Tracking Environmental Health Data for Public Health Decision Making

>>Good afternoon and good
evening or good morning, depending on from when and
where you are joining us. I’m Dr. Phoebe Thorpe. And it’s my pleasure
to welcome you to the CDC Public Health
Grand Rounds for June 2016, Tracking Environmental
Health Data for Public Health
Decision Making. It’s a very exciting
topic, so let’s get started. But a few housekeeping slides. Public Health Grand Rounds has
continuing education credits available for physicians,
nurses, pharmacists, and others. Please see the Public
Health Grand Rounds’ website for additional details. We are also on all of your
favorite social media sites, and we are live tweeting today. So please use #CDCGrandRounds
for all your tweeting needs. We have a featured video
segment called “Beyond the Data” which will be posted
shortly after the session. This month’s segment
features my interview with our first speaker
Heather Strosnider. We also have partnered with
the CDC Public Health Library to feature scientific
articles relevant to environmental
health tracking. The full listing is available
at Here is a preview of the
upcoming Grand Rounds session. Please join us live or on
the web at your convenience. And in addition to our
outstanding featured speakers, I’d like to take a moment to acknowledge the
important contributions of the individuals listed here. Thank you. And now for a few words from
CDC’s director, Dr. Tom Frieden.>>The environments
we live, work, and play in contribute
substantially to our health and well-being. For some health outcomes, being
able to draw a clear connection between changes in our
environment and the impact on our health has been easy. For other issues there’s
a gap between the data and actionable evidence, between
what we know and what we do. To close this gap in 2009
CDC launched the National Environmental Public
Health Tracking Network. This network captures and
combines data from national, state, and local
sources and uses it to describe the intricate
relationships between the environment
and health. The tracking network is
building the fundamental tool of public health in the
environmental health area — timely, accurate, actionable
surveillance information. The tracking network also
use new tools designed to help make better sense of
the data and better share it with people who need to know. Today CDC funds 26 state
and city health departments to develop and operate
local tracking networks. Many state and health
departments have used this network to respond to concerns
about environmental hazards and health outcomes
in their communities. For example, the network has
improved real-time surveillance and tracking of carbon
monoxide poisonings in Wisconsin and other states; informed
public policy to reduce melanoma in Minnesota; helped
people in Kansas and other states reduce their
risk of cancer from radon; and improved the quality
of water, air, and response to heat waves in
California and elsewhere. In the field of public health
we’re increasingly and acting on the concept of making
data more widely available so it can be used by others and
ourselves to inform decisions. This is particularly important
in environmental health where so many parts of
society, both governmental and nongovernmental,
play critical roles that can either improve or undermine how our
environment supports our health. Filling the gap between
environmental data and health outcomes is critical. The tracking network is
increasing the extent to which decisions
about future directions in environmental health
are driven by evidence and informed by health impact. Thank you.>>And now I’d like to
introduce our first speaker, Heather Strosnider.>>Thank you, Phoebe. Good afternoon, everyone, or
I guess as Phoebe said morning or evening, depending on where
and when you’re watching it. Let me start off very basic. Environmental health is a branch
of public that’s concerned with understanding
how our hazards in our environment affect
human health and the promotion of human health and
well-being in a safe and healthful environment. Environmental hazards can be
chemical, physical, biological, and it can be found in
our air, water, food, communities, and homes. People can be exposed
to environmental hazards by breathing them, touching
them, or ingesting them. Outdoor air pollutants
are one example of a class of environmental hazards. Air pollutants may be released
directly into the atmosphere by human activity or from
naturally occurring events. The Environmental Protection
Agency, the EPA, regulates many of these outdoor air
pollutants set forth by the US Clean Air Act. National air quality
standards exist for six criteria air pollutants and were developed using
science-based guidelines. Of the six pollutants,
particulate matter and ozone are the most
widespread health threats and the most well characterized. Air pollution is known to
affect our health in many ways and can lead to a
range of outcomes, including missed school or work,
emergency department visits, hospitalizations,
and even death. It can lead to negative
respiratory effects like inflammation, coughing,
wheezing, exacerbation of asthma or COPD, and lung cancer. Air pollution can impact
our cardiovascular health, leading to abnormal heart rates, hardening of the
arteries, and heart attacks. It can also impact our
central nervous system leading to strokes and our
reproductive health leading to low birth weight, preterm
births, and birth defects. In 2013, a global burden of
disease study ranked ambient or outdoor air pollution as the fourth-highest ranking
risk factor for death globally. They found that 85% of the
world’s population lives in areas where air
pollution is higher than the World Health
Organization’s air quality guidelines. One way we study
the relationship between air pollution and health
is to evaluate the association between daily fluctuations and
air pollutant concentrations and daily fluctuations
in ED visit, hospitalizations, or deaths. EPA relies on these
studies to set standards for their six criteria
air pollutants. Results from multiple
studies are pooled to generate concentration
response functions between an air pollutant
and a health outcome like emergency department
visits for respiratory outcome. The concentration response
function tells us how many additional ED visits
we can expect as air pollution increases. The most robust estimates
