Tracking Environmental Health Data for Public Health Decision Making — Grand Rounds (June 2016)

Session overview

• CDC Public Health Grand Rounds, June 2016

• Topic: Tracking Environmental Health Data for Public Health Decision Making

• Presenter: Dr. Phoebe Thorpe (host) and Heather Strosnider (first speaker), with multiple colleagues from state and local health departments

• Public health credits available; live tweeting encouraged using #CDCGrandRounds

• Featured segment: "Beyond the Data" with Heather Strosnider

• Partnership: CDC Public Health Library feature on environmental health tracking science clips

• Goal: illustrate how environmental health data tracking supports timely, evidence-based decisions

Key concepts and context

• The environments we live in substantially affect health and well-being; data gaps exist between environmental data and actionable evidence for some health issues

• 2009: CDC launched the National Environmental Public Health Tracking Network to address the gap by combining data from national, state, and local sources

• Tracking Network purpose: provide timely, accurate, actionable surveillance information and tools to interpret and share data with decision-makers

• Tracking is not just a software platform; it is a philosophy and a multidisciplinary workforce of public health professionals, informaticians, epidemiologists, engineers, statisticians, and health educators

What is the National Environmental Public Health Tracking Network?

• A web-based system that integrates health, exposure, environmental, and population data at national, state, and local levels

• Core components: gateways for data transport, data and metadata repositories, toolboxes for data management/analysis, and portals for data access (public and secure)

• Functionality: query and visualize data by content area, geography, and time; supports data sharing, map/table/chart views, and data downloads

• Framework of functional standards rather than fixed hardware/software; allows grantees to adapt to their agencies while remaining interoperable

• Used to support other public health programs (data collection, management, analysis, dissemination)

• Emphasizes a people network: programmers, informaticians, epidemiologists, engineers, statisticians, health educators

Accessing and using the tracking data (how to interact with the network)

• National tracking site layout: left navigation lists content areas; the main query panel lets you build a data request

• Steps to access data:

  • Select content area indicator and measure

  • Choose geography and years of interest

  • Explore data via maps, tables, and charts

  • Share the query and download data

• State and local tracking networks provide data at finer geographic levels (e.g., ZIP code or census tract) and topic-specific data

• Grantees: 25 states and New York City currently operate tracking programs; over 200 environmental health practitioners support state/local work

• The program has enabled 341 state/local public health actions through FY 2015; helps save time and money by increasing data accessibility

What the Tracking Network aims to achieve

• Driving public health actions by detecting and monitoring trends, identifying vulnerable populations or exposures, evaluating health-environment relationships, and assessing potential clusters

• Data accessibility and interpretation help inform decisions, policies, and interventions

• The network is a collaborative effort across federal, state, and local levels; strong emphasis on health impact in decision-making

Public health actions: examples and impact

• Actions are concrete uses of data to inform programs/policies/interventions

• 341 state/local public health actions reported across all grantees through FY2015

• Examples of actions (illustrative; not exhaustive):

  • California pesticide program: mapping pesticide pounds by township to identify exposure near schools; informed statewide regulations restricting pesticides near schools (expected 2017 regulation)

  • Maryland: blood lead data informed new blood lead testing regulations for children

  • Radon data informed home testing initiatives

  • Online tool to help residents judge smoke from wildfires

  • New York City: city-level air monitoring to identify high-pollution neighborhoods; public spray location notices

  • Massachusetts: health impact assessments (HIA) for transportation projects; environmental justice (EJ) policy data use; hospital community health needs assessments to guide policy and intervention planning

• Public health actions aim to prevent/mitigate environmental hazards and improve health outcomes through informed decisions

Illustrative data-action example: air pollution and ED visits

• Collaboration with EPA: creation of a robust modeled dataset with daily ozone and PM2.5 estimates across the U.S.

• ED data collected for respiratory outcomes; analyses combine modeled air data with ED visit data

• Example visualization from 2012 (791 U.S. counties):

  • 25% of days had ozone concentration at or above 49 ppb

  • 25% of days had ozone concentration at or below 31 ppb

  • Histogram shows the distribution of days by ozone levels

• Health impact: after days with higher ozone (e.g., 49 ppb) versus lower ozone (e.g., 31 ppb), there is an estimated $ext{increase in respiratory-related ED visits} \in [0.025, 0.04]$

  • Approximate rise: about $2.5\% \text{ to } 4\%$ increase in ED visits for all ages, with larger increases for people under 65 vs older adults

• The study aims to fill critical information gaps used by EPA to set air quality standards for ozone and PM pollutants

New York City tracking program (case study)

• The NYC tracking program is the largest local grantee and demonstrates value of data-driven action locally

• Infrastructure: dedicated bureau within the NYC health department focused on data use, visualization, and reporting

