Enviromental Health Surveillance PDF

Environmental Health
Surveillance
A Feasibility Study
November 2008
Prepared by
Narelle Mullan, Dr. Chantal Ferguson & Daniel Paech
Environmental Health Directorate
11176 JAN’09 23650
Produced by Environmental Health Directorate

Department of Health 2009 Western Australia
A Feasibility Study November 2008
Table of Contents
EXECUTIVE SUMMARY 5
1 INTRODUCTION 8
1.1 Study Objective 8
1.2 Study Purpose and Process 8
1.3 Study Scope 10
1.4 Definition of Terms 10
2 BACKGROUND AND CONCEPTS 12

2.1 Environmentally Related Disease in Australia 12
2.2 Economic Costs of Environmentally Related Diseases 14
2.3 Health Surveillance 15
2.4 Environmental Health Surveillance 17
2.5 Surveillance versus Indicators 18
2.6 Limitations of Environmental Health Surveillance 19
3 AUSTRALIAN SURVEILLANCE ACTIVITIES 20

3.1 National Health Surveillance 20
3.2 National Environmental Surveillance 23
4 INTERNATIONAL ENVIRONMENTAL HEALTH SURVEILLANCE 25

4.1 North America 25
4.2 Europe 26
4.3 Asia 27
4.4 Summary of the Review 29
5 AUSTRALIAN ENVIRONMENTAL HEALTH SURVEILLANCE 31

5.1 Partnership Framework Options 31
5.2 Planning Stage 34
5.3 Management Structure 36
5.4 Implementation Considerations 37
6 RECOMMENDATIONS 41
7 CONCLUSION 43
8 REFERENCES 44
1
Environmental Health Surveillance
List of Tables
Table 1 Documented Cost of Seven Environmentally Related Diseases in Australia 15
Table 2 Environmental and Health Factors Common to International Surveillance

Programs in Europe and North America 29
Table 3 Summary of Potential Risks 39
List of Figures
Figure 1 Key Concepts of Health Surveillance 16
Figure 2 Primary and Secondary Surveillance for Environmental Health 17
Figure 3 Environmental Health Surveillance Concept [51] 18
Figure 4 Partnership Frameworks for Australian Environmental Health Surveillance 32
Figure 5 Proposed Management Structure for National Environmental

Health Surveillance 37
Figure 6 Development Timeframe for National Environmental Health Surveillance 40
2
Acknowledgements
This project is supported by a grant from the Commonwealth Government.
Abbreviations and Acronyms

ABS Australian Bureau of Statistics
ACT Australian Capital Territory
AIHW Australian Institute of Health and Welfare
BOM Bureau of Meteorology
BSS Biosecurity Surveillance System
CDC Centers for Disease Control and Prevention
CDNA Communicable Disease Network Australia
CRC Co-operative Research Centres
DALY Disability Adjusted Life-Years
DoH Department of Health
DoHA Department of Health and Ageing
enHealth Environmental Health Committee
ENHIS Environmental Health Information System
EPA Environment Protection Agency
EPHT Environmental Public Health Tracking
ESCAP Economic and Social Commission for Asia and Pacific
EUROHEIS European Health and Environment Information System
FCCC Framework on Climate Change Convention
GIS Geographic Information System
IEIP International Emerging Infections Program
InVS French Institute for Public Health
NCRIS National Collaborative Research Infrastructure Study
NCSCH National Cancer Statistics Clearing House
NEHS National Environmental Health Strategy
NEPC National Environmental Protection Council
NEPM National Environmental Protection Measures
NHMRC National Health and Medical Research Council
NHS National Health Survey
NNDSS National Notifiable Disease Surveillance System
NNIP National Network Implementation Plan
NPI National Pollutant Inventory
NSW New South Wales
NT Northern Territory
3
OECD Organisation for Economic Co-operation and Development

QLD Queensland
RIF Rapid Inquiry Facility
SA South Australia
SAHSU Small Area Health Statistics Unit
SoE State of Environment
TAS Tasmania
UK United Kingdom
UNEP United Nations Environment Program
USA United States of America
VIC Victoria
WA Western Australia/Western Australian
WHO World Health Organisation
WMO World Meteorological Organisation
4
Executive Summary
The majority of Australian residents currently enjoy the benefits of drinking unpolluted water and
eating non-contaminated food products. This privileged position has resulted in a great deal of
complacency regarding the connections (if any) between public health and the environmental
conditions resulting from our modern, high-technology world. Today, unprecedented attention and
resources are given to monitoring the changes in environmental parameters across the country.
However, there is still a gap in that there is no nation-wide surveillance program focussed on
the long-term effects of environmental conditions on the health of our people. A surveillance
program would assist in tracking changes over time and space, and increase manager’s ability to
approach high priority issues with confidence.
The following questions (among many others) are germane to this study:
Are birth defects linked to environmental factors?
To what extent is cancer associated with toxic waste?
Is there a relationship between childhood allergies and chemical usage?
These types of questions are currently being considered by those who are passionate about
finding answers, which will then allow the Government to protect the community. The speed at
which the people of Australia can benefit from research in this field depends on the availability
and quality of relevant information. The Australian Government has an opportunity now to
unite with the USA and European Union as leaders in creating innovative ways to improve the
management and quality of information on environmental hazards and disease.
Consulting with Australian health agencies and managers of existing international programs
made it clear that environmental health surveillance builds on existing primary-level surveillance,
using a variety of analytical tools and assessment techniques. This secondary-level surveillance
results in more informed decision-making and an opportunity to feedback data quality and
completeness to primary data custodians.
In summary, the key findings of this study are:
Finding 1: Australian Environmental Health Surveillance is Feasible

A national surveillance program in environmental health is feasible, given recent developments in
technology and widespread support across all agencies and jurisdictions towards the long-term
goals.
Finding 2: Window of Opportunity

A window of opportunity has been created by recent investment into national infrastructure for
health data. Environmental health branches do not have the resources or time to develop stand-
alone surveillance systems. A chance exists to influence the development of other systems and
benefits are to be gained in building a usable resource for all States and Territories.
5
Finding 3: Technology Barriers Removed

Information technology barriers that were common in the past have been reduced and significant
developments have been made in spatial technologies which enable the storage and analysis of
data from disparate sources. In addition, Web-based programs have gained full acceptance for
secure and efficient data sharing. The study found that now that these barriers can be removed
(or at least substantially reduced), the challenge lies more in building partnerships and trust with
both data custodians and relevant stakeholders.
Innovation in this field requires governments with an appropriate long-term vision.

Comprehensive and current surveillance of environmental health issues will continue to evolve
over many years, given that it requires full commitment from Federal, State/Territory and Local
tiers of government. This is not a ‘magic bullet’, but there are immediate benefits to knowing
‘who is doing what’, to gaining the ability to identify priorities and to enabling evaluation of the
interventions required. This type of surveillance program will focus on populations, which will
complement existing individual-level health surveillance activities and assist in determining
potential environmental causes and the scale of impacts when identified. It will also assist in
determining appropriate responses to emergencies.
The primary recommendation of this feasibility study is that governments must, in the long-
term, establish an environmental health surveillance framework encompassing all levels of
government. To this end, the following recommendations are made, for completion within the next
12 months.
Recommendation 1: Support and Commitment

The support of enHealth and the Department of Health and Aging is required in seeking a
commitment from the Australian Health Protection Committee (AHPC) in taking ownership of an
environmental health surveillance program.
Recommendation 2: Partnerships
Partnerships between environmental and health agencies need to be formalised for the purpose
of surveillance. It is important that existing reference and working groups continue to function. It
is also important to increase the level of contribution from members of the working groups with
regular workshops. Representatives should be asked to formalise relationships by establishing
data-sharing agreements with environmental agencies where appropriate, thus extending the
involvement of each State and Territory.
Recommendation 3: Program Plan and Pilot Projects

Preparation should be initiated of a detailed plan for an environmental health surveillance
program, to be undertaken by Department of Health and Ageing (DoHA)-funded project officers.
This plan should include a scan of available datasets and provide an opportunity to develop
appropriate data management procedures.
It would also be necessary to identify priority areas through existing expert reference groups and
recent indicator developments from Victoria and South Australia. In addition, one or two priority
areas should be considered for pilot projects. The program plan and pilot projects will provide a
chance for external data custodians to realise their value in the surveillance program.
6
Recommendation 4: Sustainable Funding Arrangements

The project team should consider the sustainability of a national environmental health
surveillance program. It will depend on long-term financial support and a management structure
which crosses all levels of government and jurisdictions. Collaboration with agencies external to
health will have the advantage of securing funds and engagement with data custodians. It will
involve raising the profile of these important issues with the organisations responsible for the
management of hazards.
Final Conclusion
There is no time to delay. The sooner we start, the sooner we could have an explanation for
adverse health conditions, such as birth defects, childhood allergies and the cause of cancer.
Every resident in Australia stands to gain from this major investment in an environmental health
surveillance program. It has been estimated if an environmental health surveillance system in
Australia was established to support and inform public health activity, programs and policies
to reduce the burden of these environmentally related diseases by only 1%, the annual saving
would exceed $34 million. If this opportunity is not taken, there is a risk that the rest of the World
and individual Australian States and Territories will have advanced too far in other directions for
coordination across Australia to be worth consideration.
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1 Introduction
Environmental exposures are major contributors to chronic illnesses such as acute respiratory
disease, cancer and diabetes. The extent of these effects requires further investigation. Health-
care expenditure on chronic diseases exceeding $35 billion in 2000-20011. Considering this
significant financial burden and the additional social burden attributable to chronic disease in
Australia, measuring the contribution of environmental exposures to chronic disease should be a
high priority.
The Australian Government has recently provided significant resources for the surveillance of
acute illness and environmental chemicals in order to allow the preparation of a program for
protecting the population against chemical or biological attack. The National Environmental
Health Strategy (NEHS) 2007-20122 identified, as one of the eight key objectives, the
development of a national environmental health surveillance capacity to ensure that risks
are being appropriately managed by responsible stakeholders. In order to address this, the
Environmental Health Committee (enHealth) decided in January 2008 that the Western Australian
Environmental Health Directorate, under guidance from the Australian Government Office of
Health Protection, would examine the feasibility of a national environmental health surveillance
system for Australia.
1.1 Study Objective