are generated from large multicity studies. Unfortunately for ED
visits and hospitalizations, EPA must rely upon results from
multicity studies of population over 65 years of age
using Medicare data or single city studies
covering all ages or international studies. Such research is also limited
by temporal and spatial gaps in air monitoring data. Not every county
conducts air monitoring, and not every air monitor
samples air every day. The Pew Environmental
Health Commission in a 2000 report identified
a critical gap in knowledge that hinders our
national efforts to reduce or eliminate diseases
that might be prevented by better managing
environmental factors. The reasons for this gap include
one, a lack of data collected from many noninfectious diseases
despite the growing burden of chronic disease; two, environmental hazard
data collected for regulatory purposes not
for public health; and three, insufficient data
on human exposures to environmental hazards. Without these data,
we are unable to answer important questions
about the contribution of environmental hazards
to adverse health outcomes. To address this gap the
Pew called for the creation of a nationwide health
tracking network for diseases and exposures. In 2002 with appropriations
from Congress, CDC established the National
Environmental Public Health Tracking Program. Tracking the [inaudible] is an
ongoing systematic collection, integration, analysis, and
dissemination of hazard, exposure, and health
effect data. Successful and effective
tracking requires thorough evaluation of need,
impact, and feasibility. To understand where to
focus public health efforts, the tracking program
along with federal, state, and local partners routinely
determines the critical gap hindering public health action for a specific environmental
health issue based on the state of the science and
the state of practice. In 2009 CDC launched the
national environmental public health tracking network. The network is a web-based
system of integrated health, exposure, environmental, and
population data with public and secure components
at the national and the state and local levels. It consists of gateways for
securely transporting data — data and metadata repositories,
toolboxes for data management and analysis, and public and
secure portals for data access. The network is not
specific hardware or software requirements,
but rather a framework for functional standards —
standards such as the ability to allow public users
query and visualize data. This allows a grantee
to build upon or in line with the existing
technical infrastructure within their agency. The network at the national,
state, and local level can be and has been used to support
other public health programs in data collection, management,
analysis, and dissemination. But the tracking
network is much more than the technical
infrastructure and the data. It’s also a network of people, a connected multidisciplinary
workforce of experts in programming, informatics,
data science, along with epidemiologists,
engineers, statisticians, and
health educators. Together they maintain, enhance, and ultimately use
the tracking network to drive public health actions. To access the national
tracking network, you can visit our site here. You can read about different
health and environmental issues on the left and you can
access the data by clicking on explore tracking data. You can also view data
for your county only by selecting info by location. Clicking explore tracking
data launches the query panel that you see here. On the left you can see
a list of content areas for which we have data. To access the data, first
select content area indicator and measure and then the
geography and years of interest. You can then explore the data
in maps, tables, and charts. You can also share the
query and download the data. You can access state and
local tracking networks here. On grantee networks you can
find more state and local data on additional topics and data
at a finer geographic resolution like zip code or
census track. Today the tracking program funds
25 states and New York City to operate tracking programs and maintain
jurisdiction-specific components of the network. It supports over 200
environmental health practitioners at the
state and local level and has built partnerships
between health and environmental agencies
and between federal, state, and local levels. The tracking program and its
network have made strides in significantly improving
our ability to use data to inform public health actions. Our grantees have
supported 341 state and local public health actions through the end of
fiscal year 2015. And they have saved time
and money at the state and local level by
increasing data accessibility. To drive public health
actions, we mean to detect and monitor trends, identify
populations or exposures, to evaluate the relationship
between health and environment, or to assess potential clusters
in order to improve, inform, or evaluate our programs,
policies, or interventions designed to
prevent or mitigate the impact of environmental
hazards on health. Here’s an example of a
public health action. California agriculture produces
nearly half of all fruits and vegetables grown
in the US; however, agricultural production
frequently relies on the applications
of pesticides, which can be hazardous
to public health, especially vulnerable
populations like children. In California little
was known about the use of pesticides near schools. This map is from the pesticide
programs’ mapping tool and shows pounds of
pesticides applied by township. The darker the red,
the greater the pounds of pesticides applied. The California tracking
program examined the use of selected agricultural
pesticides near public schools and the 15 counties with the
highest level of pesticide use. The findings in the
report have resulted in a state-wide work group
between government agencies, farmers, schools,
and communities to develop new regulations
for restricting the use of pesticides near schools. New regulation is
expected in 2017. Other examples of public
health actions include the use of blood lead data to inform new
blood lead testing regulations for children in Maryland;
the use of radon data results to inform home testing
efforts; the development of an online tool to help
residents judge the potential danger of smoke from
wildfires; the establishment of city level air monitoring
