GIS

1. In order to properly plan, manage and monitor any public health programme, it is vital that up-to-date, relevant information is available to decision-makers at all levels of the public health system. As every disease problem or health event requires a different response and policy decision, information must be available that reflects a realistic assessment of the situation at local, national and global levels. This must be done with best available data and taking into consideration disease transmission dynamics, demographics, availability of and accessibility to existing health and social services as well as other geographic and environmental features. 2. Environmental public health tracking comprises the ongoing collection, integration, analysis, and dissemination of data from environmental hazards monitoring, human exposure tracking, and health effect surveillance. Spatial analysis tools are an essential component of Tracking Network for linking environmental hazards and potential adverse health effects. Tracking Network provides a bridge between the information silos of environmental and health data. It is important to understand how spatial and temporal trends in health outcomes and environmental factors intersect and influence each other, because understanding these relationships can better inform public health actions designed to improve community health. Factors critical to Tracking Network are the adoption of standards to provide consistent data and measures from state and national data systems (e.g., population data from the U.S. Census) and the provision of Seventeen states and local partners participated in the development and implementation of the Environmental Public Health Tracking Network. information access while adhering to health data privacy constraints [New CDC Environmental Public Health Tracking Network Includes Spatial Analysis Tools By Alex Charleston, MPH, Public Health Analyst, Environmental Health Tracking Branch, Center for Disease Control and Prevention]. 2. Geographic information systems (GIS) provide ideal platforms for the convergence of disease-specific information and their analyses in relation to population settlements, surrounding social and health services and the natural environment. They are highly suitable for analysing epidemiological data, revealing trends and interrelationships

that would be more difficult to discover in tabular format. Moreover GIS allows policy makers to easily visualize problems in relation to existing health and social services and the natural environment and so more effectively target resources [Welcome to WHO's Public Health Mapping and GIS programme, WHO, accessed on 22 jun 2010]

3. GIS (Geographic Information Systems) are used in many fields to create, store, analyze, and display data with a spatial component (i.e. location information). In recent years, the use of GIS by public health professionals has expanded rapidly, driven by the growing realization that : 1. The majority of health data have a spatial component, 2. Graphical representations, particularly maps, are extremely informative to various aspects of public health, and 3. There is value in associating health data with other data (e.g. census data, environmental data, etc).

4. GIS adds a powerful graphical and analytical dimension to public health by bringing together the fundamental epidemiological triad of person, time, and the often-neglected place. The analysis and mapping of data using Public Health GIS include: The spread of diseases over time Spatial patterns of outbreaks Population groups at risk Availability and access to health care Program intervention planning and assessment 5. Its a must in supporting the spatial information needs of evidencebased public health planning and research in areas such as chronic and infectious disease prevention and control, health promotion, surveillance, emergency preparedness and response, and pandemic

outbreaks [public health agency of aspc.gc.ca, accessed on 24 jun 2010]

canada,

gishelp@phac-

6. Investigating Local Air Pollution Sources in Dudley Square, Boston - Data on total traffic, railroads, and bus routes were incorporated into a GIS and used to create a raster image that represents traffic density. Environmental monitoring was done in these locations to investigate the impact of local traffic sources and to support the use of GIS derived estimates of air pollution exposures in health studies [ sjmelly@hsph.harvard.edu. accessed on 28 jun 2010] 7. Worcester Heart Attack Study We have geocoded subjects in the Worcester Heart Attack Study, and are in the process of drawing controls who will also be geocoded. We are using these data and multilevel Poisson and Cox models to investigate the spatial distribution of myocardial infarction incidence rates, the role of contextual socio-economic factors in explaining that spatial distribution, the spatial distribution of survival rates among persons discharged alive after their myocardial infarction, and the role of contextual soci-economic factors in explaining that spatial distribution. 8. Eastern Massachusetts Pollution Study Using data from multiple personal exposure studies, plus several other studies that have collected pollution data at multiple locations in Eastern Massachusetts, we will fit GIS regression to develop predictive models of pollution concentrations as a function of population density, distance to roads, estimated traffic count, land use data, etc. We are obtaining from the Massachusetts Department of Public Health data from birth certificates for all live births in the area for the last five years, as well as all deaths. These will be geocoded to latitude and longitude. We will then merge in block group and tract level data on socio-economic factors. We will examine whether estimated pollution exposure is associated with birthweight, gestational age, small for gestational age, and low birthweight using the birth data. We will also examine the role of contextual level SES variable in explaining the same outcome, the independent explanatory effect of block group vs tract data, and the extent to which measures of physical environment

