NACOSH Heat Stress Work Group 1 
Work Group 1 members:
          Mirella Deniz-Zaragoza  -  Warehouse Worker Resource Center
          Kathleen Dobson, CSP, Chairperson  -  Alberici Constructors, Inc.
          Nicole Hernandez-Hammer  -  Service Employees International Union
          Christopher Long  -  National Association of Manufacturers
          Kirk Sander  -  National Waste and Recycling Association
          June Spector, MD, MPH  -  University of Washington and Washington State SHARP Program
          Gavin West  -  CPWR; the Center for Construction Research & Training
Introductory Statement:
As there are over 75 industries identified by OSHA whose tasks may be impacted by heat, the work group was challenged to prioritize their recommendations related to those industries. In some situations, we believe that to prioritize one is to minimize the importance of another. 
OSHA's heat awareness campaign dates to the early 2000's, and some of the content and products contained within the campaign are outdated, and/or new scientific and/or technical information is available. The group also identified areas where content was deficient or missing. 

In making recommendations, the work group identified priorities within charge for OSHA to implement in accordance with their own strategic plan and campaign cycles. 
Where short-term recommendations were made, we advise these be conducted in the next one to two campaign cycles (6  -  12 months). Mid-term recommendations are 12  -  36 months. We did not make any long-term recommendations.   
Work Group 1's Assignment was to evaluate and provide input and recommendations on OSHA's heat illness prevention materials using the following charges established by OSHA.
 To identify whether there are communication strategies or products that are useful for employers and workers that are not currently being used by OSHA.
 To identify whether there are critical heat topics missing from materials.
 To identify whether materials are accessible to the populations most at risk of hazardous heat exposure in outdoor and indoor work settings.
 To identify whether existing guidance materials are up to date and align with current best practices in heat hazards and heat illness prevention.
 To identify specific industries or audiences that would benefit from more tailored guidance materials.
In addressing the heat illness guidance materials, the work group evaluated the following: 
 what is the product 
 when it was published 
 if the product content is still relevant
 if the perceived audience is clearly identified
 what the product format is 
 what language the product is presented in
 what the topic and message of the product is
 whether the product content aligns with current OSHA practices 
 whether the product is focused toward outdoor or indoor workers, and
 how each product is intended to be used 
The work group also: 
          reviewed the products for consistency in messaging 
          looked for missing industries; identified the benefits of having specific, tailored materials
          evaluated products for new science or current best practices
          identified missing topics; identified if the products are accessible to at-risk populations, and
          identified additional recommendations for strategies or products and whether the material complements current OSHA enforcement activities (OSHA Compliance Directive  -  2022 and the OSHA National Emphasis Program [NEP] on heat).
The work group created a matrix where products could be compared and where the group could address concerns regarding content and format. That matrix is included as part of the appendices of this report. 

Charge 1: Identify whether there are communication strategies or products that are useful for employers and workers that are not currently being used by OSHA:
There were several items identified that are either not in use by OSHA or include outdated materials. In lieu of listing out all items, we refer to the matrix and identified priorities that also fell into other charge categories. 
The work group recommends prioritizing the following for Charge 1:
Short-term:
 Review and revise outdated content (see Charge 4 response for recommendations on specific content).
 Continue to prioritize visual, audio, and/or audio-visual products, which have the potential to be more widely accessible (see Charge 3 response for recommendations).
Medium-term: 
 Reconsider timing(s) of campaign, as different regions experience hot weather at different times of year and roll out across the country during varying time periods (i.e.; Late February  -  Mid May).
 Enhance strategic partnerships (see Charge 3 response for recommendations). 
 Prioritize toolbox talk/pre-job briefing and train-the-trainer formats for health and safety personnel, trainers, supervisors, and others who may be training workers.
 Use train-the-trainer formats to widely disseminate information such as the following:
 https://www.osha.gov/sites/default/files/osha_heattraining_guide_0411.pdf, and

 interactive industry-tailored train-the-trainer heat education formats, including: Grzywacz JG, et al. Journal of Occupational & Environmental Medicine  -  61(9):735-742 September 2019 & Marquez et al. Journal of Agromedicine  -  The Effect of Participatory Heat Education on Agricultural Worker Knowledge; (online) (https://doi.org/10.1080/1059924X.2022.2058667) 17 April 2022. 
  Create worker-designated applications which could be downloadable narratives.
 Identify Audio-visual material as additional communication strategy (note: the work group understands that the expense of developing these may create feasibility issues, however using short clips, examples, controls, best practice resources may be cost-effective options)
 Include Toolbox Talks/Pre-job briefings including industries outside of construction which may include subsets of AV materials.
   Information about workers' rights and worker and employer roles and responsibilities should be included for all products.
Charge 2: Identify whether there are critical heat topics missing from materials:
Current products focus primarily on construction and agricultural industries. The work group found that the current products lacked information about indoor heat, specifically for:

 Indoor work
 Warehouse work - where heat related incidents may be related to quotas and production rates. Even at lower temperatures in warehouse settings, ventilation and humidity may be issues.
 Information related to worker productivity

For workers who are mainly out-of-doors, the group specifically identified target groups such as:
 Delivery services
 Waste management
 Airport work and 

 A lack of Information regarding lost workdays related to heat-related illnesses

The work group also identified a lack of information regarding fluctuating weather conditions - major spikes up and down in temperatures and acclimatization issues, especially related to a history of longer, hotter summer temperatures where the trending is expected to continue.

The group identified a lack of information regarding other effects of heat other than heat illnesses heat such as the effect of heat on pre-existing health conditions, i.e.; heart disease, asthma, COPD, dehydration - kidney disease as well as the impact on workers' mental well-being and how heat can cause or contribute to acute injuries  -  such as fainting due to heat and subsequent injuries related to falls.

There is a lack of methodology regarding the establishment of heat-illness risk assessments and descriptions for employers developing guidance materials for their employees (employer responsibility - guidance/guidance document needed - CALOSHA IIPP can be a good resource) and how to determine heat related hierarchy of controls, including elimination, substitution, engineering controls, administrative controls, and PPE.

Other topics the work group identified as missing or incomplete included information regarding:

 Worker hydration, food & nutrition related to successfully combating heat illness.
 Training needed for competent, qualified, or designated person
 Definition of shade and how to provide it in different (difficult) circumstances
 Guidance on personal susceptibility and accountability (e.g., medications)

 How to engage workers on this issue  -  how is the information used and are there privacy issues?
 Heat injury due to lack of food/fuel
 Personal factors  -  off hours personal activities and hydration.

 Use of wearables for dehydration & heat (NIOSH guidance may be useful) (information regarding validations and reliability, effectiveness), privacy concerns, protection of personal rights and supporting evidence from NIOSH, etc.

 Cooling methods  -  there is newer science available. 
 Inconsistencies - national emphasis program and (sample) hazard alert letter  -  see appendix D in the NEP document. In hazard alert letter there are more specifics/level of detail in abatement measures and more specific than the NEP. (general duty clause, inspections, solutions implemented) (per Jennifer Levin  -  there may not really be inconsistencies  -  information is related to OSHA direction following an inspection with employer measures to take) (We have been advised that ACCSH is reviewing) What is OSHA expecting from employers? 

The work group recommends prioritizing the following related to Charge 2:
Short-Term:
 Information about indoor heat (e.g., hazards, controls, and solutions)
 This should include warehouse environments (with consideration of ventilation and humidity) and heat-related incidents related to heavy workloads and production rates, even when temperatures do not exceed OSHA recommended limits.

 Guidance for the mobile workforce (e.g., waste companies, delivery drivers) and workers who may be in mixed indoor/outdoor environments

 Acclimatization & supporting best practices
 Definition and importance of acclimatization for existing workers, new workers, returning workers, and when heat stress conditions fluctuate 
 Practical recommendations for different ways to ensure workers are acclimatized
 Suggest that OSHA review available best practices and guidance from various OSHA State Plan States with acclimatization provisions in their heat rules, such as California: https://www.dir.ca.gov/dosh/etools/08-006/EWP_acclimatization.htm#:~:text=Acclimatization%20is%20fully%20achieved%20in,first%20day%20on%20the%20job 

 Options for measuring and monitoring environmental conditions, including guidance on: 
 Most appropriate heat metrics for different settings (e.g., indoor, outdoor)
 Key characteristics to consider in selecting instruments/monitors to measure heat exposure

Mid-Term:

 Develop & use infographics in lieu of identifying specific languages for products. 
Information about workers' rights and worker and employer roles and responsibilities should be included for all products.
Charge 3: Identify whether materials are accessible to the populations most at risk of hazardous heat exposure in outdoor and indoor work settings.