to identify neighborhoods with high levels of air
pollution in New York City; and the use of tracking
data and expertise to conduct health
impact assessments of proposed transportation and
highway plans in Massachusetts. Another example of a
public health action in progress takes
us back to that lack of a large multicity
studies on air pollution and ED visits among
populations under the age of 65. First to address gaps
in monitoring data, tracking is collaborated
with EPA to develop a robust modeled
dataset providing daily estimates of ozone and
PM 2.5 across the US. EPA provides us updated
data once a year. Tracking has also
collected ED data for repair outcomes
from 17 states. And we are just now
in the process of analyzing these data along
with the modeled air data. For example, this histogram
shows the number of days across 791 US counties in
2012 by ozone concentration. For 25% of the days ozone
concentration was 49 parts per billion or higher. Conversely, for another 25% of days ozone concentration was
31 parts per billion or less. Here you can see
the percent increase in respiratory-related ED visits over a seven-day
period following a day where ozone concentration
was 49 parts per million versus 31 parts per million
with some assumptions like temperature and PM 2.5
concentrations remain the same. Ozone results in a 2.5% to
4% increase in ED visits for all age groups with a
greater increase among people under 65 compared to
those who are older. Results of this study will
address a critical gap in available information
used by EPA to set their air pollution
standards for ozone and PM. Now I’d like to turn it
over to two of my colleagues from the state and
local level who’s going to tell you a little bit more
about the tracking program and the utility of their network
within their own jurisdictions. So it’s my pleasure to introduce to you Dr. Wendy McKelvey
to tell us about tracking in New York City. [ Applause ]>>Thanks, Heather. And thank you, CDC, for
inviting me to present on how the New York City
tracking program has advanced the use of data to drive
environmental public health action. As the only local health
department grantee, we play the important role
of demonstrating the value of a tracking program locally. CDC tracking funds supported
our health department in establishing a bureau
dedicated to promoting use of data and the knowledge
acquired from it to inform programs, policies,
and initiatives in our division of environmental health. The New York City tracking
program built the bureau infrastructure, which includes
a staff of epidemiologists, environmental scientists,
risk communicators, and GIS and informatic specialists. It includes the data
we’ve amassed from our own and other agencies
on health, exposures, and related behaviors. And it built IT systems
that allow us to integrate, visualize, and share data both
internally and externally. We also use data
to educate people about environmental
causes of disease. This is a screenshot of
our public data portal, which provides access to many of the key indicators we
use to inform our work. Strategies of the New York
City tracking program have been to identify and augment sources
of environmental health data; improve access to data through
automated reports, portals, and dashboards; and we’re
continually analyzing and interpreting data in
collaboration with stakeholders. In the early days of tracking
when we were taking inventory of available data
sources, we saw a need within our traditional city
environmental health programs that collected data but
didn’t do enough with it — one of our first internal
collaborations was with programs that were working towards
digitizing their inspections in the field. The tracking program
supported this effort by building a centralized
data warehouse that made inspection program
data easily accessible for analysis and reporting. And we now routinely
create and share reports that allow program
leadership to track performance and better target their
limited resources. I’ll describe now some
initiatives that grew out of this expanded use of
data from existing programs. The New York City letter grading
program uses publicly posted grades to communicate
inspection findings, and it applies a schedule
of more frequent inspections to the poorest performers. Inspection data is pulled
into our centralized system and tracking program staff
analyze it and report on it to inform program operations. Rat indexing is a program that can assist the city
systematically, block by block, looking for signs of rats. And inspectors place bait
where rats are mostly likely to be instead of only
where complaints come from. As with restaurant food safety,
rat inspection data is pulled into the centralized system,
allowing analysts easy access for reporting to guide
program operations. More recently we’ve used data
on childcare center placement and capacity to inform
expansion of services in the current mayor’s universal
pre-kindergarten initiative. And finally, daily
monitoring of call data from the Poison Control
Center guides staff in conducting outreach to
areas least likely to call to make sure all New York
City residents are aware of this important resource
and know how to access it. Tracking infrastructure has
also strengthened environmental emergency response
in New York City. Just after super storm Sandy,
we did not anticipate the number of people who would be
sheltering in place in buildings without power, heat, or water. Since that time we’ve used our
analytical and GIS expertise to support an electronic
data capture system to assess residential building
damage that could occur again if a similarly powerful
coastal storm hits. We’ve also leveraged our
experience centralizing data from routine field inspections
to improve upon a plan for health and safety
surveillance of evacuation shelters that are
open during certain emergencies. And since the mosquito season
has started we’ve been using tracking IT and GIS
expertise to inform the public about mosquito control
efforts to minimize risk of Zika and West Nile virus. We populate a public
website daily with notices of pesticide spray events and we provide a map
of spray locations. Now I’ll describe four
environmental health initiatives that did not grow out
of existing programs but rather took root and became
success stories with support from the tracking program. In 2008 New York City
launched a community air survey to monitor air quality at high
