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Success Stories - Improving Surveillance


Colorado - Improved Data Quality

What is the problem?

Hospital discharge data are critical to monitoring community health problems. In Colorado, the geographic location of patient hospital stays, documenting where the patient lives, is missing up to one-third of the time. This limits practitioners' and researchers' ability to assess community health outcomes. They need to know whether these outcomes might be related to environmental factors.

What did Tracking do?

In partnership with the Colorado Health and Hospital Association, the Colorado Department of Public Health and Environment has geocoded hospital discharge records from 2004 to the present. Geocodes assign a precise residence geography to at least 95% of the records.

Improved public health

Practitioners and researchers will be able to evaluate more effectively the relationship between environmental hazards or exposures and hospital stays. For example, practitioners and researchers will be able to assess the proximity and concentration of air pollutants and an excess number of hospital stays related to asthma.





Colorado - Using environmental health indicators for assessment and planning

Colorado Environmental Tracking Program Logo

What is the problem?

The legislatively mandated Colorado Public Health Improvement Plan of 2009 calls for a comprehensive set of public health indicators. These include environmental health indicators to be used in assessment and planning. Colorado does not currently have the ability to track environmental health indicators. Thus, those indicators are not included in community health assessment or in state or local-level planning. Developing Colorado environmental health indicators would meet state requirements and would help local health agencies move towards national accreditation.

What did Tracking do?

The tracking network provides the framework Colorado needs to track environmental health indicators. A group consisting of Colorado Environmental Public Health Tracking staff and members of Colorado Tracking's Technical Advisory Committee has discussed, developed, and prioritized environmental indicators for Colorado. The group used Nationally Consistent Data and Measures where appropriate. The group will also develop Colorado-specific indicators such as radon and private well water. Through Colorado's Tracking Web site, state and local health agencies will be able to query environmental health indicator data.

Improved public health

State and local public health agencies will use the new environmental health indicator data in assessments and planning to identify priorities for policies and programs throughout the state. This will help improve environmental quality and lower risk of exposure to environmental hazards. Leveraging the legislative mandate and the environmental public health tracking grantensures the development and use of a robust surveillance system for the state of Colorado and supports the goal of improving the health of Colorado residents.




Florida - Asthma and Outdoor Air Quality

Florida Environmental Tracking Program Logo

What is the problem?

Asthma is an ongoing public health concern in Florida. In 2006, more than 27,000 Florida hospital stays were due to asthma. The average asthma hospital patient was 42 years old, with an average stay of 3 days.

What did Tracking do?

The Florida Tracking Program linked Florida Department of Environmental Protection outdoor air quality data with Agency for Health Care Administration asthma hospital data. Tracking staff developed county-level maps showing the prevalence of asthma across the state. Tracking staff found that during certain times of the year, the link increased between asthma rates and outdoor air quality. That said, only more work will provide a complete picture of Florida's asthma problem.

Improved public health

The Tracking Program used this project as an opportunity to improve agency teamwork and surveillance ability. The Program works with the University of Florida and NASA to assess the effects of wildfires on asthma hospital stays. The hypothesis is that asthma hospital visits increase during years in which wildfires are endemic. During such events, timely wildfire notices and air quality messages may reduce the asthma burden. And the ultimate objective, pursued jointly with Florida's new Asthma Control Program, is to reduce the state's asthma burden.





Florida - Birth defects monitoring system

What is the problem?

Birth defects are a major cause of death and disease in Florida's children. Birth defects can also contribute substantially to long-term disability. In 2007, more than 9,000 Florida infants were born with major structural or genetic birth defects. The causes of most birth defects are unknown. The possible association between birth defects and environmental contamination is a real concern in Florida.

What did Tracking do?

The Florida Tracking Program, Florida Birth Defects Registry, and the University of South Florida developed a surveillance system to improve identifying cases and confirming diagnoses for the 12 birth defects in the Florida Tracking Network:

  • Anencephaly
  • Spina Bifida without anencephaly
  • Hypolastic left heart syndrome
  • Teratology of Fallot
  • Transposition of the great vessels
  • Cleft lip with cleft palate
  • Cleft lip without cleft palate
  • Cleft palate without cleft lip
  • Hypospadius
  • Gastroschisis
  • Reduction deformities of the upper/lower limbs
  • Down Syndrome

Improved public health

The Florida Tracking Program Active Surveillance Project has developed an improved system for monitoring birth defects. This system has helped identify higher rates of serious birth defects of the brain and spine in Puerto Rican women in Florida. These data will assist in developing prevention activities to educate these women about the health benefits of folic acid, a B vitamin that can help prevent such defects. The Florida Birth Defects Registry also uses birth defect data collected through enhanced surveillance to develop county risk profiles for selected conditions.




