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Improvements in Surveillanceand Public Health from the
California Environmental HealthTracking Program
Paul English, PhD, MPH
Jan 23, 2014
Overview
Background Components of California’s tracking program Examples and success stories
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Background3
California’s environmental health gap :Why we need environmental health
surveillance 2000-2001-- Nationally and state recognized:
Rise in chronic diseases, such as asthma, learning disabilities, andautism
Exposure to environmental hazards accounted for a significantproportion of many chronic diseases
Gap in basic information on the relationship between the environmentand health
$100 billion a year in California—fiscal toll from nine environmentally-related chronic diseases, due to related health care costs and lostproductivity
An effective surveillance system was needed to document andexplore links between hazards, exposures, and health
Sources: Pew Environmental Health Commission, 2000. SB702 ExpertWorking Group Report on Environmental Health Surveillance, 2004
(“Tracking” = “Surveillance”)
Environmental Public HealthTracking
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Environmental Public Health Tracking Network (EPHTN)
A secure, web-based network that will provide access to environmentaland health data that are collected by a wide variety of agencies.
Compile and provide access to a core set of nationally consistent data andmeasures
Exchange data
Inform and interact with the public
Enable the systematic linking of health effects, exposures, and/or hazarddatasets on an ad-hoc or ongoing basis
Provide a toolset for data analysis, visualization, reporting, and monitoring
Provide security and protection to sensitive or critical data
States added in 2009:
• Colorado
• Kansas
• Louisiana
• Minnesota
• South Carolina
About us
Within the California Dept of Public Health
Mostly funded by the Centers for Disease Control andPrevention 1 of 23 grantees
Current staffing and expertise 7 (CDC-funded), 3 (other grant funded), 1 state staff Multidisciplinary project teams: Epidemiology, environmental
science, GIS, software development, health education, programmanagement, policy
Mission: to provide data and information for public healthaction
CEHTP Program ValuesGuided by the principles of environmental justice andprecaution
Participatory processFacilitate and support the involvement of our stakeholders, includingthe community, throughout our program process.
Relevancy of actionsProduce meaningful tools, data, and information that is relevant toour stakeholders and useful for informing public health actions.
Scientific integrity and innovationAnalyze, interpret, and present data and information to our bestunderstanding and ability, using the latest and most appropriatemethods.
Transparency in decision makingMake the rationale for program activities and decisions available in amanner that is transparent and intelligible.
What should California’sTracking Program do?
Improve: surveillance value of existing data access to data
Inform: policy and decision-making program planning and
resource allocation land use and planning
decisions
Support communityaction/advocacy
Identify communities atrisk
Support advancement ofknowledge Generate hypotheses Develop methods Facilitate research through
data and tools
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Make data more useful, understandable, and accessiblefor public health action by stakeholders at the community,local, and state level
Main Tracking Program Activities11
Main programactivities/components Web portal, tools, and services Research and special projects Data requests and collaborations Needs assessment, outreach, and capacity
building Advisory group
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Web Portal, Tools,and Services Provides public access
Data queries anddownloadable datasets
General information abouttopic areas
Mapping tools
Restricted access tosome tools and services
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Examples of topicareas/data Air Agricultural pesticide use Asthma Birth defects Biomonitoring Cancer Carbon monoxide poisoning Childhood lead poisoning Drinking water Heart attacks Heat-related vulnerability Housing Maternal and Infant Health Poverty Traffic
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
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www.CEHTP.org
Research/Special Projects
Projects may utilize CEHTP Data Technical infrastructure, such as
linkage tools Other expertise
Another way to provide dataand information that is usefulfor public health action
Opportunity to focus onissues of importance toCalifornians
25 Project lead / co-lead Perchlorate and
pesticide biomonitoring Breast cancer mapping HIA on cap-and-trade
Climate change communityvulnerability mapping
Agricultural pesticidesand autism study
Heat-related illness andmortality report
Pesticides and schoolsstudy
Cost of children’senvironmental disease
Data Requests andCollaborations
Data requests For data not available on
web portal, including datagenerated using CEHTPlinkage services
Provide technicalassistance Epidemiology and statistics Communication and
facilitation Software development GIS
26 Contributed to other
projects Heat wave magnitudes & PH
impacts (Margolis)
Hypospadias, genes &environment (Stanford)
Community vulnerabilityanalysis (Pastor, Morello-Frosch)
Occupational fatality mapping(Occ. Health Branch, CDPH)
