CA ENVIRONMENTAL HEALTH TRACKING PROGRAM Technical Team Presentation Paul English, PhD, MPH Environmental Health Investigations Branch Division of Environmental and Occupational Disease Control CA Dept. of Health Services

Acknowledgements Centers for Disease Control and Prevention California Wellness Foundation

Pew Environmental Health Commission Report “America’s Environmental Health Gap: Why the Country Needs a Nationwide Health Tracking Network” Highlights lack of public health infrastructure and leadership to track chronic diseases and environmental exposures

Pew Recommendations Build State and Local Capacity for Defending Against Environmental Health Threats Create a nationwide environmental health tracking network

Pew Environmental Health Commission: Goals of Tracking Network Identify populations at risk and respond to outbreaks, clusters and emerging threats; Establish the relationships between environmental hazards and disease; Guide intervention and prevention strategies, including lifestyle improvements;

Pew Environmental Health Commission: Goals of Tracking Network (cont.) Identify, reduce and prevent harmful environmental risks; Improve the public health basis for policymaking; Enable the public’s right to know about health and the environment; and Track progress towards achieving a healthier nation and environment.

Environmental Public Health Tracking: Complexity Track health effects, exposures, hazards and target interventions Monitor effects of interventions and policies Raise awareness of environmental health issues Guide research initiatives • • Track health, disease, and risk trends Track health, disease, and risk trends • • Develop rapid Develop rapid - - response mechanisms to response mechanisms to Public Health Public Health • • Establish program priorities Establish program priorities investigate outbreaks and clusters investigate outbreaks and clusters • • • • Actions Actions Develop, implement, and evaluate public health Develop, implement, and evaluate public health Develop guidelines/standards Develop guidelines/standards • • policies and program strategies policies and program strategies Information Information Analysis & Analysis & GIS GIS Data Presentation Data Presentation Data Mining & Knowledge Discovery Data Mining & Knowledge Discovery Statistical Models Statistical Models Privacy Privacy Dissemination Dissemination Integrated Integrated Hazard Hazard Population Population Environmental Environmental Exposure Exposure Bio Bio Intervention Intervention Exposure Exposure Health Effects Health Outcomes Health Tracking Health Tracking Hazardous Hazardous Profile Profile monitoring monitoring Guidelines Guidelines Data Warehouse Data Warehouse Disease Disease Material Material Population Population Tracking Tracking Profile Profile Demography Demography Information Information Extraction & Extraction & Metadata Metadata Data Standardization Data Standardization Data Linking/Integration Data Linking/Integration Data Quality Assurance Data Quality Assurance Transformation Transformation Hazards Exposure Population Health Effects Hazards Exposure Population Health Outcomes Tracking* Tracking * Tracking Tracking* Tracking* * Demographics* Demographics * Tracking * State & National State & National • • Census Data Census Data • • Administrative Data Administrative Data • • Emergency Response Emergency Response • • Blood Lead Poisoning Blood Lead Poisoning Systems Systems Environmental Environmental Notification System Notification System (child & adult) (child & adult) • • Birth Defects Registries Birth Defects Registries Health Tracking Health Tracking • • Hazardous Substances Hazardous Substances - - • • National Report on National Report on Emergency Event Emergency Event Human Exposure to Human Exposure to • • BRFSS BRFSS Systems Systems Surveillance System Surveillance System Environmental Environmental • • Cancer Registries Cancer Registries • • Toxic Release Toxic Release Chemicals Chemicals • • Health Surveys Health Surveys Inventory Inventory • • Toxic Exposure Toxic Exposure Surveillance System Surveillance System • • Vital Statistics Vital Statistics (*) Selected Data Sources (*) Selected Data Sources

Tracking Frameworks: Questions Enviro Hazard Health Outcome Basic Distribution Questions: Right-to-Know Function What hazards are we exposed to? In what amount or concentration? Are exposures changing? How does my (community) exposure compare to others? Did the environmental policy prevent or control the hazard? What is the rate of disease X in my community? Is this high or low? Is the disease rate changing? How does my (community) disease rate compare to others? Did the health policy prevent disease? Linkage Questions: Hypothesis Formulation Does a change (+/-) in a health outcome correspond in time & place to changes in hazards? Does a change in hazards correspond in time & place to changes in health outcomes? Hypothesis Testing Investigation: Controlled Study Is the observed association in time and place valid? Can it be replicated? Note basic distribution data can inform where to look to perform case-control study.

Tracking Frameworks: Value of Linkage Hazard Outcome New Cases & Prevalence / Time Amount & Location /Time Value of linking information increases with (1) time and (2) changes in hazard loading and outcome rates. Collecting hazard and outcome information over time provides better information about population health thus addressing social, scientific and policy questions.

