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• Participants
• Session Summary
• Topline Notes

Objective: To provide all participants baseline knowledge of the current work being done in Environmental Public Health Tracking. Participants will hear and discuss Environmental Public Health Tracking (EPHT) activities provided from the perspectives of federal and state agencies, the community, national organizations, and academic Centers of Excellence. Day 1 information will service as raw material for more in-depth group discussion on Day 2.

Objective: To have open discussion and dialogue on EPHT activities that address the needs of all the stakeholders, including key information and data needs, areas for more intensive stakeholder involvement, and best methods for communicating to/with stakeholders. The discussion topics below are a general framework only; most discussion will happen in small groups with plenary debriefs.

Objective: To provide all participants baseline knowledge of the current work being done in environmental public health tracking (EPHT). Participants heard and discussed EPHT activities from the perspectives of federal and state agencies, the community, national organizations, and academic Centers of Excellence. Day 1 information served as raw material for more in-depth group discussion on Day 2.

• Presentations provided an overview of EPHT, ongoing tracking activities, and perspectives from partners in the process.
   
• Participants discussed data and the need for real data in decision-making from the perspective of policy, public health planning, environmental management, and the community.
   
• Speakers explained that EPHT is about more than information technology and surveillance. The speakers discussed the necessity for communication and for outreach and partnership. Paul English (CA DHS) touched on core components of the California EPHT Program, which also includes capacity building, exposure assessment, methods development, and policy development.
   
• Participants learned that needs are not all the same at the state, local, and national levels—a point emphasized by California’s survey—but overlap exists, as is evident both from the survey and the presentation by Jane Laping (MfCA).
   
• Tom Burke (JHU) noted that we have come a long way towards building a national EPHT network, but we still have a long way to go, and it’s not something that can happen overnight.
   
• The issue of sustainability was raised by the meeting participants. There were general concerns about sustaining funding and visibility for a program that will take a while to mature.
   
• Henry Falk (CDC) discussed the changes going on at CDC in terms of both structure and how we do business, with a more customer-centric and outcome-focused orientation. These points generated a lot of questions and discussion.
   
  • Participants expressed concern about what seems to be a focus on “hot issues” and about the “quick response” or short-term thinking coming out of CDC. Henry Falk noted that CDC’s goals development process will be data-driven, so CDC will not overlook key issues that are not “hot issues,” and short-term goals will be balanced with long-term goals. Regarding EPHT, Mike McGeehin (CDC) noted that we are not looking only at early success but at innovative approaches to long-term surveillance needs.
     
  • Claire Barnett (HSN) raised the issue of meeting the need for better data on school health and the school environment.
     
  • Michael Heumann (CSTE) noted that traditionally, states were partners with CDC, and asked what the shift to a customer orientation and the increased emphasis on research really mean. Henry Falk noted that CDC wants to expand its work with others and improve the way we do business with states… neither the customer-centric approach nor the increase in research will diminish the CDC/state relationships.
     
  • Participants closed the first discussion period with a dialogue about the need for involving the community in EPHT.
     
• Much of the discussion at the end of the day focused on the topic of biomonitoring.
   
  • Some of the issues raised addressed how we prioritize, how we keep up with the laboratory methods, whether biomonitoring will/can be done for all communities with concerns, what results mean—this last point specific to the finding of high levels of tungsten in persons from Fallon, NV—and nanoparticles research. Jim Pirkle (CDC) noted that at the national level, CDC’s Environmental Health Laboratory is setting priorities and will develop methods as much as they can as fast as they can. If there is a known exposure and a suspected health effect, the lab will conduct monitoring, and if a community concern is compelling, the lab will check it out. The lab does not work with nanoparticles. [Hal Zenick (EPA) noted that the NIOSH lab is doing some work in this area.] With reference to Fallon and tungsten, Mike McGeehin (CDC) noted that CDC did not find a clear link; however, we don’t know much about tungsten, and we need more information. The tungsten report is currently being reviewed by the National Toxicology Program.
     
  • Participants talked about biomonitoring and the capabilities of the CDC Environmental Health Laboratory; they did not touch on the needed capacity at the state laboratories.
     
  • Participants also discussed the desire for state-level Health and Nutrition Examination Surveys (HANES) and the fact that the national budget did not contain enough money for state-level surveys. New York City is moving forward on their own with community-level HANES.
     
• An important issue was raised by the participants (at the end of Tom Burke’s talk) about what all this means to communities. South Philly was given as an example, but the question is universal. If we find something is going on in a community, how does that translate into practical advice to community members and into actions to protect the health of communities?
   