Heat vulnerability indexvalidation (UC Berkeley)
710 Freeway ExpansionProject (Human ImpactPartners)
Health-effects of wildfiresanalysis (Reid)
Needs Assessment, Outreach,and Capacity Building Assess stakeholder needs
to inform program activities
Ensure stakeholders areaware of our resources
Enhance users’ ability tounderstand and use ourresources
Collaboration with “dataintermediaries”
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Activities include
Needs assessments likefocus groups, surveys,usability testing
Evaluation
Ongoingcommunications, suchas newsletter
Project-specific outreach
In-person and web-basedpresentations,demonstrations, andtrainings
Advisory Group
Provide guidance andfeedback on programactivities
27 members
Meet in person 2-3 times ayear
Representing Local, state, fed govt CBOs and NGOs Academia Healthcare
28 Roles include
Assist in data access asdata stewards and usergroups
Provide guidance ondata analysis,interpretation andvisualization
Collaborate ondissemination strategiesand activities
Use data, tools, andservices for publichealth action
Engage in programsustainability activities
Examples and Success Stories29
Enhancing Existing Data30
Geocoding Sub-county mapping and spatial
modeling
Geocoding Service
Geocoding is essentialto public health Accurately mapping disease
or other information
Without our service,government programs: Paid for commercial
geocoding services
Used free services that wereless accurate
Spent resources and timecreating their own in-housegeocoding capabilities
Did not geocode their data
Created geocoding tool Free for users (CDPH and
program partners)
Highly accurate
Secure
High throughput (up to 1million records per table; cangeocode 300,000 records/hr)
Offered as web-based tool,desktop application, and API
Developed tutorial andconducted trainings
Problem What We Did31
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Geocoding Service
Used over 63,000 times to geocode over 42 millionaddresses
Used by over 50 programs for wide variety of public healthpurposes Vital Statistics- real-time geocoding of death records Cancer Detection- map provider locations, inform service delivery Monitoring outbreaks- TB, STDs, vectors and vectorborne
diseases Emergency preparedness- mapping of sensitive sites, essential
services
“The Geocoding Service is the best in California [state government]”- Michael Byrne, former CA Geospatial Information Officer
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Geocoding Service: Successes
Sub-County Data
County-level data are oflimited utility for local-level action
Data often displayed atcounty level Concerns about
confidentiality Higher resolution data may
be of limited utility whenrates are suppressed
Explored display ofcommunity-level datathrough use of spatialstatistics Census tract maps offer
higher resolution of patterns
Smoothed surface maps arenot limited by politicalboundaries
Verified utility of datawith stakeholderadvisory group
Problem What We Did34
California Environmental Health Tracking Program, www.cehtp.org
Identified communities at risk and target activities Fresno County MCH, childhood lead poisoning prevention activities Informed asthma, air quality programs
Assessed other possible risks Fresno used data to examine MIH outcomes and lead
Informed program planning Fresno’s MCH 5-year needs assessment and planning document
“You have helped us in a huge way.”- Fresno County Director of Public Health Nursing
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Sub-County Data: Successes
Making Data More Useful andAccessible
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Childhood lead poisoning Mapping and linkage tools
Childhood Lead Poisoning
Childhood leadpoisoning still a problemin CA
Blood lead screeningdata collected by CLPPB
County-level data wasnot publicly available
Worked with CLPPB toget permission to displaydata
Developed text and dataquery system to displaydata on Blood lead levels
Age of housing
Poverty
Problem What We Did39
Data on childhood lead poisoning now available publiclyfor the first time
Used for program planning in Nevada County To identify data discrepancies
To assess trends and gaps to inform 3-year planning process
Used to advocate for more funding for childhood leadpoisoning prevention programs
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Childhood Lead Poisoning:Successes
Mapping and Linkage Tools
Data for environmentalhazards often notavailable in useful oraccessible formats
Pesticide use data indatasets containingmillions of records
Traffic data not easilyaccessed or interpretedfor public health use
Developed mappingtools that enable usersto visualize pesticideand traffic data for theircommunity
Developed linkage toolsthat enable users to linktheir data with pesticideor traffic data bygeography and time
Problem What We Did41
California Environmental Health Tracking Program, www.cehtp.org
Pesticide Mapping and LinkageTools
California Environmental Health Tracking Program, www.cehtp.org
Traffic volumelinkage tool
Public data now more accessible to the public and moreuseful for public health purposes
Uses of pesticide mapping and linkage tools Identify site for pesticide biomonitoring project Conduct studies on pesticides and autism; pesticides and birth
defects
Uses of traffic linkage tool Screen proposed development projects for possible health
impacts Conduct study on traffic and asthma
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Mapping and Linkage Tools:Successes
Conducting Surveillance andCollecting Data
