Environmental Public Health Tracking: Some Records are Vital

Suzanne K. Condon, DirectorBureau of Environmental Health

Massachusetts Department of Public Health

NAPHSIS/NCHS Joint Meeting, Salt Lake City, Utah

June 5, 2007

OutlineI. Environmental health and disease concerns

II. Collaboration, communication and resource sharing with vitals partners* 24A* Provision of resources to enhance data quality of vital records

III. Environmental Public Health Tracking: What have we learned to date?* IAQ & asthma* Lupus and 21e sites* DBPs (TTHMS) & low birth weight

IV. Linking childhood cancer & birth outcome data with municipal water supply data

V. Summary

I. Environmental Health & Disease ConcernsEnvironmental Health & Disease Concerns Report of the Pew Commission: Report of the Pew Commission:

Important42%

Not Important11%

Don't Know2%

Very Important45%

Very Important

Important

Not Important

Don't Know

Source: Pew Environmental Health Commission 2000

Public Perception of Environmental Contribution to Health

Source: MDPH (extrapolated from Community Assessment Program Telephone Tracking System)

Annual Calls Taken Regarding Perceived Annual Calls Taken Regarding Perceived Environment and Disease ClustersEnvironment and Disease Clusters

936

1310

1584

1080 1109

1368 1440

1235 1155

2117

0

500

1000

1500

2000

2500

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

II.II. Collaboration, communication and Collaboration, communication and resource sharing with vitals partnersresource sharing with vitals partners

24A M.G.L. c. 111, §24A authorizes the

Commissioner of MDPH to approve “scientific studies and research which have for their purpose the reduction of morbidity and mortality within the commonwealth.” Receiving §24A approval protects any data or other information collected for purposes of the research as confidential.

II.II. Collaboration, communication and Collaboration, communication and resource sharing with vitals partnersresource sharing with vitals partners

Provision of resources to enhance data quality of vital records Geo-coding of birth and death records

III. Environmental Public Health Tracking: III. Environmental Public Health Tracking: What have we accomplished to date? What have we accomplished to date?

Density of Tier-Classified 21e Sites with Lupus-Density of Tier-Classified 21e Sites with Lupus-Suspected Chemicals and Neighborhoods with the Suspected Chemicals and Neighborhoods with the

Highest Rates of LupusHighest Rates of Lupus

Asthma Prevalence in Massachusetts Schools with Moisture/Mold ProblemsAsthma Prevalence in Massachusetts Schools with Moisture/Mold Problems11

2003/2004 - 2005/2006 School Years2003/2004 - 2005/2006 School Years

Prevalence2

Asthma Prevalence Low0% - 8%

Moderate8.1% - 12%

High12.1% - 22%

Total

# % # % # %

Schools with moisture/mold problems1

20 51.3 32 74.4 19 90.5 71

Schools without moisture/mold problems

19 48.7 11 25.6 2 9.5 32

Total3 39 100.0 43 100.0 21 100.0 103

Chi square 10.8p value < 0.01

1 Schools with moisture/mold problems are those where at least one classroom or library had water damaged ceiling tiles or carpet or visible mold growth on ceiling or carpet.

2 Prevalence of asthma in a school represents the prevalence during the school year during which the IAQ was assessed.

3 Excludes 5 schools that did not report prevalence data.

Several epidemiological studies have shown increased risk of impaired fetal growth associated with exposures to disinfection byproducts (e.g., Bove et al. 1995, 2002 ; Infante-Rivard 2004; Savitz et al. 2005)

Third trimester of pregnancy: time during which fetal growth and birth weight may be most sensitive to environmental exposure opportunities (Kline et al. 1989)

Scientific Purpose in Linking Birth Outcomes and DBPs in Drinking Water

Variables Available for Linkage

Environmental Data• Water Quality Data

Health Data• Low Birth Weight Data

Linkage Variables - Environmental Data

Drinking water quality data from municipal water supplies are housed in Massachusetts Department of Environmental Protection Water Quality System database

Water quality data from approximately 1988-present are computerized, with most complete data beginning in 1993 for public water supply (PWS) systems