resolution across neighborhoods and to identify important
local sources of pollution. It’s been so well received that last fall the New York City
Council passed a law requiring it to be ongoing. Local air monitoring identified
residual heating oil often used in older buildings as a major
determinant of sulfur dioxide and fine particulate
matter pollution patterns across New York City
neighborhoods. This finding supported a rule
now in effect to phase out use of residual heating
oil in all buildings. And by bringing local air
pollution data together with local tracking data
on related health effects, we’ve been able to
estimate health benefits of air pollution control,
and we use these estimates to prioritize the
highest risk neighborhoods for boiler switching and
energy efficiency upgrades. These graphs show
the 70% decline in average winter sulfur
dioxide air pollution between 2008 and 2014. The phase out of residual
heating oil is one reason for the decline in conjunction
with state regulations to reduce allowable sulfur
content of heating oil. Reducing the use of toxic
pesticide products is a signature aim of the New
York City tracking program. Early on we acquired data from the New York State
pesticide Sales and Use Registry and found that the
quantity of pesticides used in New York City rivaled use in
agricultural areas of the state. We were especially concerned because pesticides used
indoors are in close contact with residents and
more likely to persist in the absence of
light and weather. Integrated pest management
is a safer and more effective alternative
to conventional spraying. IPN controls pests
by depriving them of food, shelter, and water. It uses minimal amounts of the least toxic
chemicals applied directly where pest problems
originate rather than indiscriminately
applied throughout the home. One of the earliest tracking
program collaborations was with Columbia University
on an intervention study of IPN and public housing. We published a manuscript
suggesting that IPN reduces
pest counts more and for a more sustained time
than conventional methods. And in 2005 we used our data,
our findings, and our knowledge to promote passage
of local law 37, which requires all city agencies
to use IPN wherever possible and to eliminate use of products
that may be carcinogenic or reproductive toxicants. The New York City tracking
program works closely with our climate and health
program, which is supported by the CDC Climate Ready
Cities and States Initiative to improve resilience
to climate effects. Back in 2008 tracking
data was used to identify a more appropriate
threshold for heat advisories in New York City, based on actual observed
heat-related health effects. We use tracking data to
target messages about heat to the most vulnerable
neighborhoods. The map here displays an
index that was created from an analysis of deaths
during past heat waves. We tracked population
access to air-conditioning to support the climate
program in advocating for increased access
to vulnerable groups. And we’ve recently begun to
provide data to support a study to assess potential health
impacts of power outages. On our public data portal
we bring key climate and health indicators together
in a neighborhood-based report that can guide community
priorities for increasing climate
resilience. The indicators in this report
are from a wide variety of data sources ranging
from local health surveys to the US Geological Survey. My last example is
about our efforts to reduce exposure to mercury. In 2004 the New York City Health
Department conducted a local health and nutrition
examination survey similar to the national HANES
of about 2,000 adults. And we measured mercury in the
blood and urine of participants. This figure displays estimates
of blood mercury levels of five micrograms
per liter or higher, which is the New York
State reportable level. We found that the overall
New York City estimate of elevated levels was 2.50
times the national estimate and almost half of Asians
had reportable levels. We analyzed the data to
better understand the source of exposure, which
is typically fish when blood levels are elevated. We identified foreign-born
Chinese New Yorkers as having especially high
blood mercury levels. And you can see here
that almost one-quarter of this group reported
consuming fish 20 or more times in
the last 30 days. These findings led
to an outreach effort to encourage the
highest risk groups to choose fish lower in mercury. The developing nervous
system is most vulnerable to mercury exposure, so
we’ve targeted our outreach to pregnant and breast-feeding
women and those who care for young children. But fish also contain
nutrients that are beneficial to the developing
nervous system. So we developed a brochure
to emphasize that people can and should keep eating fish but higher risk groups should
choose lower mercury species. We released our message
to the press and to healthcare providers through an electronic
messaging system, and we’ve distributed
hundreds of thousands of copies of our brochure in
English, Chinese, Japanese, Korean, and Spanish. And it is available
on our website. These are just a few
articles that appeared in theNew York Timesafter
we released our findings. Tracking program staff also
analyzed urine mercury levels, which typically reflect exposure
from sources other than fish. We identified some very
elevated levels in women, mostly Dominican, who reported
using skin-lightening creams. This is an image of one of
the products we confiscated from a study participant. You can see ammoniated mercury
is a principal ingredient. Our findings led to extensive
outreach and education about the danger of mercury-containing
skin-lightening creams. I was on the job
about two months when I remember attending
then Commissioner of Health [inaudible]
bilingual conference with the vice-consulate from
the Dominican consulate warning people about the products. Shortly afterwards
we canvassed stores in Dominican neighborhoods
where we identified and embargoed hundreds
of products that listed mercury
as an ingredient. We conducted a second New
York City HANES in 2013/2014, which provided an opportunity
to see if our and others’ work to reduce exposure to
mercury has been successful. Preliminary analyses we have
done suggest that they have. Looking towards the
future, we’ll continue to use state-of-the-art IT to