• Janice Nolen (ALA) wanted to know more about where we are with national asthma surveillance efforts. Participants discussed the fact that the CDC EPHT program and asthma program were working together to improve state-based surveillance. Though EPHT started out with demonstration projects, CDC has not lost sight of the fact that we are building a nationwide system. The demonstration projects are providing the groundwork for how we implement a nationwide system—by building a system that provides not only national estimates but also state and local data.
   
• Janie Fields (CEHI) brought up the children’s longitudinal health study and concerns that funding this study will decrease funding for EPHT or other efforts. Participants agreed that better communications and outreach are needed for the various efforts— in terms of both how they complement each other and how they differ. Colleen Boyle (CDC) noted that CDC has been told that there will not be a trade-off, but we do need to be able to explain the differences.
   
• The final point of discussion was in regard to the need to bring HMOs or third-party payers to the table. Participants agreed on the importance of that point.

Objective: To have open discussion and dialogue on EPHT activities that address the needs of stakeholders, including key information and data needs, areas for more intensive stakeholder involvement, and best methods for communicating with stakeholders. The discussion topics below are a general framework only; most discussion will happen in small groups with plenary debriefs.

• Judy Qualters (CDC) provided a summary of the presentations and discussion from Day 1.
   
• The meeting participants divided into seven groups with each person within a group representing a different perspective, such as community, state, national, and local.
   
• The groups each had a facilitator walk them through three discussion sessions.
   
  • Group Session 1: Participants discussed thoughts about overall EPHT efforts, identified issues that are unclear, and identified areas of mutual interest and concern.
     
  • Group Session 2: Participants discussed expectations, information/data needs from EPHT, and major environmental public health issues that need to be addressed by EPHT.
     
  • Group Session 3: Participants shared best communication methods and channels for disseminating EPHT information. They also discussed how to get involved with new EPHT activities and suggested other partners to engage.
     
• After each session, each group shared a summary of its discussion. These summaries are captured in the Topline notes. (download a PDF of the Topline notes at http://www.cdc.gov/nceh/tracking/dialogue04/pdfs/notes.pdf)
  [PDF 164 Kb]
   
• At the end of the day, each group was asked to provide its top three priorities regarding the following three questions.
   
  • How can CDC best communicate with you to keep you in the loop about developments, changes, and improvements to the EPHT network as it evolves?
     
  • Do you have any suggestions for other groups that we should be actively engaging in the EPHT network planning and implementation process?
     
  • Given that your needs as an organization or individual may have to be long-term aspirations for the EPHT network, what kind of information can we be providing to you in the short- to mid-term that will meet your needs, keep you on track, and help you move forward?
     
• The remainder of the meeting time was dedicated to final thoughts with open discussion of any other advice, insights, or questions.
   
• Gina Solomon (NRDC) voiced concern about the level of involvement of NGOs. The more NGOs understand and are engaged in the program, the better they are able to promote it. Gina liked the information that was being shared during the meeting, and she hopes this information exchange continues. Mike McGeehin (CDC) agreed and stated that CDC will increase efforts to continue this dialogue.
   
• Susan Polan (TFAH) informed the group of the status of EPHT legislation. Legislation on EPHT has raised the profile and will be introduced again as bipartisan legislation in the fall.
   
• Andy Smith (ME BH) stated that he supports this type of meeting and format. In fact, he is interested in having topic-focused meetings including science and academic, epidemiology, etc. The states need direction for the next round of grants. Mike McGeehin (CDC) stated that he is aware of that, and CDC has difficult decisions to make. When the decisions are made, CDC will inform states as quickly as possible. CDC will continue to prioritize in the best way to spend limited resources.
   
• Janice Nolen (ALA) expressed that the ALA is very pleased to be involved in EPHT and would like to be involved in the strategic planning for the EPHT program. She also emphasized the need to focus more on the indoor environment. Mike McGeehin replied that CDC will be working on the strategic plan for the national program in FY05, and we accept her offer to help.
   
• Tom Burke (JHU) stated that, considering the success of this meeting, he wonders how the CDC Futures Initiative will play a role in EPHT. He would like to see the momentum continue. The EPHT program cannot devolve into a health system; it must involve the environment as well. Mike McGeehin suggested that EPHT could be a model program to implement the CDC Futures Initiative, because EPHT is cross-cutting and breaks down silos among state, local, and federal health and environmental agencies and other new partners.
   
• Communities want to continue to be involved, recognizing that EPHT will not have all the answers they seek. The program should be kept simple, and the community should be kept involved. Mike McGeehin assured the participants that as the program grows, CDC’s focus is to share data that can be used. Judy Qualters said that CDC is focused on keeping the program direction practical and feasible. We want something that will make data available for researchers and communities to use.
   
• Claire Barnett (HSN) expressed that consideration should be given to the quality of the whole indoor environment, not just the quality of indoor air. In terms of strategy, she would like to see EPHT move forward and expand. She emphasized focusing on children so they will grow into healthy adults. Mike McGeehin replied that we are considering children’s health issues as we move forward with the program.
   