(pollution) explain some of the social gradient in outcome. Using the death data, we will investigate whether rates of death for causes are related to pollution exposure, and again whether pollution explains some of the social gradient in death rate.
9. Normative Aging Study The normative aging study is a long term prospective cohort study of approximately 2500 persons who were free of disease in the early 1970s, and who have been followed since then. Using the geocoded exposure data discussed above, and address history , we will geocode their address and estimate cumulative exposure in each participant. We will estimate the association with myocardial infarction, COPD, and death on follow-up. 10. ACCESS Study Together with researchers from the Channing Laboratory we will be using GIS to investigate the impact of air pollution from traffic on the development of asthma in a cohort of children born in the Boston area. 11. Occupational Health Taiwan Petrochemical Study This NIEHS-funded study is conducted in Kaohsiung, Taiwan - a highly industrialized city with a high population density. These characteristics allow various levels of residential exposure across sufficient numbers of individuals and are ideal for an environmental epidemiologic study of cancer risks associated with residential petrochemical exposure. Detailed residential history for each study subject is collected, in order to develop a GIS-based scoring scheme of residential exposure to petrochemicals which takes into account both the proximity and wind direction factors. Area sampling on selected volatile organic compounds (VOCs) is conducted and the data will be used to calibrate the spatial surfaces of pollutants [sjmelly@hsph.harvard.edu. accessed on 28 jun 2010].

12. Play Across Boston GIS is being used to support the Play Across Boston project by mapping recreational facilities, open space and locations of recreational programs. GIS data together with data from the US census was used to explore how accessibility to recreational facilities varies across the city of Boston and in 4 nearby communities.

Project on Human Development in Chicago Neighborhoods (PHDCN) Data from surveys, analyses of videotapes of city streets, the US Census and other sources are being used to investigate factors that contribute to physical activity and obesity in Chicago youth. With GIS software we are investigating the density of fast food restaurants near homes and schools. We are also studying factors that influence the prevalence of walking or biking to work. Area-based socioeconomic measures for health research (also known as the Public Health Disparities Geocoding Project) See the The Public Health Disparities Geocoding Project for more details Currently, most US public health surveillance systems lack socioeconomic data, thereby precluding monitoring of socioeconomic disparities in health, as well as their contribution to racial/ethnic disparities in health. One possible solution is to use geocoding and area based socioeconomic measures (ABSMs), to characterize both the cases and population in the catchment area, thereby enabling computation of rates stratified by the area-based measure of socioeconomic position. Yet, it is unknown which ABSMs, at which level of geography, would be most apt for monitoring US socioeconomic inequalities in health, overall and within diverse racial/ethnic-gender groups.

We accordingly launched the Public Health Disparities Geocoding Project to ascertain which ABSMs, at which geographic level (census block group [BG], census tract [CT], or ZIP Code [ZC]), would be suitable for monitoring US socioeconomic inequalities in the health. Drawing on 1990 census data and public health surveillance systems of 2 New England states, Massachusetts and Rhode Island, we analyzed data for: (a) 7 types of outcomes: mortality (all cause and causespecific), cancer incidence (all-sites and site-specific), low birth weight, childhood lead poisoning, sexually transmitted infections, tuberculosis, and non-fatal weapons-related injuries, and (b) 18 different ABSMs. We conducted these analyses for both the total population and diverse racial/ethnic-gender groups, at all 3 geographic levels. Our key methodologic finding was that the ABSM most apt for monitoring socioeconomic inequalities in health was the census tract