Breast cancer mapping project Water system boundary tool
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Breast Cancer Mapping Project
No proactive breastcancer “cluster”detection
Breast cancerinformation notprovided at communitylevel
Scientific expertsunsure about selectinga method for sub-county mapping Concern about utility and
potential formisunderstanding bycommunity members
Convened advisorygroup of breast canceradvocates Guided the development of
breast cancer mappingprotocol, resultsdissemination
Created mappingprotocol Use Scan Statistic at
census tract level Exclude results arising
from population shifts ortemporary changes indetection rates
Includes demographicanalysis from clinical andcensus data
Problem What We Did46
Final Areasof Concern
Many areas arelocated withincounties that do not,as a whole, haverates much higherthan the state rate
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North SF BaySouth SF Bay
West LA / East VenturaSouth OrangeCounty boundaries
Data Source: California Cancer Registry, 2000-‐2008Prepared by the California Breast Cancer Mapping Project
West LA / East VenturaSouth SF BayNorth SF Bay
South OrangeCounty boundaries
Final Areas ofConcern
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West LA / East VenturaSouth SF BayNorth SF Bay
South OrangeCounty boundaries
Comparing areas of concern with counties
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Invasive breast cancer rates aggregated over 2000-2008
Breast Cancer Mapping Project:Successes Established community-led proactive breast cancer
mapping protocol using established statistical methods
Identified areas of concern in counties previouslyunknown to have elevated rates
Ventura County hospital used results to educateproviders and target outreach activities to populations atrisk as identified in report
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Water System Boundary Tool
8000+ public watersystems No requirement for
reporting of customerservice areas
Many water systems lackthe capacity to digitizetheir maps
System boundaryinformation needed Emergency
preparedness Outbreak investigations Epidemiology
Developed web-basedtool to crowd-sourceboundary data collection Secure access by public
water system and statepersonnel
Can upload, draw, edit,and download boundaries
Can input multipleboundaries per system totrack changes over time
Boundaries available tothe public as a singlestatewide map as well asfor individual systems
Problem What We Did51
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Water System Boundary Tool:Successes Collected data for water systems serving 90% of state
population
Enabled or enhanced research studies Water costs; nitrate pollution in agricultural communities;
cumulative impacts
Support drinking water management activities Water supply permits, sample siting plans, reporting
requirements Identify locations of private well users Create plans to improve drinking water quality and waste water
management
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Conducting Research
Pesticides use near schools Cost of environmental disease in
children
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Pesticides and Schools Study
Agricultural pesticideswidely used in CA
Childhood exposure topesticides raisesspecial concerns,because children
Proximity to fieldsincreases probability ofexposure
Assess amount andtypes of ag pesticidesused near public schools For top 15 ag counties Public schools: 2,511 Students enrolled:
1,457,230 2.3 million pesticide
records
Enhanced data Digitized school
boundaries Linked pesticide use data,
field location data, andschool propertyboundaries
Problem What We Did55
Pesticides and Schools Study
Undergoing final approval Created list of “pesticides of public health concern” Improved geographic data on schools Identified pesticides with highest use near schools Identified counties/schools with highest pesticide use nearby Characterized populations attending schools near the most
pesticide use
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1.2 miles
Geocoded point
Cost of Environmental Diseasein Children
Growing concern aboutthe environment andthe relationship withhealth
Costs drive many policydecisions
Economic analysisuseful for settingpriorities, resourceallocation, andconsidering pollutionprevention
Currently conductingstudy1) Select significant
childhood diseasesknown to be impacted bythe environment
2) Calculate the diseaseburden
3) Determine the costs(direct, indirect, lostpotential earnings, annual&/or lifetime)
4) Estimate theenvironmentalcontribution to thedisease
5) Calculate cost of diseaseattributed to theenvironment
Problem What We Did57
Informing Policy andPlanning
Validation of heat alerts Climate change vulnerability
assessment
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Heat Alert Sensitivity Study
Due to budget cuts, theCity of San Josewanted evidence formaintaining for coolingcenters
Heat alert systems area first line of defense,trigger preventativeaction
No overall consistentcriteria to definethresholds for heatalerts
No systematicevaluation on sensitivityof heat alerts to healthoutcomes
Used CEHTP data toconfirmed accuracy ofheat alerts
Assessed if heat alertspredicted times whenpeople suffered the mostheat illness
In San Jose area, heat-related emergency roomvisits peaked followingheat alerts
Visit subsided when theheat alerts stopped
Problem What We Did59
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Results informed budget, policy decisions City of San Jose decided to allow cooling centers to
