of death.

These problems, I would maintain, constitute a research agenda for this data base, and should not impede the

production and use of occupational data reported on the

death certificate.

Conclusion

The Workshop has provided, I believe, a balanced and

thorough appraisal of issues associated with options for

producing occupational mortality data. Broad consensus

has emerged, I believe, on an approach to provide continuous, detailed, and high-quality occupational mortality data

through the existing national vital statistics system; a desire

to support NCHS in obtaining appropriated funds for this

purpcxxy and a recommendation for leadership at the Federal level, through research, analysis, and demonstration

activities. The Workshop clearly can serve as the basis for a

major, sustained national thrust to develop a data base for

occupational health by exploiting existing information reported routinely on the death certificate of every State.

References

Kaminski,R., J. Brockert, J. Sestito, and T. Frazier. 1981. Occupational information on death certificates A survey of State

practices.Ant. J. Public Health 71(5):52S-526.

Kupper, L. L., A. J. McMichael,J. J. Symons, and B. M. Most.

1978. On the utility of proportional mortality analysis.J. Chronic

Diseases 15:15-22,

National Center for Health Statistics. 1982.Guidelinesfor implementing field and que~ programs for registration of births and

deaths, 1983.NCHS Insbuction Manual, Part 18. Hyattsville,Md.

National Gmter for Health Statistics. 1983.Guidelines for Reporting Occupation and Indu.my on Death Certificates. Hyattsville,Md.

42
Rosenberg, H. M., D. Bumham, R. Spirtas, and V. Valdisera. Rosenberg, H. M., J. Sestito, J. Maurer, et al. 1984. Occupation

1979. Occupation and industry information from the death and industry coding from the death certificate: The recent NCHScertificate: Assessment of the completeness of reporting. Smtkti- NIOSH experience. Paper presented to the Washington Statistical

cal Uses of Admhukirztive Recoin%With Emphasis on Motialhy and Society, Washington, D.C.

Disability Reseamh, edited by L. Del Bene, and F. Scheuren.

Washington: Social Security Administration.

43
Summary of recommendations

from participant questionnaires

Questionnaires were given to the 46 participants who

did not represent the Bureau of Labor Statistics (BLS), the

National Center for H.@th Statistics (NCHS), the National

Institute for Occupational Safety and Health (NIOSH), or

the National Cancer Institute (NCI). (See appendix II for a

copy of the questionnaire.) Thirty-seven participants completed and returned their questionnaires. The form directed participants to weight the 10 options by indicating

whether they agreed or disagreed with the implementation

of each option. The following is a summary of the responses. These are not necessarily an unbiased sample of

the opinions of the participants. Further, the discussion of

the results includes interpretations by NCHS staff members.

Option Nos. 1 through 4. Occupation and

industry coding from death certificates

It is difficult to assess the industry and occupation

(1/0) coding Option Nos. 1 through 4 independently because many of the responses obviously considered these

options as one issue. The overwhelming number of respondents strongly agreed (36/37) with Option No. 2 (annual

coding of industry and occupation for all States). Many

respondents identified this option as the ultimate goal of

the system, rather than a strategy for immediate implementation.

Those who strongly agreed with Option Nos. 1 (the

current system) and 4 (annual coding for a subset of States

or causes) felt that these options were the most practical

approach for current implementation but should be expanded to include all jurisdictions willing to participate.

Th~~e were several alternatives for implementing Option

No, 4.

. Bring States into the system as they are ready.

. Sample causes of death that may be occupationally

related.

. Sample certificates from all States for industry and

occupation coding.

● Sample death certificates by industry.

Those respondents who recommended implementation

of the reporting system during census years only (Option

No. 3) viewed it as a subset of Option No. 2 (full implementation) and suggested major pericensal reports based on

annually generated data.

Many respondent comments highlighted two important

foci of I/O coding frosm death certificates. First, a national

system is needed for surveillance, for providing impetus to

the States, developing methodologies of analysis and presentation, and for guaranteeing quality and comparability

of the data collected in the different registration areas. The

second focus is at the State level for developing intervention

strategies for the prevention of occupational morbidity and

mortality. As one respondent summarized: “We currently

have no good baseline data on the magnitude of occupa44

tional illness in the U.S. (existing data being very poor with

regard to chronic disease). State-based data are critical to

State occupational health programs—for program and policy planning, prioritizing of resources, and trend surveillance.”

Fifteen respondents (41percent) recommended that

automated coding of industry and occupation be explored.

Several participants also suggested that a quality assurance

program must be built into the system. Other suggestions

included the following

. Link 1/0 codes to specific occupational exposures,

. Establish a committee to develop a list of reasons that

1/0 coding should be done.

. Fund State demonstration projects emphasizing the use

of the data.

. Request continued funding from NCI.

● Request funding from the Agency for Toxic Substance

and Disease Registry (ATSDR).

. Request funding from Congress.

One respondent summarized several of the issues concerning coding death certificates as follows

Funding for the basic Vital Statistics Cooperative Program must be established before adding new components and processes.

There is a need to include sufficient funding for quality

control that includes followup to check the accuracy of

the data reported.

NCHS needs to develop an automated coding process

so States can electronically record the literal entries for

industry and occupation.

NCHS needs to provide leadership on how to present

1/0 data in tabular and graphic displays.

NIOSH and BLS should work with States on how to

interpret and use 1/0 specific mortality data.

Option No. 5. Mortality followback surveys

Many respondents endorsed the use of mortality folIowback surveys as a valuable supplemental approach to

Option Nos. 1 through 4. Although these surveys would

have the problem of a limited sample size, the surveys could

direct analytic research efforts, provide extremely important information on the quality of the data collected on

death certificates, and obtain information on covariates for

specific hypothesis testing. It was felt that the followback

studies could not provide State-level data or generate national estimates.

