01-ENV-02 Committee: Environmental/Occupational Title: Development of Environmental Public Health Indicators Statement of the problem: In the last several years there has been increasing interest in the development of public health indicators for use by state and federal health agencies in tracking the occurrence of environmental hazards, exposures and adverse health outcomes. This interest has been stimulated by the recognition that there were critical gaps in our knowledge of the occurrence patterns of a large number of non-communicable diseases. A series of reports published by the National Academies (IOM, 1988; NRC, 1997,1999) provided recommendations and guidance for health agencies on how these knowledge gaps might be narrowed.  For the past several years CSTE has supported efforts to develop indicators for chronic diseases (Lengerich, 1999). By using the chronic disease indicators, CSTE believes states can bring consistency to their temporal analyses and comparisons between populations, and have data for use as benchmarks in chronic disease program assessment. More recently, CSTE has collaborated with the State and Territorial Injury Prevention Directors’ Association to develop a set of injury indicators.  During 2000, CSTE, CDC, ATSDR and EPA have collaborated on the development of a set of environmental public health indicators, or EPHI. The goal of the EPHI project is to develop a set of indicators that can be used by local, state and national agencies to track hazards, exposures, and adverse health events related to the environment. In addition to state and federal agencies, several organizations have participated in EPHI development: the Association of State and Territorial Health Officials (ASTHO), the National Association of City and County Health Officials (NACCHO), and the Public Health Foundation (PHF).  In late 2000 the Pew Environmental Health Commission proposed a Nationwide Health Tracking Network, which could identify occurrence patterns of chronic diseases related to environmental factors. They recommended:  “… nationwide baseline tracking of priority chronic diseases–asthma and chronic respiratory diseases; birth defects; developmental disorders; cancers; neurological diseases–and priority exposures, such as PCBs, and dioxin; heavy metals; pesticides and water and air contaminants.” (Pew, 2000) The candidate environmental public health indicators listed here should be used as a major part of the foundation of such a tracking program.  Statement of desired action(s) to be taken: CSTE supports and encourages the use of Environmental Public Health Indicators, developed in collaboration with CDC’s National Center for Environmental Health, for building state-based surveillance programs for environmental hazards, exposures, and adverse health outcomes. In support of this position statement is a list of proposed core and optional environmental public health indicators, along with background information for each indicator. The indicator list was developed to be consistent with CSTE efforts in chronic disease and injury indicators Summary of proposed core environmental public health indicators: Hazard Indicators (presence of contaminants or hazardous conditions) · Level of criteria pollutants in ambient air  · Amount of hazardous and toxic chemicals released in ambient air · Proximity of population to areas not meeting ambient air quality standards · Vehicle miles driven · Noise complaints  · Amount of pesticide used · Pattern of pesticide use · Level of residual pesticide in food · Chemical spills · Degree to which recreational waters meet water quality regulations or guidelines · Level of monitored contaminants in ambient water · Point-source discharges into ambient water · Level of contaminants in shellfish and sport and commercial fish · Degree to which drinking water systems comply with regulations or guidelines · Level of monitored contaminants in drinking water Exposure Indicator (presence of biomarkers of exposure) · Elevated blood lead level (in children) Health Effect Indicators (occurrence of morbidity or mortality attributed to exposure) · Carbon Monoxide (CO) poisoning deaths · Temperature-attributed deaths  · Hearing loss · Pesticide-related poisoning and illness · Unusual pattern of acute asthma events · Unusual pattern of cardiovascular and respiratory events (with environmental contribution) · Methemoglobinemia · Melanoma · Outbreaks attributed to consumption of ambient water contaminants · Outbreaks attributed to consumption of contaminated shellfish or sport and commercial fish · Outbreaks attributed to contaminated drinking water Intervention Indicators (implementation of programs or official policies addressing environmental hazards) · Implementation of programs that address motor vehicle emissions  · Level of alternative fuel use in registered vehicles · Availability of mass transit · Schools with indoor air policies that address environmental hazards  · Jurisdictions with laws pertaining to smoke-free indoor air · Complaint-related indoor air inspections · Jurisdictions with emergency preparedness training programs, plans, and protocols · Jurisdictions that conduct annual multi-institutional exercises to prepare for response to disasters · Employee compliance with pesticide-related training standards · Fish or seafood consumption advisories  · Activity restrictions (health-related) in ambient water · Implementation of sanitary surveys · Degree to which drinking water systems meet operational and maintenance standards · Boil-water advisories  Coordination: Agencies for Response: Richard J. Jackson, MD Director Centers for Disease Control and Prevention National Center for Environmental Health Mailstop: F29 4770 Buford Hwy, NE Atlanta, GA 30341 Henry Falk Assistant Administrator Agency for Toxic Substances and Disease Registry Mailstop: E 28 1600 Clifton Road, NE Atlanta, GA 30333 Kathleen Rest Acting Director CDC National Institute for Occupational Safety and Health 200 Independence Ave., SW Washington, DC 20201 Christie Whitman,  Administrator Environmental Protection Agency 1200 Pennsylvania Ave., NW Washington, DC 20460 George E. Hardy, MD, MPH Executive Director Association of State and Territorial Health Officials  1275 K. Street, NW Suite 800 Washington, DC 20005 Agencies for information: Robert E Roberts Executive Director Environmental Council of States 444 N Capitol St. NW Suite 445 Washington, DC 20001 Tom Milne Executive Director National Association of City and County Health Officials 1100 17th Street, 2nd Floor Washington, DC 20036 Ronald Bialek, M.P.P. President Public Health Foundation 1200 L Street, N.W. Suite 350 Washington, DC 20005 Dr. Smoak Director American Medical Association 515 N State Street Chicago, Illinois 60610 Mohammad Akhter Executive Director American Public Health Association 800 I. Street N.W. Washington, DC 2001 Nelson Fabian Director National Environmental Health Association 720-S. Colorado Blvd. Suite 970-S Denver, CO 80246 Occupational Safety & Health Administration US Department of Labor 200 Constitution Avenue, N.W. Washington, D.C. 20210 Author: Henry Anderson, MD Bureau of Public Health Wisconsin Division of Health One West Wilson Street Madison WI 53701 Phone: 608-266-1253 Fax: 608-266- E-mail: anderha@dhfs.state.wi.us References: Institute of Medicine. The Future of Public Health, National Academy Press, Washington, DC, 1988. Lengerich, EJ (ed.). Indicators for Chronic Disease Surveillance: Consensus of CSTE, ASTCDPD, and CDC. Atlanta, GA: Council of State and Territorial Epidemiologists, November 1999.  National Research Council. Assessment of performance measures in public health, substance abuse, and mental health. National Academy Press, Washington, DC, 1997. National Research Council. Health performance measurement in the public sector: Principles and policies for implementing an information network. National Academy Press, Washington, DC, 1999. Pew Environmental Health Commission. America’s environmental health gap: Why the country needs a nationwide health tracking network. Baltimore, MD, 2000. http://pewenvirohealth.jhsph.edu/html/reports/pewtrackingtechnical.pdf State and Territorial Injury Prevention Directors’ Association. Consensus Recommendations for Injury Surveillance in State Health Departments. Marietta, GA. 1999. Attachment: Environmental Public Health Indicators, May 2001