Using Tracking Infrastructure to Support Public Health Programs ...

Using Tracking Infrastructure to Support Public Health Programs, Policies, and Emergency Response in New York City Nancy Loder Jeffery, RN, MPH; Wendy McKelvey, PhD; Thomas Matte, MD, MPH rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr

Objective: To describe how the New York City (NYC) Tracking Program has used nationally mandated Secure Portal infrastructure and staff analytical expertise to support programs and inform policy. Setting: The NYC Health Department assesses, investigates, and acts on a wide range of environmental concerns to protect the health of New Yorkers. Design: Specific examples of highly effective policies or initiatives that relied on the NYC Tracking Program are described, including restaurant sanitary grade posting, rat indexing, converting boilers to cleaner-burning fuels, reducing exposure to mercury from fish and contaminated products, and responding to Superstorm Sandy. Conclusions: The NYC Tracking Program supports the Health Department in using inspectional, administrative, and health data to guide operations. Tracking has also allowed internal and external partners to use these data to guide policy development. KEY WORDS: biomonitoring, environmental health, NYC, policy,

tracking

The New York City (NYC) Tracking Program is part of the NYC Department of Health and Mental Hygiene (Health Department)—a local agency that devotes a large portion of its environmental health resources to core public health operations, such as ensuring food and child care safety, controlling pests, preventing poisoning and other unintentional injuries, and responding to emergencies. The NYC Health Department also participates in developing policy to improve indoor and outdoor air quality and reduce associated health risks. J Public Health Management Practice, 2015, 21(2 Supp), S102–S106 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright 

The NYC Tracking Program supports environmental health programs in managing, analyzing, and reporting on essential operational data with a Secure Portal infrastructure that was created to meet National Tracking Program functional requirements.1 Most of the agency’s environmental health programs contribute data to the Secure Portal, including those that inspect food service establishments, control stray animals and pests, conduct pesticide use surveillance, regulate child care services, monitor local outdoor air, and manage and conduct surveillance of hazards in the home. The operational data generated by these programs are managed by informatics specialists through the Secure Portal, which consists of SQL Server databases with a Microsoft Reporting Services (RS) front end and controlled access capabilities. The Secure Portal allows Tracking Program epidemiologists and geographic information systems specialists easy access to data to support situational awareness and surveillance needs. For example, it supports (1) use of inspection data to guide programmatic practice; (2) linkage of health and exposure data to inform policy development; (3) fulfillment of public records requests, and (4) analyses of data to report on environmental conditions during emergencies.

Author Affiliations: Division of Environmental Health, Environmental Surveillance and Policy, New York City Department of Health and Mental Hygiene, New York. The CDC National Tracking Program has been instrumental in supporting and enhancing New York City Department of Health and Mental Hygiene (NYC Health Department) environmental health programs, policies, and emergency response. The views expressed here are those of the authors and do not necessarily reflect the official positions of the Centers for Disease Control and Prevention (CDC). The authors declare no conflicts of interest. Correspondence: Nancy Loder Jeffery, RN, MPH, Division of Environmental Health, Environmental Surveillance and Policy, New York City Department of Health and Mental Hygiene, 125 Worth St, Room 326, CN 34E, New York, NY 10013 ([email protected]). DOI: 10.1097/PHH.0000000000000170

S102 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Using Tracking Infrastructure in New York City

Analysts use the Secure Portal to deliver data analytic reports to preapproved user groups almost instantaneously. Recipients are managers of environmental and other health programs and the Health Department press office. Hundreds of reports are currently available through the Secure Portal on the reporting services front end, and more than 2000 are run and viewed by internal users each month. Described later and summarized in the Table are several highly effective policies or initiatives that could not have been launched or sustained without the NYC Tracking Program and the Secure Portal infrastructure.