(CT) poverty level, since it: (a) consistently detected expected socioeconomic gradients in health across a wide range of health outcomes, among both the total population and diverse racial/ethnic gender groups, (b) yielded maximal geocoding and linkage to areabased socioeconomic data, and (c) was readily interpretable to and could feasibly be used by state health department staff. PUBLICATIONS OF THE PUBLIC HEALTH DISPARITIES GEOCODING PROJECT
Socioeconomic trends in breast cancer incidence To date, despite suggestive evidence about possible changes in the socioeconomic patterning of breast cancer, no studies have investigated whether the socioeconomic gradient in breast cancer among women in the United States is changing over time. Our proposed study seeks to test the hypothesis that: (a) this gradient is decreasing, because (b) incidence rates are rising more quickly among wome n residing in less affluent areas. Moreover, to aid interpretation of study findings, we propose to test the same hypothesis among men, because if patterns are similar it would suggest that factors driving the patterns are not only reproductive but non-reproductive, e.g., anthropometric or environmental.

To test our hypotheses, we will obtain cancer data from the Northern California Cancer Center (NCCC), covering 5 counties in the San Francisco Bay Area (1973-2002; n ~ 70,000 females and ~ 490 male cases), the Los Angeles Cancer Surveillance Program (1973-2002; n ~ 129,400 female and ~ 940 male cases); and the Massachusetts Cancer Registry (1982-2002; n ~ 93,100 female and ~ 760 male cases), along with relevant 1970 to 2000 US census data. We will then geocode each cancer registry record, based on each patients residential address, to its corresponding latitude, longitude and census tract, generate state -ofthe-art census-derived area-based socioeconomic measures, and link each geocoded record to the relevant area-based socioeconomic measures. We will likewise generate denominators stratified by the areabased socioeconomic measures, using data from the 1970 -2000 decennial censuses.
Developing & Evaluating Recreational Areas Objective Measures of Outdoor

An interdisciplinary research team from the fields of physical activity/public health, geography, landscape architecture, and parks and recreation will develop and evaluate objective measures of outdoor recreational settings where walking, bicycling and other linear activities can be performed. Selection of measures will be based on ecological models and social cognitive theory, current evidence from public health/physical activity studies, practice guidelines from landscape architecture, and formative work that the research team will conduct. Existing GIS databases, observation/auditing of facilities, and other methods will be used to develop objective GIS measures of facility characteristics.
Neighborhood and school environments and accelerometers: estimates of youth physical activity levels. This study takes advantage of a large existing database of physical activity measurements collected among sixth and seventh graders in ten Massachusetts middle schools to see if the environment at school or in the neighborhood is associated with the children's activity levels.

The physical activity data, measured by accelerometer and self-report, allow us to identify active and sedentary periods by time of day for 251 students. We are assessing factors such as density, mix of land uses, and completeness of the sidewalk network, using GIS data, aerial photographic maps, and site visits for each school and its surrounding neighborhood. We will also be looking at the layout of the schools themselves including collecting inf ormation on the size of the campus and the presence of stairs. Description of using GIS to study local features and physical activity Among the questions we will be asking is whether the pedestrian environment in the neighborhood is related to physical activity for students on weekends, and if active-school environments are associated with more activity during the school day. The datab ase also includes information on weather conditions, and the researchers will see if the neighborhood environment influences whether children walked or biked to school in bad weather.