The group recognizes that there are numerous regional priorities for translation (e.g. Spanish, Russian, Cantonese, and other languages in various regions across the country) and some languages for which there is not a written format. Because of this, the workgroup does not feel it can recommend a triaged list of language translation priorities across the U.S. 

The work group used the following to aid in determining language accessibility: 

      https://www.census.gov/acs/www/about/why-we-ask-each-question/language/ 
      https://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html 

The workgroup recommends as short-term priorities:
 At a minimum, Spanish translation for all products. 
 Suggest to OSHA to conduct an analysis of languages identified in reported heat illness cases and local inspections or to incorporate information about language prevalence among workers in the US to prioritize languages.
 Use language translations which are conducted by professional translators, in accordance with best practices (e.g., https://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/downloads/ToolkitPart11.pdf)
 Prioritize visual, audio, and/or audio-visual products, which may require less need for translation. Examples include:
 Infographics or short clips of worker narratives and controls/best practices, materials for toolbox talk/pre-job briefing materials 
 Post radio scripts or media kits with key messages that can be used for radio spots, local community TV
 Enhance strategic alliances such as the following: 
 Partner with organizations that won or received honorable mentions as part of EPA's Let's Talk About Heat Challenge: https://www.epa.gov/innovation/lets-talk-about-heat-challenge. Examine whether strategies and products being used by this and other organizations could be adopted by federal OSHA. Encourage these organizations, who are conducting effective outreach in their communities, to address the importance of worker health and safety and to link to OSHA guidance, if they are not doing so already.
 Review how information is available and accessible if phones are not permitted or when satellite/cell signals are not accessible - how to get info in non-technical manners. 
 Review effectiveness of infographics versus word documents.
 Review the turn-around time for OSHA to deliver printed documents for heat-related materials. (if someone wanted printed materials direct from OSHA, what is the timeframe for delivery?)

Mid-Range Priorities:

      Analyze what types of materials are being accessed (who and how do people access the materials) (cross-cutting issue  -  is key messaging understandable and retained by the user/reader) (The work group identified surveying targeted audiences as a potential method)
 Identify if at-risk populations are aware of materials?
 Leverage strategies on a region-by-region basis to disseminate information:
 Strategic partnerships, alliances
 compliance assistance specialists/OSHA Office of Outreach
                  
 Use OSHA QuickTakes as a means

          o   Develop language and translation materials for a wider range of audience
          o   Identify audio routes - radio stations, local community TV (regional) (OSHA to post radio scripts or media kits for those in local settings)
          o   Establish targeted mailings for at-risk populations
          o   Use community outreach and local markets, gatekeepers - i.e.; churches, libraries, community health centers (cooling centers) and elementary or secondary schools near agriculture sites	
Charge 4:  Identify whether existing guidance materials are up to date and align with current best practices in heat hazards and heat illness prevention
As a note, the workgroup did not have access to US data on heat illness cases as we formulated responses.
The workgroup recommends short-term prioritizing:
 The correcting of inconsistencies across products and with the OSHA NEP.

 Correct broken links in older documents such as:
 Heat Hazards: Working Outdoors in Warm Climates Fact Sheet (2005) (English: PDF)
 Clarify symptoms, particularly recognition of heat stroke:
 Heat Outreach Wallet Card (2012) (English: PDF) (Spanish: PDF) (2013) (Portuguese: PDF)
 Heat Safety Fact Sheet (Oil & Gas/Construction) (2011) (English: PDF) (Spanish: PDF)
 Heat Safety Illustrated, Low-Literacy Fact Sheet (Construction/Agriculture) (2011) (English: PDF)
 Heat Illness Signs and Symptoms Infographic English (ZIP) (2021)
 Awareness Video (English) (Spanish)
 Ensure consistency in hydration recommendations:
 Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
 Ensure consistency with OSHA NEP:
 Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
 Incorporate new evidence (see next section and resources below**)
 Mid-range priority: 

Conduct a technical review to update and incorporate current science.  Targeted examples to include:

 Acclimatization:
 Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
 Prevent Heat Illness at Work Infographic English (ZIP) (2021)
 Caffeine: 
 Heat Hazards: Working Outdoors in Warm Climates Fact Sheet (2005) (English: PDF) 
 Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
 Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
             Cooling:
                   Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
                   Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
                   Heat Illness Medical Emergency Infographic English (ZIP) (2021)
 Heat illnesses/symptoms:
 Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
 Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
 Respirators:
 Heat Hazards: Working Outdoors in Warm Climates Fact Sheet (2005) (English: PDF)
 Solar radiation:
 Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
 NIOSH/OSHA Heat Safety Tool App (iPhone) (android)
 Wind/air flow:
 Heat Illness: Protecting Workers from the Effects of Heat Fact Sheet (2014) (English: PDF)
 Heat Stress QuickCard(TM) (2017) (English: PDF) (Spanish: PDF) (2011) (Vietnamese: PDF)
 OSHA-NIOSH INFOSHEET: Protecting Workers from Heat Illness (2011) https://www.cdc.gov/niosh/docs/2011-174/default.html
Resource Materials: (focusing on what is technical versus what is general information)
      Acclimatization:
        Adaptations and mechanisms of human heat acclimation: Applications for competitive athletes and sports - PubMed (nih.gov)
        Heat Acclimation Decay and Re-Induction: A Systematic Review and Meta-Analysis - PubMed (nih.gov)
     Caffeine:
        Marginal effects of a large caffeine dose on heat balance during exercise-heat stress - PubMed (nih.gov)
        Caffeine during exercise in the heat: thermoregulation and fluid-electrolyte balance - PubMed (nih.gov)
        Thermoregulatory responses to exercise in the heat: chronic caffeine intake has no effect - PubMed (nih.gov)
     Cooling methods:
        Cooling intervention studies among outdoor occupational groups: A review of the literature - PubMed (nih.gov)
         Cooling Interventions Among Agricultural Workers: A Pilot Study - PubMed (nih.gov)
        First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis - PubMed (nih.gov)
        Tarp-Assisted Cooling as a Method of Whole-Body Cooling in Hyperthermic Individuals https://pubmed.ncbi.nlm.nih.gov/27865532/ 
     Fitness/personal factors:
        Individual Responses to Heat Stress: Implications for Hyperthermia and Physical Work Capacity - PubMed (nih.gov)
        Occupational heat stress management: Does one size fit all? - PubMed (nih.gov)
     Physiological monitoring: Heat Safety in the Workplace: Modified Delphi Consensus to Establish Strategies and Resources to Protect the US Workers - PMC (nih.gov)
     Respirators/masks related to thermal comfort & heat illness:
        Heat stress evaluation of two-layer chemical demilitarization ensembles with a full face negative pressure respirator - PubMed (nih.gov)
        Thermal discomfort of respiratory protective devices - PubMed (nih.gov)
     Sun correction: 
        Review of Tom Bernard material -  "Direct sun with modest air movement will raise the black globe temperature about 13 to 15 °F above the air temperature."  This is different from dry air temp or heat index. There is some further discussion of sun effects with and related to different metrics here: Bernard TE, Iheanacho I. Heat index and adjusted temperature as surrogates for wet bulb globe temperature to screen for occupational heat stress. J Occup Environ Hyg. 2015;12(5):323-33. doi: 10.1080/15459624.2014.989365. PMID: 25616731. Confusion over sun correction versus solar radiation? (JS)
     General: 
        Recently updated ACGIH Heat Stress/Strain TLV
        Heat Safety in the Workplace: Modified Delphi Consensus to Establish Strategies and Resources to Protect the US Workers - PMC (nih.gov)

Charge 5: Identify specific industries or audiences that would benefit from more tailored guidance materials 
Because there is often under-recognition of heat illness by health care providers (HCP), especially those unfamiliar with occupational medicine, information or material should be available to any HCP regarding medications and personal risk factors/role in heat illness prevention. 
Short-term prioritizing: The group specifically identified health care providers in addition to those recommended in the OSHA NEP instructional document, which include:
 Local employers in high-hazard and targeted industries.
 Unions
 worker centers
 COSH groups (Councils for Occupational Safety and Health), and others such as: 

 Organizations committed to advancing protections for underserved worker populations.
 Local companies and employer associations (e.g., trade associations, contractor groups, farm bureaus, local chambers of commerce) in high-hazard industries.
 Insurance companies.
 Local professional associations (e.g., local safety councils, local agriculture extensions).
 Temporary employment agencies providing employees to targeted employers.
 Local newspapers, TV stations, and trade magazines (these can help inform the public and hard-to-reach employers).
 Local government (e.g., health departments, departments of correction, emergency services, construction permitting agencies, and departments of transportation).
 Local suppliers of materials or services, equipment transportation companies, such as              landscapers, and delivery services.