● Restaurant Grade Posting Regular food safety inspection of the nearly 24 000 NYC restaurants is a core Health Department function. It involves more than 100 sanitarians collecting data using standardized forms on handheld computers that tally violations into a final score. Inspection data are transferred to the Secure Portal nightly. Analysis of these data, beginning in 2008, suggested that existing public health incentives were not resulting in improvements in restaurant sanitation. Tracking results informed the design of a risk-based inspection program that targeted restaurants for more frequent inspections on the basis of past performance and translated inspection scores to letter grades—A, B, or C—that could be publicly posted. This analysis was provided to the NYC Board of Health to support its proposed change to the health code establishing the risk-based program and requiring posting of the letter grades.2 Tracking program staff have subsequently documented and publicly reported improvements in restaurant food safety.3 Numerous reports have been developed and are available on the portal to assist all aspects of Food Safety program operations and management. Reports provide immediate information that can be used to respond to internal and external inquiries. Inspection data are also used to target training, identify solutions to operational challenges, and evaluate programmatic modifications. The Tracking Program data tools have ensured the successful implementation of an initiative that has improved overall restaurant sanitation: nearly 50% of restaurants received the equivalent of an “A” grade on their most recent initial inspection compared with 31% prior to the initiative.

● Rat Indexing In NYC, rodent control activities have been traditionally initiated by complaints. However, complaints do not necessarily reflect the true burden of pests in any

❘ S103

given area. The development of a handheld computer system in 2007 by the Health Department’s Bureau of Pest Control to collect data during field inspections offered an opportunity for improvement. In Rat Indexing, sanitarians proactively inspect areas, lot-by-lot, looking for signs of or conditions conducive to rats.4 The data are copied for management in the Secure Portal infrastructure and used to generate management reports, trigger follow-up actions, and link rat indexing data with other data sources to better understand the environmental factors that drive infestations, such as building density, parks and vacant land, and proximity to rail or subway lines. This approach has allowed the Health Department to direct its limited resources to where problems are the most severe. The data are also publicly available through a Rat Information Portal, www.nyc.gov/rats, which allows users to map data and access information on how to control and prevent infestations.

● Converting Boilers to Cleaner Fuels The New York City Community Air Survey (NYCCAS) was launched in 2008 as part of NYC’s long-term sustainability plan, referred to as PlaNYC. The purpose of NYCCAS is to provide locally resolved ambient air quality data that can be used to inform and track initiatives to improve outdoor air quality.5 About 100 integrated filter-based sampling units6 are located throughout the city to measure street-level concentrations of common air pollutants including fine particles (PM2.5 ), ozone, elemental carbon, nitrogen oxides (NOx ), and sulfur dioxide (SO2 ). By linking these data, which are managed through Secure Portal infrastructure, with indicators of air emission sources, such as traffic density or boiler permits, geographic information systems analysts develop land use regression6 models that describe how pollutant levels vary over space and time and predict average levels throughout the city, including unmonitored locations. Modeling results are then used to develop neighborhood-level air quality indicators. Results from the first year of monitoring showed that levels of air pollutants important to public health, specifically PM2.5 and SO2 and nickel (Ni) in PM2.5 , were higher in areas with a higher density of buildings with boilers burning oil, particularly grades no. 4 and 6 residual heating oil.7 Analyses were also conducted to evaluate impacts of these pollutants on respiratory and cardiovascular emergency department visits, hospitalizations, and deaths, demonstrating significant impacts throughout the city but wide variation by neighborhood—with the largest share of the health burden occurring in low-income neighborhoods.8

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

S104 ❘ Journal of Public Health Management and Practice TABLE ● NYC Tracking Program’s Contributions qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq

Name of Initiative

Description of Initiative

Tracking Program’s Role and Impact

Restaurant Grade Posting

Risk-based inspection of restaurants using letter grades to communicate results

Rat Indexing

Systematic, proactive rat infestation inspection program designed to target interventions

Converting Boilers to Cleaner Fuels

1. A local-level ambient air monitoring program (NYCCAS) to inform and track initiatives aimed at improving outdoor air quality 2. Local scale air quality health impact assessments

Reducing Exposure to Mercury

Biomonitoring component of local NYC HANES to assess mercury levels among NYC adults

Responding to Superstorm Sandy

NYC Tracking Program Response to Superstorm Sandy

Role: Analyzed restaurant inspection and health data to inform development of new inspection program; program evaluation Impact: Improved food safety and sanitary practices; informed policymakers Role: Analyzed rat inspection data to develop enhanced surveillance; developed online tool to allow public access to rat inspection data, and related information Impact: Improved public health response to rat infestations; informed policymakers and community Role: 1. Identified heating oil as a major contributor to variation in local air pollution levels; 2. Linked air pollution and health data to estimate impacts of exposure; informed regulatory and voluntary initiatives to shift to cleaner heating fuels Impact: Increased use of public health data to inform initiatives; with others helped to improve NYC air quality; informed policymakers and community; evaluated regulatory impacts Role: Analyzed mercury biomonitoring data and identified at-risk populations; identified, reduced, and prevented exposure to environmental hazard Impact: Reduced exposure to mercury; informed public and health care providers Role: Analyzed data to report on hazards and concerns and inform the public, providers, and the city response Impact: Identified at-risk populations; informed public and providers; supported response to emerging threats

Abbreviations: NYC, New York City; NYCCAS, New York City Community Air Survey; NYC HANES, New York City Health and Nutrition Examination Survey.