The primary overarching objective of the feasibility study was to:
Examine a range of potential environmental health surveillance systems for Australia

and consider issues associated with implementation, providing a firm basis to
determine whether the project has enough merit to continue into a more detailed
business case.
1.2 Study Purpose and Process

The purpose of this study was to determine whether it would be feasible to conduct national
environmental health surveillance in Australia. In addition, if deemed feasible, the study’s second
purpose was to propose a model of environmental health surveillance that would be appropriate
for use in Australia to the Australian Government Department of Health and Ageing (DoHA).
In the past, environmental and health data have been collected and analysed separately with
little integration other than in research projects examining isolated issues. It is widely agreed
that environmental and health agencies should be working closer together to address public
health concerns, particularly given the recent improvements in data linkage technology. However,
despite developments internationally in this area, there has so far been no progression in
Australia towards an integrated environmental health system. Therefore enHealth decided that
the feasibility of environmental health surveillance in Australia should be examined.
The first part of the feasibility study was to conduct an international literature review in order to
determine what had been proposed and established to date in environmental health surveillance
in other regions of the world. World organisations and representatives from relevant international
8
health and environmental agencies were contacted by e-mail or telephone and in some cases
met in person, to gather more information on relevant literature. In addition to this international
literature review, a search was undertaken to determine whether any environmental health
surveillance or monitoring activities were already underway within Australia.
1.2.1 Australian Government Partners

The primary advisory group for this project was the DoHA Environmental Health Section within
the Office of Health Protection. Regular e-mailing and teleconferences were conducted to
communicate direction and gather advice from the Australian Government team. In addition,
when an environmental health surveillance system was initially proposed, it was acknowledged
that the Biosecurity Surveillance System (BSS) was a parallel project that needed to be
examined so that duplication of resources would be avoided. It was also considered important to
consult with the BSS project team to discover what aspects of the project were successful and
areas in which tasks could have been done differently. Individuals from the following divisions/
departments within the Australian Government were consulted throughout the feasibility study:
Office of Health Protection, Surveillance Branch. For a complete list of Australian Government
representatives, see Appendix A.
1.2.2 Interstate Working Group

In addition to the Australian Government advisory group, representatives from each Australian
State and Territory, as well Australian Government representatives, were invited to form an
Interstate Working Group (IWG). Established to strengthen interstate partnerships, this IWG was
considered integral for a successful co-ordinated national surveillance system. The following
stakeholder agencies/organisations were represented in the Interstate Working Group:
Department of Health and Ageing
Department of Health WA
NSW Department of Health
VIC Department of Health Services
TAS Department of Health and Human Services
ACT Health
NT Department of Health and Community Services
QLD Health
SA Department of Health.
Representatives from Victoria, Queensland, New South Wales, South Australia, Tasmania,
Australian Capital Territory and the Northern Territory, as well as Australian Government
representatives, were contacted in order to gather and disseminate ideas. For a complete list of
Interstate Working Group members, see Appendix A.
1.2.3 Western Australian Reference Group

A Western Australian Reference Group was established with representatives from across
disciplines including health and environment State government agencies, Local Government
and university and research sectors. The following government and non-government agencies/
organisations were represented in the Western Australian Reference Group:
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WA Department of Health
Environmental Protection Authority
University of Western Australia
WA Institute for Medical Research
Edith Cowan University
WA Land Information System
City of Mandurah.
This group met formally three times during the study period to discuss the undertakings of the
feasibility project and provide input into the draft report. Locally, the study received widespread
support from stakeholders. For a complete list of members of the Western Australian Reference
Group, see Appendix A.
1.3 Study Scope

Due to the limited time frame in which to conduct this project (six months), a number of
boundaries were placed on the study. This study did not attempt to uncover the national
data sources that would be utilised in such a system nor did it attempt to suggest specific
environmental or health measures that would be appropriate for surveillance. This study
focused on the processes undertaken to establish the appropriate framework that could be
implemented nationally to co-ordinate better the collection and analysis of environmental hazard,
environmental exposure and health data between and within States and Territories. A summary
of the timeframe, resources and ethical and legal issues for a national framework to become
successful is also provided.
This study provides:

a background to environmental health surveillance;
an outline of surveillance activities in Australia relevant to environmental health and
overview of international environmental health surveillance systems;
a discussion of the key findings leading to the proposed Australian framework;
recommendations for the future, including potential funding options.
1.4 Definition of Terms

Presented in this section are a few definitions to clarify the meaning of specific terms used
throughout this report. Some of these terms may be defined differently by other authors or in
other contexts; however, the definitions remain consistent with those used previously in the
context of environmental health surveillance3,4,51.
Environmental health covers those aspects of human health determined by physical,

chemical, biological and social factors in the environment. Environmental health practice
covers the assessment, correction, control and prevention of environmental factors that can
adversely affect health, as well as the enhancement of those aspects of the environment
that can improve human health5,51.
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For the purpose of this report environmental hazards are any chemical or physical agents
or biological toxins that are present in the environment and which have the capacity to
produce a particular type of adverse human health or environmental effect. Examples of
environmental hazards include: pesticides, tobacco smoke (chemical agents); ionizing and
non-ionizing radiation (physical agents); and water-borne pathogens51.
Environmental exposures result when individuals come into contact with environmental
hazards such as those mentioned above. Some of these agents may be present in
air, food, water, soil, buildings or other structures. Exposures can be chronic or acute
and are often related to social, economic and cultural factors such as employment,
income, housing, race, ethnicity, types of food consumed and how food is produced and
processed51.
Environmentally related diseases refer to chronic diseases, birth defects, developmental
disabilities and other adverse health effects that may be related to exposure to
environmental hazards (i.e., chemicals, physical agents, biomechanical stressors, or
biological toxins) in the environment51.
Environmental health surveillance is the systematic, ongoing collection, integration,
analysis and interpretation of data about environmental hazards, exposure to
environmental hazards and health effects potentially related to exposure to environmental
hazards in order to prevent and monitor disease6.
Health Risk Assessment is the process of estimating the potential impact of a chemical,
biological, physical or social agent on a specified human population system under a
specific set of conditions and during a certain timeframe5.
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2 Background and Concepts

This section summarises (1) current knowledge about disease and the environment, (2)
environmentally related diseases in Australia and (3) the economic costs of selected diseases.
This summary is not intended to be a comprehensive review. Our intention is to highlight
evidence to support the scientific, economic and social rationale for developing an Australian-
wide environmental health surveillance system, which can provide the capacity to inform and
evaluate efforts by all levels of government for addressing these concerns.
2.1 Environmentally Related Disease in Australia

Most diseases are multi-factorial, resulting from a combination of genetic, environmental, lifestyle
and socioeconomic factors that act over an individual’s lifetime7,8. For many pollutants, scientists
know with some certainty that exposure to these pollutants, at sufficiently high concentrations,
can cause a variety of adverse health effects9. For other pollutants for which scientific evidence
is less conclusive, scientists can only establish an ‘association’ between exposure and health
outcomes. Some effects on health may be short-term and reversible, such as irritated eyes from
smog, whereas other effects, such as emphysema, heart disease, and cancer, are chronic and
can be fatal [9]. Some effects, for example asthmas attacks, may appear shortly after exposure,
whereas others, such as cancer, may exhibit a long lead time before the disease appears.
In the public health arena, environmental health refers to the various impacts of the environment
on health. By studying exposures to populations, relationships between exposures and health
effects become more evident. Recently there has been a further examination of environmental
causes of human disease. This stems from a growing understanding that the state of the
environment is linked to human health and well being, and that environmental degradation may
lead to new hazards and increased levels of disease10,11. In a recent report, it was estimated that
8-9% of the total global disease burden may be attributed to pollution, but considerably more in
developing countries12.
All Australian residents are affected by a number of different environmentally related diseases.
This section describes a number of diseases that are thought to be influenced by environmental
factors. The working group acknowledges that many diseases are multi-factorial and that
environmental factors may contribute to virtually all diseases. Therefore the discussion of the
diseases below has been limited to a few conditions considered important in surveillance.
Asthma
Asthma is one of the most common diseases in Australia. Overall, asthma contributed 2.6% of
all disability adjusted life years (DALYs) in Australia in 1996 and was the ninth leading contributor
to the overall burden of disease. The prevalence of asthma in Australia is amongst the highest in
the world, with 14-16% of children and 10-12% of adults having these symptoms13. Although it is
not a major cause of death, asthma is a common problem managed by doctors and is a frequent
reason for hospitalisation of children, and it is therefore a severe economic burden.
12
Cancer
Cancer is diagnosed in approximately 90,000 Australian residents each year and was the main
underlying cause of death in Australia in 2002, 2003 and 2004, causing 28% of all deaths each
year14,15. In 2003, cancer was the leading contributor to the overall burden of disease amongst
Australian residents (19%)15.
Cardiovascular Disease
Cardiovascular disease is a leading cause of death and disability, with reports suggesting it
accounts for 17% of the overall disease burden in Australia16. From the 2004–05 National Health
Survey, it is estimated that 638,000 persons currently have ischemic heart disease, which
equates to 3% of the adult population16.
Birth Defects
Birth defects are common throughout Australia; However, no nationally collated data are
available on birth defects. Based on WA statistics, approximately 5% of Australian babies are
born with a defect each year17. There is an estimated prevalence of autism-spectrum disorders
across Australia of 62.5 per 10,000 for 6-12 year old children18. This means that approximately
one in 160 children in this age group, which represents 10,625 children, present with an autism
spectrum disorder in Australia {Australian Advisory Board on Autism Spectrum Disorders,
2007 #64).
The following diseases and conditions could all be considered relevant to environmental health
surveillance:
Respiratory (Asthma/Chronic Obstructive Pulmonary Disease)
Adverse Reproductive Outcomes
Cancer
Developmental Disorders (Autism, Learning Impairment)
Diabetes
Cardiovascular Disease
Dermatitis
Autoimmune Diseases
Kidney Disease
Neurological Diseases
Food-borne Illness
Vector-borne Diseases.
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2.2 Economic Costs of Environmentally Related Diseases

