University of Pittsburgh Graduate School of Public Health Academic Partner for Excellence in Environmental Public Healt

1. University of PittsburghGraduate School of Public Health Academic Partner for Excellence in Environmental Public Health Tracking Evelyn Talbott, Dr. P.H., M.P.H. Tracking 2007: The role of the Academic Partner in Implementation October 4th, 2007

2. National Environmental Public Health Tracking Network • In fiscal year 2005, Congress provided CDC with funding of $24 million to do the following: • Continue developing a nationwide environmental public health tracking network toward implementation of a national tracking system in September of 2008 • develop capacity in environmental health within state and local health departments. • Several state and local health departments, including PADOH and ACHD, were funded to build capacity in environmental health

5. Epidemiology Evelyn Talbott, Dr. P.H. MPH (PI) Jeanne Zborowski, Ph.D ,MS (Co-PI) Environmental Exposures Conrad Volz, Dr.P.H. Bernard Goldstein, M.D. Data Linkage/Statistical Algorithms and Analysis Richard Bilonick, Ph.D. Gary Marsh, Ph.D. Mike Wagner,MD,Ph.D Geographic Information Systems (GIS) and Spatial Data Analysis Ravi Sharma, Ph.D. Bambang Parmanto,PHD Xiaohui Xu, MS, Ph.D. UPACE Advisory Committee Members Aaron Barchowsky, Ph.D. Center for Environmental Oncology Devra Davis, Ph.D. (Director) Center for Healthy Environments and Communities Robbie Ali, M.D. (Director) Global Health Network Ronald LaPorte, Ph.D. (Director) University of PittsburghPublic Health Alliance Staff Jean Lennon, C.M.A., Judy Rager, M.P.H, Juley Rycheck-Stragand, MPH Current Collaborators Allegheny County (PA) Health Department Bruce Dixon, M.D., Director, Gerald Barron, M.P.H., Luann Brink, Ph.D., Jo Ann Glad, M.P.H. PA Department of Health James Logue, Dr.P.H., M.P.H., Director Environmental Epidemiology University of PittsburghAcademic Partner for Excellence in Environmental Public Health Tracking

6. The University of Pittsburgh has several goals to aid in implementationI. Developing analytical tools available for EPHT • SOVAT (Spatial Online Visualization and Analysis Tool): An OLAP/GIS system for Environmental Health Tracking (Bambang Parmanto, Ph.D.) • Rapid Assessment and Characterization of Environmental Risks (RACER) Tool (Gary M. Marsh, Ph.D. ; Michael Cunningham, M.S.)

7. SOVAT • SOVAT is an intuitive tool for EPHT. Minimal technical skill is required. Potentially useful not only for researchers, but also for local and state public health staff • SOVAT is cost-effective (ultimately license free): no ArcGIS license is needed • Powerful for EPHT: combines map (spatial analysis), charts, and large multidimensional DB • Excellent for integration of various data sets (environmental, health, & demographic data sets) • Web-based deployment: iSOVAT (http://www.sovat.pitt.edu)

8. RACER • to help fill the research gap by evaluating the sensitivity of some commonly used statistical methods for identifying and characterizing risks • To provide a web-based software tool that will enable public health officials and others to evaluate feasibility of conducting health tracking activities or targeted investigations

9. RACER (cont.) • Developing web-based version for use by public health officials and researchers • Creating input screens to allow for simple, step-by-step entry of environmental exposure data • Help screens and interpretation of output to assist health officials in using tool and disseminating results

10. II. Developing Training Tools • Supercourse: Epidemiology, the Internet and Global Health (Ronald LaPorte, Ph.D.; Mita Lovalekar, M.D.) • Repository of over 3000 lectures available worldwide in 151 countries • Newly created EPHTN surveillance supercourse with certificate based training • Developing a UPACE-EPHTN supercourse front page to serve as a portal for access of these lectures such as the CDC –EPHT 101 modules.