These results were shared with stakeholders, spurring new legislation and support for emissions reduction programs. For example, Tracking staff worked with the NYC Department of Environmental Protection and the Mayor’s Office of Long-Term Planning and Sustainability in developing regulations that require the phaseout of high polluting heating oils (grades no. 4 and 6 residual heating oil) used in many buildings across the city.9 The NYCCAS data have shown that these regulations, along with state limits on sulfur content of distillate heating oil (no. 2 oil), led to 69% and 35% declines in wintertime SO2 (indicator of heating oil emissions) and nickel in fine particulate matter (indicator of residual heating oil emissions) levels, respectively. Neighborhoods with the greatest reductions in emissions from boilers saw the greatest improvements in air quality, with an almost 2-fold greater improvement in SO2 and Ni levels compared with neighborhoods with fewer boiler conversions. Continuing analysis of NYCCAS data by Tracking Program staff has shown that heating oil phaseout combined with other targeted efforts by the City, and in concert with state and federal actions to reduce emissions from regional and national sources, has improved NYC air quality.

Our most recent health impact analyses show that airquality improvements are saving an estimated 780 lives annually.10 Tracking staff are continuing to use NYCCAS data to inform City air quality initiatives; to improve understanding of air quality in environmental justice neighborhoods; and, most recently, in testifying to the NYC Council in support of updating the NYC Air Code.

● Reducing Exposure to Mercury Past concerns over potential exposure to mercury through environmental releases (intentional, cultural use, or unintentional) and fish consumption led the NYC Tracking Program to collaborate with the 2004 NYC Health and Nutrition Examination Survey (NYC HANES) to incorporate biomonitoring into their public health surveillance. The Tracking Program managed and analyzed mercury data from collected blood and urine samples. Unanticipated, high urine mercury levels in Dominican women and other women of color were identified and, through follow-up interviews, found to be related to the use of illegal

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Using Tracking Infrastructure in New York City

mercury-containing skin-lightening creams. This led the Health Department to embargo products in stores, provide extensive public and health care provider education, and issue national and international alerts. Elevated blood mercury levels were found in Asians and other groups that consume fish frequently. In response, a multilingual educational brochure, “Eat Fish, Choose Wisely,” was developed, targeted to reproductive-aged women and parents of young children; it is available through the NYC Call Center (311), which has distributed almost 200 000 copies. The brochure is also distributed at NYC’s Women, Infants and Children (WIC) programs and was adopted by Fresh Direct, the largest online grocery delivery service in NYC. The Tracking Program published mercury biomonitoring results in peer-reviewed journals,11,12 and staff have provided guidance to other jurisdictions. Data are now being collected by the 2013 NYC HANES follow-up survey and will be analyzed by the Tracking Program to evaluate the effectiveness of past public health interventions and inform future efforts.

● Responding to Superstorm Sandy When Sandy struck the City in October 2012, there were many questions concerning health impacts and environmental exposures. Our Secure Portal infrastructure supported data access and reported dissemination to help inform the city response. Among the poststorm hazards and health risks of concern were power outages and lack of heat causing cold stress or exposures to carbon monoxide and other pollutants from generators or supplemental heating sources. In some flooded neighborhoods, many residents remained in their homes in high-rise buildings without power, heat, or running water. City-run evacuation shelters were opened in all 5 boroughs to accommodate those who evacuated, and shelter surveillance was initiated by the Health Department. Ambient air quality and respiratory health concerns were raised by widespread demolition and use of temporary boilers and generators in flooded neighborhoods. To assess the hazards and concerns, tracking program analysts used the Secure Portal infrastructure to access, analyze, and report on routinely collected data, including poison control center calls data, syndromic surveillance of emergency department visits and property, and building characteristics data. In addition, the Health Department collected data on sanitary conditions in evacuation shelters and used regulatory and specially deployed NYCCAS air monitors to collect data on ambient air pollution. Analyses of these data were used to inform the public, providers, and the city response. For example, data