Maryland - Answering community concerns about cancer

Maryland Environmental Tracking Program Logo

What is the problem?

Community concerns about cancer and potential links to environmental hazards occur relatively frequently in Maryland. Before the Maryland Tracking Program began in 2002, most concerns about cancer and the environment were addressed only by the Maryland Cancer Registry and possibly local health departments. Maryland had no systematic way to respond to frequently asked questions from individuals, groups, and communities about cancer and the environment.

What did Tracking do?

The Tracking Program, working with the Maryland Cancer Registry, geocoded all residential addresses in the Registry. Now the Maryland Cancer Registry can accurately show cancer data in maps and carry out geospatial analyses of cancer information. Also, for the first time, there is an established process for evaluation of cancer concerns in Maryland. The new process involves a coordinated response that includes the Maryland Cancer Registry, the Center for Environmental Health Coordination, the Maryland Department of the Environment (MDE), and local health departments and is now available on the Tracking Program's Web site.

Improved public health

The Tracking Program has worked with the Maryland Cancer Registry on two major cancer investigations, one in Poolesville and another in Frederick. The first looked at concerns about cancer and drinking water; the second involved concerns about cancer in a community. In both cases, the Maryland Tracking Program provided maps showing the geographic distribution of cancer and geo-statistical analyses of the cancer cases. The results of these two investigations were presented at community meetings. To date, there is no evidence of cancer clusters, but experts were able to answer questions from community residents.





Maryland - Improving drinking water quality data in private water wells

What is the problem?

About 16% of Marylanders depend on owner-drilled private water wells for drinking water. Private wells can become contaminated with both manmade and naturally occurring hazards. In many cases the private water wells are tested less frequently than public water sources, and the results from private wells are not added to easily accessible water quality data sources. Private well water data are reported to local health departments only when wells are first drilled, when the property is sold, or when home/property improvements are made. Private well water data are usually kept in local health departments and are not easily and quickly available to state environmental public health officials.

What did Tracking do?

The Maryland Tracking Program collaborated with other environmental public health partners in the state to develop a new way for local health departments to upload water quality data on private water wells to a database located at the MDE. Tracking also developed computer software that now makes it possible to store private well water data in the MDE database and then transfer data electronically to the Tracking Program's secure portal.

Improved public health

Having private well water data in one location will help environmental public health officials to better understand water quality in private wells used for drinking water. The data can now be seen using simple-to-use but sophisticated data selection, analysis and display tools such as building data queries or map displays. This could aid responses to drinking water-related inquiries and help inform future decision making. Another benefit is improved efficiency; in response to questions or concerns about this water source, environmental public health officials seeking private well data will be able to save time by both viewing and analyzing these data on the Maryland Tracking Network.





Maryland - Tracking air pollution and asthma

What is the problem?

In 2007, an estimated 550,000 (12.9%) Maryland adults and 190,000 (13.6%) children reported a lifetime history of asthma. In addition, about 43,000 Maryland residents were treated for asthma in emergency departments, and nearly 9,800 persons were hospitalized for asthma. Fine particulate matter, also known as PM2.5, which comes from vehicles, power plants and wildfires as well as other sources, can go deep in the lungs of adults and children, and can contribute to asthma attacks and more asthma emergency department visits and hospital stays.

What did Tracking do?

The Maryland Tracking Program used asthma emergency room visit and hospital discharge data from the health department and air data from the MDE and the Environmental Protection Agency (EPA) to carry out an EPA- funded project, to examine the relationship between asthma rates and fine particulate levels in and around Baltimore.

Improved public health

This data linkage project, which used 2005-2006 data, found that asthma emergency department visits and inpatient hospital stays went up on days when on-the-ground air monitors recorded more PM2.5 in the air. Local public health officials from Baltimore and nearby communities can use these results to determine if local policies that regulate PM2.5 sources should be re-evaluated and perhaps modified.




Minnesota - Tracking the impact of a statewide carbon monoxide (CO) alarm law

Minnesota Environmental Tracking Program Logo

What is the problem?

Each year, accidental CO poisonings result in several deaths and hospitalizations in Minnesota. The highest number of CO poisonings occurs during the winter months. Minnesota took an important step to prevent CO poisonings when the state passed a law that requires CO alarms in all single-family homes and multi-dwelling units. The law was put into effect from 2007 to 2009. However, with no system to track CO poisonings, the Minnesota Department of Health could not know whether the law helped lower the number of CO poisonings in the state.