open as part of the city’s heat alert response
Conducted similar analysis in Los Angeles
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Heat Alert Sensitivity Study:Successes
Climate Change VulnerabilityAssessment
Multiple factors affect acommunity’svulnerability to climatechange Risk of exposure to
environmental impacts ofclimate change
Capacity to adapt tochanging environment
Sensitivity to climatechange events
Developedmethodology toscreen for areas ofgreatest concern
Piloted in twocounties: Fresno andLos Angeles
Problem What We Did62
Climate Change Vulnerability Assessment*
• Data were ranked by quintiles and mapped forcensus tracts; Final vulnerability score a sum &re-ranking across all metric ranks
* English et al, Intl J Climate Change, 2013
Metric Source
Central air conditioning CA Energy Commission (2009)Tree canopy National Land Cover Database (2001)Impervious surface National Land Cover Database (2001)Public transit routes SCAG 2011; Fresno COG 2011Elderly living alone Census 2000Household car access Census 2000Wildfire risk CAL FIRE 2003Flood risk FEMA (Fresno 2009; LA 2008)Sea rise inundation Pacific Institute 2009 (LA only)
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LA County (including residential & sensitive populations land use mask)
Final CDPH Climate Scores
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46% of African Americans and 36% of Latinosreside in the two highest risk categoriescompared to 30% of whites
Los Angeles County
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In LA County, median income in thehighest risk area is 40% lower than thelowest risk area
Climate Change VulnerabilityAssessment: Successes Developed screening methodology that can be used and
adapted locally
Los Angeles Department of Public Health used resultsto: Plan for service deliveries during climate related emergencies
(such as extended heat events and power outages) Coordinate with Community Emergency Response Teams to
assist the vulnerable populations in their cities when impacted
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California Environmental Health Tracking Program,www.cehtp.org
CEHTP staff: Natalie Collins Liang Guo Galatea King Max Richardson Eric Roberts Jackie Valle Alexa Wilkie Michelle Wong
Tracking ImplementationAdvisory Group
Environmental HealthInvestigations Branch, CaliforniaDepartment of Public Health
National Environmental HealthTracking Program, Centers forDisease Control and Prevention
Publications69
Publications (cont)
Roberts EM, English PB, Wong M, Wolff C, Falade M. 2008. Continuous Local Rate Modeling forCommunication in Public Health: A Practical Approach. Journal of Public Health Managementand Practice 14(6):562-568.
Knowlton K, Rotkin-Ellman M, King G, Margolis H, Smith D, Solomon G, Trent R, English P.2008. The 2006 California Heat Wave: Impacts on Hospitalizations and Emergency DepartmentVisits. . Environ Health Perspect doi:10.1289/ehp.11594 available via http://dx.doi.org/ [Online 22August 2008]
Roberts EM, English PB, Grether JK, Windham GC, Somberg L, Wolff C. 2007. MaternalResidence Near Agricultural Pesticide Applications and Autism Spectrum Disorders AmongChildren in the California Central Valley. Environ Health Perspect: doi:10.1289/ehp.10168.[Online 30 July 2007]http://ehp.niehs.nih.gov/docs/2007/10168/abstract.html
Roberts E, English P, Van den Eeeden S, Ray G. Progress in Pediatric Asthma Surveillance I:The Application of Health Service Utilization Data in Alameda County, CA. 2006. Prev Chronic DisJul. http: www.cdc.gov/pcd/issues/2006/jul/05_0186.htm.
Roberts E, English P, Wong M, Wolff C, Valdez S, Van den Eeden S, Ray G. 2006
Progress in Pediatric Asthma Surveillance II: Geospatial Patterns of Asthma in Alameda County,California. Prev Chronic Dis Jul. http: www.cdc.gov/pcd/issues/2006/jul/05_0186.htm.
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Dataacquisition
Datacleaning,
management, geocoding
CalculateNCDMs,
othermeasures,
andmodeledstatistics
Incorporateinto
indicatorsrepository
Create/update
dataquery
interface
Create/update
supportingtext and
metadata
Deployment Outreach
Data refresh(annuallyand as
needed)
PushNCDMsto CDC
Checkdata for
consistency
Check withcontent
experts*/resources
Checkdata
display
Review bycontentexperts*
Usertesting /usability
Flowchart for ContentAreas:
TesFng:
*Content experts include data stewards and staff from content specific programs and organizaFons. Background text willbe developed in a parallel process, and will also be reviewed by content experts when appropriate.
ValidateXML and/orconfirmationfrom CDC
Dataacquisition
Datacleaning,
management
Pilot majorfuncFons
DevelopsoPware(web-‐enable)
CommunicaFons:
-‐InstrucFons-‐DocumentaFon-‐Text-‐Tutorials-‐Metadata-‐Other usabilityenhancements
Deployment
Outreach
Data refresh(as needed)
Checkdata for
consistency
Flowchart for Tools:
Tes$ng:
Checkdata for
consistency
Check formajor
boUlenecks
TestfuncFonality
User tesFngInternal and
partner reviewfor usability
Outline/refine user
requirements
What we track/data we use
Health Environmental Demographic Geographic
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Maternal andInfant Health
Childhood leadpoisoning
Air qualityHazards:
Exposures:
Health:
Differ by:
Data steward
Purpose for collection
Data quality, format
Data availability
Funding
Drinkingwater quality
Pesticides
Traffic
Carbon Monoxidepoisoning
CancerAsthma
Heart Attacks
Birth defects
Biomonitoring
Data collection and access