Population & International Health Dept. Spatial Aspects of Contraceptive Use in Malawi Malawi faces immense reproductive health challenges. The objective of this study is to see if analysis of spatially referenced health data can identify gradients of access to specific contraceptive services and determine whether and how the gradient affects the utilization of services. The spatial analysis in this study involves layering geocoded data from the Malawi Health Facility Inventory and the 2000 Malawi Demographic and Health Survey. It is among the first examples of using kernel density estimation as a means of identifying the presence and health significance of access to health services [jaime.hart@channing.harvard.edu.] Trucking Industry Particle (TrIP) Study Researchers from the Channing Laboratory will be using GIS to develop exposure models to explore the relationship between workplace exposure to diesel exhaust and other particle exposures and lung cancer in a large cohort of trucking industry employees. Nurses Health Study Geocoding of large cohort to investigate health effects of air pollution using EPA databases. This will involve use of GIS regression approaches to estimate exposure at residential addresses. Home Allergens and Asthma Study In a birth cohort, we geocoded participants' addresses and measured serum IgE in the mothers of participants. We then utilized kriging methods to map serum IgE levels and found that within the Boston City limits, mothers had higher serum IgE levels compared with levels from mothers living in the suburbs. With the help of our colleagues at the Harvard School of Public Health, Department of Biostatistics, we will link the health outcomes in children from this birth cohort with exposures in the environment.

The overall focus of the new research will be developing and extending statistical methods to best quantify a spatial region to be an area with a disproportional incidence of disease, otherwise known as a hotspot. This type of research can be utilized to prove, or disprove, an existence of a disease (e.g. asthma) cluster or other adverse health effects in regions

that can be linked to environmental hazards. In particular, for the Boston Home Allergens study, one could use this research to statistically test if there is an increase in incidences of asthma occurring in areas closer to highways. Therefore these methods could be used as a way to relate previously non-linkable sources of environmental hazards to increases in adverse health outcomes. The research problem will first be approached by extending the currently most popular method, the Scan Statistic, from binary to censored outcomes and to also allow for other known predictors. The second approach would be to extend cumulative residual methods that are currently applied to failure time outcomes to include a spatial component that would be able to detect significant clustering.
Division of Rheumatology, Immunology & Allergy The Roxbury Lupus Project is the result of the NIEHS-funded environmental justice collaboration between investigators from the Division of Rheumatology, Immunology and Allergy at Brigham and Women's Hospital, the community-based lupus advocacy group Women of Courage and the Massachusetts Dept of Public Health, Bureau of Environmental Health Assessment. In collaboration with the Dept of Biostatistics, HSPH, we will be using GIS to examine exposure models to evaluate the possible effects of environmental exposures (residential and occupational exposures to petrochemicals) and phase II drug metabolizing enzyme genetic polymorphisms on risk of systemic lupus erythematosus in the female residents of the Boston neighborhoods of Roxbury, Dorchester and Mattapan. Children's Hospital, Boston Informatics Program We are developing a state-wide and national syndromic surveillance system for the early detection of outbreaks (naturally occurring and bioterrorism). The AEGIS (Automated Epidemiologic Geotemporal Integrated Surveillance) system automatically processes live data from hospital emergency departments, running algorithms to detect abnormal temporal and spatial patterns of disease. The system reports directly to the Massachusetts Department of Public Health in real time.

Using Maps to Assess Food Access in Rural Maine

By Teresa Hubley, Research Associate, Edmund S. Muskie School for Public Service, University of Southern Maine The University of Southern Maines (USM) Edmund S. Muskie School of Public Service recently assembled a team that uses GIS to explore the influence that rural residential locations have on public health nutrition. The focus for this team is the effect that access to grocery outlets has on food choices and nutrition education needs. The goal is to provide useful policy suggestions that may help overcome the barriers facing impoverished people in rural areas as they strive to provide their families with healthy foods
Attendance Distribution Analysis: Using GIS to Identify Training Gaps in Target Markets By Matthew Smith, Data Analyst, CBE; and Kristin A. Watkins, CBE Library and Grants Coordinator

The Nebraska agency Center for Biopreparedness Education (CBE) was formed in 2002 to provide biopreparedness education to Nebraska public health systems and first responders to help them respond to infectious disease, chemical, biological, radiological, nuclear, and explosive emergencies. To ensure optimal training coverage, GIS was used to identify potential gaps in training for targeted groups. The use of GIS proved successful, and CBE now has an easily updatable database from which powerful visual images that highlight the impact of preparedness training statewide can be quickly extracted. CBE uses GIS to appropriately adjust marketing and strategic planning to better reach underrepresented geographic regions and professions.