Option Nos. 6 and 7. Using NHANES,

NHIS, or other NCHS surveys with the

National Death Index

In general, the comments on these options listed many

problems of this approach, for instance, sample size and

time constraints. This approach should not be considered as

an alternative to Option Nos. 1 through 4. However, as an

ad hoc basis to test certain hypotheses, the availability of

covariate information from these data sets may make con-
sideration of mortality followup worthwhile. The problems

of the sample sizes available for specific occupation or

industxy analyses and the length of time it would take to

generate an appropriate number of deaths make these

approaches less desirable.

Those responding to this option felt that it was important to include occupational data on the National Health

and Nutrition Examination Survey (NHANES) and the

National Health Interview Survey (NHIS). Many participants left this section blank or emphasized its potential

contribution for morbidity analyses rather than mortality

research. Several respondents mentioned that NCHS data

should be examined for investigating reproductive hazards.

Option No. 8. Use of the National

Longitudinal Mortality Study (NLMS), the

Continuous Work History Sample (CWHS),

or Internal Revenue Service (IRS) Record

Followup with the NDI

Many participants did not respond to these issues.

Those that did indicated that these efforts certainly should

not distract from implementing an 1/0 coding option from

death certificates. Some responses were positive for using

NLMS or CWHS. Several participants raised concerns

about the availability of data for analysis. Concerns were

also raised about the quality of the occupational information available from IRS tax forms.

Option No. 9. Use of BLS Annual Survey

of injuries and illnesses (ASOII) or the

Supplementary Data System (SDS) for

Occupational Mortality Surveillance

Many concerns were raised about the completeness of

coverage and the quality of these data. The annual survey

was seen as more valuable for the industries it covers and

could possibly by useful for surveillance of injuries.

Option No. 10. Use of the compressed

vital statistics files

Comments ranged from “inappropriate” to “very valuable” for identi~ing excess cause-specific mortality and

mapping. Several persons commented on the value and

uses of ecologic data for surveillance.

Other suggestions

Below is a list of options useful for occupational mortality surveillance identified on the evaluation forms:

●

●

●

●

●

●

●

●

●

●

●

●

Large sample of U.S. Bureau of the Census long forms.

Data linkage “like the Swedes,” that is, the U.S Bureau

of the Census linked with cancer incidence data and

mortality information supplemented by followback

studies.

Use of the National Hospital Discharge Survey.

Incorporation of Medical Examiners’ data for E-code

deaths into Option No. 2.

Need to link mortality data with exposure information

from the Occupational Safety and Health Administration (OSHA).

Modify NDI to include cause of death.

Facilitate use of IRS address file.

Encourage record linkage and followup studies for

death certificates, coroner’s reports, OSHA inspections, NIOSH investigations, and workers’ compensation claims.

Use end-stage renal disease program data.

Set aside money for State demonstration projects.

Code 1/0 on NCI’S Surveillance, Epidemiology, and

End Results cancer registry data.

Use OSHA forms for research and surveillance.

45
Chapter IV.

Postscripts from

sponsoring agencies

Postscript Bureau of Labor

Statistics

by VWliamEisenberg,AssociateCommissioner

for Occupational Safety and Health Statistics,

Bureau of Labor Statistics

We, at the Bureau of Labor Statistics(BLS), are deeply

committed to improving occupational injury, illness, and

fatality statisti~ and we heartily support interagency effort$ such as this Workshop, that are directed to the same

end. We are particularly happy to be here at this first

gathering under the tripartite agreement.

In the occupational illness are% BLS sponsored a

symposium on various aspects of obtaining occupational

illnessdata (U.S. Department of Labor, 1985).This symposium brought together officials and professional staff from

State departments of labor and State departments of health,

from the National Center for Health Statistics,the National

Institute for Occupational Safety and Health, BLS, and the

Occupational Safety and Health Administration, as well as

representatives of labor, business, and academia. As a

result of that symposium, a BLS-State health department

committee was established to focus on ways to improve

health and safety statistics, including fatalities.

In an effort to improve our statistics program overall,

we contracted with the National Academy of Sciencesfor

SDexpert panel study of our data series, with fatalities a

major emphasis, to help fashion SD effective statistical

program for sumeillance and prevention (National Research Council, 1987).

As regards occupational fatalities BLS recognizesthat,

if the death certificate system is to become a primary

source of this information, the quality of the industry and

occupation reporting on death certificates and the standardization of industry and occupation coding are fundamental requisites. We also recognize that, if it is to become

a viable system a common definition for “at work” fatalities is necessary as well as the participation of all States in

the program.

In closing I would like to express our thanks to the

National Center for Health Statistics for sponsoring this

conference, which focuses on such an important area in

occupational health and safety, and we look forward to

other promising collaborative efforts under our tripartite

agreement.

References

NationalResearchCouncil.1987.Counting Injurz”esand illnesses

in the Workplace: Rvposats fm a Better System. Washington

NationalAcademyPress.

U.S. Departmentof Labor, Bureau of Labor Statistics.1985.

Tonwu% Impmved Measurement and Repom”ng of Occupational

Illness and Disease. $mposium Proceedings. Washington:U.S.

Departmentof Labor.
Postscript: National Institute for

Occupational Safety and Health

by Edward L. Baker, M.D., M.P.H., Deputy

Director, National Institute for Occupational

Safety and Health

This Workshop was important for many reasons. First,

it provided an important opportunity to discuss the merits

of several options for the use of death certificates in

surveillance of occupational illness and injury. Second, it

provided an opportunity for continued interaction of occupational health professionals interested in surveillance systems. Finally, it represented an affirmation of the

opportunity to improve surveillance data for occupational

disorders. In response to this opportunity, the National

Institute for Occupational Safety and Health (NIOSH) is

committed to a cxmtinued, coordinated involvement designed to evaluate the utility of existing approaches to

surveillance and to develop new surveillance systems. Central to this reassessment is the necessity of linking sumeillanee efforts with intervention programs to protect the

health of individual workers. In this regard, I would like to

review NIOSH plans for the future.