❘ S105

reports were created to track evacuation shelter census and to support sanitarians assessing shelter environmental and food safety conditions. Tracking familiarity with carbon monoxide and hypothermia surveillance and seasonal pattern awareness of asthma and respiratory illness assisted interpretation of reports of these health outcomes. The finding that counts of coldrelated illness, carbon monoxide exposure, and gasoline exposure (from fuel siphoning) rose in the first several days after the storm was used to reinforce public warnings and provider health alerts about hazards of living in buildings without power and heat. Property and building-level data were used by tracking geographic information systems specialists to generate tactical maps to guide door-to-door canvassing by the National Guard and Health Department in potentially impacted high-rise buildings in initially flooded areas.

● Conclusion Health departments are charged with responding to existing or emerging public health threats. Electronic data collection by larger local health departments is increasingly the norm during routine inspections and emergency response and greatly facilitates public health action. Prior to the establishment of the NYC Tracking Program, data from our inspection programs and mandatory or voluntary event reporting were underutilized. Critical public health infrastructure within our agency has been enhanced by use of our Secure Portal to enable programs to more fully use their own data to guide their operations and policies. REFERENCES 1. Centers for Disease Control and Prevention. National environmental public health tracking: environmental public health tracking network vision document (version 1.0). http://www.cdc.gov/nceh/tracking/netvision/netvision .htm. Published October 20, 2004. Accessed May 23, 2014. 2. New York City Health Code §81 Food Preparation and Food Establishments, grading of inspection results and posting of grades by certain food service establishments. http://www.nyc.gov/html/doh/downloads/pdf/rii/ article81-book.pdf. Accessed May 23, 2014. 3. The New York City Department of Health and Mental Hygiene. Restaurant letter grading results: the first 18 months. http://www.nyc.gov/html/doh/html/services/restaurantinspection.shtml. Accessed May 23, 2014. 4. Centers for Disease Control and Prevention. Evaluation of a neighborhood rat-management program—New York City, December 2007-August 2009. MMWR Morb Mortal Wkly Rep. 2012;61(37):733-736. http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6137a1.htm. Accessed May 24, 2014.

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

S106 ❘ Journal of Public Health Management and Practice 5. The New York City Department of Health and Mental Hygiene. About the NYC community air survey. www.nyc.gov/ health/nyccas. Accessed May 22, 2014. 6. Matte T, Ross Z, Kheirbek I, et al. Monitoring intraurban spatial patterns of multiple combustion air pollutants in New York City: Design and implementation. J Expo Sci Environ Epidemiol. 2013;23:223-231. doi:10.1038/jes.2012.126. 7. The New York City Department of Health and Mental Hygiene. The New York City Community Air Survey— Results From Year One Monitoring 2008–2009. http://www .nyc.gov/html/doh/downloads/pdf/environmental/commair-survey-report.pdf. Published 2011. Accessed May 23, 2014. 8. Kheirbek I, Wheeler K, Walters S, Kass D, Matte T. PM2.5 and ozone health impacts and disparities in New York City: sensitivity to spatial and temporal resolution. Air Qual Atmos Health. 2013;6(2):473-486. doi:10.1007/s11869-0120185-4.

9. Local Laws of the City of New York, For the Year 2010. No.43. A local law to amend the administrative code of the city of New York, in relation to the use of clean heating oil in New York City. http://www.nyc.gov/html/gbee/ downloads/pdf/ll43-2010.pdf. Published August 16, 2010. 10. The New York City Department of Health and Mental Hygiene. New York City trends in air pollution and its health consequences. http://www.nyc.gov/html/doh/ downloads/pdf/environmental/air-quality-report-2013. pdf. Published September 26, 2013. Accessed May 23, 2014. 11. McKelvey W, Gwynn C, Jeffery N, et al. A biomonitoring study of lead, cadmium, and mercury in the blood of New York City adults. Environ Health Perspect. 2007;115(10):14351441. 12. McKelvey W, Jeffery N, Clark N, Kass D, Parsons PJ. Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City. Environ Health Perspect. 2011;119(2):203-209.

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.