bring together and analyze data that can inform existing
environmental health programs including food safety,
childcare, pest control, poison control, and
emergency response. And we’ll continue to promote
use of data and collaborations to improve air quality
and increase resilience to extreme weather events,
reduce pesticide use, and more recently to support
the current mayor’s Vision Zero Initiative to reduce traffic
deaths and injuries to zero. And we have other
ideas brewing as well. So I thank you. And now I’d like to introduce
our next speaker, Jan Sullivan. [ Applause ]>>Thank you, Wendy. For my presentation I’ve chosen
to share with you some expansive and impactful applications
of Massachusetts tracking that reflect the department’s
goal of health in all policy. Tracking grantees have
moved through this continuum from portal development
to data utilization. Whereas Wendy and Heather
have previously talked, we’ve developed nationally
standardized measures enabling regional and national
environmental health assessments where each grantee has
enhanced its capacity to address local
environmental health issues. Grantees have all moved into
a data utilization stage where we had originally
set our sights since first initiating tracking. My example applications
fall into two categories: Health surveillance and policy. For health outcome surveillance, the Massachusetts focus is
almost always at the community and census track levels. Historically our residents and
other stakeholders have looked for and used data at smaller
than county geographic levels for program planning
and evaluation, even when giving
attention to national issues like lead in drinking water. I have three examples of surveillance data
utilization affecting local and state policy. The first is our development
of community health profiles for each of our 351
cities and towns. Rather than slowly
provide detailed health and environmental data that
can be queried by content area on our public tracking portal, we wanted to also pull
selected datasets together along with elements of data
interpretation to give residents and decision makers
a fuller vision of a community’s
environmental health status. Each profile is 10 pages with
the goal of focusing attention on needs and opportunities
for local and state primary
prevention efforts. Descriptive information on
the community sets the stage, followed by various
environmental and health indicators, concluding with prevention
information and other resources. We start with demographics,
including race and ethnicity, then move to health issues. This page presents lead
screening results for children. One important element
of our profiles is that the messaging
guides interpretation. Here we present the
rate of heart attack and asthma emergency
department visits. The data presented in these
profiles are automatically updated when new data are
uploaded to our data warehouse. Here’s air quality
data for Boston; drinking water quality data
including lead exceedances and information on Boston’s
climate change vulnerabilities; our data sources, where to
obtain further information; and on the last page a glossary. A second surveillance
example looks at blood lead data in children. This slide is an
example of output from our blood lead dashboard
here showing a number of metropolitan communities
in Boston. The dashboard is a component of
our secure or nonpublic portal, its goal being to apply
our blood lead data to automatically identify spikes in incidence exceeding
a statistical threshold that could trigger corrective
actions, such as evaluation of drinking water
corrosion plans or case management activities. Our secure portal warehouses
our individual level data, such as blood lead,
cancer incidence, and birth outcome reports. A related activity
is the development of a community lead report card. The report card is
generated automatically as data are uploaded
to the portal. We plan to provide these
annually to our local boards of health, pediatricians,
and other partners. Even more so than our
community profiles, the lead report card is targeted
to influence local policy to prevent lead exposure by
increasing screening rates in high-risk populations, lead
inspections, and the number of homes being deleaded. The back page of the report card
provides maps here of Boston of blood lead prevalence and
screening by census track to aid in targeting vulnerable
populations. We also have a public database on home inspection
results by address. The third example of surveillance data
utilization provides a map view of identified census track
level populations vulnerable to heat events. Other data views we’re
developing will include additional social determinants
of health and the results of predictive modeling
of future impacts. Our climate change surveillance
data inform preparedness efforts of local health and
are being used to develop school curriculum
to enhance awareness. Moving from data surveillance to
the policy impacts of tracking, an important observation is that
the inclusion of health data in policy is largely
because for the first time and as a direct result
of tracking health and environmental data are
accessible to our stakeholders. I’ve divided the health and
policy data utilization examples into two categories:
Environmental policy and community health policy. Health impact assessments
are one example of health impacting
environmental policy. In Massachusetts a healthy
transportation compact was formed whereby multiple
state agencies agreed to collectively implement
the compact with the goal of developing methods and conducting health
impact assessments that include health
data for air, rail, and road transportation
projects. The inclusion of
health as a part of formal policy is
a major step forward for environmental policy
making in Massachusetts. This pathway diagram
is an overview of the health impact
assessment planning process for transportation projects. Adapted from CDC’s Health
Impact Assessment web content, these pathways help the end
user make the connection between their project and potentially relevant
health impacts. One specific healthy
transportation compact project is called Grounding McGrath — the McGrath being
an elevated highway in the Boston area
that’s shown on the left. This slide is meant to
illustrate how the consideration of health and the inclusion
of the public’s voice through the health impact