NIOSH is committed to the development of an occupational health-hazard-illness-injury coding system, survey,

and surveillance capability (PHS, 1986). A variety of approaches are recommended along with a proposed revision

of the initial objeetive, to read: “By 1990, using the surveillance systems initiated by 1985, injury, illness, and mortality

trends should be depicted for at least 10 to 15 hazards, and

10 to 15 new priorities should be generated annually for

possible epidemiologic or toxicologic research.”

NIOSH injury surveillance data that are based on the

Bureau of Labor Statistics’ (BLS) annual survey differ from

the results obtained from the National Electronic Injury

Surveillance System sample of work-related injuries seen in

emergency rooms. The reasons for these differences need

to be understood. High-risk jobs need to be identified.

Effective intervention pro@ams must be implemented.

These steps will require the combined efforts of Federal

agencies (NIOSH, BLS, the National Center for Health

Statistics (NCHS), the National Cancer Institute (NCI), the

Occupational Safety and Health Administration (OSHA),

and the Mining Safety and Health Administration) and

State departments of health and labor. The precedent set

for Federal and State collaboration by the tripartite efforts

during this meeting points the way toward meaningful next

steps.

Trend analysis for disease and mortality can be based

on the current efforts to adapt NCHS surveys, NHANES

and NHIS, for use in occupational disease surveillance.

Mortality trends for a subset of States currently part of the

Surveillance Cooperative Agreements between NIOSH and

the States (SCANS) and Capacity Building States program

and, eventually, for all States (the consensus of opinion at

the Workshop) form another component of the desired

surveillance program.

The proposal made by Dr. Millar for SENSOR is

designed to enlist medical care providers in the effort to

identitj selected occupational disorders for further research and intervention. The concept of sentinel physicians

along with the effort initiated by NIOSH in 1983 to make

use of sentinel health events (Rutstein et al., 1983) provides

a means of getting primary care providers to “. . . routinely

elicit occupational health exposures as a part of patient

history . . . “ (PHS, 1986).

Clearly, an expanded program for occupational injury

and disease surveillance will require new funding. As evidence of the NIOSH commitment to these efforts, there

will bean announcement soon of another round of NIOSHState cooperative agreements, totaling about $1,000,000 in

fiscal year 87. It is reasonable for the States to assume that

many of the factors that we have discussed at this Workshop will find their way into these guidelines. Specifically,

reference will be made to the concept of occupational

injury and disease smveillance centerq the continuation of

State efforq the existence of State capabilities (in some

cases working cooperatively with NIOSH staff to follow up

on the leads developed from surveillance efforts); the commitment of NIOSH to staff consultation in addition to

dollars; and, in some cases, the assignment of a NIOSH

Epidemic Intelligence Service officer to a State. Another

proposal was to build on the cooperative agreements a “line

of credit” to States consisting of a specified number of

Health Hazard Evaluations or similar forms of technical

assistance.

Because more active provider reporting of occupational disorders through the Sentinel Event Notification

System for Occupational Risks (SENSOR) was discussed

briefly by Dr. Millar in his opening remarks, I would like to

take this opportunity to describe it in greater detail.

Although many States require health providers to report occupational illness and injury, none maintains a

comprehensive system to deteet and respond to such reports. Because little action is taken in response to case

reports, physicians and other providers have little interest in

continuing to contribute to a reporting system that just

collects data. The SENSOR project proposes a comprehensive system that would utilize a network of sentinelproviders

to recognize and report selectedoccupationaldisordm to a

swveillance center. The center would be responsible for

analyzing a case report and directing three types of responset management of the reported case, screening for

possible disease in coworkers of the case, and evaluation of

worksite factors potentially responsible for the case. AIthough primarily useful as a surveillance system designed

for case identification, data from a SENSOR projeet could

be used to monitor trends in the occurrence of selected

occupational disorders within a State.

As discussed by Langmuir (1976) and by Foege and

colleagues (1976), the purpose of surveillance is not only to

collect and analyze data but also to direct active prevention

programs designed to control and, in some cases, eliminate

the occurrence of preventable disorders. In the past, a

number of States have enacted speeific regulations

47
requiring physicians and other health-care providers to

report selected occupational diseases (table 5). Unfortunately, in most instances, these provider reporting programs were not linked to specific intervention efforts.

Table 5. Surveillance ●ctlvittes for oecupmiorml diseaee reported

by health departntents in 50 Sfatas, New York City, ●nd

Washington, D.C.: 1985

Number ofdeprlrrrt?rrfs

Surwwncehporllrrg

Item adhlty

Healttr-caraprcrviders. . . . . . . . . . . . . . . . . . . . . . .

Mandato~reporfing . . . . . . . . . . . . . . . . . . . . . . .

Volunlaryraporting. . . . . . . . . . . . . . . . . . . . . . . .

PenalUaefornotreporting. . . . . . . . . . . . . . . . . . . .

Sixeanlinel healthevente . . . . . . . . . . . . . . . . . . . .

Repotting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dataanalyzad . . . . . . . . . . . . . . . . . . . . . . . . . . .

Followupconducfad. . . . . . . . . . . . . . . . . . . . . . .

Worker adueatbn linkerlto reporting. . . . . . . . . . . . .

31

27

4

16

19

7

8

18

7

SOIJW2 kwcQn d d., lee7.

Other shortcomings of provider reporting systems htwe

limited their usefulness. These include the uncertainty

among providers of the nature of a specific occupational

disorder, that is, lack of case reporting criteria. In the case

of communicable disease reporting, developmentof reporting criteria have greatly facilitated the epidemiologic investigation of selected conditions (Thacker et al., 1983).

Another limitation of existing occupational disease reporting systems, which is similar to that observed in communicable disease reporting (CDC, 1987), is the lack of a

defined network of sentinel providers who have responsibility to report selected conditions to an appropriate State

agency. Finally, in most States, the resources needed to

r=eive, anal~e, and direct a response to a provider report

are minimal or lacking.

To address these-limitations, a uniform provider reporting system will be developed for use by States to

perform active surveillance of selected occupational conditions. The SENSOR system will build on previous experience of State health and labor departments. To some

extent, prior support from NIOSH has contributed to the

development of this capacity.