Chronic diseases are among the most prevalent, costly and preventable of all health problems
{National Public Health Partnership Group, 2001 #46}. Individuals with chronic health conditions
are the heaviest users of medical-care services, incur high medical-care costs, lead to
productivity loss caused by their inability to work, and suffer premature mortality. The prevention
and management of chronic disease is considered one of the most significant challenges facing
organised health-care systems. Around 70% of the total burden of illness and injury currently
experienced by Australian residents is due to chronic diseases, and this is expected to increase
to 80% by 202019.
The most recent cost estimates attributable to disease were calculated in 2000-01.
Cardiovascular disease is the most expensive disease group in terms of direct health care
expenditure at over $5.5 billion, which represented 11% of Australia’s total allocated health
system expenditure during that period20. Health system expenditure on cancer was $2.7 billion
or 5% of all public health expenditure in Australia14. Of this cancer-related expenditure, 71% was
spent on in-patient, out-patient and day-care services14.
Nervous system disorders were estimated to cost $4.9 billion (9.9%), musculoskeletal diseases
$4.6 billion (9.2%), injuries $4.0 billion (8.0%), respiratory diseases $3.7 billion (7.5%), mental
disorders $3.7 billion (7.5%) and oral health $3.4 billion (6.9%) in Australia in 200520. These
conditions, together with cardiovascular disease, were reported to account for around $30 billion,
or 60% of total allocated health expenditure {Australian Institute of Health and Welfare, 2005
#70}. In 2000-2001, direct health system expenditure on asthma was approximately $615 million,
almost half (47%) of which was on pharmaceuticals {Australian Institute of Health and Welfare,
2005 #30}.
Table 1 shows the estimated annual cost of selected environmentally related diseases in
Australia. If an environmental health surveillance system in Australia was established to
support and inform public health activity, programs and policies to reduce the burden of these
environmentally related diseases by only 1%, the annual saving would exceed $34 million.
14
Table 1 Documented Cost of Seven Environmentally Related Diseases in Australia
Cost in 2001 Estimated Cost

Diseases EAFa
(million)b 2008 (million)c
Asthma 44%d $308 $403
COPD 42%d $1,052 $1,375
Cancer 14.5% e
$423 $553
Lung Cancer 30%f $41 $54
Leukaemia 2%f $3 $4
Cardiovascular Disease 16%f $880 $1,151

Congenital Abnormalities 5%f $1 $1 (~1.3)

Cost of seven environmentally-related diseases $2,664 $3,483

a = EAFs (environmental attributable fraction) based on estimates by WHO 21
b = cost estimate calculated by multiplying total direct cost of disease in 2001 by environmental attributable fraction

c = estimated using health price index22
d = global average EAF (developing and developed countries)
e = global average for men and women combined
f = developed country average

2.3 Health Surveillance

In general, surveillance will tell us what our problems are, how big they are, where the solutions
should be directed, how well (or poorly) solutions have worked, and whether, over time, there is
improvement or deterioration in a given condition. Surveillance is used extensively in the health
industry for both communicable and non-communicable diseases and is essential to successful
sustained public health intervention for the purpose of prevention.
Health surveillance refers to the continuous, routine and systematic collection of data related to
health or exposures of populations over the long-term, and the associated analysis, interpretation
and timely dissemination of the results23. Systematic, regular and properly integrated health
information also provides:
insights into the distribution of various diseases across population groups and geographic
regions;
underlying trends in causal and associated determinants of health;
opportunities to identify emerging public health issues; and
increased capacity to test the strength and direction of the relationship between various risk
factors (e.g., environmental hazards) and diseases in different settings.
Health Canada48 has developed guidelines for evaluating health surveillance systems that also
included an outline of the key concepts of a health surveillance system (Figure 1). This diagram
shows the transition from data collection through to dissemination of the results of surveillance
programs, which in turn leads to more informed decision making and most importantly ’action’.
15
The overarching aim of health surveillance in Australia is to reduce morbidity and mortality,
and improve the health and well-being of individuals. In the long-term, accurate and timely
surveillance data would permit public health and government agencies to determine:
existing gaps in data sources;
disease impacts and trends for the population;
gaps in policy provision at the State/Territory and national levels;
disease clusters and outbreaks at an earlier point in time and therefore minimise the public
health impact;
populations and geographic areas that are most affected by environmental hazards;
effectiveness of various public health interventions in preventing adverse health outcomes
caused by environmental hazards;
which information should be disseminated to inform State and Territory policy and program
decision making36.
Once successful, environmental health surveillance can be highly effective for informing State/
Territory and national policy decisions.
Figure 1 Key Concepts of Health Surveillance
Public,
Information Management Basic Research Professional &
Stakeholder Input
Data Collection
R Actions
Health Knowledge
E Integration • Programs Health
Surveillance Synthesis and
Q Decision Making
• Interventions Outcomes
• Policy
U
I Analysis
R
E
M Interpretation
E
N
Surveillance Applied
T Products Social &
Research & Other
S Economic
Epidemiological Considerations
Considerations
Studies
Dissemination
Management
Coordination
Legislation & Regulation
Source: Health Canada48
Figure 1 also shows that a surveillance system alone cannot provide all the answers. Research
and professional stakeholder input enhances information obtained via surveillance. Therefore, to
maximise effectiveness, surveillance systems should operate within this wider context.
16
2.4 Environmental Health Surveillance

To date, data systems established and used for surveillance in Australia have focused primarily
on either environmental indicators or health outcomes, with few linkages between the two23.
Environmental health surveillance encompasses the collection, integration, analysis and
interpretation of data about environmental hazards, exposure to environmental hazards and
health effects potentially related to exposure to environmental hazards in order to prevent and
monitor disease6.
A simplified version of the Canadian health surveillance model was initially considered for
environmental health with some adjustments to reflect two stages of surveillance. Data collection
through to dissemination was classified as “Primary Surveillance”. Knowledge synthesis and
decision making process, with input from researchers and stakeholders, was classified as
“Secondary Surveillance”. While primary surveillance programs are in place at Local Government
and State/Territory levels in the form of routine data collection, the analysis and interpretation
of these databases are often for regulation and monitoring purposes. Secondary surveillance
builds upon the results of primary surveillance and, combined with input from researchers and
stakeholders associated with environmental health, provides a greater understanding of the
issues and therefore aids decision making.
Figure 2 Primary and Secondary Surveillance for Environmental Health
Information Management
Secondary Surveillance
Data Collection
Integration
Knowledge
Primary
Surveillance Analysis Synthesis Actions Improved
• Programs
of and Health
• Interventions
• Environment
• Exposure
Interpretation Decision • Policy Outcomes
• Health Making
• Demographics Surveillance
Tools
Research Stakeholders
Dissemination Social & Economic Considerations
Majority External Agencies Environmental Health Management

Legislation & Regulation
The actions resulting from improved decision making will take place in a number of settings.
Community members will be better informed about health risks from environmental hazards,
empowering individuals with the knowledge they require to manage their own health. Local
Government will have access to information that will facilitate priority setting when allocating
resources to monitoring environmental hazards. The improved knowledge base will also allow
State/Territory Government to quantify more accurately the actual risk to the community, leading
to a risk-based approach to managing environmental health.
17
Bringing together relevant primary surveillance for the purpose of secondary environmental
health surveillance will also be valuable to stakeholders in agencies with the responsibility of
town planning, new development and the approvals process. The ability to see health information
integrated with other sources increases the potential of health being considered at all stages of
the planning process.
While the Health Canada model shows the wider context in which surveillance operates, the
California Policy Research Center describes a simpler model, clearly showing the two streams
of data collection required for environmental health surveillance (Figure 3). It also depicts how
a surveillance system aims to track hazards, exposures and health outcomes, with the aim of
linking hazard and exposure information with health information to facilitate the examination of
potential relationships between them [51].
Figure 3 Canadian Environmental Health Surveillance Concept51
• Characteristic of • Identifiable health outcome

chemicals, physical agents,
biomechanical stressors, Identity Health
and biological toxins Hazard
Outcome
• How much is used and
where?
• What is released to • Prevalence of outcome can

environment? be determined
• Amount, location and time Environmental Disease
Hazard Prevalence
• Who is exposed? • Populations can be

• What is the amount taken in identified
dose(s), place, and time? Population Population • Location and time of
• What is the exposure Exposure Affected disease
pathway?
Linkage
• Are there association between exposure/hazard(s) and
health outcome(s)?
2.5 Surveillance versus Indicators

An important part of this project was to get an understanding of the differences between
environmental health indicators and environmental health surveillance. Environmental health
indicators are measures that summarise technical information in ways that can be more readily
interpreted than the data themselves might be, particularly for policy and stakeholder audiences.
Indicators can be scientifically based but portray data about important parameters35.
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Indicators are integral to surveillance because they simplify data for relevant users and contribute
to policy relevance when implementing any change that results from information generated
by environmental health surveillance. They present an agreed interpretation and provide
benchmarks for specific environmental issues. Indicators also provide a source for determining
early success and tangible results of an environmental health surveillance system.
An environmental health surveillance system would incorporate aspects of environmental

indicator data within each State/Territory. The Victorian Environmental Health Indicator Project
[34] developed the environmental health indicator framework suggested by enHealth. The
Victorian project aimed to monitor specific environmental indicators known to adversely impact
on health. Indicators were labelled as immediately attainable, likely to be developed in the near
future, in the early stages of development or ideal but not yet feasible [34]. They were also based
on environmental categories including water quality, air quality, climate and geography, built
environment, food safety, land contamination and vector-borne disease.
2.6 Limitations of Environmental Health Surveillance

