1. 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

2. Acknowledgements Centers for Disease Control and Prevention
California Wellness Foundation

3. 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

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

5. 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;

6. 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.

8. 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

9. 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.

10. 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.

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

12. 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

13. 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

14. The National Environmental Public Health Tracking Program - 2002WA 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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.

23. 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.

24. 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

25. 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

26. 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

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

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

29. Data linkage for case/control analyses

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

31. 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