The SENSOR system will consist of two organizational

components (figure 3). First, a network of sentinel providers, individual practitioners of clinic groups, will be developed. The function of the sentinel provider network will be

to recognize and report cases of selected occupational

disorders. The second component, a surveillance center,

will receive the report from the provider, analyze the data,

and direct action toward the individual cases, coworkers of

the case, and to the workplace. In addition to fulfilling a

central role in the coordination of response to provider

reports of occupational disorders, the center would provide

technical consultation in a wider variety of occupational

health issues (for example, surveillance using vital records,

hospital discharge records, or workers’ compensation files

to monitor trends of occupational disorders). Because State

Recognition

n

Sentinel

Provider

Reporting

I

*

n

Surveillance

Analysis Center

Action

/1143

BmlxI

Figure 3. Sentinel event notification system for occupational risks

(SENSOR): 1987

health departments and labor departments have variable,

shared responsibilities in occupational safety and health,

the creation of a surveillance center will serve to unite

complementary programs that currently exist in relative

isolation.

To facilitate the recognition of selected occupational

conditions by the sentinel provider network, NIOSH will

develop and maintain a list of conditions that lend themselves to provider reporting. To the greatest extent feasible,

such conditions should be attributable to work in a high

percentage of cases, reasonably frequent, easily diagnosable

by practitioners having no access to sophisticated diagnostic

tests, of reasonably short latency, and potentially reversible

following case identification.

In addition to developing a list of conditions, NIOSH

will develop a set of reporting criteria that can be used by

practitioners to facilitate recognition. Such criteria are to be

used for the purposes of improving provider recognition of

selected occupational conditions and enhancing uniform

reporting between different regions of the country. Analyses of these case reports will provide useful information

regarding the characteristics of selected occupational conditions, their sequelae, and other important and clinical

epidemiologic features.

Reporting by providers to State health departments has

relied on a passive system in which the provider is encouraged to mail in reports of cases using forms developed by

the requesting agency. In view of the recent advances in

computer technolog and telecommunication techniques,

other alternatives exist for transferring information from

providers to a central surveillance center. To facilitate a

more active transmission of data from providers to a central

surveillance center, NIOSH will support the development

of computer technology that would allow for the transmission of data on suspected cases from providers to the center

for analysis and possible response.

48
Utilizing staff epidemiologists, statisticians, and other

occupational health professionals, the surveillance center

will analyze cases reported from the provider network and

determine whether additional actions are appropriate. In

many States, opportunities exist for disseminating the results of such analyses through publications directed at

public health professionals, physicians, and other professionals. The results of such analyses may also be appropriate for inclusion in the Centers for Disease Control’s

Morbidity and Mortality WeekZy Repoti.

Three types of action could result from the receipt of a

definite case report. First, individual case management

recommendations will be developed by NIOSH for the

conditions to be placed under active surveillance. Such

guidelines will be made available to practitioners reporting

these cases as a form of consultative assistance. The second

type of action will be directed at coworkers of the case.

Because coworkers with similar workplace exposures may

be at risk for the development of occupational illness or

injury similar to that experienced by the case, medical

evaluation of such workers to detect early, potentially

reversible health disorders is appropriate. Finally, action

directed at specific workplace causes will be coordinated by

the surveillance. center in response to the report of an

individual case. In view of the variable capacity of State

programs tb control occupational safe~ and health hazards,

local resources will be examined to determine the most

appropriate mechanism for directing such worksite action.

Provider reporting systems have been in effect in a

number of States for many years, but because of various

shortcomings, have not developed active surveillance of

occupational illness and injury. To achieve a more uniform,

active approach to provider reporting, SENSOR will be

created as a cooperative State-Federal effort designed to

develop local capability for the recognition, reporting, and

prevention of selected occupational disorders. To demonstrate the feasibility of this approach, NIOSH will fund a

sti’all number of SENSOR projects in fiscal year 87. Ultimately, joint State-Federal support will be essential to

maintaining SENSOR activity within a State.

SENSOR should not be viewed as the sole approach to

the surveillance of occupational illness and injury. Other

approaches to the identification of cases of occupational

illness or injury and to monitoring trends of occurrence of

these disorders have been developed by NIOSH and some

States and will continue to function (Frazier, 1985;

Halperin and Frazier, 1985). These programs will address

other of the six objectives enunciated by NIOSH for improving surveillance in the future

● Improve hazard surveillance.

● Develop uniform approaches for using existing health

data sources.

. Disseminate information and share methodology.

. Perform surveillance for Leading Work-Related Disease and Injuries.

In closing, in my view we are presented with an unusual

opportunity for improving surveillance data for occupational illness and injury. This can only be accomplished by a

collaborative effort involving NIOSH and other Federal

and State agencies committed to improving the collection of

accurate data and, more importantly, a direct intervention

program designed to improve the health of the U.S. workforce. I am convinced that through the activities, such as

this Workshop, which have been organized over the past

several months, we will achieve a dramatic improvement in

the surveillance of occupational illness and injury for this

country.

References

Centers for Disease Control. 1987. Comprehensive Surveillance

Plan. Washingtorr U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Gmtrol.

Foege, W. H., R. Hogan, and L. H. Newton. 1976. Surveillance

projects for selected diseases. ht. 1 Epidemiol. 5(1):29-37.

Frazier, T. M. 1985. Occupational health reporting systems–

U.S.A.A 1 Industr. Med. 8441-446.

Halpenn, W. E., and T. M. Frazier. 1985. Smveillance for the

effects of workplace exposure. Annu, Rev. Public Healtiz 6419-

432.

Langmuir, A. D. 1976. William Fam Founder of modem concepts

of surveillance. ht. J. Epidemiol 5(1):13-18.

Muldoon, J. T., L. A. Wintermeyer, J. A. Eure, et al. 1987. State

activities for swveillance of occupational disease and injury.

Surveillance Summaries. Washin~om U.S. Department of Health

and Human Services, Public Health Service, Centers for Disease

Control.