The characteristics of many chronic diseases make it challenging to link them with environmental
hazards. For example, the exact time of onset for many cancers such as breast and bowel
cancer is often unknown, which can complicate the temporal characteristics of exposure23. Long
latency periods are frequently apparent between the onset of exposure and clinical manifestation
of disease. Many diseases also differ in antecedent exposure profiles (risk factors for onset or
occurrence)23.
When examining environmental exposures, direct measurement is not always available. It is not
easy to determine relevant parameters or whether there should be threshold levels for certain
exposures. In addition, the timing of onset of the exposure is increasingly difficult to establish with
increasing mobility of individuals23.
The problems outlined above highlight the primary barrier for environmental health surveillance:
if the data on environmental hazards, exposures and disease outcomes are not of sufficiently
high quality, then the linkages and results from analysis of data will be less effective. However,
once partnerships have been established at State/Territory and national levels between health
and environmental agencies, gaps in data will become more apparent and subsequently data
collections improved.
19
3 Australian Surveillance Activities

This chapter is a review of recent surveillance activities relevant to environmental health at the
national level in Australia. It includes a description of Australian-wide health and environment
surveillance systems and demonstrates that existing surveillance programs in the health and
environment sector are focused on tracking outcomes rather than causes. There is no current
surveillance system in Australia which links these two areas of environmental quality and health
impacts.
3.1 National Health Surveillance

At the national level in Australia, there are policies, procedures and organisations responsible
for determining and monitoring components of disease, health and well-being of the Australian
population. The Australian Government Department of Health and Ageing is the key agency, with
the Population Health Division and the Office of Health Protection having existing programs and
interest in surveillance of chronic and communicable diseases, respectively.
In this section, several examples of national programs will be described. In some situations, the
primary responsibility for data collection and coordination lays with other Federal agencies, e.g.,
Australian Bureau of Statistics, or State/Territory jurisdictions.
3.1.1 National Chronic Disease Surveillance

In Australia, several forms of chronic disease surveillance occur. Included in this summary are
two examples: cancer and asthma.
Cancer registration is required under State and Territory legislation24, with registrations collated
by cancer registries that are supported by a mixture of State and Territory government and non-
government organisations. In June 1984, the National Health and Medical Research Council
(NHMRC) endorsed the concept of national collection of cancer statistics24. In April 1985, the
National Committee on Health and Vital Statistics agreed that the National Cancer Statistics
Clearing House (NCSCH) should be operated by the then-Australian Institute of Health under
the supervision of the Australasian Association of Cancer Registries. The NCSCH provides
an ongoing facility for compiling data produced by individual State and Territory registries
and identifies cross-border duplicate registrations. The aim of the NCSCH is to foster the
development and dissemination of national cancer statistics for Australia and specifically to:
enable computation and publication of national statistics on cancer;
allow tracking of interstate movement of cancer cases via record linkage so that the same
cancer case in not counted more than once;
facilitate exchange of scientific and technical information between cancer registries;
promote standardisation in the collection and classification of cancer data; and
facilitate cancer research both nationally and internationally.
20
The NCSCH primarily produces reports of national cancer incidence and mortality data.
Periodically, analyses of specific cancer sites, cancer histology, differentials in cancer rates by
country of birth, geographical variation, trends over time and survival are undertaken on an
accumulation of data that permits examination in greater depth24.
A specific example of an area in which chronic disease surveillance has been successful is in
asthma prevention. The Australian Health Ministers declared asthma as the sixth National Health
Priority Area in 1999, with a positive outcome of that initiative being the establishment of the
Australian System for Monitoring Asthma. This system has enabled the dissemination of reliable,
up-to-date and useful information about asthma.
The first baseline Asthma in Australia report, released by the AIHW in 2003, presented the most
recent statistics available and indicated the strengths and weaknesses of Australia’s existing
asthma programs, whilst highlighting potential areas of intervention.
Although not yet implemented, a chronic disease information hub is being developed by the
AIHW, under the auspices of the Population Health Information Development Group and the
work program with DoHA. This will be a Web-based information tool that will provide detailed
information about the chronic disease environment in Australia. Included in the information
hub will be details about current policy issues and frameworks surrounding chronic disease,
links to relevant sources of data, and links to information about indicators, such as the Chronic
Diseases Indicators Database25. It will also provide an on-line forum for surveillance practitioners
and others interested in data and indicator development and related activities. It will be a useful
resource for policymakers, researchers, health professionals and the general public25. The
information hub is planned to be updated frequently and it is aimed to reflect the most current
information available. A working prototype is expected to be completed during 2008.
3.1.2 National Health and Well-Being Surveillance

The National Health Survey conducted by the Australian Bureau of Statistics (ABS) is a regular
population survey designed to obtain national benchmark information on a range of health-related
issues and to enable the monitoring of trends in health over time30. The survey is conducted
triennially, collecting information about the health status of Australian residents, their use of
health services and facilities, and health-related aspects of their lifestyle30. Australia’s Health is
a biennial health report of the AIHW that has been produced since 198831. It provides a national
source of information on patterns of health and illness, determinants of health, the supply and
use of health services, and health services expenditure31. Both the Survey and the Health report
are used to monitor trends in the health and well-being of Australian residents.
In order to provide further understanding of population health status within each State and
Territory, the majority of Health Departments also conduct a health survey, e.g., the Western
Australian Health and Well-Being Survey. For the Western Australian Survey, questions have
been chosen in conjunction with experts from within the Department of Health, the TVW
Telethon Institute for Child Health Research and other jurisdictional health bodies, principally the
NSW Health and the SA Department of Health, to address national and State/Territory health
guidelines and priority areas [49]. Collaboration between jurisdictions continues to occur and has
resulted in some questions being standardised, allowing comparisons across States/Territories.
21
3.1.3 National Communicable Disease Surveillance

The Office of Health Protection within the Department of Health and Ageing has primary
responsibility for the national collation of data on notifiable diseases. Complementing this is
OzFoodNet, which is a successful demonstration of surveillance, related to communicable
disease but in some cases not directly related to cause. The work of OzFoodNet complements
that of the NNDSS.
The National Notifiable Diseases Surveillance System (NNDSS) was established in 1990 through
the Communicable Disease Network Australia (CDNA). This system co-ordinates the national
surveillance of more than 50 communicable diseases or disease groups [28]. Following a case
of a nationally notifiable disease, treating doctor(s) and/or laboratory/ies are required to notify
the State/Territory Department of Health. Notifications are made to the State or Territory health
authority under the provisions of the public health legislation in their jurisdiction. Computerised,
de-identified records of notifications are supplied to DoHA on a daily basis.
Notification data provided include a unique record reference number, State or Territory identifier,
disease code, date of onset, date of notification to the relevant health authority, gender, age,
indigenous status and postcode of residence28. The mechanism of notification varies between
the States and Territories and in some cases different diseases are notifiable by different
mechanisms28. These records are then collated, analysed and published on the Internet and in
the quarterly journal Communicable Disease Intelligence to provide feedback on, national level
data and State/Territory data comparisons to the States and Territories28.
The Biosecurity Surveillance System (BSS) Program is an initiative of the Department of

Health and Ageing to improve the surveillance, management and reporting of communicable
disease in Australia. The BSS Program consists of four different surveillance components,
including a secure communication network, an outbreak management system, an enhanced
notifiable disease surveillance system, and a sentinel GP syndromic surveillance network. Each
component serves a specific purpose and strengthens existing systems and components of
Australian biosecurity surveillance.
Key components of the BSS that have been implemented to date include: a secure
communication system, the Health Alert Network (HAN), an outbreak management system, Net
Epi, an improved Sentinel GP and syndromic surveillance system (SSS), a more sophisticated
National Notifiable Disease Surveillance System (NNDSS) and an improved data warehouse
(BSS Data Warehouse).
Work on the BSS program continues to deliver the remaining components of the BSS and
further leverage e-technologies for support of surveillance, management and reporting of
disease incidence and outbreaks in the Australian community. The Department aims, with the
co-operation of the States and Territories, to upgrade national biosecurity surveillance further by
building on, and strengthening, existing systems and components of public health infrastructure
and by identifying and closing apparent gaps in current surveillance. The project is being
undertaken by the Surveillance Branch of the Office of Health Protection.
DoHA established OzFoodNet in 2000 as a collaborative initiative with Australia’s State and
Territory health authorities to provide better understanding of the causes and incidence of
gastrointestinal and food-borne illness in the community29. It is overseen by the CDNA and is
supported by technical assistance from the National Centre for Epidemiology and Population
22
Health at the Australian National University, Food Standards Australia New Zealand and the
Public Health Laboratory Network29.
The OzFoodNet operational structure was examined closely in this study as a potential guiding
framework for the Environmental Health Surveillance System. In the OzFoodNet structure, health
departments from each of Australia’s States and Territories are funded to employ one or more
epidemiologist(s) to focus on food-borne illness surveillance29. A co-ordinating epidemiologist
in each State and Territory ensures a consistent direction and methodology for OzFoodNet
nationwide. The OzFoodNet governing team is based in the Office of Health Protection and
oversees all the activities of the OzFoodNet working group29.
Information sharing is a crucial component of OzFoodNet. Network members are expected to

communicate frequently about issues such as unexpected clusters of food-borne diseases in
Australia. OzFoodNet’s Management Committee provides strategic direction and oversight of
the network’s core work and research activities. In addition, a Scientific Review Panel provides
technical advice, and helps with the development and evaluation of OzFoodNet activities29.
3.2 National Environmental Surveillance

Mechanisms exist through which environmental monitoring occurs at Local, State/Territory and
National levels. The primary focus of environmental monitoring is to collect data on environmental
indicators and hazards in order to comply with legislative standards. Areas in which
environmental data are collated nationally include the national state of environment reporting, the
National Pollutant Inventory (NPI), and the National Air Monitoring Network.
3.2.1 National State of Environment Reporting