What did Tracking do?

Minnesota's Tracking Program worked with the National Tracking Network to gather data and create ways to measure CO poisonings in the state. The programs put this information into a tracking report that local newspapers used to inform readers about CO poisoning prevention. Minnesota's Tracking Program and the state Behavioral Risk Factor Surveillance System (BRFSS) are working together to collect data on the number of Minnesota homes that have CO alarms. Using data from years before and after the CO alarm law, the tracking program can follow changes in the use of CO alarms and the impact on CO poisonings and exposures.

Improved public health

The CO alarm law and the system for tracking CO poisonings are examples of the way tracking data can have an effect on state and local policy. Minnesota state and local health agencies will use CO tracking and BRFSS data to measure the effectiveness of the state CO alarm law. Indoor air and healthy homes programs will also use tracking data to determine the effectiveness of activities to improve public health.




Minnesota - Understanding the relationship between climate change and public health

What is the problem?

The global climate is changing, causing rising temperatures, melting ice and snow, rising sea levels, and climate uncertainty. However, it is hard to measure the changes in climate regionally and locally. State and local health departments need help to understand climate change better and prepare for its possible health impacts.

Minnesota is in a unique geographic position at the transition between the eastern forests and drier Great Plains. In this region, diseases carried by ticks and other insects or animals are common and influenced by changes in temperature and humidity. Minnesota is also located in a region where people are likely to suffer more from extreme heat.

What did Tracking do?

Minnesota's tracking staff worked with CDC and other states in the National Tracking Network to gather data about and find ways to measure illnesses and deaths caused by heat. Minnesota's Tracking Program is using data from hospital stays and death certificates to track health outcomes of extreme heat, such as deaths, heat exhaustion, and heat stroke.

Improved public health

Minnesota's Tracking Program is working with state and local health programs to help them to prepare for the health effects of climate change using climate and health data along with sound science. Data provided by Minnesota's climate change tracking program will help public health officials to develop effective strategies to prepare for the health effects of climate change.




New Jersey - Helping to reduce the number of children that are exposed to lead

New Jersey Environmental Tracking Program Logo

What is the problem?

Childhood lead poisoning is a problem in New Jersey, mainly because of exposure to lead-based paint. Before 1950, indoor paint had high levels of lead. In New Jersey, about 30% of housing was built before 1950. In several counties, 40–50% of the housing was built before 1950. These homes pose the highest risks for exposure to lead-based paints.

What did Tracking do?

Through a partnership with the New Jersey Tracking Network, the New Jersey Child and Adolescent Health Program now conducts more sophisticated data analyses than were previously available. Geocoding and mapping of childhood lead datasets has become routine. Childhood lead poisoning rates are now available by county, municipality, year of birth, and calendar year of lead testing. This has helped public health officials target resources where they are most needed.

Improved public health

The number of New Jersey children under age 17 who have been reported with childhood lead poisoning (greater or equal to 10 ug/dL) has decreased from 4,048 in 2005 to 1,358 in 2010. This is a 66% decrease. In the future, the New Jersey Department of Health and Senior Services (NJDHSS) will begin to look at the distribution of blood lead levels below 10 ug/dL. This will help to continue the decrease in lead exposure among New Jersey's children.




New Jersey - Improving the ability to share environmental information between state agencies

What is the problem?

Creating environmental datasets for public health purposes and sharing them between state agencies can be expensive, difficult, and slow. The New Jersey Department of Environmental Protection (NJDEP) wanted a secure and easy way to share numerous environmental datasets with the New Jersey Department of Health and Senior Services (NJDHSS) on an ongoing basis.

What did Tracking do?

NJDEP Tracking partners worked with other Tracking states and the U.S. Environmental Protection Agency (USEPA) to design and build improvements to an existing national environmental network. The National Environmental Information Exchange Network (EN) fit their needs. EN enhancements have now made the environmental datasets more useful for public health tracking. They have expanded the information available for tracking use. These improvements allow Tracking partners in all states to share meaningful environmental data between state agencies, which was difficult to do previously.

Improved public health

The New Jersey Tracking Program now uses the EN to obtain environmental datasets. NJSHAD now analyzes and publishes these as drinking water and air quality indicators. Because of New Jersey's leadership, interagency environmental data sharing improved not only in New Jersey, but in all Tracking states. U.S. EPA is now working to make the expanded EN air monitoring and drinking water data exchange the national standard for state environmental protection agencies.





New Jersey - Providing information on disease rates to advocacy organizations, health planners, health care providers, and governmental agencies

What is the problem?