Public Health Semite. 1986. The 1990 Heaith Objectives for the

Nation: A Midcourse Review. Washington: U.S. Government

Printing Office.

Rutstein, D. D., R. J. Mulhm, T. M. Frazier, et al. 1983. Sentinel

health events (occupational): A basis for physician recognition

and public health surveillance. An 1 Public Health 76(9):1054-

1062.

Thacker, S.B., R. Choi, and P.S. Brachman. 1983. The surveillance

of infectious disease. JAiM4 249(9):1181-1185.

. Develop a model occupational disease reporting system

for health care providers (SENSOR),

. Incorporate occupational health issues into national

and regional surveys.

49
Postscript Nationai Center for

Health Statistics

by Manning Feinleib, M.D., Dr. P.H., Director,

National Center for Health Statistics

As evidenced by these Proceedin~ this Workshop was

quite sueeessful, bringing together experts from Federal

and State ageneie$ Congresq academia, indushy, and labor

to evaluate a wide range of options for studying occupational effects on mortality. I would like to thank members

of the National Center for Health Statistics’ (NCHS) staff,

in particular, Drs. Patricia Buffler, Bruce Cohen, and Harry

Rosenberg for organizing the Workshop. Further, with the

help of other participants, a great deal of effort was devoted

to carefully drafting and documenting the options presented to the Workshop. Finally, the format for the program that allowed a long working group time was

successful in generating vigorous discussion that could only

be briefly recounted in the working group reports.

NCHS will take all of the reeommendations under

advisement. There appears to be consensus that the goal

should be the eventual nationwide coding of industry and

occupation on the death eertiikates. The achievement of

this goal will not be simple. As was noted before, not all

States code this information. Therefore, an educational

initiative is needed to make the States aware of the value of

indushy and occupation information on the death certificate. Such an initiative would be best accomplished by the

institutions that are devoted to the study of the working

population and occupational health, including not only the

Department of Labor, the National Institute for Occupational Safety and Health, the National Institute of Environmental Health Sciences, the Environmental Prot-”on

Agency, and the Agency for Toxic Substances and Disease

Registry, but also labor and industrial groups.

The value of occupation and industry coding would

become clearer if there were more studies available that

demonstrate their use. There are a few, by now elassi@

studies that demonstrate the utility of some kinds of data.

But new analyses and new ways of combining data from

different sources are needed to expand the usefulness of

the data that already are available. This work can be

accomplished by the academic community working with the

various State and Federal agencies.

The Memorandum of Understanding that was signed

at this Workshop encourages collaboration in the analyses

of data and in planning and implementation of programs to

promote and expedite collection of information essential

for improving occupationally related health. Within NCHS,

our occupational program will emphasize the analysqs of

multiple sets of data already available and a coordinated

approach to the collection of data in the future. In addition,

NCHS will continue to stren@hen its capabilities to provide

users with data relevant to subnational problems through

programs such as benchmark communities or model-based

estimation for small area data analyses. Finally, on the

advice of this Workshop, we will evaluate ways to obtain

funding to continue and improve the collection of the

industry and occupation coding from death certificates.

50
Appendixes

I. Memorandum of understanding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

IL Workshop participant questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

III. Workshop participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

51
Appendix L

Memorandum of

Understanding

Among the Bureau of Labor Statistics, the

National Center for Health Statistics, and the

National Inat”Wte for Occupational Safety and

Health

L Purpose

In response to the need to improve occupational health and

safety information, the Bureau of Labor Statistics (BLS),

the National Center for Health Statistics (NCHS), and the

National Institute for Occupational Safety and Health

(NIOSH) enter into this Memorandum of Understanding

for the primary purpose of developing collaborative plans

for improving occupational illness and injury reporting

systems and surveys.

Il.

1.

2.

3.

4.

5.

6.

Provisions and goals

Exchange data and information relevant to respective

agency programs, capabilities, and needs.

As necessary, collaborate on the development of issue

papers psition papera proposals, and projects of

mutual ctmcem and interest.

Identi& program areas where tripartite assistance or

support is needed and identify

● kinds of assistance or support needed

● when needed

● resources involved.

For projects or propos~s submitted for official ap

proval of joint agen~ heads, develop funding and

resource requirements and timetables for implementation.

Jointly pursue the cooperation of other agencies in the

implementation of projects or proposals where involvement of other Federal and State agencies is required.

Develop options that promote the recognition and

reporting of occupational illnesses and injuries.

7.

8.

Develop options that promote and expedite obtaining

information essential for improving health and safety

reporting systems, sumey~ and data.

Collaborate in phmnin~ sponsorin~ and conducting

seminars, conferences, or similar forums of discussion

to exchange information, resolve problems, rept

progress, and so forth.

Ill. Performance requirements

A.

B.

c.

Designation of representative(s)

Each agenq will designate a person or persons to

coordinate and carry out the provisions outlined in this

Memorandum of Understanding. The agency representatives are as follows Ronald W. Wilson (NCHS);

Edward L. Baker, M.D. (NIOSH); and William M.

Eisenberg (BLS).

Meetings

To accomplish the purpose and goals defined in this

Memorandum of Understanding the joint agency representatives will meet regularly (at least semiannually).

In the planning development, and execution of projects

proposed under this tripartite agreement, meetings on

such projects involving agencies not party to this agreement will be jointly attended.

Notification

The joint agenq representatives will make oral or

written reports as requested by joint agenq officials.

All written communications pertaining to joint project

work will be mutually exchanged and copies of such

communications will be sent to agency heads or their

representatives, as appropriate.

52
Amendix Il.

Workshop participant

questionnaire

OCCUPATIONALMORTALITYDATAMORKSHOP:

Option Preference Questionnaire

The purpose of this questionnaire is to determirieyour personal preference for

option? that NCHS might implement to produce occupational mortality statistics

a$ part of its ongoing. program (or’ encourage other agencies in their data

collection efforts). Please circle how strongly you agree or disagree with each

option for this purpose.