The National Strategy for Ecologically Sustainable Development (Objective 14.2) of December
1992 called for National State of Environment (SoE) reporting33, which led, in part, to the
production of the first SoE report in 1996. In Australia, SoE reporting occurs at national and
State/Territory levels. The National SoE report provides accurate, up-to-date and accessible
information about environmental conditions as well as trends and pressures for the Australian
continent, surrounding seas and Australia’s external territories10. SoE reporting is based on
scientific assessment of the pressures and condition of the environment and heritage. It is used
to:
report on major causal factors that are influencing Australia’s environment and heritage;
report on the effectiveness of responses designed to address change;
identify the issues most relevant to the sustainability of Australia’s environment and
heritage;
contribute to public understanding of the state of Australia’s environment and heritage;
identify relevant gaps in information;
further develop and improve the SoE reporting process; and
facilitate policy development at all levels of government.
Since 1999, Australian Government legislation mandates the preparation and tabling of
the National SoE report in Parliament through the Environment Protection and Biodiversity
Conservation Act 1999 (section 516B) which specified that:
23
The Minister must cause a report on the environment in the Australian jurisdiction to be
prepared in accordance with the regulations (if any) every 5 years. The first report was
prepared by 31 December 2001.
The report must deal with the matters prescribed by the regulations.
The Minister must cause a copy of the report to be laid before each House of the
Parliament within 15 sitting days of that House after the day on which he or she receives
the report.
The National SoE report is the major mechanism within which resource management and
environmental and heritage issues are comprehensively reported and analysed, on scales that
transcend State and Territory boundaries10. National SoE reporting is carried out at a continental
scale on the land, coastal and marine environments, and includes Australia’s external territories.
The environment and heritage are covered in eight major themes: atmosphere, land, inland
waters, coasts and oceans, biodiversity, human settlements, natural and cultural heritage and the
Australian Antarctic Territory.
The regular publishing of SoE information provides scope for changes in policy and practice
regarding environmental and heritage pressures. It also provides capacity for environmental
conditions to be tracked over the long-term10. In addition, the data from the SoE report is used to
fulfill reporting obligations to international organisations, such as the Organisation for Economic
Co-operation and Development (OECD), UN Environment Programme (UNEP), UN Economic
and Social Commission for Asia and the Pacific (ESCAP), Convention on Biological Diversity,
Framework on Climate Change Convention (FCCC), Montreal Process for forestry reporting and
World Meteorological Organisation (WMO)10.
3.2.2 National Pollutant Inventory

The National Pollutant Inventory (NPI) is a co-operative program implemented by the Federal,
State and Territory governments that provides the community, industry and government with
information about substance emissions in Australia34. The NPI shows emission estimates for 93
toxic substances and the source and location of these emissions. One of the main goals of the
NPI is to encourage facilities to reduce substance emissions and decrease waste. Reporting
facilities have the option of reporting on cleaner production activities and pollution control
developments that they have undertaken during the reporting year. Since NPI reporting started,
1245 facilities have provided information on their emission reduction activities33.
3.2.3 National Air Quality Database

The Bureau of Meteorology (BOM) is currently developing a National Air Quality Database to
monitor ambient air quality in Australia. The BOM will collate air quality monitoring data from
each State and Territory based on National Environmental Protection Measures (NEPM) for
ambient air quality as determined by the National Environmental Protection Council (NEPC). The
database will be updated by the BOM each year and access to the data will be governed by the
BOM. Data will be available to relevant stakeholders for research and surveillance purposes. This
project is still in the initial development stages and at present only data from Western Australia
has been collated into the national database.
24
4 International Environmental Health Surveillance

In this section, an overview of progression in North America, Europe and Asia towards
environmental health surveillance is provided. The results of this review led to a selection of
systems that were examined in further detail. This detailed evaluation can be found in
Appendix B.
4.1 North America
4.1.1 USA
In California in October 2001, Senate Bill 702 declared the legislature’s intent to establish an
environmental health surveillance system for the state. This was the first program of its kind to be
developed in North America and was proposed in close consultation with the Centers for Disease
Control and Prevention (CDC). At the same time, as the State of California was examining
the feasibility of linking environmental and health data, the CDC were seeking to establish the
foundations for a National Environmental Public Health Tracking Program (EPHT). This project
idea came after a health commission report was released indicating that there was a lack of co-
ordination in public health when dealing with environmental health threats in the USA. The EPHT
program was envisaged as a multi-disciplinary collaboration that would involve the ongoing
collection, integration, analysis, interpretation and dissemination of data from environmental
hazard monitoring, human exposure surveillance and health effects surveillance37.
The CDC was given initial funding by Congress of $17.5 million in early 2002, in order to
establish the tracking program. They used the initial resources to fund 17 states, three local
health departments and three schools of public health to begin development of tracking networks
and to expand capacity in environmental public health at state and local levels6. The idea was
first to develop state environmental health surveillance then attempt to link state data through
a national surveillance network. In addition, the funding provided to state environmental health
tracking was planned to create demonstrations of successful projects, in order to secure
sustainable funding from the National Congress. Over the past six years, each state has been
given autonomy to develop environmental health tracking, with some guidance from the CDC.
The primary focus has been on establishing formal relationships between environmental and
health agencies and trying to collate disparate data sets.
More recently, the CDC has developed the Tracking Network, an on-line database of information,
which forms the cornerstone of the tracking program. The Tracking Network was scheduled
for implementation in September 2008. It contains information to be able to be disseminated
throughout the national network to public health professionals, assisting in improving
environmental health policy and practice37. The Tracking Network is currently being implemented
through the National Network Implementation Plan (NNIP)37.
25
4.1.2 Canada
In Canada the focus of surveillance has been on data sources. In 2001 an assessment of
the current state of environmental and occupational health (EOH) surveillance in Canada
was commissioned by the Federal, Provincial and Territorial Environmental and Occupational
Health Surveillance Working Group (EOHSWG) [38]. The assessment report, Strengthening
Environmental and Occupational Health Surveillance in Canada, concluded that there was a
need to improve national EOH surveillance. One initiative resulting from the report’s findings
was the compilation of an inventory of federal, provincial and territorial environmental and
occupational health data sources that would be helpful for surveillance purposes38.
Subsequently, work on the inventory began in 2001 under the auspices of the EOHSWG as
an essential initial step in building national EOH surveillance capacity in Canada. The needs-
assessment stage of this work included the determination of which data sources currently exist in
the area of environmental and occupational health. Most of the databases listed in the inventory
contain environmental monitoring data and/or health surveillance data38. The monitoring data
gathered on environmental conditions can be overlaid with data on health outcomes to provide
information on the linkages between environmental hazards and human health.
4.2 Europe
The European Environment and Health Information System (ENHIS) is an indicator-based
system introduced in 1994. The idea of bringing health and environmental data together arose
after a meeting of European Union health ministers who realised there was insufficient data on
these parameters in East and West Europe, post-communism. The ENHIS project involves 53
Member States of the WHO European region who work collaboratively under the guidance of the
WHO. ENHIS uses a core set of indicators, selected on the basis of relevance and availability of
data, describing environmental exposures, health effects and policy measures for these issues.
These indicators are also intended to help in monitoring and evaluating progress made towards
national and international commitments made by countries.
In many European countries, methods and standards of assessing the impact of environmental
hazards on human health still need to be established or improved. As a result, ENHIS was
established to form a harmonised and evidence-based system to support public health and
environmental policies in Europe. The system enables users to:
use scientific information on public health and the environmental conditions in particular
countries;
monitor the health and environment trends in particular countries and evaluate the
effectiveness of relevant policies;
make comparisons of these countries’ progress towards the targets set in the Europe-wide
action programs; and
exchange knowledge and good practices to benefit public health and the environment
throughout Europe.
Through establishing a comprehensive Europe-wide database, ENHIS assists countries in

building their capacity to operate and upgrade existing national monitoring systems, and fosters
participation in international networks in order to improve integration of health aspects in other
policy areas39. The ENHIS project has recently narrowed its focus to children’s health in project-
specific analyses. For further information on ENHIS, refer to Appendix B.
26
Surveillance activities within European countries are more detailed and reflect changes
across local authorities. These programs tended to be based on routinely collected data on
environmental hazards. Health statistics are included when they are publicly available data and
where known associations between the two have already been established. For example, Czech
Republic regularly publishes blood lead levels of children40, because the data are available and,
historically, environmental factors have been associated with high levels of lead in children.
When surveillance programs are located in government institutions with the role of conducting
surveillance rather than monitoring hazards, there is further emphasis on analysis of data beyond
the creation of indicators. The French Institute for Public Health Surveillance41 is a government
institution reporting to the Ministry of Health. Here all health surveillance activites are combined,
including infectious disease, occupational health, chronic diseases, injuries and environmental
health. As well as scientific units, there are corporate services to support the scientists in the
areas of communication, documentation, finance and human resources.
The Netherlands have an independent Institute of Public Health and the Environment which is
commissioned to conduct environmental monitoring and provide the technical infrastructure for
surveillance on behalf of the Ministry for Health, Welfare and Sport, and the Ministry for Housing,
Spatial Planning and the Environment50.
The most comprehensive modelling of environmental health issues is being conducted in the
United Kingdom, by the Small Area Statistics Unit at Imperial College in London. One of the
differences between this program and others in Europe is that data analysis and collection is
based on routinely collected health data, and environmental information is sought on a project-
by-project basis. This has been resource intensive and required close arrangement between the
University and the Federal health body, the National Health Service (NHS).
The Environmental Health Surveillance System for Scotland (EHS3) has been funded by the
Scottish Executive since 2003. While managed within the Health Protection branch, data is
provided from a range of agencies including local authorities, Scottish Water and the Scottish
Environmental Protection Agency. At this stage, EHS3 presents information on environmental
indicators with data not yet linked to health. This information is presented in Health Protection
Scotland’s weekly newsletter.
4.3 Asia
The majority of countries in Asia are still developing and therefore have a much lower standard
of living and standard of health than Australia. The disease burden in Asia has historically been
attributable to communicable diseases and therefore the basic priority of environmental health is
on minimising and monitoring these diseases.
One monitoring program that includes parts of the Asian region is the International Emerging
Infections Program (IEIP). The IEIP is a core component of the CDC’s Global Disease Detection
Program and, as of 2007, included five member countries (China, Egypt, Guatemala, Kenya and
Thailand). The program serves as an international and national resource for global infectious
disease surveillance and response.
27
Currently, IEIP sites incorporate five core activities:

Disease surveillance
Outbreak support
Public health research for disease control and prevention
Training and capacity building
Networking with other IEIP sites.
Specific goals of the IEIP include conducting emerging infectious disease surveillance and
research, providing diagnostic and epidemiology resources when outbreaks occur, training
local scientists, serving as platforms for regional infectious disease control activities, and
disseminating proven public health tools. Although the IEIP benefits developing countries in
Central America, Asia and Africa, the focus of the program is still on protecting the USA from
emerging threats.
Recently, there has also been a move to establish non-communicable disease surveillance.
Recognising the importance of setting up a simple, inexpensive, reliable and sustainable
system of non-communicable surveillance in South-East Asia, a workshop was run by
the WHO South-East Asia Regional Office in 200243. The WHO facilitated the initiation of
national non-communicable surveillance networks in six member countries: Bangladesh,
India, Indonesia, Nepal, Sri Lanka and Thailand. National workshops held in these countries
established consensus on the need to develop a strategy and plan of action for surveillance
of non-communicable diseases and their risk factors43. The member countries have also
begun to assess their own national surveillance capacity and identify requirements for regional
collaboration. At an inter-country consultation convened in Yangon (Myanmar) in August 2002,
the regional strategic plan for integrated disease surveillance for South-East Asia was drafted.
The participants at the meeting recognised the emerging problem of non-communicable disease
in the region and recommended incorporating non-communicable disease surveillance within
their national health information systems43.
It has also been recognised that establishing surveillance of common risk factors for major
non-communicable diseases in the region is a worthwhile and feasible aim for the WHO and
member countries. Non-communicable disease risk factor surveillance would provide vital
input into regional health information systems and assist countries in establishing a regional
network for non-communicable disease surveillance health planning. Member countries are
currently supported in adapting the STEPwise approach; a framework of non-communicable
disease risk factor surveillance developed by the WHO with the aim of providing standardised
materials and tools for collection of risk-specific health data that predict the major chronic
diseases. Demonstration projects for evaluating the feasibility of implementing the STEPwise
approach have been completed in some of these countries. For example, Indonesia has
already incorporated the STEPwise approach successfully at the national level. Although some
projects and programs are underway in environmental health surveillance in Asia, the tracking
and monitoring of environmental health issues are still relatively under-developed and under-
resourced compared with North America and Europe.
28
4.4 Summary of the Review

Australia’s current national health and environmental monitoring systems illustrate that data
collation already takes place within specific topic areas, but that, importantly, there is limited
cross-organisational collaboration between agencies. At present, environmental and health data
are only linked through isolated academic research projects, such as asthma and air pollution,
rather than on an ongoing, sustainable basis. At this point in time, environmental health branches
do not have the resources or time to develop stand-alone surveillance systems. There is now a
chance to influence the development of other national systems to gain efficiency by building a
resource for all States and Territories to use.
Environmental health surveillance is a relatively new topic on the global environmental health
agenda and Australia can learn from the successes and failures of systems in North America
and Europe. Common to all successful programs was a joint commitment between the realms of
health and environment, often at the Federal level. Technical solutions varied but all programs
were using the Internet as a medium for communication.
Spatial software was also a feature of several programs as it can cope with the overlaying,
analysis and visualising of disparate environment and health information. At the same time links
with the research sector are considered valuable for guiding appropriate analyses and building
up the capacity of each country to model such complex relationships.
A key component of the US surveillance program is collaboration with national biomonitoring

programs. Biomonitoring is the direct measurement of environmental chemicals or metabolites
in human specimens (such as blood or urine). It is a way of measuring internal dose rather than
an external source of exposure. It is a powerful tool although at the same time an expensive
program to establish, and involves a potentially invasive testing procedure.
Initial consultation with research groups and environmental agencies indicates that there is
movement within Australia to conduct human biomonitoring beyond clinical trials and localised
projects. Environmental health groups across Australia should engage with these experts and
look at the most effective means of achieving a presence in this emerging science.
Differences between the established programs were primarily found in the data collections. The
currency, geographic resolution and timeliness varied greatly between the programs examined.
The table below outlines the most common health and environmental hazards included in
national surveillance programs examined.
Table 2 Environmental and Health Factors Common to International Surveillance

Programs in Europe and North America
Air Pollution Childhood Lead
Drinking Water Birth Defects
Toxic Sites Hospitalisations
Radiation Cancer

29
In Australia’s favour is our smaller population and high quality of health data. However, the size
and diversity of Australia’s geographic and environmental regions pose increased difficulty in
terms of the geographical relevance of national data. Environmental hazards in one part of
Australia may differ substantially from those in other areas of Australia.
In conclusion, the benefits in terms of informed policy development across States and Territories
and the advantages in terms of identification of gaps in data collection outweigh the limitations of
such a system.
30
5 Australian Environmental Health Surveillance

National surveillance of environmental health issues in Australia will require both partnerships
and technical solutions. To invest in one without the other will almost certainly result in failure.
The variety of issues included and the level of detail required must be weighed against the effort
needed to establish commitment from all partners. Choosing a ‘system’ for Australia begins with
choosing the optimum partnership framework.
The type of technical solution and data required will depend on the number of agencies that are
willing to work towards the long-term vision. This section describes the choice of partnership
frameworks, recommending the best option for environmental health today, and outlines issues
around implementation such as timeframe and investment. Cross-agency involvement will be
a strength and advantage of this surveillance system over others that currently exist within the
Australian Health sector.
5.1 Partnership Framework Options

Partnerships must go beyond the existing one between State/Territory and Federal
Environmental Health Branches. State/Territory Environmental Health Branches are not
responsible for all of the information required for long-term surveillance in this field. These
branches are not able to provide health information for the purpose of surveillance, and hazard
data is often limited to drinking water and food safety. Whilst it would be interesting to compare
these hazards across State/Territory borders, the long-term benefits will be restricted without any
health information gathered on the same scale.
Extended partnership can involve a range of agencies and there are three feasible frameworks
to consider for Australia: Federal, State/Territory, or an all-encompassing Federal, State/Territory
and Local framework. Figure 4 shows the various agencies involved.
31
Figure 4 Partnership Frameworks for Australian Environmental Health Surveillance
Agency
Health Other
Surveillance Branch Population Environment, ABS, BOM,

Federal Environmental Health
Health Climate Change
Government
Health Info, Collections,

Environment, Water, Planning,
State Environmental Health Cancer, Comm Disease,
Resources etc
Epidemiology etc
Planning, Community Services

Local Environmental Health
etc
Federal Focus
State Focus

Federal, State and Local Involvement
ABS = Australian Bureau of Statistics

BOM = Bureau of Meterology
5.1.1 Federal Surveillance

Federal government agency partnerships can be formally established to ensure that information
relevant to environmental health issues, which is currently part of other Federal-level surveillance
activities, is collated and disseminated on a regular basis. The advantage of this approach is
that a tangible result can be achieved in a shorter timeframe with minimal imposition on data
custodians in State/Territory and Local Governments. Although currency of the data will be in
some cases several years behind, the output will be targeted towards policy advisors, agencies
external to health and environment, and the general public.
5.1.2 State/Territory Surveillance

The State/Territory partnerships proposed in this framework include other sections within State/
Territory Health Departments which are responsible for data collections, such as hospitalisations,
births, cancer and mental health registries. Whilst there will be some overlap between what
each branch is already providing towards existing national surveillance (e.g., communicable
diseases), relationships must be formalised so that consideration can be given as to how useful
each dataset is for environmental health purposes. In this situation, a link with those responsible
for data collection and management will prove valuable, even if State/Territory data is sourced
Federally.
32
There will also be circumstances in which the sharing of information between State/Territory
Agencies will need to occur on a finer resolution in time or space. For example, cancer statistics
are currently reported annually for each Statistical Local Area (SLA) and environmental health
may require monthly information by suburb for a particular cancer type. Including State/Territory
Cancer Registries as partners in the environmental health surveillance program will increase the
chances, in the future, of obtaining a more detailed breakdown of statistics, which currently only
happens on an ad-hoc basis.
A significant proportion of environmental monitoring is conducted by a number of State/Territory

Agencies. There are times when their work priorities and resources are driven by health
concerns, whether real or perceived. Partnerships between agencies such as Health, Water,
Planning, Resources and Environment, are at times formed under stressful circumstances
following a disaster or community-instigated investigation. Pre-emptive discussions for the
purpose of improving surveillance and the ability to measure these health concerns will be to
everyone’s advantage and should lead to a positive outcome.
A State/Territory surveillance system which gathers data from other agencies that operate
at the State/Territory level is the first step towards a successful national program. Research
into overseas systems has shown that programs with both environment and health agencies
committed to the long-term goal have been successful. Once this framework is in place,
consideration can be given to sharing this information across State/Territory borders and for
examination at the Federal level.
5.1.3 Federal, State/Territory and Local Surveillance

Previous work in the field of surveillance and indicators for environmental health has highlighted
the valuable contribution made by Local Government Environmental Health Branches. As
the close connection to local communities and local issues, they are already conducting
primary surveillance on a daily basis. State Environmental Agencies will be required to lead
Local Governments towards the long-term goal of making this primary surveillance available
for national surveillance. There are numerous efforts underway in Australia that will be
considered part of any future surveillance program. In the meantime, communication to all Local
Governments on State/Territory and Federal advances towards national surveillance should be a
priority.
The ultimate solution (one that some members of the public may believe is already in place) is for
primary data collections from all agencies, including Local Government, to be passed via secure
electronic means to a Federal surveillance system. Our investigations have found that this will
be challenging to achieve in the short-term. The technology is now available, but government
agencies and the public must be reassured that their data is not being misused. In some
circumstances, programs must be enhanced or widened in order to be considered useful.
The Australian surveillance system will take a staged approach to achieving this goal. Initially
a hybrid between the Federal and State surveillance partnership frameworks is suggested until
such time, likely up to two years, that data is available to be shared via electronic means. The
longer term vision of delivering a network of expertise across Australia as well as the technology
to view and interpret information on environmental health issues is closer to five years into
the future. The long-term aim is for the surveillance program to move from development into
production, ultimately being a system that requires only updating and maintenance. This
33
surveillance system is expected to evolve over time. As co-operation between partner agencies
and data standards improve, additional indicators and datasets will become available.
5.2 Planning Stage