• Capabilities: local data warehouse, IT systems, GIS, data integration from multiple agencies, public and internal data portals

• Data access and dissemination: public data portal with key indicators; automated reports, dashboards, and internal sharing mechanisms

• Strategies:

  • Identify and augment data sources

  • Improve access via automated reports, portals, dashboards

  • Ongoing collaboration with stakeholders to interpret data

• Data sources and uses:

  • Digitization of inspections; centralized data warehouse for inspection data

  • Public-facing and internal reporting to guide operations

• Public health actions enabled by NYC data:

  • Letter grading program for restaurants; regular inspections driven by data quality

  • Rat indexing to target inspection efforts (bait in likely hotspots)

  • Data-informed expansion of universal pre-K services (childcare placement/capacity)

  • Daily Poison Control Center call data used to target outreach in under-served areas

• Public health emergency preparedness and response:

  • Post-Sandy damage assessment system for residential buildings

  • Health and safety surveillance for evacuation shelters during emergencies

  • Mosquito control data: daily pesticide spray notices and spray-location maps

• Four major NYC initiatives (success stories) driven by tracking data:
  1) Community air survey (launched 2008): high-resolution neighborhood air quality mapping; identified heating oil as major local sulfur dioxide and PM pollution source; led to policy action including a phase-out and health-benefit estimations used to prioritize boiler upgrades and energy efficiency; 70% decline in average winter SO2 from 2008 to 2014; health impact estimates supported policy changes
  2) Reducing pesticide exposure: data from NYS Pesticide Sales and Use Registry showed urban use comparable to rural areas; promoted Integrated Pest Management (IPM) and restricted city agencies from using highly toxic products (Local Law 37, 2005); collaboration with Columbia University demonstrated IPM reduced pest counts more effectively and sustainably
  3) Climate-ready resilience and health: heat advisory thresholds updated using tracking data; population access to air conditioning used to advocate for resilience measures; climate-health indicators published in a neighborhood report to guide community priorities
  4) Mercury exposure reduction: 2004 HANES-like local health study found NYC levels 2.5x national average; higher exposure in foreign-born Chinese New Yorkers linked to high fish consumption; outreach materials promoted choosing lower-mercury fish; resources translated into multiple languages; subsequent HANES (2013/2014) suggests reductions in exposures; follow-on efforts include education against mercury-containing skin-lightening creams and enforcement actions (confiscated products)

• Additional NYC efforts:

  • Ongoing collaboration with climate and health programs (CDC Climate Ready initiatives)

  • Public health messaging and data support for heat vulnerability planning, with neighborhood-level indicators combining health, climate, and social data

Massachusetts Tracking: health surveillance and policy integration

• Goals: health in all policy; standardized measures enabling regional/national assessments; data utilization at local levels

• Health surveillance examples (community- and census tract-focused):

  • Development of community health profiles for all 351 Massachusetts cities/towns: combines health/environmental data with interpretation to guide prevention efforts; profiles updated automatically as data are uploaded

  • Blood lead surveillance dashboard for metropolitan areas: secure portal containing individual-level data (blood lead, cancer, birth outcomes) and a community lead report card that guides policy to increase screening, inspections, and leaded housing remediation; maps show blood lead prevalence by census tract

  • Heat vulnerability mapping: census tract-level populations identified as heat-exposed; plans to add social determinants of health and predictive modeling for future impacts

  • Climate change surveillance data inform preparedness; data support school curricula on climate resilience

• Health policy applications:

  • Health Impact Assessments (HIA) for transportation projects within a Massachusetts Healthy Transportation Compact; HIA integrates health data (air quality, noise, active transportation opportunities) into planning decisions

  • Grounding McGrath project (elevated highway) shows how health and public input shape design toward reduced air/noise exposure and increased physical activity opportunities; a tool is being developed to let practitioners access tracking data for HIAs, including social determinants and custom geographies

  • Environmental Justice (EJ) policy evolution: new health criteria proposed to identify vulnerable EJ populations, but a two-stage approach preserves broad EJ definitions while adding health data to identify vulnerable groups for prioritization; mapping of current EJ populations in Boston demonstrates multi-criteria classification

  • Data-driven hospital community health needs assessments: collaboration with hospital coalitions to identify and monitor health indicators (e.g., diabetes, stroke) and use tracking portal tools for social determinants and geography-based outputs

• Overall message: Massachusetts emphasizes health data accessibility to influence local policies, including environmental justice and transportation decisions; tracking data are increasingly embedded in policy development and community planning

Public access, outreach, and capacity building

• Public access and outreach are core components; tracking offices monitor portal usage, page visits, data queries, and dissemination of materials

• Massachusetts: quarterly training with 351 local health departments; demonstrations of tracking in every session to promote use by local health actors

