The Vulnerable Worker Notes from the Field Robert Harrison MD, MPH - PDF document

The Vulnerable Worker – Notes from the Field Robert Harrison MD, MPH Public Health Medical Officer California Department of Public Health Clinical Professor of Medicine University of California, San Francisco TEL: 415 885 7580 Email: robert.harrison@ucsf.edu Disclosure I have nothing to disclose Tony Mazzocchi 1926 - 2002

“ Statistics are human beings with the tears wiped away ” Irving Selikoff, MD 1915-1992 Which of these most closely describes the “vulnerable (precarious” worker?” 1. Lack of access to medical treatment 2. Fear of reporting injury or illness 3. Language and/or cultural barriers 4. Contingent employment 5. Low wage 6. All of the above 3.1 million new residents in last 10 years 10 million immigrants By 2030, 1 in 5 residents will be age 65 or older

Inequality worsening American Community Survey 2006-2010, American FactFinder. Accessed March 2014. Wages of low-wage workers falling “A Generation of Widening Inequality.” The California Budget Office. November 2011.

Historical trends in unionization and inequality Eisenbrey, R and Gordon, C. “ As unions decline, inequality rises.” Economic Policy Institute. June 6, 2012 Union membership in last 20 years Current Population Survey 1994-2010, Accessed March 2014. Low-wage workforce in CA • 89 occupations with hourly median wage less than $11.93 • Over 4 million workers • 28.4% of the CA employed workforce

Lowest paid occupations in CA, 2012 May 2012 State Occupational Employment and Wage Estimates California. Occupational Employment Statistics. Bureau of Labor Statistics. Accessed March 2014. What does the future hold for CA? There will be an estimated 929,000 new low-wage jobs by 2020. Of the new jobs created by 2020, 36.2% of them will be low-wage. Occupation Title % Occupation Title # New Growth Jobs by by 2020 2020 Home health aides 52.4% Personal care aides 138,200 Personal care aides 42.6% Retail salespersons 103,600 Bicycle repairers 35.7% Combined food preparation 73,400 and serving Pharmacy aides 32.1% Cashiers 64,600 Nonfarm animal caretakers 31.1% Waiters and waitresses 59,600 Projections of Employment by Industry and Occupation. State of California Employment Development Department. Accessed February 2014. Asuncion Valdivia July 28, 2004 • 53 y.o. man with dizziness, nausea, confusion after picking grapes for 10 hours in >100 o heat in Kern County • Paramedics initially called but did not arrive on scene • Brought to Kern County Medical Center by son, died on arrival with body temperature > 108 o

“ Meeting in the Sun ” July 28, 2005 • July 13 - Salud Rodriguez dies in bell pepper field • July 14 - Ramon Hernandez dies in melon field • July 20 - Agustine Gudino dies in tomato field • July 31 - Constantino Cruz dies in tomato field August 3, 2005 This is a tragedy…and we will do everything it takes to prevent this from happening again ” August 8, 2005 Emergency regulations for heat illness Public health action Effective July 27, 2006 Effective July 27, 2006

May 14, 2008 • Maria Isabel Vasquez, age 17, two months pregnant • Immigrant from Oaxaca • Pruning grapes, employed by labor contractor x 3 days • 95 degree heat in Atwater • Collapsed and taken by driver to clinic with core temp = 108 o • Died 2 days later "Maria's death should have been prevented, and all Californians must do everything in their power to ensure no other worker suffers the same fate." - Gov. Arnold Schwarzenegger, May 28, 2008 Other faces Maria Isabel Jimenez Ramiro Rodriguez May 14, 2008 July 9, 2008 17 y.o. picking grapes 48 y.o. picking nectarines Jose Hernandez Jorge Herrera June 20, 2008 July 31, 2008 64 y.o. picking squash 37 y.o. loading grapes Abdon Garcia Maria Alvarez July 9, 2008 August 2, 2008 46 y.o. loading grapes 63 y.o. picking grapes

“Bob – the leaves are falling all over the sidewalk!”

“Here Bob, I got a flyer in the mail. Call this guy he says he can do it tomorrow. ” 117,000 looking for work each day 50/50 private households and construction contractors Moving and hauling, landscaping, painting, roofing, drywall

“You know Robin, I heard these guys may not be really trained all that well.” “Okay fine Bob, but we really need those branches trimmed”

+ “I just called an arborist guy, he’s coming out here tomorrow to give us a bid” Very awkward posture Going solar! My roof in Noe Valley. Could he trip? It’s a long way down Will this hold if he falls?