The first stage of a surveillance system for environmental health will be the creation of a detailed
project plan. It will be developed in close consultation with the advisory groups and will provide,
in detail, the approach that Federal and State surveillance will take, ensuring that the two are
complementary and able to connect when the time is right.
Initial observations, based on the evaluation of international surveillance systems in this field,
are outlined below. It is expected that the planning stage will determine the requirements of
all stakeholders and data custodians, and allow planners to organise the scope of the project
accordingly.
5.2.1 Federal Focus of Planning Stage

Coordinating formal data-sharing agreements for those datasets which are not publicly available
should be considered a priority at the Federal level. Relationships between Federal Environment,
Water, Heritage and the Arts will be important in order to identify synergies in surveillance
activities and raise awareness of environmental health at the highest level.
It would also be reasonable to expect a Federal-based environmental health surveillance project

to identify statistics/indicators associated with existing Federal surveillance programs, as well as
listings of research papers and studies that are relevant to environmental health issues. These
can be collated into a user-friendly format, such as those produced by the WHO in Europe (see
Appendix C for an example), which will provide a starting reference point for other agencies
in the field, as well as policy officers throughout government departments. While DoHA will
coordinate this task, staff will need to work closely with each jurisdiction to build up a resource
that will complement any more detailed data collections in the future.
5.2.2 State/Territory Focus of Planning Stage

Each State/Territory will have a strong focus on partnership development and, where possible,
establishing formal data-sharing agreements between State/Territory agencies for a limited
number of environmental health issues. This will require preparation work to ensure that all
States/Territories are putting their efforts into gathering information consistently. The planning
stage will need to identify useful outputs for each level of stakeholders and the most appropriate
format of dissemination.
With a stronger emphasis on data provision, the planning stage will devote increased resources
and time towards establishing an inventory of data within each State/Territory. It will address for
each data set related to an environmental health issue of interest, the following detail:
Timeframe of collection
Geographical resolution
Privacy concerns
Gaps in coverage
Data formats.
34
There has been considerable work in both Victoria and South Australia addressing this aspect
of surveillance. A small team of experts with experience in this component could form a working
group to identify priority datasets common across majority of States/Territories. The Victorian
Environmental Health Indicators report34 lists the following content areas as being immediately
attainable across all jurisdictions:
Water quality
Air quality
Climate and geography
Built environment
Food safety
Land contamination
Vector-borne disease.
The planning stage will also allow each State/Territory to liaise closely with Local Governments
to ensure that the primary data collections are appropriate for surveillance purposes, and
most importantly, that the surveillance system will deliver information that either enhances or
complements their existing work programs. A workshop held in June 2008 began to address
what Local Government requirements may expect (see Appendix D for workshop notes). The
workshop highlighted the following points:
disseminating information via a Web-portal is an opportunity to educate Local Governments
on the priorities for environmental health at national and State/Territory levels;
one agency should develop a template for a Web-portal that can be used across all
jurisdictions in Australia and be careful not to duplicate or replace existing Intranet and
Internet sites for the State/Territory Environmental Health Branches;
conceptual decision-making tools that allow comparisons between disparate environmental
health themes (e.g., food safety vs. air quality) in a qualitative manner can assist,
particularly when detailed data is unavailable;
two-way flow of information was important; State/Territory agencies have valuable data and
knowledge that should be shared with Local Government and vice versa;
meta-data collection of past and present projects of relevance to environmental health,
referenced in both space and time would be useful;
finest resolution of data should be collected and varying levels of secure access granted to
end-users (rather than pre-defined boundaries);
A relatively small team of State/Territory environmental health surveillance experts can work
on the identification of data indicators and technical solutions. For the more intensive task of
managing data collection and maintaining communication with the Federal environmental health
surveillance activities, each State/Territory will require a staff member assigned to surveillance on
a full-time basis.
5.2.3 Building Analysis Capability and Pilot Projects

Experience in the UK and USA has shown that the amount of effort and resources spent on data
collation and creation of standard indicators should match the amount of effort directed towards
building the capability to analyse environmental health issues appropriately. Sound analysis
methods and robust assessment tools are necessary for a surveillance system to produce the
35
evidence required to inform policy development and guide management in decision making.
It is important to move beyond reporting indicators on each aspect of the environment and
disease of interest so that this surveillance system can deliver more than each agency can do
separately. The terminology may vary: value-adding – enhancement - assessment - analysis;
however, the need to transform data into evidence via analysis is universal across government
agencies.
Initially it is proposed that the surveillance program will support pilot projects that focus on
developing skill sets in the analysis of environmental health issues. Pilot projects have been
identified as an essential aspect of environmental health surveillance in Australia. There are
two ways in which pilot projects can benefit the objectives of a surveillance program: firstly, to
build trust between data custodians by demonstrating responsible management of what is often-
complex data; secondly, to assist with providing advocacy materials for the surveillance program
that highlight the benefits of environmental hazard and exposure, and outcome modelling.
Support should be given to pilot projects that can demonstrate the benefit of multiple State/
Territory involvement. It is expected that a pilot project involving several States/Territories is
likely to be around a known environmental health risk. Consideration should also be given
to demonstrating how a surveillance system can help identify gaps in information required to
establish a relationship of emerging importance.
Two examples of existing projects that demonstrate cross-agency collaboration as well as

detailed assessment techniques are from Western Australia and Queensland:
The Mosquito Monitoring Program which is implemented through the Department of Health
in Western Australia involves cross-agency integration between Environmental Health,
Communicable Disease, Local Governments, Bureau of Meteorology and the University of
Western Australia.
The Clean and Healthy Air for Gladstone Project is a Queensland Government initiative,
established to gain a better understanding of air pollution in the Gladstone area, and
to identify any potential associated risks to public health. The two-year project is being
conducted by the Environmental Protection Agency (EPA) and Queensland Health (QH),
working in consultation with the community and industry.
5.3 Management Structure

For the program to start and continue at both Federal and State/Territory levels of Government,
this program should be managed by the Environmental Health Section within the Office of Health
Protection at the Australian Government Department of Health and Ageing (DoHA) (Figure 5),
with close liaison with the Surveillance Branch within DoHA. The Surveillance Branch has an
existing technology infrastructure that may be considered useful in the future, as well as an
interest in accessing environmental monitoring data for existing surveillance programs. The
Environmental Health Section can assist, with its close relationship to Federal Environmental
Agencies and its vested interest in national surveillance of the issues within their portfolios.
The structure must also encourage all States/Territories to work in a collaborative manner and
ensure that data is being collected in a consistent manner. Such a role should be undertaken by
a small team from one or several States/Territories, known as the Operational Office. Beyond
ensuring State/Territory participation, this office will also have the task of sourcing external
36
funding if required, managing a data content/indicators working group, and developing generic
software solutions to be implemented for all State/Territory EH Agencies.
Finally, a position in each jurisdiction will have the task of developing cross-agency partnerships
at the State/Territory level. It is expected to be a challenging and intensive role and crucial to the
future success of the program. Similar models in Australia, such as CDNA and OzFoodNet, have
proven the advantage of having State/Territory-based positions when the source of information is
from numerous State/Territory-based organisations.
Figure 5 Proposed Management Structure for National Environmental Health

Surveillance
‘Links’ to existing Federal

Surveillance
Surveillance Expertise National Department of Health and Ageing
Coordination Policy Relevance
Office of Health Protection
enHealth
Sourcing External Funding, Management of pilot

Advisory Group, Juridictional
projects, State Software IT development, Liaison
Support, Result Dissemination
Officer Across State Health and Environmental
EH
Surveillance
Operational
Office
TAS NSW VIC WA NT ACT QLD SA

EH Surv EH Surv EH Surv EH Surv EH Surv EH Surv EH Surv EH Surv
5.4 Implementation Considerations

Throughout this study, there has been across-the-board support on the subject of surveillance,
and excitement over its long-term potential. It was also encouraging that all parties could relate
to the issues around implementation of such a large-scale program. This section gives a broad
overview of how Australia might begin to develop a sustainable surveillance program, highlighting
the immediate benefits to managers in environmental health.
5.4.1 Investment Options

Within Government, investment should ideally come from a range of agencies or Treasury
Departments, given the improvements to all government functions that will be the long-term
outcome of environmental health surveillance. However, in the short term, funding from the
Departments of Health and Departments of Environment at the State/Territory and Federal
levels will be sought for capacity building (approximately $250,000). Within 2 years from now, a
long-term commitment will be sought for the five-year implementation stage. The exact amount
is difficult to estimate but similar programs overseas have required more than $5 million for
the implementation stage and additional regular funding to secure the program and enable a
continued search for emerging issues in environmental health.
37
5.4.1.1 External Collaboration

There is potential for the surveillance program to seek opportunities from initiatives that
encourage governments to participate in research activities with a national focus. Two examples
include:
National Collaborative Research Infrastructure Strategy

The Government announced in 2004 that the National Collaborative Research Infrastructure
Strategy (NCRIS) would be implemented to provide greater strategic direction to Australia’s
investment in research infrastructure. One of the nominated research capability areas of this
strategy, and that most relevant to environmental health surveillance, is Population Health and
Clinical Data Linkage.
Co-operative Research Centres