• New York City: track distribution of outreach materials (e.g., fish mercury brochure) in multiple languages; broad dissemination to healthcare providers and press; robust public-facing materials

• Unfunded partners and data access: national portal provides access to data from central or federal sources for all states even if not funded; the program is a framework, not a turnkey software solution; unfunded states can join and adopt the framework with guidance

• Fellowship and expansion: CDC hosts an ASTHO fellowship program to broaden participation to states/counties/cities not currently funded; strong interest in program expansion

Interagency collaboration and data sources

• CDC internal collaborations with other CDC programs for data (e.g., cancer registries, birth defects surveillance, vital statistics)

• External collaborations: EPA, NASA (satellite data for air pollution and climate), USGS (groundwater contamination)

• These collaborations enable richer analyses and more robust environmental health surveillance and policy development

Q&A highlights and practical considerations

• Microenvironmental data in restaurants: general surveillance requires strategic targeting; NYC monitors environmental antecedents and contamination risk factors rather than attempting universal microenvironment data collection in every restaurant

• Pesticide use in NYC vs agricultural areas: urban pest control (cockroaches, rodents, etc.) accounts for substantial pesticide use; NYC data show significant urban pesticide application, reinforcing IPM promotion and regulatory restrictions on toxic products

• Prioritization in a resource-constrained setting: a two-pronged approach combining department priorities (e.g., reducing health disparities, environmental justice) with stakeholder input (state advisory groups) and the value of health impact assessments to quantify effects and guide prioritization

• Collaboration and efficiency: leveraging related CDC programs (climate/health; hazardous chemicals exposure) to build tracking capacity and avoid duplication; cross-program data integrations strengthen overall tracking utility

• Expanding the program to more states: strong eagerness to grow; ASTHO fellowship helps unfunded jurisdictions join and learn the framework

• Tribal partnerships: national-level GLITEC (Great Lakes Inter-Tribal Epidemiology Center) and state-level tribal projects; inclusion of tribes is part of the broader tracking ecosystem

• Data access for unfunded states: national portal provides central data (where available); unfunded states can participate and benefit from sharing data through the framework; data availability from federal sources helps fill gaps

• Action-oriented outcomes: CDC emphasizes public health actions as tracking outcomes; 341 actions reported demonstrate progress toward translating data into programs/policies/interventions

• Public engagement: sustained outreach is essential to translate data into community awareness and action; monitoring portal visits and disseminating multilingual materials helps broaden impact

Key numerical references and concepts (LaTeX-formatted)

• Number of states/cities funded: $26$

• Current funded sites (states + NYC): $25$ states and New York City

• Public health actions reported (through FY2015): $341$

• County-level model example: 791 US counties with ozone/PM data considered in the example

• Ozone day distribution (example): $P( ext{O}_3 ext{ days} \, \ge 49\,\text{ppb}) = 0.25$

• Ozone-associated increase in ED visits (example): $\Delta ED / ED \in [0.025, 0.04]$, i.e., a $2.5\%\text{ to }4\%$ increase

• Winter sulfur dioxide decline in NYC: approximately $70\%$ decline between 2008 and 2014

• Mercury exposure finding (NYC HANES 2004): elevated blood mercury levels $\ge 5\,\mu g/L$; NYC population with elevated exposure was about $2.5\text{ times}$ the national estimate

• Translation of a health impact assessment concept: a generic CRF representation can be used: $RR = e^{\beta \Delta C}$ or equivalently $H = f(C)$, where $C$ is pollutant concentration and $H$ is health outcome risk

• Lead data and profiles: 351 communities/profiles in Massachusetts; blood lead dashboards and lead report cards are updated automatically as data are uploaded

Final synthesis: what tracking means for public health decision making

• Tracking is a comprehensive approach to environmental health data that integrates data, builds capacity, standardizes measures, and supports action at national, state, and local levels

• It emphasizes data accessibility, cross-sector collaboration, and transparency to drive policy, program decisions, and public engagement

• The network helps identify gaps, monitor trends, and evaluate the health impacts of environmental factors, enabling more effective interventions and healthier communities

• The program continues to evolve with new tools, data sources, and partnerships, expanding the reach to unfunded jurisdictions, tribal partners, and hospital/community health needs assessments

• Overall takeaway: Tracking represents a shift toward data- and informatics-driven environmental health practice, moving beyond data collection to concrete, evidence-based actions that reduce hazards and improve population health

References and next steps

• Visit the National Environmental Public Health Tracking Network and explore data by location and topic

• Review state/local tracking program portals for examples of dashboards, lead report cards, heat vulnerability maps, and HIA-related tools

• Consider opportunities to engage with ASTHO fellowship or other CDC collaborations to bring tracking approaches to additional jurisdictions

• Explore public data portals and multilingual outreach materials to understand how data are communicated to communities