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Volume XXlll, No.1 April 2009 The Independent Medical Business Newspaper O ver the last half-century we have witnessed a dramatic change in our nation’s health burden, from concern with infectious diseases such as pneumonia and tuberculosis, to treating and managing chronic conditions like asthma, heart disease, diabetes, and cancer. The last halfcentury has also spawned rapid advances in the development and production of tens of thousands of chemical compounds, many of which have made their way into our food, water, soil, air, and homes. And while the majority of Americans believe that exposure to environmental factors, such as pollution, causes increased rates of disease, evidence linking chemical exposures to disease is often lacking. Environmental health tracking and biomonitoring are two tools that can help us bridge this gap in the evidence, and help shed light on the relationships between exposure to environmental hazards and health outcomes. Minnesota’s Environmental Public Health Tracking Here, as in other states, existing data on environmental hazards, exposures to chemicals, and health Environmental health tracking Bridging the gap between environmental factors and disease By Michonne Bertrand, MPH outcomes have never been accessible in one place and systematically monitored. Instead, data are collected across many programs, for various purposes, and are housed separately. The newly developed Minnesota Environmental Public Health Tracking (MN EPHT) system at the Minnesota Department of Health (MDH) represents a systematic approach to gathering and integrating environmental and health data. MN EPHT collects relevant information from disparate sources—focusing on the factors that have the greatest probability of affecting public health— analyzes it, and makes it available to those who can act to prevent or control disease. MN EPHT data will be analyzed to recognize trends over time and geographic patterns, to identify disparities in exposures and health status, and to determine opportunities for research and public health action. MN EPHT includes three types of data: • Environmental hazard data indicate the potential for people to be exposed to an environmental contaminant or hazardous condition. These data include information on water and air quality. • Exposure data indicate the presence of environmental contaminants in the body. An example of exposure data is the level of lead measured in children’s blood by clinicians around the state. • Health outcomes data indicate the occurrence of diseases or health conditions that are known or suspected to be linked to exposure to environmental hazards. MN EPHT health outcomes data include information on hospital visits for respiratory disease and heart attacks; specific cancers that are thought to be linked to environmental factors; carbon monoxide poisonings; birth defects; and birth outcomes such as low birth weight, preterm births, and mortality. As other priorities are identified, additional data will be analyzed. Some of the priorities currently being explored are mortality due to cardiovascular and respiratory disease; indicators of climate change; and pesticide poisonings. As with any data surveillance system, the ultimate goal of MN EPHT is to drive public health action and policy. In order to reach this goal, MN EPHT data must be accessible and understandable to a wide audience of stakeholders. The data will be released in a variety of ways in the coming months. MDH will release the first environmental public health tracking data report this spring. The report will include a summary of the environmental public health tracking data measures that are currently available, as well as a description of the limitations of the data and recommendations for improving the data. MDH is also in the process of developing a Web-based data access portal for MN EPHT. This por- The publisher’s sale of this reprint does not constitute or imply any endorsement or sponsorship of any project, service, company or organization. Minnesota Physician Reprints (612-728-8600) • 2812 East 26th Street, Mpls., MN 55406. Do not edit or alter reprints. Reproductions not permitted. tal will provide current, accurate information to help inform individual decisions as well as public policy to prevent disease and promote health. The first stage of portal development will be a public portal for Web-based queries of MN EPHT data; this public portal will be launched this year. Eventually MN EPHT hopes to develop a secure data portal in addition to the public portal; the secure portal would grant data access to specific approved users, such as local public health agencies and health researchers. Specific processes for authenticating and authorizing access to a secure portal will be developed to ensure that data are secure. Biomonitoring pilot program Another tool that has the potential to shed light on the links between environmental chemicals and disease is biomonitoring. Biomonitoring is the direct measurement of chemicals in people’s bodies—in their blood, urine, or some other body fluid or tissue. Depending on how it is conducted, biomonitoring can be used to identify populations that are most at risk for exposure, to track changes in exposure over time, and to help target programs and interventions to reduce exposures. MDH is currently implementing three biomonitoring projects as part of a pilot biomonitoring program: • The Minneapolis Children’s Arsenic Study is measuring exposure to arsenic in children living in specified neighborhoods in south Minneapolis where elevated levels of arsenic were detected in the soil. Total arsenic levels are being measured in the children’s Resources For more information about environmental health tracking and biomonitoring, please visit: • The Environmental Health Tracking and Biomonitoring programs at the Minnesota Department of Health (established by the Legislature in 2007): www.health.state.mn.us/tracking. • National Environmental Public Health Tracking Network: www.cdc.gov/nceh/tracking. • National Biomonitoring Program: www.cdc.gov/biomonitoring. urine; if the total arsenic level is above 15 ug/L, the urine sample is further analyzed to determine how much of the arsenic is organic (generally a safe form of arsenic) and how much is inorganic (a potentially harmful form of arsenic). The study will help determine whether children living in the community as a whole have elevated levels of arsenic when compared to the level considered “normal” from a health viewpoint and when compared to average levels found in the U.S. population. Results will be released this year. • The East Metro PFC Biomonitoring Study is measuring exposure to PFCs (perfluorocarbons) in adults living in two communities in Washington County, where the drinking water was found to be contaminated with PFCs. The two communities are defined not by geographic boundaries, but by their drinking water source. The first community is defined as households that are served by the Oakdale municipal water supply. The second community is households with private wells contaminated with PFCs in Lake Elmo and Cottage Grove. The levels of seven PFCs—the same PFCs that were measured in the drinking water in the east metro area—are being measured in blood serum. The study will help determine whether the community as a whole has elevated levels of PFCs in comparison to the national average, when available. Study results will be released this year. • The Lake Superior Mercury Biomonitoring Study is being conducted at MDH in collaboration with state newborn screening programs in Wisconsin and Michigan and is funded primarily by the U.S. Environmental Protection Agency. Mercury is being measured in newborn dried blood spots. The mercury in the newborns’ blood indicates the mothers’ exposure to mercury while the baby was in utero. It is anticipated that study results will be released in 2010. MDH staff are working with physicians in each of the project communities to ensure that medical providers have the necessary resources for providing study participants and other community members with appropriate follow-up care and counseling. One of the challenges of the science of biomonitoring is that the ability to measure chemicals in people’s bodies has far outpaced the ability to explain what the presence of those chemicals means for people’s health. For many chemicals, little is known about potential health effects in humans and the levels in the body that are considered safe or unsafe. As pilot projects, these biomonitoring studies are limited in scope. The biomonitoring projects will determine the ranges in the levels of selected chemicals in the study communities and are not designed to determine the ways people are exposed to the chemicals or the health effects associated with exposure to the chemicals. However, in making recommendations for designing an ongoing biomonitoring program, MDH will consider how biomonitoring data could be used in the future to support research to help us better understand health outcomes and exposure pathways. Environmental health data in action Community members have many concerns about the ways that the environment around them might be affecting their health. Given the current gaps in the data about the environment and health, physicians may find themselves without answers to patients’ questions. As time goes on, data from the environmental public health tracking and biomonitoring programs in Minnesota—and from similar programs in other states and at the national level— will provide insights into noninfectious diseases. As we learn more about the role of the environment in contributing to the occurrence of disease, physicians will be better able to help their patients understand and make informed choices to reduce exposures to chemicals and potentially prevent disease. Michonne Bertrand, MPH, is coordinator of the Environmental Public Health Tracking and Biomonitoring program at the Minnesota Department of Health.