Irma Ortiz • 40 y.o. woman • Mixed dry powder with diacetyl x 5 years • Symptoms of shortness of breath and cough. Treated for asthma. • FEV1 = 0.55 L (18% predicted). HRCT with ground glass opacities. California Department of Health Services http://www.dhs.ca.gov/ohb/flavorings.htm Baltimore Sun - April 23, 2006 Sacramento Bee - July 30, 2006 Bronchiolitis obliterans • NIOSH study at “ sentinel ” microwave popcorn plant • 4 of 8 workers on lung transplant list • One recent death

Toxicology studies Exposed • Multifocal necrotizing bronchitis in rats exposed to 285-371 ppm of diacetyl Control Hubbs et aL: Necrosis of nasal and airway epithelium in rats inhaling vapors of artificial butter flavoring. Tox Applied Pharm 185:128 (2002). Epidemiology studies Abnormal Spirometry by Diacetyl Exposure • Airways obstruction in 40 35 popcorn workers 30 25 % affected 20 related to cumulative 15 10 diacetyl exposure 5 0 levels (dose-response Lowest Second Third Highest quartile quartile relationship) Cumulative diacetyl exposure quartiles Kreiss K et al. Clinical bronchiolitis obliterans in workers at a microwave popcorn plant. NEJM 347:330 (2002). Public health action • Risk notification of employers, HCPs • Study of CA companies with use of diacetyl • Proposed Cal/OSHA standard

April 27, 2007 MMWR Publication Materna B et al. Industry-wide Medical Surveillance of Workers in California Flavor Manufacturing Companies: Cross-sectional Results Kim TJ, Materna BL. Prudhomme JC, Fedan KB, Enright PL,Sahakian NM, Windham GC, Kriess K: Amer J Ind Med 53: 857-65, 2010. Petition for emergency standard CalOSHA 2006 - 2010 • AFL/CIO petition 8/24/06 for emergency standard granted by Standards Board 1/18/07 - referred to advisory committee • Advisory meetings held 9/28/06, 2/13/07, 3/21/07, and 5/18/07 • Public hearing 11/19/09 • Final standard passed September 16, 2010

§ 5197 Occupational Exposure to Food Flavorings Containing Diacetyl. • Medical surveillance at least every 6 months if > 1% diacetyl is used, or case of fixed obstructive lung disease • “ Knowledgeable ” occupational or pulmonary medicine • Mandatory Flavor Worker Questionnaires • Spirometry by NIOSH-certified technician • Medical removal benefits DCM fatalities in bathtub refinishers: US • In early 2012, Michigan FACE, Fed/OSHA, and NIOSH collaborated on an MMWR article documenting a total of 13 fatalities among bathtub refinishers in US between 2000 and 2011. • All were linked to DCM inhalation.

.87 g/m3 ----------------------------------------------------------- ACGIH STEL

Baptist Church, Southern California (May 2010) • 24 year-old maintenance worker was assigned to strip the Baptismal Font of the church using DCM-containing stripper. • Worker applied ~ 1 gallon of “Klean-Strip Premium Sprayable Stripper” to floor. 56

June 23, 2017 - California

European Union banned sale to general public in 2009 “Paint strippers containing DCM are used by members of the general public at home to remove paints, varnishes and lacquers both indoors and outdoors. The safe use of DCM by them cannot be ensured by training or monitoring. Therefore, the only measure effective in eliminating the risks arising for the general public from paint strippers containing DCM is a ban, with respect to the general public, on the marketing, supply and use of such paint strippers.” April 28, 2017 - Tennessee

Drew Wynne February 12, 1986 - October 14, 2017 Joshua Atkins November 9, 1986 – February 12, 2018

Artificial Stone Silicosis: Disease Resurgence Among Artificial Stone Workers Kramer et al: Chest 2012

Outbreak of silicosis in Spanish quartz conglomerate workers Perez-Alonso et al., Int J Occ Environ Health, 2014 MMWR Case Report February 13, 2015

Fatal silicosis in engineered stone fabrication worker – CA, 2019* 37 year old immigrant from El Salvador with 8 years exposure to silica dust (>20x PEL) while fabricating engineering stone. Biopsy + mixed dust pneumoconiosis 2013 (K. Jones), systemic sclerosis. Died from respiratory failure - September 2018. * Heinzerling, Flattery, Weinberg, Blanc, Balmes, Elicker, Potocko, Guiness, Harrison) Bronchiolitis obliterans is best characterized by: A. Reversible airways obstruction on PFTs B. Mosaic attenuation and bronchial wall thickening on HRCT C. Response to bronchodilators D. Mononuclear cell infiltration and poorly formed granulomas on pathology

Silica dust exposure can cause all EXCEPT: A. Bilateral diffuse ground glass opacities B. Increased risk of TB C. Systemic sclerosis D. Liver cancer Acute methylene chloride fatalities may be due to: A. Carboxyhemoglobin formation B. CNS depression C. Cardiac sensitization D. All of the above