11. III. Data Linkage Methods for EPHT • Application of methodology of spatial and/or temporal data linkage of environmental and health data (Ravi K. Sharma, Ph.D.) • Testing Rapid Inquiry Facility (RIF) Application, Imperial College • Real time asthma ED electronic surveillance

12. IV. Conduct Epidemiological studies for data linkage • Study 1:Local Variation in Particulate Matter during Pregnancy and Term Low Birth Weight in Allegheny County, PA • Study 2:Case-Crossover Analysis of Air Pollution and Cardiopulmonary Hospitalizations: Using Routinely Collected Health and Environmental Data for Tracking • Study 3:Cigarette Smoking and the Risk of Adult Leukemia: Results from the Three Mile Island Cohort Study

13. V. Biomaker exposure assessment • The Pittsburgh Fish Study (Conrad Dan Volz, Dr.P.H. ) • Biomonitoring of Fish Caught in the Monongahela, Ohio and Allegheny Rivers for Human Exposure Assessment and Pollution Source Identification

14. VI. Participation in Workgroups with EPHT Program Partners • Content work groups: MI , Asthma, Hospitalizations, Vital Statistics • Standards and Network Development (SND) • Program Marketing and Outreach • Portal AVR (analysis, visualization and reporting) toolkit team • Meta data subgroup

15. University of Pittsburgh UPACE-EPHT Team

16. Environmental Public Health Tracking Network: Data Acquisition and Linkage: The Challenge Hazard databases: TRI, EPA air toxics, water quality measures, etc. Exposure databases: Biomonitoring information- Blood lead, arsenic, mercury, etc. Health outcomes databases: Mortality, morbidity (admissions, ED visits, office visits, medication usage, etc) Data linkage strategies Evaluate associations Direct Research and Interventions

17. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The question remains, at the end of this major effort, will the Environmental Public Health Tracking Network be able to track and link hazards, exposures and outcomes in a way that will have real life effects and impact on the public health of our communities?

18. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • Moreover, will investigators be able to establish new relationships between environmental hazards and disease? • Perhaps most importantly, will public health professionals have the ability to intervene upon these conditions to make a difference?

19. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The two primary objectives of the nationwide health tracking are to: • 1) Identify populations at risk and respond to outbreaks, clusters, and emerging threats and • 2) Establish the relationship between environmental hazards and disease

20. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • At the heart of a national surveillance and tracking system is the context of “Who” and “What” to track. • It is unrealistic to think each citizen will wear a personal monitor for every potential pollutant and a companion biomonitoring device that would detect an enhanced body burden.

21. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The second best design for a national surveillance system is that which takes advantage of a common area and population, linking variables which share similar time, and space coordinates. An example of time, person and place are the hallmarks of epidemiological investigations.

22. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • These “ecological studies” are often used to consider the trends of disease over time in a certain population or cohort and are hypothesis generating investigations .

23. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • In ecologic studies, the group rather than the individual is the unit of comparison. • Disease rates in various groups, usually defined as a group living within specific geographic areas are compared. • The variation in rates from one area to another may be explained by correlations between these rates and risk factors or “exposures” distinct to certain areas.

24. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • These studies are constrained by the use of group rates of disease or hospitalizations as well as area –wide averages of hazard exposure measures. • Linkage is by way of census tract, geocode, Zip code or county.

25. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The data are often available in electronic format and de-identified, making linkage of both the hazard/ environmental exposure and the outcome feasible. • Emergency room visits and admissions, hospitalizations, data from cancer registries, etc offer significant potential for such ecological investigations.

26. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • What examples currently exist that show that ecological studies have utility in the EPHT mode? • Examples of ecological studies which have yielded important information on an exposure and outcome are available in the literature; however most have been conducted within the context of a research study.

27. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • Investigators obtain the necessary data on confounders within a disease-exposure relationship. • Confounders are risk factors which if present can affect both exposure and outcome. • Pancreatic cancer has been linked to cigarette smoking; however, heavy cigarette smoking is often related to heavy coffee drinking. • If one does not control for cigarette smoking, coffee intake would arise as a significant

28. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • Another classic example is that of the effect of age of a population on chronic disease mortality rates. • Cancer rates increase exponentially as we age. If there are two communities with vastly different age distributions, one community will appear to be riddled with higher rates of disease when in reality the age difference is the defining factor • Age adjustment should have been carried out prior to the comparison.

29. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The combination of a deliberate and thoughtful consideration of the rationale for the study as well as adjustment for confounders takes time • In the case of surveillance, access to sufficient data might be limited.

30. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • Problems related to misinterpretation can be avoided if the age, race and gender distribution of a population are known and a large enough sample size is available for study. • Moreover, access to detailed census information on the area under investigation and careful consideration of the area of exposure will help ensure the most specificity of representation of the exposure to the exposed population.

31. Examples of Public Health Tracking in a Real Life Setting • In 1990 Arden Pope was able to obtain hospitalization admission data on pulmonary and cardiovascular outcomes in children and adults related to a steel mill in the area which had ceased operation for a discrete period of time. • A precipitous drop occurred in the number of hospitalizations (25%) during closure with an increase in rates and numbers when the plant reopened.

32. Examples of Public Health Tracking in a Real Life Setting

33. Examples of Public Health Tracking in a Real Life Setting • Another example is the now famous decrement in blood lead levels in the late 1970’s as a result of the removal of lead from gasoline. • The EPA ruling in l975 resulted in the removal of lead in gasoline for all noncommercial vehicles • The result of this removal was 37% decrease in average blood lead levels in the U.S. from February l976 through February l980.

34. Examples of Public Health Tracking in a Real Life Setting

35. Examples of Public Health Tracking in a Real Life Setting An additional example is related to aeroallergens and pollen counts in a defined area as related to childhood asthma exacerbations. Such evidence can provide an intervention strategy in a defined neighborhood or municipality.

36. Risk Ratios of asthma admissions and ER visits by level / type of pollen Clinical and Experimental Allergy, 2000, Volume 30, 1724-1732

37. Examples of Public Health Tracking in a Real Life Setting These examples of ecological studies demonstrate that for a given group of subjects, when the “pollutant” in question was removed or reduced, a concomitant reduction in a biological response (biomarker of exposure) (in this case blood lead levels) or health outcome (reduction in hospital admissions for asthma/ respiratory illnesses) occurred.

38. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? . The ecological design just described must be viewed in the context of several important pitfalls. When using data on group rates and group exposures, a major issue is one of defining the true “exposed population” and “exposed area”.

39. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? Within a given county there may be varying levels of an air pollutant which is dependent upon topography and wind direction and the differences in exposure levels among subgroups of sensitive populations may not provide adequate sample size to quantify the response to such an exposure

40. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • What alternatives does an environmental public health tracking network offer in such cases? • Biomonitoring of unique and/or sensitive subsets of the population is one way to help target groups more likely to be affected by an exposure. Moreover, when a unique exposure occurs in more than one locale, a national tracking program would have the ability to link this information for multiple sites.

41. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • Can the concept of the Environmental Public Health Tracking work in a real life setting? • The answer is a “Yes”, given appropriate cooperation from participating states and city health departments and the ability to link high quality data on hazards, exposures and outcomes.

42. Can the Concept of Environmental Public Health Tracking Work in a Real Life Setting? • The EPHTN has the potential to yield important new information on the risk factors and environmental triggers that have remained elusive for a number of chronic diseases and conditions. • The ability to link hazards and exposures to disease endpoints in a responsible way is a critical step in the protection of our nation’s public health.

43. ALS Registry Study Example • Potential project involving a rare disease (ALS) in the SW PA area ALS Cases Environmental Exposure Tracking Relation?

44. Possible Environmental Links • Exposure to heavy metals (Hg, Pb, Cd, and Se) • Solvent exposure • Agriculture chemical exposure (Pesticide) • Cigarette smoking • Proximity to toxic waste sites/ landfills and chemical plants

46. Motor Neuron Disease (G12.2) Mortality, 2000-2004 in Southwest Pennsylvania CountiesStandardized Mortality Ratios (compared to PA) with 95% CIs Rager, October 3 2007

47. Measures of current and prior metal exposure

48. Future plans • Continue to support the National Tracking efforts by: • Epidemiological studies demonstrating data linkage • Training local or state professionals through Supercourse modules and certificates • Participate in designing, developing and evaluating surveillance system (Asthma ED visit surveillance) • Continue to develop testing software for EPHT

49. Thank you