assessment process have directly led to the proposal on the right where community design is
considering the reduction of exposure to air and noise
pollution and the promotion of opportunities for
physical activity in the development process. I want to also highlight that Massachusetts is going
beyond just the support of the health impact
assessment process by currently developing a tool for health impact
assessment practitioners to directly access tracking
data based on the types of health impact
assessment projects and to include social
determinants of health data. In a highway project
health impact assessment, the tool will identify
relevant vulnerable populations such as children and health
indicators such as asthma and provide them
for consideration with environmental data. An additional feature of
the tool is the inclusion of a mapping function that
creates custom geographies at the census track or
community level in accordance with the geographic
specifications of the project. In this map the red area
remember represents the geographic focus of
the highway project and the green area represents
the affected census tracks for which the social
determinants of health and other health data
would be extracted from the tracking portal. A second example of an
environmental policy driven by the availability
of tracking data is in Massachusetts
environmental justice policy. There has long been interest by
government and advocacy groups to include health in our
environmental justice policy. Recently a revised policy
went out for public comment and it included a
new health criteria in the actual definition of an environmental
justice population. After careful analysis, we
realized that the addition of health criteria in the definition itself was
not consistent with the intent of environmental
justice to ensure that all populations
have a voice in environmental
policy decision-making. Adding health into the
definition could favor ill populations already with a voice over minority and
poor populations. So our department instead
proposed a two-stage environmental justice policy where the more broad
environmental justice definition remained essentially
as it has been but health data would
be added to identify and prioritize vulnerable
environmental justice populations. This map illustrates the
current EJ populations in metropolitan Boston. The different colors reflect the
different criteria contributing to the population status as an environmental
justice population. The new stage proposed
in the policy by the Massachusetts Department of Public Health
would require the use of selected tracking data
such as low birth weight and asthma data to identify
vulnerable populations. Both health impact assessments and environmental justice
policies engage public stakeholder in environmental
decisions and projects. Historically environmental
justice policy did not always result in public voices
being heard, particularly if an environmental regulatory
standard was not exceeded. The inclusion of tracking
health data as proposed by our department could
significantly increase public participation in a wide range
of decisions related to projects with potential environmental
health impacts. This last example I’ll share is of Massachusetts
tracking data used to drive community
health policy. You may be aware that every
three years hospitals must identify the health needs of
the communities that they serve and importantly implement
strategies to address those needs
within the community. Tracking offers much of
the data that hospitals and others conducting community
health needs assessments have struggled to obtain — data that
can more clearly identify needs than previously available
and data that can be used to evaluate intervention
strategies. Massachusetts has entered
into a collaboration with hospital coalitions to identify health
indicators of interest. We’re collaborating with
other departmental bureaus to receive additional indicators
such as diabetes, stroke, and behavioral risk factor
surveillance survey data. The tracking program is creating
another tool to meet the needs of hospitals using our
tracking portal infrastructure. Here is a view of the community
health needs assessment tools’ initial query selections
showing choices by community or hospital service area. Here’s one example
of the output. Thousands of lines of data
are potentially available. With this tool we
provide the functionality for viewing the data by
social determinants of health and for custom-created
geographies, similar to our health
impact assessment tool. What I’ve shared with you
are just a few examples. It’s not an exaggeration
to say that tracking in Massachusetts is overwhelmed
with requests from our governor, our commissioner,
other Department of Public Health programs,
state environmental agencies, other stakeholders for the
applications of tracking data to guide policies and
inform decision-making all because environmental health
data are now accessible through tracking. And I believe we are
only touching the surface of tracking’s potential. Thank you for your interest. And I’ll turn the
podium back to Heather. [ Applause ]>>Well, thank you, Wendy
and Jan, for being here today and for sharing with us how
tracking has improved the utility of data to inform state and local environmental
health decisions. These two presentations
represent what tracking means for all of our 26 funded state
and local health programs. Together we’ve been able
to improve the availability and the accessibility of
data, and we have been able to standardize those data
in a way that allows us to monitor trends and patterns
across the US and over time and to respond to those
state and local concerns. And we really have come
a long way since 2002 when this program began. But as Jan said, we’re
only touching the surface on this program’s potential. I know I can speak for
others in this program when I say I’m very excited
to be a part of this program and I’m very excited to see
this program continue to grow. It is truly a collaborative
program in support of the many vital environmental
health programs here at CDC, as well as at the
state and local level. Tracking is not an
out-of-the-box software solution; it is a philosophy for
conducting environmental health in a data- and
informatics-driven world. So please visit our
website and learn more about applying tracking
data and expertise to your environmental
health decisions. So with that, I would like to