Organizations and agencies have ongoing needs for accurate timely health outcome data for the regions and populations they serve. It can be difficult to find and obtain health related data, especially data for a particular community.

What did Tracking do?

NJSHAD has become a one-stop New Jersey public health resource. Advocates for Children of New Jersey said, "we use SHAD Query to get a lot of the health related data we need, such as statistics on low infant birth weight and infant mortality. SHAD is self explanatory, and has both county and municipal level data, and you can get data by race and age-group." A consultant to New Jersey's Federally Qualified Health Centers said, "when you need to make a compelling case to document unmet needs, the data is specific and available. That can be important in a place like New Jersey, where there are huge health disparities by race, ethnicity, or education level."

Improved public health

NJ SHAD data has already made a difference. When Advocates for Children of New Jersey published NJ SHAD data as part of their annual NJ Kids Count 2010 County Profile Rankings, a low ranked county in southern New Jersey was surprised by some of their numbers. The county has responded by creating a workgroup to track and improve their county's health statistics. As stated by Advocates for Children of New Jersey, "when numbers are put in a book, you can't ignore them."




New Hampshire - Improving melanoma reporting measures

New Hampshire Environmental Tracking Program Logo

What is the problem?

In the U.S., melanoma rates have tripled over the past two decades. In New Hampshire, the rates have also gone up and appear to be higher than the national rate. Melanoma is a form of skin cancer. It is often linked to ultraviolet radiation (UV) from the sun and tanning equipment. Many New Hampshire public health officials are concerned about the growing number of melanoma cases. As a result, they asked the NH Tracking Program for a review of the data to see if it was correct. They also wanted to identify people who are most at risk.

What did Tracking do?

The New Hampshire Tracking Network staff worked with the New Hampshire Cancer Registry to review state and national melanoma data. The review found melanoma cases were underreported in the past. The use of incorrect data may have caused the melanoma rates to seem higher. Researchers did find that young women in New Hampshire have a 38% higher rate of melanoma than other groups nationwide.

Improved public health

The New Hampshire Tracking Network published the findings in an issue brief. Public health education meetings were also held with state health officers and other interested groups about the rise in melanoma cases. The New Hampshire Tracking Network published articles in state print media to promote melanoma awareness, with an emphasis on UV exposure reduction, especially for at-risk populations such as young women and elderly men.




New York - Tracking carbon monoxide risk factors to prevent poisonings

New York Environmental Tracking Program Logo

What is the problem?

Many New Yorkers use portable generators when the power goes out. Generator use increases the risk of carbon monoxide (CO) poisoning. Little information is available about how many households use portable generators during power outages. Also, the number of households that have properly installed and maintained CO alarms is unknown.

What did Tracking do?

To learn more about portable generator and CO alarm use, New York State's Tracking Program added questions to the 2008 New York State Behavioral Risk Factor Surveillance System survey. The Tracking Program collected and analyzed survey results that showed nearly 20% of state residents and more than 33% of residents living outside major cities had a portable generator. Almost 30% of all residents did not have a CO alarm in their homes.

Improved public health

The state department of health used the tracking program information to identify areas most at risk for CO poisoning. The state worked with local health departments and other partners to distribute generator safety posters and CO poisoning-prevention door hangers to area residents. The survey data will track the success of the generator campaign. The data will also show whether people follow the 2009 state law mandating CO alarms in all homes.





New York - Providing neighborhood-level cancer data

What is the problem?

New York residents would like to see maps showing new cancer cases in their neighborhoods. The state has long struggled with how to respond to this need, which requires sharing detailed data while protecting patient identity.

What did Tracking do?

New York State's Tracking Program worked with partners to develop the Environmental Facilities and Cancer Mapping application. It contains maps that show the number of cancer cases and locations of environmental facilities at the census block level. Users can search for data on 23 types of cancer and see locations of 15 types of environmental facilities.

Because showing data at the block level could risk patients' privacy, the Tracking Program developed the Geographic Aggregation Tool to group blocks with few cases. This reduces the likelihood of identifying specific people.

Improved public health

With these tools, health departments can respond more quickly and easily able to information requests. The public can also use this information to better understand cancer in their neighborhoods. Before the Tracking Program, this level of cancer information was not available to the public.





New York - Assisting with public health investigations

What is the problem?

A citizen asked the health department to look into respiratory disease in communities near an upstate New York coal-fired power plant. Getting, processing, and evaluating the necessary data can take a long time. Community members often want this information quickly.

What did Tracking do?

Using data gathered through the state Tracking Program, the health department quickly was able to find the rates of hospital stays for asthma and other respiratory diseases in areas downwind of the power plant. The results showed fewer than expected hospital stays for asthma, bronchitis, and chronic obstructive pulmonary disease.

