1. Integration, Analysis, and Visualization of Health and Environmental Data in the National Tracking Network Heather Strosnider Acting Science Development Team Lead US CDC’s National Environmental Health Tracking Program Frontiers in Spatial Epidemiology London 11/6/2012 National Center for Environmental Health Agency for Toxic Substances and Disease Registry

2. Pew Commission: Environmental Health Review, 2000  Chronic conditions account for 4 out of every 5 deaths in the United States  Little information is routinely collected on non- infectious disease  Environmental monitoring conducted regulatory purposes  Little human exposure data  Answers needed about the role of the environment on health outcomes Recommended a “Nationwide Health Tracking Network for diseases and exposures”

3. Tracking Program Goals Goal 1 Build a Sustainable National Environmental Public Health Tracking Network Goal 2 Advance Environmental Public Health Science and Research Goal 3 Disseminate Information to Guide Policy, Practice, and Other Actions to Improve the Nation’s Health Goal 4 Enhance Environmental Public Health Tracking Workforce and Infrastructure Goal 5 Foster Collaboration Among Health and Environmental Programs

4.  Detect and monitor trends  Generate hypotheses  Guide action  Inform policymaking  Provide information  Track progress Tracking Network: Integrated Data for Environmental Health

5. Tracking Program  National Network  Public Portals  Secure Portals  Standardized Data  Data Utilization  Engage Partners  Build Capacity DATA INFORMATION KNOWLEDGE ACTION

6. National Public Portal  15 datasets  2.2 GB of data  18.7 million rows of data  257 measures National Public Portal  15 datasets  2.2 GB of data  18.7 million rows of data  257 measures

7. 24 state and city public portals

8. Total Coverage165 million (55%) Asian9.6 million (70%) Black18.5 million (48%) Hispanic28 million (61%) Native American1.4 million (48%) Other2.8 million (57%) White132 million (55%) Total Coverage of US Population by Tracking Program

9. 60% (156) measures cover more than Tracking states and city

10. Content and Data  Asthma  Birth Defects  Cancer  CO Poisoning  Childhood Lead  Developmental Disabilities  Heart Attacks  Reproductive Birth Outcomes  Biomonitoring  Climate Change  Community Design  Homes  Outdoor Air  Population Characteristics  Water

11. Criteria for Prioritization  Burden - Magnitude and severity  Information system factors  Resonates with partners  Scientific plausibility  Ability to take action  Direction from Congress

12. CMS T4 Tables Middleware SQL JAVA Spring Hibernate Blaze DS Flex Anychart ESRI Flex Map Portal T3 Tables SQL

13. Percent of children tested with confirmed elevated blood lead levels, by birth cohort MEASURES4 COUNTIES2736 (87%) YEARS8 VARIABLEBLL category

14. Average annual number of Cleft Lip with or without Cleft Palate among live births MEASURES26 DEFECTS12 VARIABLEAge, Race, Ethnicity, Infant Sex Number of states providing birth defect data

15. Estimated prevalence of ASDs per 1000 children 8 years old

16. Percent of children, 3-17, receiving early intervention, special education, or related services for developmental disability Autism Spectrum Disorders Developmental Delay Emotional Disturbance Hearing Impairments Intellectual Disability Specific Learning Disabilities Speech or Language Impairments

17. Total Arsenic concentration in urine (µg/g of creatinine) ANALYTES11 VARIABLEAge, Race, Ethnicity, Sex

18. HIA Estimated percent change in death rate from baseline associated with 20% reduction in air pollution

19.  Integrated messaging with data  Added new base layers to maps  Improved export by adding supporting info

20. New Data Over the Next Year SUMMER 2012FALL 2012 Children’s Environmental Health - launched Access to Parks BRFSS Smoking Prevalence Extreme Heat Events Drinking Water - Atrazine, DEHP, PCE, TCE, Radium, Uranium Air toxics Asthma ED visits Heat ED visits, hospital, mortality Annual blood lead levels in children Pesticide exposures reported to poison control centers Chemical Incidents from ATSDR’s National Toxic Substance Incidents Program USGS Well Water WINTER 2013SPRING 2013

21. Extreme Heat Days and Events Number of extreme heat events Climate Change Definition (Required) Percentile Fahrenheit Heat Metric Percentile Max Daily Temperature Max Daily Heat Index Threshold: Absolute or Relative 2 or more days Minimum Duration 3 or more days