Please Circle

Strongly Strongly

Disagree A!lE9

Industry/Occupation Coding on Death Certificates

Option 1: Use existing system

Option 2: Use annual 1/0 coding for all States

Option 3: Use pericensal approach

Option 4: Use annual, for subset of causes and/or

subset of States (please specify)

Cmmnents:

Use ofNCHS Surveys for Followup

Option 5: Use mortality followback surveys

12 345

12345

12345

12345

12345

Caunents:

53
Option 6a: Followup MANESsurveys using NDI

Cmnents:

-.

Option 6b: FOI’1OWUPNHISsu’rveys using NDI

Cmuents:

Option 7: Followup other NCHS Surveys using NDI

(PI ease specify)

Please Circle

Strongly Stron91y

Disa&e@ &9B- -

12 345

12 345

12 345

Comments:

54
Please Circle

Strongly Strongly

Disagree A9Jx!2

Other Data Sources

Option 8a: Use National Longitudinal Mortality Study 12345

Cmunents:

Option 8b: Use Continuous Work History Sample

Cmnents:

Option 8c: Use IRS Record Followup with NDI or

other data systems (please specify)

12345

12345

Cements:
Please Circle

Strortgly Strongly

Disagree &

Option 9iJ: Use BLS Annual Survey of Illness and 12 345

Injury for occupational mortality surveillance

Conments:

Option 9b: Use Supplementary Data System (BLS) and/or

other workers’ compensation data systems

Comments:

Option 10: Use Compressed Mortality File

Corments:

Option 11: Other options (please specify)

Cournents:

12 345

12345

12345
11. The purpose of this section is to identify your preference for different

options or groups of options under varying resource constraints. Please

use the option numbers designated below, our discussions in the working

groups, and reasonable cost estimates to design a program given the funding

constraints:

Option 1

Option 2

Option 3

Option 4

Option 5

Option 6a

Option 6b

Option 7

Option 8a

Option 8b

Option 8C

Option !?a

Option 10

Option 11

Existing 1/0 Coding on Death Certificates

Annual 1/0 Coding for all States

Pericensal approach

Subset of causes and/or subset of States

Mortality folJowback surveys

Followback of NHANES using NDI

Followback ofNHIS using NDI

Followback of other NCHS surveys using NDI

National Longitudinal Mortality Survey

Continuous work History Sample followup using NDI

IRS record followup or other data system (please specify) using NDI

Annual Survey of Occupational Illness and Injury (BLS)

Compressed Mortality File

Other options (please specify)

1. What option or group of options should be implemented if less than $400,000

per year for funding is available?

2. What option or group of options should be implemented if between $400,000-

$800,000 is available?

57
3. What option or group of options should be implemented if between $800,000-

$1,200,000 is available?

4. What options should be implemented if there are no financial constraints?

III. This is an opportunity for you to provide any additional comnents on the

workshop.

A. Are there additional options that you feel NCHSshould explore?

f). Additional comments.

58
Appendix111.

Workshop participants

Dr. Henry Anderson

WisconsinDivisionof Health

P.O. Box 309

Madison, Wisconsin 53705

Faye Aziz

Social SecurityAdministration

1875 Connecticut Avenue, NW

Room 320-D

Washington, DC 20009

Dr. Edward Baker

Assistant Director, National Institute of

Occupational Safety and Health

Room 3007 Building1

Centers for Disease Control

1600 Clifton Road, NE

Atlanta, Georgia 30333

Dr. Gilbert Beebe

National Cancer Institute

Room 8C41 Landow Building

7910 Woodmont Avenue

Bethesda, Maryland 20892

Robert Bilgrad

Natiomd Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Dr.’Aaron Blair

Occupational Studies Section

National Cancer Institute

Room 4C16 Landow Building

7910 Woodmont Avenue

Bethesda, Maryland 20892

Fred Blosser

Occupational Safety and

Health Reporter

The Bureau of National Affairs, Inc.