This linkage project focused on total trihalomethane (TTHM) data

Linkage Variables - Health

Low birth weight data obtained from Massachusetts Registry of Vital Records and Statistics, housed in the Massachusetts Department of Public Health

Collect information on nearly 80,000 annual births in Massachusetts

Computerized since 1969 and available in Access database

Health Data

Low birth weight data

Low birth weight defined as infant weight of less than 2,500 grams at birth

Key variables readily available include date of birth, maternal address at birth, birth weight, gender, some maternal risk factor information (e.g., smoking status)

Linkage GoalsAssess low birth weight data in relation to nearest TTHM sampling location in community for possible relationships (i.e., greater occurrence of low birth weight babies in areas with higher TTHM levels)

Assign each live birth to nearest TTHM sampling location based on maternal address at birth

Assign TTHM level corresponding to the last trimester of pregnancy for each live birth

Calculate total low birth weight odds ratios according to TTHM exposure categories (≤ 40 ppb, >40-80 ppb, >80 ppb) across all communities

ResultsLinkage Analyses for Greater Boston Area

Communities served by the Massachusetts Water Resources Authority (MWRA), improves exposure assessment by relying on weekly, rather than quarterly, monitoring data (1999-2001). In addition, the water treatment regimens employed by the treatment system studies minimize the geographic variability of TTHMs

In addition to third trimester risk estimates typically derived in such studies, first, second and full pregnancy estimates were also calculated

Term Low Birth Weight & ExposureTerm Low Birth Weight & Exposure(all races N=780)(all races N=780)

Exposure 1st Trimester 2nd Trimester 3rd Trimester

< 40 1.00 1.00 1.00

40 to <50 0.87 (0.72, 1.05) 1.04 (0.84, 1.29) 1.05 (0.79, 1.39)

50 to <60 0.90 (0.73, 1.11) 1.12 (0.92, 1.49) 0.84 (0.63, 1.11)

60 to 70+ 0.92 (0.73, 1.15) 1.17 (0.92, 1.49) 0.89 (0.66, 1.19)

70+ 0.87 (0.67, 1.13) 1.31 (1.06, 1.66) 0.96 (0.70, 1.32)

Using logistic regression, a statistically significant increased risk for TLBW was found among those with high (70+ ug/L) TTHM exposure.

Using logistic regression and adjusting for potential confounding factors, a statistically significant risk for term low birth weight was found among those with high (70+ ppb) TTHM exposure

To account for the potential impact of geographic variation in TTHM, a crude sensitivity analysis was conducted

Using existing exposure values assigned to each mother, the values were weighted on the basis of TTHM data from a single sampling site closest to the mother’s residence

This analysis raised the possibility that some unaccounted for geographic variation in TTHM data could lead to different exposure results and thus different overall results

Results, cont.

IV. Linking Childhood Cancer & Birth Outcome IV. Linking Childhood Cancer & Birth Outcome Data with Municipal Water Supply DataData with Municipal Water Supply Data

Overall Goal To assess opportunities for exposure to

VOCs during fetal development and the risk of childhood cancer

Linkage

Cancer registry records and Registry of Vital Statistics records are linked to identify the maternal residence at time of birth for childhood cancer cases

Linkage Files Registry of Vital Records

Child’s name* Child’s DOB* Child’s gender Maternal residence at birth

MA Cancer Registry Child’s name* Child’s DOB* Cancer diagnosis Date of Diagnosis

*Linkage Variables

Linkage Steps Records in Cancer Registry and Vitals Registry each have a separate ID

number

To maintain privacy of confidential cancer data, personal identifiers are not share with researcher

Using name and DOB, MDPH Privacy Officer matches Cancer Registry and Vitals Registry files, and assigns a unique Match ID number to matched records

Using the registry ID number and Match ID number, an analytic file is created that contains cancer type, DOB, and maternal residence (city/town, zip code) but not name

The analytic file is used by the researcher to assign exposure values and determine the risk of cancer while protecting privacy

V. SummaryV. Summary Public remains concern about health impacts and possible

environmental exposures

Use of vital records is often critical in responding to concerns

Linkage of existing data sets alone cannot answer complex environmental health questions

Data sharing agreements are important, but more important is the collaboration with data stewards and when possible the sharing of resources