22. Under Evaluation for the Public Portal  Air toxics  Ischemic heart disease mortality benefits associated w/ reducing PM2.5  Mortality associated with extreme heat events  Addt’l cardio and resp hospitalizations, ED visits, & mortality  Temporal & spatial patterns in pollen  Radon in homes  Private well water  Occupational health  ALS (from ATSDR registry)  Vulnerability measures  Pesticide residue in food  New modeled air  Intellectual disabilities from ADDM  BLL 5 to <10  USGS soil  Precipitation  PM speciation and source

23. Future Functionality  Improved metadata  Enhanced charting options  View benchmarks  Exploring  Animated time map  Ability to compare related measures  Ability to compare populations

25. Percent living in poverty 2002 Percent uninsured 2002 Percent smoke 2002 Percent low birthweight 2002-2006

26. Addressing Gaps in Data, Methods & Information  Evaluating national, state, and local data systems  Inventory of available data and quality  Recommendations for reaching national consistency  Evaluating and developing methods  Environmental epidemiology  Exposure assessment  Linking health and environmental data  Tracking environmental health  Picture of America report  Surveillance summaries  Impact of exposure  Evaluation of policies and programs

27. Addressing Gaps in Data, Methods & Information  Evaluating methods for defining extreme heat events  Linking PM 2.5 with cleft birth defects and reproductive birth outcomes  Estimating IHD benefits associated with reductions in PM 2.5  Evaluating and developing models for estimating air pollution

28. Tracking in Action  200+ skilled EPH practitioners in 23 states and NYC  18 ASTHO fellowships since 2008  133 publications and health reports since 2002  132 public health actions since 2005 http://www.cdc.gov/nceh/tracking/successstories.htm

29. Reducing Effects of Extreme Heat in California  Cooling centers costly, but can be life-saving  San Jose city leaders needed proof of health impacts of heat before approving cooling centers  Tracking identified increase of heat-related ER visits during heat events  City leaders approved cooling centers to open

30. Reducing Asthma Hospital Stays in New York City  Increase in childhood asthma hospital stays and ED visits  Data used to urge update of asthma management plans for school start  Decreasing rates of asthma hospital stays  Advisories now standard practice

31. Reducing Arsenic Exposure in Oregon  Known elevated levels of arsenic in private wells  Oregon does not require water to be tested for arsenic  Using data on arsenic levels in drinking water Educated community by explaining results and encouraged water testing Prompted state legislation to add arsenic to list of substances to test in private wells

32. Improving Water Quality Data in Wisconsin  Tracking Program enhanced community drinking water data by identifying water sources and connecting population to their water system  Data used to identify and prioritize water sources that are likely to be contaminated and areas of greatest risk

33. Addressing Childhood Lead Poisoning Risk in Missouri  Many children living in St. Louis have elevated blood lead levels  Tracking Program looked at relationship between building demolitions and BLLs of children living nearby  Children exposed to multiple demolitions showed a rise in BLLs  Demolition site work practices revised and inspections increased

34. Value  “The [Pew] Commission estimates that the annual cost for a Nationwide Health Tracking Network is $275 million.”  For ~ 10% of this investment –  National Network  Environmental health infrastructure in 23 states and NYC  Mentoring and resources for unfunded states  Increased responsiveness to community concerns  Resource to other PH programs  Opportunities to be proactive vs reactive  Informing policy changes  Improving our understanding of impact on health

35. External Program Review Grantees report that Tracking is one of the most significant and far-reaching national environmental health programs. Programmatic and policy improvements directly attributed to Tracking:  Data availability, quality, and specificity  Intra- and inter- agency collaboration between health and environmental programs  Data-driven prioritization of and interventions to address environmental public health problems.

36. Thank you HStrosnider@cdc.gov ephtracking.cdc.gov For more information please contact Agency for Toxic Substances and Disease Registry or the Centers for Disease Control and Prevention ATSDR: 4770 Buford Highway NE, Chamblee, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1- 888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.atsdr.cdc.gov CDC: 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1- 888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Agency for Toxic Substances and Disease Registry National Center for Environmental Health Agency for Toxic Substances and Disease Registry