Improved public health

The Tracking Program data on respiratory-related hospital stays were readily available. The health department investigated respiratory disease in the area and efficiently and quickly provided findings to local residents and to the media.




Pennsylvania - Arsenic concentrations in groundwater

Pennsylvania Environmental Tracking Program Logo

What is the problem?

Pennsylvania has a large rural population dependent on private wells for drinking water. Some of these wells pull groundwater that contains high levels of arsenic. Several studies have suggested that long-term exposure to arsenic contamination in groundwater increases the risk of developing bladder, kidney, liver, bronchus and lung, and prostate cancer.

What did Tracking do?

In order to better evaluate distribution of arsenic in the state's ground water, USGS, Pennsylvania Department of Health, and Pennsylvania Department of Environmental Protection began surveillance in 2005 to relate arsenic concentrations in major aquifers. Aquifers are a formation, group of formations, or part of a formation that contains sufficient saturated, permeable material to yield significant quantities of water to wells and springs. Of 169 domestic wells and springs tested, arsenic was detected in 18. Of these, 10 wells had total arsenic levels greater than the U.S. Environmental Protection Agency (EPA) maximum containment level.

Improved public health

Pennsylvania's Tracking Program counseled families in high risk areas to use bottled water and referred one person to a doctor because of extremely high arsenic levels. Also, doctors were advised to provide arsenic tests to residents in areas where severely elevated arsenic concentrations had been identified.




Vermont - Understanding the geography of asthma

Vermont Environmental Tracking Program Logo

What is the problem?

Asthma affects about 11% of adults and 10% of children in Vermont. Some areas of the state have higher rates of hospital stays and emergency room visits due to asthma, but the reasons remain unknown. Rutland County has the highest hospital stays rate of all Vermont counties. The Department of Environmental Conservation's air monitoring data show that this county also has the most days per year of air pollution from fine particulate matter.

What did Tracking do?

Differences in hospitalization rates between geographic areas may result from local population characteristics. They also may be caused by local environmental exposures to fine particulate matter and ozone pollution or mold and allergens in older housing. The Vermont Tracking Program will partner with the department of health's CDC-funded Asthma Program to use tracking data to identify trends and patterns in asthma hospitalizations and emergency department visits. Better understanding of asthma triggers could lead to better ways to prevent asthma.

Improved public health

The Vermont Tracking Program plans to use this information to determine the most appropriate public health actions. These actions will lead to fewer hospitalizations and emergency department visits due to asthma.




Vermont - Improving cross-border public health investigations

What is the problem?

The New England states occupy a small area, and complex environmental issues and public health events often cross borders. One example of this is the tritium contaminated groundwater at Vermont Yankee Nuclear Power Station, which borders Massachusetts and New Hampshire. Coordination and data-sharing among public health, environmental, agriculture and emergency management agencies in-state and with bordering states was required to analyze risk and monitor the investigation and remediation.

What did Tracking do?

Sharing data across borders will help Vermont and neighboring states better analyze, interpret, and respond to public health hazards.

Improved public health

The Vermont Tracking Program will make data sharing easier both within the state and with neighboring states. It will also improve response time to public inquiries and help public health professionals use the best resources for public health actions.




Washington - Improved Public Health Surveillance and Action for Lead

Washington Environmental Tracking Program Logo

What is the problem?

An outdated, paper-based system made lead test reporting inefficient in Washington. State and local health agencies also had no way to share information about lead poisoning investigations in a secure, electronic environment. Using fax machines, paper and phones made ensuring the privacy of lab reports difficult and led to delays in case follow-up.

What did Tracking do?

The Washington Tracking Network improved the flow of environmental public health data by helping to build Washington's electronic lab reporting system: Public Health Reporting of Electronic Data (PHRED). PHRED makes it easier to handle public health reports like blood lead testing. Once agency workers receive data from PHRED, they can transfer reports of concern into the Public Health Issues Management System (PHIMS). Within hours, local health officials can access PHIMS and carry out their investigations.

Improved public health

Systems like PHRED and PHIMS make public health surveillance and response faster. Labs can now report electronic lead poisoning test results more efficiently and securely. The state Child Blood Lead Registry receives more standardized and complete test results. Local public health officials now are alerted quickly to possible lead poisoning cases, cutting delays and saving costs during case investigations. PHIMS provides state and local health agencies an easy, secure way to communicate about ongoing investigations, also providing technical assistance more quickly, maintaining privacy, and improving public health response and prevention.


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