thank you all for your time and attendance today and open
the floor for any questions. We will be taking questions from the public online first
before the folks in the room. And please be mindful of other
participants who have questions and keep your questions
brief and actually questions when you step up to the mics
in the back of the room. So with that, we’ll
take questions.>>First question from
our Twitter followers: Wondering if the environmental
health tracking program will collect microenvirodata? In restaurants envirofactors
matter in food safety and
public health.>>That was microenvirofactors?>>That’s what it says.>>Not sure how to
interpret that. But more broadly speaking,
taking a step back is that when it comes to
conducting surveillance or monitoring we have to
be strategic about where and how we employ that. It would be difficult to
have widespread monitoring in every restaurant. So I think for restaurants
we have systems in place that help us identify
those types of problems.>>Right, exactly. And in New York City
what we’re monitoring in restaurants are
the conditions, the contributing factors,
the environmental antecedents that lead to contamination
of food. Our inspections programs
are complex, they have a long checklist of
items to check to make sure that food is safe
from contamination. Outbreaks are investigated. And sources are identified. And of course, this
is all with the data that we’ve been emphasizing
is so important, you know, to make sure that we are
efficient and effective with our boots on the ground
environmental health programs.>>Any questions from
anybody in the room? There are mics — well,
you can use the mic also in front of you.>>Okay, thanks. I noticed, Dr. McKelvy, in
your presentation you said that pesticide use in New
York City rivaled the use in agricultural areas;
can you say why? I was guessing that it
was bed bugs or rodents.>>There is a lot of
insecticide use that goes on to control cockroaches and
other insects, rodent control, fungicide application. If you visit our portal, we
actually show the quantity of pesticides used commercially
that’s been reported to New York State through
the Pesticides Sales and Use Registry. And you can see it’s a lot. You know, controlling pests in an urban environment
is a challenge. So that was a finding
that was a surprise to us. And it really argued for
doing something about it; hence our promotion of
IPM and our restriction of city agencies, you know, to
not use the more toxic products.>>Thank you.>>Dr. Bryce.>>Thank you very much
for great presentations. So it seems that there’s a
universe of potential problems that could be addressed
by tracking. And there are probably not
enough resources to include all of them in a tracking platform. So I’m wondering if Wendy
or Jan, you can speak to how you work at
this state and local to prioritize what
could be most important, what could be most
valuable to take on next?>>Part of our —
I guess it’s kind of a two-prong approach,
I guess. You know, our commissioner
sets departmental priorities. And one of her key interests
and commitments currently is to reduce health disparities. So along the lines of
building our capacity to look at social determinants
of health, that will help address
disparities, as well as strengthening our
environmental justice policy. So part of our work is driven by departmental commitments
and interests. And then we also have
a state advisory group that we meet with twice a year. And, for example, our
community profiles came out of that work group, that we had
a number of representatives from local health in that group. And they said that
they really wanted to see a snapshot
of their community. So I think it’s, you know, a
combination to set priorities.>>And I would emphasize
the importance of health impact assessment,
the kind of quantification of health impacts that
really are so important in driving what our
priorities should be. You know, so, for example,
remember Heather’s slide on air pollution and
the deaths worldwide. It’s a lot. I think people don’t
realize that — you know, there’s concern
about often exposures that maybe don’t
rival the impact of air pollution, for example. And conducting the health
impact assessment helps to quantify the magnitude
of these problems to argue for okay, this is something
we really need to focus on. Same with the climate
effects — extreme heat. There are health effects that
I think are not as recognized, but with the data and health
impact assessment we’re able to communicate that better.>>I guess I would add
just one other thing, and that is that we do
try to I guess capitalize on other programs
within the bureau. And that includes our
climate and health work that is funded by CDC. We also are building some
information onto our portal in the next year or
so related to exposure to hazardous chemicals. And that is driven by
the work that we’ve done through our ATSDR cooperative
agreement within CDC. So I think that, you know, to gain some efficiencies
we’ve got work going on in other program areas. And it all seems to
lend itself to tracking and to strengthening tracking. So we’re trying to
do that as well.>>Any other questions?>>So with these wonderful
examples of the benefits to the tracking grantee states,
is there a possibility or desire to expand the number of states?>>Well, we are certainly
very eager to continue to grow this program and
its capacity not just within the existing states
but across the country. We do host a fellowship
program with ASTHO, which is the Association
of State and Territorial Health
Organizations, where we’ve been able to
offer fellowships to states and counties and state cities
that we don’t currently fund to help them sort of get
introduced to tracking and start applying
the tracking concept to their own health decisions. So we’re very eager to do that. Yes?>>Do you have any
tribal partners in the tracking program
at this time?>>We do, actually. At the national level we
have a project involving — I’m looking at Alex;
it’s the Great Lakes — GLITEC is the acronym. It’s the Great Lakes
Inter-Tribal Epicenter that we’ve started up
at the national level. But several of our grantees have
projects going on with tribes within their own
states or jurisdictions. Any other questions? Please?>>Thanks, again, for an outstanding
set of presentations. Follow up to one of
the prior questions. So for state or local public
