Environmental and Public Health Tracking and Biomonitoring ......Biomonitoring Pilot Program in Minnesota Minnesota Statutes 144.995- 144.998 4 Pilot projects: – Perfluorocarbons

MPCA, September 21, 2009

Environmental Public HealthTracking and Biomonitoring:

Bridging the gap

Jean Johnson, PhDMinnesota Department of Health

Chronic Disease and Environmental Epidemiology

Outline:

Understanding health and the environmentWhat is Environmental Public Health Tracking (EPHT)?National and state program priorities and activities for trackingWhat is biomonitoring?MN biomonitoring pilot program

Shifts in the disease burden, public concern, and scientific uncertainty

There has been a dramatic shift in the health burden from infectious diseases to chronic diseases in last half century

During the same period of time, tens of thousands of new chemical compounds have been produced and are in use by manufacturers and consumers

Many of these chemicals have made their way into our air, water, soil, food, homes and bodies

85% of Americans believe that the environment plays a significant role in health (MMWR 1990)

Links between chronic diseases and environmental factors are not well understood.

Presenter

Presentation Notes

As you probably know, there has been a dramatic shift in the health burden in the last 50 or 60 years. Years ago, people used to be sick mostly with infectious disease like tuberculosis, polio, and measles. And people more commonly died of these types of diseases. Now chronic diseases are more common, with four out of five deaths in the US stemming from chronic diseases, like cancer and heart disease. We know that many chronic conditions are on the rise, including learning disabilities and asthma.

Exposure-Disease Continuum

Dose Exposure to environmental contaminant

Exposure to target organ or tissue

Pre-clinical effect

Clinical disease

pharmacokinetics

exposure assessment

risk assessment

environmental monitoring toxicology environmental/

occupational epidemiology

environmental/ occupational medicine

disease surveillance

EPH Tracking

Biomonitoring

What is Environmental Public Health Tracking?

Idea originated with a September, 2000 report of the Pew Environmental Health Commission to Congress: State of Environmental Public Health of the United States.

– Current environmental public health system is “fragmented ”

– Information gaps and data “silos” preclude health scientists from understanding relationships between environmental exposures and disease

– Recommended systematic, coordinated public health surveillance of environmental hazards, exposures and disease

– Web-based, secure, electronic network of integrated and nationally-consistent health and environmental data is needed.

Presenter

Presentation Notes

By making data on environmental hazards, exposures and health available in one place and by systematically monitoring those data, the environmental health tracking program will create new opportunities for learning about the risks of environmental exposures and for understanding the relationships between the environment and health.

EPHT at the CDC

Congress first appropriated funding to the CDC to plan and establish a national EPHT network in 2002.

The national EPHT program …– Brings together existing health and environmental data systems– Draws from state networks and from national data systems– Calculates measures that are consistent across states– Makes information available through a web-based, secure

electronic network

CDC launched their national portal in July, 2009

Presenter

Presentation Notes

So that’s what tracking is. Where is it happening? The CDC currently funds 16 states and 1 city to implement the national environmental health tracking network, which is a web-based electronic network that will contain nationally consistent data on health and the environment. These grantees are also funded develop their own local data networks

CDC funds the National EPHT Program: (2009)

CDC currently funds 22 states, 1 city, and 4 academic partners to implement EPHT network.

Presenter

Presentation Notes

We are pleased to announce that Mn is now a grantee and joins 21 other states around the country in a cooperative agreement with the CDC to form a national EPHT network.

EPHT in Minnesota

A law passed in 2007 by the Minnesota state legislature directs the commissioner of health to develop a state-level EPHT and Biomonitoring program.

Minnesota’s EPHT program goals…

– Characterize statewide & localized trends and geographic patterns in occurrence of chronic diseases, environmental hazards, and exposures.

– Disseminate data to the public & researchers.

– Evaluate the efficacy of public health actions

Presenter

Presentation Notes

Minnesota is not one of the states funded by the national tracking program, but we are fortunate to have a state legislature that values this work. In 2007, the MN legislature passed a law directing the health department to develop a tracking program.

Environmental Health Tracking System:using data to drive public health action

Public health action can be education, research, intervention, mitigation or policy

Data Collection

Data Integration

Public Health Action

Dissemination of

Information

Data collection: “deconstruction of data silos”

Identify data sources, establish data sharing agreements

MN Dept of Agriculture

Minnesota Department of Health

MN Pollution Control Agency

Univ. of Minnesota

Kinds of EPHT data: Hazards

Hazard Exposure Health outcome

Pollutants measured in the water, air, or other environmental mediaE.g., fine particulate matter and ozone in the air

Presenter

Presentation Notes

As I mentioned, the path from environmental hazard to health outcomes and diseases is complicated, so there are different types of data that a tracking program would monitor. First of all, a hazard must be present in the environment. Hazards are agents or factors in the environment that may adversely affect health. An example of a hazard is particulate matter in the air, or pollutants in the drinking water.