1231 25th Street, NW

Washington, DC 20037

Dr. Greg Bond

Dow Chemical Company

1803Building

Midland, Michigan 48674

Dr, Demis Bregman

SurveillanceBranch

National Institute for Occupational

Safety and Health

4676 Columbia Parkway

R-18

Cincinnati, Ohio 45226

John E. Brockert

Director, Bureau of Health Statistics

Utah Department of Health

P.O. BOX 16700

Salt Lake City, Utah 84116-0700

David Brown

SurveillanceBranch

National Institute for Occupational

Safety and Health

4676 Columbia Parkway

R-18

Cincinnati, Ohio 45226

Warren Buckler

Director, Division of Statistical

Operations and Services

Officeof Research and Statistics

Social SecurityAdministration

Room 2B2 Operations Building“

6401 SecurityBoulevard

Baltimore, Maryland 21235

Dr. Patricia Buffler

Professor, EpidemiologyResearch Unit

University of Texas School of Public Health

P.O. BOX 20186

Houston, Texas 77225

carol Burnett

SurveillanceBranch

National Institute for Occupational

Safety and Health

4676 Columbia Parkway

R-18

Cincinnati, Ohio 45226

Dr. Harvey Checkoway

Res. Assoc. Professor of Epidemiology

Department of Epidemiology

Universityof North Carolina

Chapel Hill, North Carolina 27514

Dr. Bruce Cohen

National Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Dr. John A. Cooper

Chief, IMmmural Programs Branch

National Cancer Institute

Landow Building

7910 Woodmont Avenue

Bethesda, Maryland 20892

59
Dr. Deborah Dawson

Division of Health Intemiew Statistics

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Karen M. Deasy

Office of the Dircetor, NIOSH

Room 714B HHH Building

200 Indepcndenee Avenue, SW

Washington, DC 20201

Dr. Eliibeth Delzell

Assistant Professor of Epidemiology

University of Alabama at Birmingham

209 Tidwell Hall

Birmingham, Alabama 35294

Dr. Ernest M. Dixon

6305 Evermay Drive

Mclean, Virginia 22101

Gwendolyn Doebbert

Health Data and Statistics Branch

Department of Health Serviees

7144P Street

Sacramento, California 95814

Joseph DuBois

Mathematical Statistician

U.S. Department of Labor

OSHA- Room N3626

200 Constitution Avenue, NW

Washington, DC 20210

William Eisenberg

Associate Commissioner for

Occupational Safety and Health Statistics

Bureau of Labor Statistics

Room 4014 Patrick Henry Building

601D Street, NW

Washington, DC 20212

Dr. William Faymweather

Manager, Epidemiology Section

E.I. DuPont deNemours and Company N 11510

Wilmington, Delaware 19898

Dr. Jacob Feldman

Director, Office of Analysis and

Epidemiology

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Dr. Ralph Frankowski

Professor of Biometry

University of Texas

Health Sciences Center at Houston

School of Public Health

P.O. BOX 20186

Houston, Texas 77225-0186

Dr. Todd Frazier

Surveillance Branch

National Institute for Occupational

Safety and Health

4676 Columbia Parkway

R-18

Cincinnati, Ohio 45226

Frank Frodyma

Acting Director of Policy

U.S. Department of Labor

Occupational Safety and Health

Administration

Room N3626

200 Constitution Avenue, NW

Washington, DC 20210

Dr. John Froines

Associate Professor

Division of Occupational Health

and Environmental Scienees

School of Public Health

University of California at Los Angeles

Los Angeles, California 90024

Eric Fmmin

Health and Safety Department

Ameriean Confederation of Textile

Workers’ Unions

15 Union Square

New Yorlq New York 10003

George Gay

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

“Lillian Guralnick

North 63

510N Street, SW

Washington, DC 20004

Hawey Hilaski

Bureau of Labor Statistics

Room 4014 Patrick Henry Building

601D Street, NW

Washington, DC 20212

Dr. Patricia Honchar

Bureau of Epidemiology

Texas State Department of Health

1100 W. 49th Street

Austin, Texas 78756

Allan Hoskin

Manager, Statistics Department

National Safety Council

444 N. Michigan Avenue

Chicago, Illinois 60611

Edward Hunter

Planning and Evaluation Officer

Office of Program Evaluation and Planning

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

60
Robert Israel

Deputy Director

National Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Deborah Keimig

Committee on National Statistics

National Academy of Sciences

2101 Constitution Avenue, NW

Washington, DC 20418

Dr. Carl A. Keller

National Institute of Environmental

Health Sciences

Room 2B55, Building 31

Bethesda, Maryland 20892

Barbara Kerr

Officeof the Center Director

National Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Karl Kroncbusch

U.S. Congress

Officeof TechnologyAssessment

Washington,DC 20510

Dr. Philip Landrigan

Professor of Community Medicine and

Director, Division of Environmental and

Occupational Medicine

Mt. Sinai School of Medicine

New Yorl$ New York 10029

Dr. David Lilienfeld

Assistant Professor of Community

Medicine

Divisionof Environmental and

Occupational Medicine

Mt. Sinai School of Medicine

New York New York 10029

Dr. Jay Imbin

National Cancer Institute

Landow Building

7910 Woodmont Avenue

Bethesda, Maryland 20892

Dr. Thomas Mason

National Cancer Institute

Room 3A06 Landow Building

7910 Woodmont Avenue

Bethesda, Maryland 20892

Jeffrey Maurer

National Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Dr. James M. Melius

Director, Division of SurveillanceHazard

Evaluations and Field Studies,

NIOSH

4676 Columbia Parkway- R-18

Cincinnati, Ohio 45226

Dr. Samuel Milham

Department of Health and Human Services-ET 13

State of Washington Government

Olympia,Washington 98504

Dr. J. Donald Millar

Director, NIOSH

Room 3007 Building1

Centers for Disease Control

MOOClifton Road, NE

Atlanta, Georgia 30333

Dr. Michael Mo]]

National Institute for Occupational Safety

and Health

Morgantown, West Virginia

Dr. Robert J. Mullan

Division of Surveillance,Hazard

Evaluations and Field Studies

National Institute for Occupational

Safety and Health

4676 Columbia Parkway

Cincinnati, OH 45226

MelvinL. Myers

Director, Officeof Program Planning

and Evaluation,

NIOSH

Room 3040 Building1

Centers for Disease Control

1600 Clifton Road, NE

Atlanta, Georgia 30333

Raymond D. Nashold, Ph.D.