• Paul English (CA DHS) reiterated that the environmental public health workforce must continue to grow as well. Mike McGeehin agreed that we need to get more environmental health professionals recruited, trained, and certified. CDC’s Futures Initiative is reviewing training the public health workforce at the state and local level.
   
• Judy Qualters thanked everyone and stated that a summary of the meeting would follow in a few weeks and would be E-mailed to the participants.
   
• Mike McGeehin thanked everyone for coming and sharing their thoughts, recommendations, and ideas. He stated that EPHT is a difficult program to establish, but it is critical to have interpretable data. The program is more manageable if we work with talented people such as the meeting participants. CDC plans to keep in touch and will work to find the best way to keep everyone informed as decisions are made. Special thanks to the Trust for America’s Health for requesting this meeting.

1. What do you think of the EPHT effort overall?
   • Positive:
     • Impressive effort
     • Ambitious
     • Future oriented
     • Diverse—planting 1,000 flowers (i.e., initiating demonstration projects)
     • Resources have been devoted
     • Absolutely needed
   • Concerns:
     • Not enough resources or resource commitment, and concerns about sustainability
     • Because CDC may be reinventing prior or current efforts, we need to engage the environmental epidemiology community more.
     • Concerns about transitioning from state-based efforts to a national effort
       • Ensuring compatibility across states
       • Establishing national indicators
     • Sense of disconnection by nongovernmental organizations (NGOs), community-based organizations (CBOs), and unfunded states
     • Worry if CDC and its partners will ever be able to link environmental data to health outcomes
     • Tendency to view the partners as only users and not contributors. They want to be involved!
        
2. What is missing or unclear?
   • True community participation and leadership; sense that it is citizen-driven; sense that community has been defined broadly
   • A plan for moving from baby steps to full system/plan to move from individual state efforts to “national” network
   • Adequate funding
   • Clarity on how to feed/meet needs of national program and the community/local level
   • Tools and standardized components may force all into a cookie-cutter approach and miss or leave unmet the diverse needs.
   • Effective communication across and up/down
   • Data structures reflect the same “silo” thinking that the Environmental Public Health Tracking (EPHT) programs are in.
   • Plan to show what the system can do, but also plan to set appropriate expectations about what it can’t do.
   • Effective inclusion of state health labs in the process
      
3. What are areas of overlap or common mission?
   • The meeting participants need EPHT information to use for health education and promotion.
   • The partners need EPHT information to use for policy and advocacy.
   • Committed to
     • Citizen-driven effort
     • Moving beyond data collection and dissemination to real use
     • Having an impact on health outcomes
     • Getting labs involved
     • Data/solid science
     • Bridging the environmental health/public health gap
   • CDC and its partners all need to educate all players.
   • Common desire for success of the system
   • Common fear that failure to show quick payoffs will hurt us
      
4. What do you need to get from the EPHT Network?
   • Scalable system
   • Able to make causal links
   • Able to use for policy development
   • Inclusion of all states
   • Better characterization of things like who is exposed, symptoms, etc.—things that preceded health outcomes
   • Greater data accessibility, standardization of case definitions and terms such as “epidemic,” methods, and improvements in data reliability and usability
   • Ability to get at behaviors
   • Ability to share/link/integrate data
   • CDC/NCEH commitment to listening
   • CDC/Office of the Director (OD) commitment to sustaining EPHT
   • User-friendly dissemination of information
   • Involvement of technical experts from the environmental agencies and disease-specific public health programs
   • Inclusion of marginalized communities in the process
   • Inclusion of mechanisms for feedback—are CDC’s partners getting the right information?
   • Ability to share data with users in raw form and not just in report form
   • Vision of how the CDC-funded state and local programs will move from 1,000 disconnected flowers (demonstration projects) to garden (integrated system)
   • Justification that persuades us and can also be used by us with skeptics
   • Ability to mine data at specific community level (i.e., south Philadelphia)
   • Ability to zoom-in at census track level
   • Ability to use for hypotheses generation; details of who, why, how, where
   • Way to provide clear “lay person” understanding of the underlying science
   • Ability to act as a data clearinghouse that
     • is a directory to existing data,
     • is tiered, based on data quality and other parameters,
     • includes historical data, and
     • places responsibility for adding and updating information on the data collector
   • Ability to detect when environmental agents or diseases exceed a critical level (“red flags”), and availability of a multidisciplinary response team to intervene
   • An advisory group for partners
   • Timely/real-time results
   • Technical assistance to communities about how to implement EPHT and use the data
   • Capacity building and training to develop workforce
   • Funding
      