Kinds of EPHT data: Exposures


Measurements of chemicals and their metabolites in the body; a direct measure of exposure to environmental hazards

E.g., blood lead levels

Presenter

Presentation Notes

But, just because a hazard is out there does not mean that people are exposed. So it is also helpful to know whether people are exposed, and at what levels. Exposures are usually measured by looking in the body to see how much of a chemical has actually gotten into people. This is the most direct measure of exposure. Chemical exposures can be measured in blood, urine or other tissues. A common example of an exposure measurement is measuring blood lead levels in children. The CDC also conducts national surveillance of chemical exposure as part of the National Health and Nutrition Examination Survey – or NHANES – to measure many chemicals in people’s bodies. [Most recent survey included 148 chemicals]

Kinds of EPHT data: Health outcomes


Chronic or acute health conditions potentially related to environmental exposures; public health surveillance data

E.g., asthma hospitalizations and mortality

Presenter

Presentation Notes

Then, even if people are exposed to a hazard, they will not all develop problems from it. There are many factors that can influence whether there is a health outcome, and not everyone is affected equally by risks. Health outcomes are the chronic or acute health conditions potentially related to environmental exposures. An example of a health outcome that might be tracked includes asthma. Health outcomes can be tracked over time, across geographic regions, by age, gender, race and other factors.

Core Tracking “Content Areas”Priorities of the CDC program:

– Hazards• Air Quality (Particulate matter and ozone)• Drinking Water (arsenic, nitrate and DBP)

– Exposure• Blood Lead

– Health Outcomes• Hospitalizations (asthma, COPD and MI)• Birth Defects• Birth Outcomes• Selected Cancers• Carbon Monoxide Poisonings

Presenter

Presentation Notes

The preliminary focus of the program has been to collect and analyze data that are consistent with the national Environmental Public Health Tracking Network, which includes 16 other states and New York City. The data content areas that are part of this initial focus include measures of air quality; water quality; childhood lead exposure; hospitalizations for respiratory disease and heart attacks; cancer; carbon monoxide poisoning; birth defects; and birth outcomes.

Air Quality Tracking Data and Measures

Data source: EPA Air Quality System (AQS) Short term PM2.5 exposure-– percent of days with 24-hr average over the NAAQS– number of person days with 24 hr avg. over the NAAQS

Long term PM2.5 exposure-– Annual average ambient conc. PM2.5– Percent of population living in counties that exced the NAAQS of

15 µg/m3Short term ozone exposure-– Number of days with maximum 8-hr avg conc. Over NAAQS– Number of person days with max. 8hr. Avg ozone conc over

NAAQS

Health People 2010 objectives

Reduce the proportion of persons exposed to air that does not meet the US EPA’s health based standard to PM by 2018Reduce the proportion of persons expoed to air that does not meet US EPA’s health based standards for ozone by 2012New data sources are being explored

“Developmental” Tracking Priorities in Minnesota and CDCMinnesota is working in collaboration with other

states to develop new methods for tracking:

Climate Change– Heat-related illness– Population vulnerability– Vector-born diseases– Extreme weather emergencies

Pesticide Hazards and Associated Illness

We hope to develop and pilot new tracking indicators over the next 2 years

Web Portal for Data Access

Presenter

Presentation Notes

A major product of the national tracking program has been the development of an electronic network for the collection, integration and dissemination of data. Many states are now working to build web-based portals for displaying Tracking data. This is a screen shot of the New Mexico tracking portal. Currently we are working with IT staff at MDH to develop a demonstration portal for Minnesota. We hope to be able to continue to build this portal over the next 2 years so that the public can have direct access to environmental public health data.

Asthma Hospitalization Rates in Twin Cities Metro and Greater Minnesota

0

5

10

15

20

25

1998 1999 2000 2001 2002 2003 2004 2005 2006Rat

e pe

r 10,

000

popu

latio

nGreater MN children Greater MN adultsTwin Cities metro children Twin Cities metro adults

Source: Minnesota Hospital Association, MDH Asthma Program

Presenter

Presentation Notes

Despite the statewide decline in asthma hospitalization rates, there are some differences in trends for Twin Cities metro area and Greater Minnesota adults and children. Children in the 7-county metro area have consistently had the highest rates of asthma hospitalizations in the state; however their rates have decreased dramatically between 1998 and 2006 (top line on graph). Hospitalization rates for adults in the Twin Cities are also declining (light blue line), while rates for adults in Greater Minnesota (pink line) have remained relatively stable. Hospitalization rates for children in Greater Minnesota (green line) have risen over the same time period.

BiomonitoringDefinition: The direct

measurement of chemicals or their metabolites in

human specimens, e.g.blood or urine.

“The most health relevant method of determining

human exposure to environmental hazards is

biomonitoring.”

Public Health Goal: to monitor and track trends over time, to identify exposure disparities, to target and evaluate interventions, and make better public policy decisions for protecting health.

