The Vulnerable Worker –Notes from the Field

Robert Harrison MD, MPHPublic Health Medical Officer

California Department of Public HealthClinical Professor of Medicine

University of California, San Francisco

TEL: 415 885 7580Email: robert.harrison@ucsf.edu

Disclosure

I have nothing to disclose

Tony Mazzocchi1926 - 2002

“Statistics are human beings with the tears wiped away”

Irving Selikoff, MD1915-1992

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 years10 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 inunionization 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?

Occupation Title # NewJobs by 2020

Personal care aides 138,200

Retail salespersons 103,600

Combined food preparation and serving

73,400

Cashiers 64,600

Waiters and waitresses 59,600

Occupation Title % Growthby 2020

Home health aides 52.4%

Personal care aides 42.6%

Bicycle repairers 35.7%

Pharmacy aides 32.1%

Nonfarm animal caretakers 31.1%

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.

Projections of Employment by Industry and Occupation. State of California Employment Development Department. Accessed February 2014.

Asuncion ValdiviaJuly 28, 2004

• 53 y.o. man with dizziness, nausea,confusion after picking grapes for 10 hoursin >100o heat in Kern County

• Paramedics initially called but did notarrive on scene

• Brought to Kern County Medical Center byson, died on arrival with body temperature> 108o

“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, 2005Emergency regulations for heat illness

Public health action

Effective July 27, 2006Effective 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 = 108o

• Died 2 days later

"Maria's death should have been prevented,and all Californians must do everything in theirpower to ensure no other worker suffers the same fate."- Gov. Arnold Schwarzenegger, May 28, 2008

Other facesMaria Isabel JimenezMay 14, 200817 y.o. picking grapes

Jose HernandezJune 20, 200864 y.o. picking squash

Abdon GarciaJuly 9, 200846 y.o. loading grapes

Ramiro RodriguezJuly 9, 200848 y.o. picking nectarines

Jorge HerreraJuly 31, 200837 y.o. loading grapes

Maria AlvarezAugust 2, 200863 y.o. picking grapes

“Bob – the leaves are falling allover the sidewalk!”

“Here Bob, I got a flyer in the mail. Call this guy he says he can do ittomorrow. ”

117,000 looking for work each day

50/50 private households and construction contractorsMoving and hauling, landscaping, painting, roofing, drywall

“You know Robin, I heard theseguys may not be really trained allthat well.”

“Okay fine Bob, but we really needthose branches trimmed”

+

“I just called an arborist guy, he’s coming out here tomorrow to giveus a bid”

Going solar!My roof in Noe Valley.

It’s a long way down

Will this hold if he falls?

Very awkward posture

Could he trip?

Irma Ortiz

• 40 y.o. woman

• Mixed dry powder withdiacetyl x 5 years

• Symptoms of shortnessof breath and cough.Treated for asthma.

• FEV1 = 0.55 L (18%predicted). HRCT withground glass opacities.

California Department of Health Serviceshttp://www.dhs.ca.gov/ohb/flavorings.htmBaltimore Sun - April 23, 2006Sacramento Bee - July 30, 2006

Bronchiolitis obliterans

• NIOSH study at“sentinel” microwavepopcorn plant

• 4 of 8 workers on lungtransplant list

• One recent death

Toxicology studies

• Multifocal necrotizingbronchitis in ratsexposed to 285-371ppm of diacetyl

Exposed

Control

Hubbs et aL: Necrosis of nasal and airway epitheliumin rats inhaling vapors of artificial butter flavoring. ToxApplied Pharm 185:128 (2002).

Epidemiology studies

• Airways obstruction inpopcorn workersrelated to cumulativediacetyl exposurelevels (dose-responserelationship)

0

5

10

15

20

25

30

35

40

Lowestquartile

Second Third Highestquartile

% a

ffec

ted

Cumulative diacetyl exposure quartiles

Abnormal Spirometry by Diacetyl Exposure

Kreiss K et al. Clinical bronchiolitis obliterans

in workers at a microwave popcorn plant. NEJM 347:330 (2002).

Public health action

• Risk notification ofemployers, HCPs

• Study of CAcompanies withuse of diacetyl

• ProposedCal/OSHAstandard

April 27, 2007 MMWR PublicationMaterna 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 8/24/06for emergency standardgranted by StandardsBoard 1/18/07 - referredto advisory committee

• Advisory meetings held9/28/06, 2/13/07, 3/21/07,and 5/18/07

• Public hearing 11/19/09

• Final standard passedSeptember 16, 2010

§ 5197 Occupational Exposure to FoodFlavorings Containing Diacetyl.

• Medical surveillance at least every 6months if > 1% diacetyl is used, or case offixed obstructive lung disease

• “Knowledgeable” occupational orpulmonary 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, andNIOSH collaborated on an MMWR articledocumenting a total of 13 fatalities amongbathtub refinishers in USbetween 2000 and 2011.

• All were linked to DCMinhalation.

.87 g/m3ACGIH STEL

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Baptist Church, Southern California(May 2010)

• 24 year-old maintenance worker wasassigned to strip the Baptismal Font of thechurch using DCM-containing stripper.

• Worker applied ~ 1 gallon of“Klean-Strip PremiumSprayable 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 WynneFebruary 12, 1986 - October 14, 2017

Joshua AtkinsNovember 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 OccEnviron Health, 2014

MMWR Case Report February 13, 2015

37 year old immigrant from El Salvador with 8 yearsexposure to silica dust (>20x PEL) while fabricating

engineering stone. Biopsy + mixed dust pneumoconiosis2013 (K. Jones), systemic sclerosis. Died from

respiratory failure - September 2018.

Fatal silicosis in engineered stonefabrication worker – CA, 2019*

* 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 wallthickening on HRCT

C. Response to bronchodilators

D. Mononuclear cell infiltration and poorlyformed 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