health staff interested in these issues who are
working in a non-funded and non-grantee state,
are there data portals or other places they can go to
try to at least get a handle on what might be the priority
environmental health issues they should be tracking at
the state or local level?>>Yeah, absolutely. So we actually have had
many unfunded state partners who have been involved in
tracking and, for instance, even submit data from the
state health department to the national level. And at the national level on our national public portal
anytime data are already available centrally
or federally, we obtain the data
from that resource. And we obtain data
for all states, not just the ones
that are funded. So there are data available
for all states for some of our conditions up
on the national portal. But this program, like I said, it’s not as if it’s a
software solution or hardware or something you
buy; it is a concept, a framework for conducting
environmental health surveillance. And that is something that unfunded states can
join us in at any point. We have a guide for helping
them getting started. Some of the first things is
really taking an assessment of the technical
infrastructure within your state and understanding the data
resource that are available and understanding what are the
state and local priorities? So we do offer a framework for
that and welcome any states, county, or city who
would be interested in collaborating with us. Yes?>>Hi, there. Three great presentations,
thanks. This is a question for Heather. We saw two state and
local presentations that were chocked full of
action and public health impact. So I’m wondering about
all of the grantees, to what degree is CDC either
encouraging or thinking of what CDC could do to
focus all the grantees to be so action- and impact-oriented?>>Well, I think
that they really are. So from the very
beginning of the program, we’ve been interested in tracking what we call
these public health actions. So where we’ve been able to
use data in support of programs or policies or interventions. And we’ve been tracking
that all along. And at this point
we’ve got 341 reported, and that’s from all
of our grantees. And that really is
just what’s reported, a snapshot of what’s going on. There’s I would say we could
have brought up, you know, 26 different programs and had
pretty lengthy presentations as well. And I think that’s one of the
good things about this program, is it’s about —
again, it’s about how to conduct environmental
health surveillance and it’s about establishing
core competency and functionality both in a
public health professional sort of way and also in a
technical infrastructure, and then applying that to your
state and local health issues. So I would say that all of
our programs are as equally –>>Okay. So it’s not
just tracking process; it’s action impact
for all the grantees.>>Correct.>>Okay. That’s great.>>Correct, correct. And we really have been — Jan’s slide kind of alluded to the first few years was
really capacity building and piloting, taking
that sort of assessment. Then it was building that
technical infrastructure, centralizing our data
sources, and cleaning it up. Then it was, like,
building the portals and disseminating the data. And we’ve been really focused
these last couple FOA cycles on using that data. So we were really
focused on that endpoint. Yes?>>This is from our Grand Rounds
email box: Could you talk more about how CDC is working
with other federal agencies in addition to EPA
to collect data?>>Of course. So we collaborate internally
with other CDC programs. We obtain cancer
data, for instance, from the National Program
of Cancer Registries. We also work very closely
with birth defects. In fact, I think some of
our grantees at the state and local level have been able to support birth
defect surveillance, so they’re a very
close partner of ours at all levels of government. And, of course, then
vital statistics — the National Center
for Health Statistics. We obviously work
with them as well in obtaining those
data that they have. But we also work with
organizations like NASA or USGS to obtain satellite data that can help us understand air
pollution or climate or weather. And USGS, it’s mostly with
groundwater contamination. Any last questions? Dr. Bryce?>>One more, I got to ask a lot. But the public access
is, I think, a crucial component of this. Do you track the public access
and/or do you have outreach programs to make the public
aware of this information in terms of knowing
what’s in your environment, the more you know, the more you
learn, the more action can come from that, the grass
roots stuff can grow? How do you drive the general
public to this data source?>>So an important component
of the program has always been that awareness and outreach. We have staff dedicated to that
aspect of it, both in the sense of understanding — both in the
sense of reaching out to people to bring then to
the network but also in understanding
what their needs are and how we can best deliver data to their specific
issue or concern. So we have a number
of different sort of campaigns targeting
different groups that need data to make those types
of decisions. And all of our networks
are set up so that they can track the number
of people who visit our site, what they’re looking at,
what they’re querying. So we do have that feedback loop where we can see what data is
being used most frequently, maybe what data needs
to be tweaked. And we do track those numbers.>>I guess I could — in Massachusetts I guess I
could add that we have — I alluded to our 351
local health departments. And we do quarterly
training with them. And I think at every session we
have at least one presentation or demonstration of tracking
because we are really keen on promoting it for
local health agents.>>And in New York City
we also track, of course, the use of our online materials
and materials developed through with support from the
tracking program, for example, the brochure I mentioned on
fish, which was so popular. Literally we’re up to hundreds of thousands distributed
up to now. And we have many materials
that the data support and we track distribution
of those.>>I’m sorry, we’ve
reached the end of the hour. Everyone please thank the speakers for their excellent
presentations. [ Applause ]>>Thank you so much for coming. And we’ll see you next month. [ Applause ]

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