Year1976 1980 1984 1988 1992 1996 2000 2004

0

2

4

6

8

10

12

14

16

18

Blo

od le

ad le

vels

(g/d

L)Blood lead levels in

the U.S. population, 1976-2002NHANES II, III, 1999-2002

unleadedgasoline

introduced1975

leadpaintban1976

lead solderedcans, phase-out

begins 1978

lead &copper

rule1991

lead solderedcans, phase-out

ends 1992

leadedgas

removalcomplete

1991

Exposure of the U.S. Population to Tobacco Smoke:Serum Cotinine Levels, 12,000 People, 1988-1991

Serum cotinine (ng/mL)

Per

cent

age

of p

opul

atio

n

0

1

2

3

4

5

0.1 1.0 10 100 1000

Nonsmokers(ETS exposure) Smokers

0.00

0.10

0.20

Ser

um c

otin

ine

(50t

hpe

rcen

tile

in n

g/m

L)

1988 - 1991 1999 - 2000

0.20

0.05

Decline in Exposure of U.S. Populationto Environmental Tobacco Smoke

Temporal trends for five polyfluoroalkyl concentrations (ng/mL) from the CDC NHANES and American Red Cross study populations for the population geometric means (95% confidence intervals.)

Source: Olsen et al, 2008, Env. Sci. Technol, 42, 4989-4995.

Biomonitoring has shown levels of Perflurorochemicals (PFCs) declining in the general population since 2000.3M stopped production in 2002.

Biomonitoring Pilot Program in MinnesotaMinnesota Statutes 144.995- 144.998

4 Pilot projects:– Perfluorocarbons (PFCs)– Arsenic– Mercury– Environmental phenols and cotinine

Projects must be done in communities “likely to be exposed” and conducted in a manner that is community-based

Seeks recommendations for ongoing “Base” biomonitoring program

Developing guidelines and recommendations for an ongoing program

MDH has developed guidelines to guide decisions for the pilot projects including:

– Ensuring privacy– Informed consent (NIH)– Inclusion of children– Storage (banking) of samples– Interpretation of results– Follow-up support and medical consultation

With recommendations of the Advisory Panel, MDH is engaged in a strategic planning process that will recommend:

– A statement of vision and purpose for a state biomonitoring program– Best practices, strategies and methods for biomonitoring– Criteria and a process for selecting chemicals for future biomonitoring

Lessons learned will be summarized. Development of recommendations and strategic planning is ongoing.

Presenter

Presentation Notes

The Legislation also directs MDH and the Advisory Panel, to develop guidelines for biomonitoring and recommendations for an ongoing state biomonitoring program. We have completed a set of program guidelines to guide the pilot projects. A strategic planning process is underway to develop recommendations for the future.

Integration of Biomonitoring and Tracking

A priority for CDC and many statesNew federal grants to public health laboratories have been awarded and encouraged collaboration between environmental epidemiologists (funded Tracking programs) and laboratoriansGoal: track population exposures over time and integrate data on a scale that can be linked with health outcome and source data

Environ. Health Tracking and Biomonitoring:Bridging the Gap

Jean Johnson, PhDChronic Disease and Environmental Epidemiology SectionHealth Promotion and Chronic Disease DivisionMinnesota Department of Health

Next:

•Biomonitoring Projects and Lessons Learned

•Tracking asthma in MN

•Linking data: air quality and asthma

Our staff:

Michonne BertrandAdrienne KariJean JohnsonMary Jeanne LeavittJeannette SampleDeanna ScherLeslie SchreierAl Williams

Our Partners:

Environmental Health

Public Health Lab

Univ. Of MN

MPCA

MDA

Advisory Panel

Measuring the Impact of PM Reductions by EH

Indicators

Minnesota Department of HealthJean Johnson, Chuck Stroebel, Allan Williams, Paula Lindgren and

Wendy Brunner

Minnesota Pollution Control AgencyGregory Pratt, Lisa Herschberger, Kari Palmer, Margaret McCourtney

Olmsted Medical Center, Rochester, MNBarbara Yawn, Peter Wollan

MeasuringImpacts & Accountability

Regulatory or Policy Changes

Reductions in

Population Exposures

Reductions in Population

Health Outcomes

(Attributable Fraction)

•PM10•PM2.5•PM2.5 species•Co-variates: ozone, pollen

•Hospitalizations•ED Visits•EMS Runs•Clinic Visits• Prescriptions

Data Linkage Methods in Environmental Epidemiology

CorrelationEcologicalCase-controlCohortCase-crossoverTime seriesPanel studiesSpatial epidemiology

Ecological StudiesExposures and health outcomes are measured in groups of people rather

than individuals, as the unit of analysis

– County, zipcodes or census block level

– Uses aggregate measures of exposures• Average exposure over a specific time period• Proportion of defined population exposed

– Compares to aggregate health measure• Counts or rates of disease

Traditional used for “exploratory analysis” due to validity concern“ecologic fallacy” –error due to misclassification of individual exposure

Plays a larger role in environmental epi when large populations are assumed to share the same exposure

for example-air pollution epidemiology studies

Documents

Environmental and Public Health Tracking and Biomonitoring ......Biomonitoring Pilot Program in Minnesota Minnesota Statutes 144.995- 144.998 4 Pilot projects: – Perfluorocarbons