SB 702 Senate Bill 702 (Escutia) signed by Gray Davis in Oct. 2001 mandates that CDHS lay the groundwork to establishing a Environmental Health Tracking Network Collaborative project with UC, and Cal/EPA

Bill Mandates Creation of an expert working group to develop possible approaches to establishing tracking network (including estimated costs) Prepare report to DHS, Cal/EPA, and legislative committees Develop health and environmental measurements for tracking

CDC National Environmental Public Health Tracking Cooperative Agreement Funded to CA Dept. of Health Services, in partnership with Office of Environmental Health Hazard Assessment, Cal/EPA Three years, $791,000 annually

The National Environmental Public Health Tracking Program - 2002 WA ME MT ND OR MN VT NH ID NY SD WI MA Centers of Excellence Enhancement and Demonstration Project Planning and Capacity Building JOHNS HOPKINS UNIVERSITY TULANE UNIVERSITY UNIVERSITY OF CALIFORNIA, BERKELEY HOUSTON, TX WASHINGTON, D.C. NEW YORK CITY, NY NJ DE MD RI WY MI CT IA PA NE NV OH UT IL IN CO CA WV KS VA MO KY NC TN AZ OK NM AR SC MS AL GA TX LA FL AK

CDC Agreement Goals Begin process of implementing a standards-based health and environment tracking network Increase state, local, and national capacity for environmental health tracking Improve collaborations between State’s public health and environmental agencies Improve dissemination of environmental health data to policy decision-makers and other stakeholders

CDC Agreement Objectives (6) Involve stakeholders by convening a Planning Consortium for program planning, implementation, and evaluation. Identify and prioritize state and local needs to develop a tracking network Needs assessments Feasibility of using indicators for surveillance Prioritizing informational, hardware, software needs

CDC Agreement Objectives (6) Collaborate with UC in developing training programs. Develop technical plans for an electronic standards-based tracking network Data transfer Data linkage Security Dissemination Integration with other systems

CDC Agreement Objectives (6) Develop an outreach and education strategy for communicating information Developing and evaluating communication strategies Conduct a pilot project that will track asthma prevalence and adverse pregnancy outcomes and link to hazard data on traffic exhaust exposures.

Planning Consortium Composed of representation from: U.S. EPA, UC, Cal/EPA, CDHS technical experts (e.g. CCR, EHL) County/tribal health/environmental officials Health care providers Environmental Groups NGOs, CBOs

California Environmental Health Tracking Program SB 702 Working Group Planning Consortium CA Dept. of Health/OEHHA Tracking Program Staff/Co-Investigators Teams Evaluation Outreach Education UC Tracking Center of Excellence Technical Needs Assessment

Recommendations of CDC Technical Workgroup Env. Health Surveillance System (EHSS) should be developed in cooperation with NEDSS EHSS should consist of a network of distributed data sources, which could send or receive data. EHSS should adopt metadata standards that permit standardized search for all sourced info.

Recommendations of CDC Technical Workgroup Architects of EHSS should work with federal partners and private standard-setting organizations to share, create, modify data, and develop process, performance and technology standards. Architects should adopt a formal technology neutral methodolgy for modeling, analysis and design of the EHSS. EHSS should identify, integrate, and make available tools for data analysis, interpretation, and presentation.

Recommendations of CDC Technical Workgroup Architects should explore developing relationship with private providers to gain access to non-traditional surveillance/tracking sources. Architects should ensure that there are data sharing agreements between relevant agencies at state and federal levels. Architects should develop a comprehensive IT security plan and include technical specifications.

CA Env. Health Tracking Pilot Goals To examine the feasibility of tracking routinely available data on asthma and adverse pregnancy outcomes To identify elevated “hotspot” areas of concern of these health outcomes and traffic-related pollutants

CA Env. Health Tracking Pilot Goals To explore GIS methods of mapping and linking pollution and health data for health communication and data dissemination for local stakeholders (i.e. Pacific Institute, West Oakland, Alameda County) To assist local health departments in planning and allocation of resources

CA Env. Health Tracking Program Pilot (Alameda County) Routinely Generated Data Stakeholder Web Access - Visualization Healthy Home Inspections of “Hot Spots” (In-Home Asthma Triggers) Asthma ER & Hosp, Physician Visits, Medication Use (Medi-Cal & Kaiser) Geocoding, Analysis, & Mapping for “Hot-Spot” Identification Linkage Case/Control Analysis (GIS Buffer Proximity Analysis) Evaluation Adverse Pregnancy Outcomes (IUGR & Preterm) Modeling & Contour Mapping Traffic Exposure (Traffic counts, Meteorology, Point Sources, Emissions, Land use, DEMs) Stakeholder Web Access - Visualization

“Smoothed” Low Birthweight Rates, San Diego County, CA, 1990

Modeled Total NOx from line and point sources in southern San Diego County, 2000, ADMS-Urban software

Data linkage for case/control analyses

Evaluation Completeness of Reporting Representativeness Usefulness Targeting areas for in-home inspections? Useful for accessing env. health burden? Cost

Key Challenges/Opportunities Strategies to expand/build tracking network in era of severe state budget cuts Need to produce timely information on hazards/health outcomes that are useful to local stakeholders How to engage/involve local communities on tracking activities How to promote closer involvement/collaboration of environmental agencies