5. What you need to get from the system—specific issue/content areas:
   • Indoor air quality and outdoor air quality
   • Food safety
   • Hazard data useful to public health
   • Biomonitoring data
   • Asthma
   • Neurodevelopmental disorders
   • Neurodegenerative disorders
   • Autoimmune disorders
   • Cancer
      
6. How do you get information now?
   • Very piecemeal, and you need to know where it is to find it
   • Often required to go to multiple sources for environmental health information
   • All information is reactive.
   • Better access to environmental conditions than health
   • Sometimes:
     • No data
     • Poor quality data
     • Different data can give you different answers depending on quality.
     • Data case definition for health outcomes not consistent
   • Some information comes from community members.
   • Use local organization information
   • Get information from patients and doctors
   • Use census data
      
7. What do you most need short term?
   • Forums/mechanisms to get the environmental health/public health dialogue going
   • Assessing/identifying current usable data sources (for example through a data clearinghouse)
   • Optimizing use and acquisition of the data CDC has
   • Identification and description of all current state/local EPHT advisory boards
   • Better connection with unfunded states
   • Third party data sets
   • Mandates from leadership levels to get disease experts involved in the EPHT effort
   • Mandates from funding agencies that require funded programs to work with others, build bridges, etc.
   • Models that CDC and its partners can use immediately
   • Guidelines on exposure assessments
   • Clarity on national priorities
   • Training/capacity building of workforce, especially on how to start the environmental health/public health bridge building
   • Improved coordination among bioterrorism, tracking, and biomonitoring programs
   • Accessible, non-computer tools
   • Sharing of best practices
   • Completed development of the environmental public health indicators
   • Content/issue areas:
     • Occupational exposure data
     • NASA data
     • Data on indoor air quality or role of indoor air quality in this system
   • CDC’s long- and short-term strategic vision
     • Vision/goals/direction for the nation program
   • Information on what the states are doing
      
8. How can CDC best communicate with you?
   • Electronic communication channels (video, Web site, E-mail, listserv, newsletter)
   • Regular forums/meetings
   • Workshops
   • Point of contact for community organizations to work with CDC
   • Use varied and enough channels that CDC will reach tipping point where informal networks for sharing are created.
   • Use NGOs to get information out to constituents.
   • Charge states with bringing people to table.
   • Also, do not forget creating mechanisms for partners to get information to CDC, not just one-way communication.
   • What content you need in communication:
     • Local health departments need information on risk communication
     • What is being planned for next phase
     • More information on other state EPHT efforts
     • More communication to policymakers
        
9. How would you like to be involved?
   • Finding role for unfunded states
   • Advocating for next phase
   • Evaluating efforts
   • Translating environmental data for use by public health
   • Providing input on the developmental process
   • Focusing on involving
     • CBOs
     • Unfunded states
     • Centers of Excellence
   • Using existing meetings well to spread and advance the EPHT agenda
   • Using CDC partners to reach their constituencies
     • NGOs
     • CBOs
   • The partners have specific expertise they are ready and willing to use to support EPHT
      
10. Who needs to be at the table that CDC has not already involved?
    • The “right” environmental health people—move beyond the environmental health “information technology” staff to include the environmental scientists as well.
    • State EPAs
    • GIS experts
    • Information technology
    • Unfunded states
    • Health care providers
    • Tribal governments
    • Environmental justice community
    • School districts
    • Medicaid/Medicare
    • International experts
    • Other federal agencies, including National Institutes of Health and United States Geological Survey
    • Health insurance payers
    • Home insurance payers
    • Communities of color
    • Marginalized communities
    • Labor unions
    • Policymakers from all levels and branches of government
      • Legislators
      • National Governors Association (NGA)
      • National Conference of State Legislators (NCSL)
      • Congressional staff
      • United States Conference of Mayors (USCM)
      • National Association of Counties (NACo)
    • Industrial hygienists
    • State and local air quality folks
    • Faith community
    • Pharmacy chains
    • Poison control
    • Pediatric Certified Nurse Practitioners
    • Industry
       
11. Who needs to be at the table that CDC has not already involved — specific organizations?
    • NGA
    • NCSL
    • USCM
    • NACo
    • Collaborative on Health and the Environment
    • Environmental Defense Fund
    • Sierra Club
    • Children’s Environmental Health Network
    • Pesticide Action Network
    • Professional association for heating ventilation and air conditioning contractors
    • Disease-specific nongovernmental organizations
    • Learning disability community
    • American Medical Association/Association of Medical Schools
    • American Public Health Association, Environment Section
    • Specific government agencies
      • National Institutes of Health
      • Department of Defense/Veterans Affairs
      • Occupational Safety and Health Administration
      • Food and Drug Administration (FDA)
      • U.S. Department of Agriculture (USDA)
      • State-based Medicaid
      • Centers for Medicare & Medicaid Services
      • Department of Education