Director, Center for Health Statistics

and State Registrar

Divisionof Health

P.o. Box 309

Madison, Wisconsin53701

Dr. Janet Norwood

Commissioner

Bureau of Labor Statistics

441G Street, NW

Washington, DC 20212

John Patterson

Director, Division of Vital Statistics

National Center for Health Statistics

3700 East-West Highway

Hyattsville,Maryland 20782

Dr. Dennis Perrotta

Director, EpidemiologyDivision

Bureau of Epidemiolo~

Texas State Department of Health

1100 W. 49th Street

Austin, Texas 78756

William G. Phillips

417 6th Streetj SE

Washington, DC 20003

61
Dr. Gail Poe

Office of Associate Director of Vital and

Health Statistics Systems

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Dr. Earl Pollack

National Academy of Sciences

2101 Constitution Avenue, NW

Washington, DC 20418

Dr. Patricia Potrzebowski

Director, Division of Health Statistics

and Research

P.O. Box 90

Harrisburg Pennsylvania 17108

John Priebe

Labor Force Statistics Branch

Population Division

U.S. Bureau of the Census

Washington, DC 20237

Dr. Harry M. Rosenberg

Chief, Mortality Statistics Branch

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Charles J. Rothwell

Former Director

State Center for Health Statistics

Post office Box 2091

Raleigh, North Carolina 27602

Dr. Linda Rudolph

Chief, Occupational Health Sumeillance

and Evaluation Program

California Department of Health Services

2151 Berkeley Way

Berkeley, California 54704

Peter Sailer

Statistics of Income Division, DRST

Internal Revenue Service

Washington, DC 20224

Dr. David Savitz

Assistant Professor of Epidemiology

School of Public Health

University of North Carolina

Chapel Hill, North Carolina 27514

Fritz Scheuren

Statistics of Income Division, DRST

Internal Revenue Semite

Washington, DC 20224

Dr. Joseph Schwerha

Director, Industrial Medicine

U.S. Steel

Room 2581

6(XIGrant Street‘

Pittsburgh, Pennsylvania 15230

Thomas SCOUR

Labor For=” statistics Branch

Population Division

Bureau of the Census

Washington, DC 20237

Dr. John Sestito

Surveillance Branch

National Institute for

Occupational Safety and Health

4676 Columbia Parkway

R-18

Cincinnati, Ohio 45226

Dr. Michael Silverstein

Assistant Director of Health and Safety

UAW Health and Safety Department

8000 E. Jefferson

Detroit, Michigan 48213

Dr. Robert Spirtas

Environmental Epidemiology Branch

Occupational Studies Section

Room 4C16 Landow Building

Bethesda, Maryland 20205

Elsie Stanton

NationaJ Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Dr. Alice Stark

Bureau of Environmental Epidemiology

and Occupational Health

New York State Department of Health

Room 742 ESP Tower Building

Albany, New York 12237

George Stelluto

Bureau of Labor Statistics

441G Street, NW

Washington, DC 20212

Dr. William Stewart

Assistant Professor of Epidemiology

Occupational Epidemiology Program

Johns Hopkins School of Hygiene

Room 6033

615 N. Wolfe Street

Baltimore, Maryland 21205

Sabrina Sturba

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

George VanAmburg

State Registrar

3500 N. Logan Street

P.O. Box 30035

Lansing Michigan 48909

62
Dr. Diane Wagener

Board on Environmental Studies

and Toxicology

National Academy of Sciences

2101 Constitution Avenue, NW

Washington, DC 20418

Dr. Bailus Walker

Commissioner

Massachusetts Department of

Public Health

150 Tremont

Boston, Massachusetts 02111

Lacola Washington

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Dr. James Weeks

Deputy Administrator for Occupational Health

United Mine Workers of America

900 15th Street, NW

Washington, DC 20005

Ronald W. Wilson

Director, Division of Epidemiology and

Health Promotion

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

Janice Windau

Bureau of Labor Statistics

Room 4014 Patrick Henry Building

601 D Street, NW

Washington, DC 20212

Diana Zuckerman

House Government Operations Committee

Subcommittee on Intergovernmental Relations

and Human Resources

B372 Raybum House Office Building

Washington, DC 20515

63

wLS. Oovemunt Printing OffLee 1988$ 201-855/80006
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5.

SERIES 10.

SERIES 11,

SERIES 12.

SERIES 13.

Programa and Collation Procaduras—Reports describing

the general programs of the National Center for Health

Statistics and its offices and divisions and the date collection methods used. They also include definitions and

other material necesssry for understanding the data.

Data Evaluation and Mathoda Reaaarch—Studies of new

statistical methodology including experimental tests of

new survey methods, studies of vital statistics collection

methods, new analytical techniques, objective evaluations

of reliability of collected data, and contributions to

statistical theory. Studies also include comparison of

U.S. methodology with those of other countries.

Analytical and Epidemiological Studies— Repotis presenting analytical or interpretive studies based on vital

and heelth statistics, carrying the analysis further than

the expository types of reports in the other series.

Documants and Committaa Reports-Final repons of

major committees concerned with vital and health statistics and documents such as recommended model vital

regwtration laws and revised birth and death certificates.

Comparative Intamational Vial and Haalth Statistics

Reports-Analytical and descriptive reporw comparing

U.S. vital and health statistics with those of other countries.

Data From tha National Health Interview Survay-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other

haalth-ralated topics, all based on data collected in the

continuing national household interview survey.

Data From tha National Health Examination Survay and

tha National Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement

Of national sampie.s of th,e civilian noninstitutionaliz~d

population provide the basis for (1) estimates of the

medically defined prevalence of specific diseases in the

United States and the distributions of the population

with respect to physical, physiological, and psychological characteristics and (2) analysis of relationships

among the various measurements without reference to

an explicit finite universe of persona.

Data From tha Inatitutionaliied Population Survays-Discontinued in 1975. Reports from these surveys are included in Series 13.

Data on Haalth Ro~ourcas Utilization—Statistics on the

utilization of health manpower and facilities providing

long-term care, ambulato~ care, hospital care, and family

planning servicas.

SERIES 14.

SERIES 15.

SERIES 20.

SERIES 21.

SERIES 22.

SERIES 23.

Data on Health Rasourcea: Manpower and Facilitiaa—

Statistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities.

Data From Special Surveys-Statistics on health and

health-related topics collected in special surveys that

are not a part of the continuing data systems of the

National Center for Health Statistics.

Data on Mortality-Various statistics on mortality other

than as included in regular annual or monthly reports.

Special analyses by cause of death, age, and other demographic variables; geographic and time saries analyses;

and statistics on characteristics of deaths not available

from the vital records based on sample surveys of those

records.

Data on Natahty, Marriage, and Divorce-Various statistics on natality, marriage, and divorce other than as

included in regular annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses; studies of fertility; and statistics on

characteristics of births not available from the vital

records based on sample surveys of those records.

Data From the National Mofiality and NatalitySurveya—

Disoontmuedin 1975. Reports from these sample surveys

based on vital records are included in Series 20 and 21,

respectively.

Data From tha National Survey of Family GrowtftStatistics on fertility, family formation and dissolution,

family planning, and related maternal and infant health

topics derived from a periodic survey of “a nationwide

probability sample of women 15-44 years of age.

For answers to questions about this report or for a list of titles of

reports published in these series, contact:

Scientific and Technical Information Branch

National Center for Health Statistics

Centers for Disease Control

Public Health Service

Hyattsville, Md. 20782

301-436-8500
U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Semlce

Centers for Dmease Control

National Center for Health Stawxlcs

3700 East-West Highway

Hyattsville, Maryland 20782

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