The Co-operative Research Centres (CRC) Programme was established in 1990 to strengthen
collaborative research links between industry, research organisations, educational institutions
and relevant government agencies. Since the start of the Programme, at least 158 Co-operative
Research Centres have been established. Environmental health surveillance is relevant to
several industry sectors:
Medical Science and Technology (Asthma and Airways)
Agriculture and Rural Based Manufacturing (Australian Biosecurity CRC for Emerging
Infectious Diseases)
Information and Communication Technology (Smart Internet Technology, Spatial
Information)
Environment (Water Quality, Bushfires).
5.4.1.2 Government Sources

The fundamental first step of any surveillance program, of building the required partnerships,
is unlikely to appeal to programs with a strong research focus. This is the responsibility of
Government and as such the resources to facilitate its development should be considered by
both Federal and State/Territory Departments. Potential pathways to explore include:
Submitting a proposal for funding from the Federal Health and Environment Budgets;
Extending existing Australian Government surveillance budgets to encompass
environmental health aspects;
State-Territory initiatives that give financial incentives to agencies that can demonstrate the
efficient use of electronic data sharing across agencies.
5.4.1.3 Potential Risks

This study has also identified several areas of concern that must be considered and managed
well from the beginning of a surveillance program in environmental health. These are outlined in
the Table below.
38
Table 3 Summary of Potential Risks

Area of concern Level of Risk Comments
All data to remain within Health Department and
experience with data linkage has shown that
Privacy laws Low
facilitating secure access to information decreases
breaches of privacy.
Surveillance in this area has to be a priority for all
Change in political tiers of government and political parties given the
Med
priorities long time frame beyond 5 years. Advocacy to all key
stakeholders is important.
External funding may result in a loss of control over
Sustainable funding High the project and minimal focus on partnerships. These
programs can be short term and technology focused.
Recent IT developments have proved that data
Technical solution
sharing of spatial information is achievable via the
delivering required Low
Internet. including complex analysis tools, will be
functionality
more challenging.
With a high profile there is potential for the public and
Managing decision-makers to have un-realistic expectations
Med
expectations around the analysis and assessment of the data
collected.

5.4.2 Benefits to Environmental Health

The long-term benefits to Environmental Health Branches have been highlighted in this report.
However there are also immediate operational benefits to each State/Territory Environmental
Branch. These include but are not limited to:
Accessing a nation-wide network of experts via official means rather than relying on
personal relationships or single-points of reference.
Cost savings in time and resources spent investigating public queries. Simple questions
about health and the environment often take months to answer and can result in pressure
from media and the public. Improving access to data sources from the Health and
Environment Departments will go a long way to improving working conditions for all in this
field.
Prioritising the monitoring of long-term trends. Currently environmental health staff spend
a lot of time on acute incidents such as hazardous chemical releases or point-source
pollution. Surveillance will facilitate the monitoring of long-term trends and apply science of
assessment and epidemiology to detect environmental causes of illness, thus putting acute
incidents into perspective.
39
5.4.3 Timeframe
It is also important that all parties understand the long timeframes involved in order to
achieve true and complete surveillance at the national level. There must be a strong focus on
partnerships initially, followed by several years of technology development and implementation.
Figure 6 gives a summary of the timeframe associated with the effort, investment levels and
increasing benefits of implementing a national environmental health surveillance program. The
reality of surveillance of environmental health is that it will continually evolve over time and will
need to have the flexibility to add emerging diseases and incorporate improved monitoring.
Figure 6 Development Timeframe for National Environmental Health Surveillance
Investment
Benefits
Technology
Partnership
2010 2012 2014 2016 2018 2020 ...
40
6 Recommendations
The primary recommendation of this feasibility study is that the Australian Government should go
forward and establish the framework for all levels of government to participate in environmental
health surveillance. A strong relationship needs to be forged between all levels of government
and across numerous disciplines, coming together with optimism for a greater understanding of
the complex relationship between environmental hazards and adverse health conditions.
Health and environmental agencies are now managed by separate government agencies and
often separate State/Territory and Federal Ministers. Whilst this has been seen as a major
obstacle in the past, a review of existing surveillance programs overseas has shown that this
envisaged problem can be overcome. At a local level, communication takes place between
officers and researchers on specific projects; however, formal agreements to share valuable
monitoring data for national and on-going consideration are missing.
The detailed evaluation of programs also highlighted the benefits of investing in a long-term
solution. High level indicator-based programs through to the level of detailed Local Government
data sharing have resulted in immediate savings in the time taken to respond to public queries,
improved communication between agencies and facilitated further research into the links
between hazards, exposures and health outcomes. The time has now come to build towards this
long-term vision. In order to bring Australia closer to a comprehensive surveillance program, the
recommendations below are to be considered.
6.1 Recommendation 1 – Commitment from enHealth and the

Australian Health Protection Committee (AHPC) to Support
The support of Health agencies at the State/Territory and Federal level is crucial to the success of
environmental health surveillance. The enHealth provides national leadership on environmental
health issues, sets priorities, coordinates national policies and programs and provides a pivotal
link between international forum and environmental health stakeholders in Australia. The
Australia Health Protection Committee (AHPC) provides advice to Australian Health Ministers’
Advisory Council on Australia’s preparedness for health emergencies and approaches to address
any deficits and to coordinate the national health response to significant incidents. Without
formal recognition of the national environmental health surveillance project from both of these
organisations, any further work on the subject remains an academic discussion, without a real
opportunity to engage other agencies or build a system with any long-term vision.
6.2 Recommendation 2 – Formalise Partnerships between

Environmental and Health Agencies
All jurisdictions and associated agencies consulted as part of this project have expressed their
support for surveillance in this field to be established. It is important that existing reference and
working groups continue to function and increase the level of contribution with regular workshops.
Extending the involvement of each State/Territory, representatives will be asked to formalise
41
within-State/Territory relationships by establishing data-sharing agreements with environmental

agencies where appropriate.
This recommendation will also involve further development towards identifying key environmental
health indicators at the Local and State/Territory level. Close collaboration with the South
Australian and Victorian Environmental Health Branches, which have both begun to address the
indicator requirements in environmental health, will ensure that a knowledgeable working group
will progress this key component of a surveillance system.
Finally, close partnerships with individuals and/or organisations that are capable of modelling
environmental hazards, exposed populations and adverse health outcomes must be maintained.
The program must also encourage researchers studying in this field to explore the subject of
surveillance in order to meet Australia’s future need for experts within the system.
6.3 Recommendation 3 – Prepare a detailed Environmental

Health Surveillance Project Plan and Pilot Project
Having established that this project is feasible and worth further investment, preparation should
be initiated of a detailed plan for an environmental health surveillance program, to be undertaken
by DoHA-funded project officers. The project plan will be developed in close consultation with
those stakeholders identified as partners and will guide the development of a national system.
It will take into consideration both existing surveillance programs as well as national technical
initiatives in the health and environment sectors. This project plan should include a scan of
available datasets and also provide an opportunity to develop appropriate data management
procedures.
It is also recommended that a pilot project be run in parallel, demonstrating surveillance of

one or more nominated national environmental health issue/s. The results will be improved
communication between all parties and a tangible solution that clearly shows the path from data
collection, integration, analysis and dissemination of results to key stakeholders.
6.4 Recommendation 4 – Sustainable Funding Arrangements

The project team should consider the sustainability of a national environmental health
surveillance program. It will depend on long-term financial support and a management structure
which crosses all levels of government and jurisdictions. Collaboration arrangements will have
the advantage of securing commitment and raising the profile of these important issues with the
organisations responsible for the management of hazards.
The time is right on many fronts. The public’s awareness has increased sufficiently to enable
their understanding of why it is necessary to invest in such an important area of public health. If
establishing trust and formal agreements between all parties for the purpose of environmental
health surveillance is not a priority for this government, the same restrictions will exist in perhaps
20 years from now, with a consequent substantial decrease in the general level of public health.
42
7 Conclusion
There is no time to delay. The sooner we start, the sooner we could have an explanation for
adverse health conditions, such as birth defects, childhood allergies and the cause of cancer.
Every resident in Australia stands to gain from this major investment in an environmental health
surveillance program. If this opportunity is not taken, there is a risk that the rest of the World
and individual Australian States and Territories will have advanced too far in other directions for
coordination across Australia to be worth consideration.
43
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Appendix A
Western Australian Reference Group
Name Position Organisation

Jim Dodds Director, Environmental Health Directorate Department of Health WA
(EHD)

John Hardy Manager of Science and Policy, EHD Department of Health WA

Narelle Mullan Principal Project Officer, Science and Policy Department of Health WA
Unit, EHD
Dr. Chantal Ferguson Public Health Registrar Department of Health WA
Di Rosman Manager, Data Linkage Unit Department of Health WA
Dr. Jim Codde Director , Public Health Intelligence Department of Health WA
Alison Daly Manager, Health Outcome Assessment Unit Department of Health WA
Dr. Jane Heyworth Sub-Dean, Faculty of Medicine, Dentistry & University of Western Australia
Health Sciences
Dr. Lin Fritschi Associate Professor WA Institute for Medical
Research
Dr. Andrea Hinwood Senior Lecturer, School of Natural Sciences Edith Cowan University
Rod Nowrojee Manager Spatial Services Environmental Protection
Authority
Dr. Marnie Leybourne Director WA Land Information Systems
Brendan Ingle Manager, Environmental Health City of Mandurah
Daniel Paech Research Assistant Department of Health WA
Interstate Working Group

Name Position Organisation
Jenny Paradowski Director, Environmental Health Section Department of Health and Ageing
Blair O’Connor Project Manager, Environmental Health Department of Health and Ageing
Section
Ben Leitch BSS Project Manager, Surveillance Branch Department of Health and Ageing
Robert McKenzie Environmental Health Scientist Vic. Department of Human
Services
Wayne Smith Director, Environmental Health Branch NSW Health
Chris Lease Director, Applied Environmental Health SA Health
Uma Rajappa Senior Policy Officer, Environmental Health Queensland Health
Unit
Dr. Andrew Langley Public Health Physician, Central Population Queensland Health
Health Services
Stuart Heggie State Manager, Environmental Health Tasmanian Department of Health
ad Human Services
Melissa Langhorne Director, Environmental Health ACT Health
Xavier Schobben Director, Environmental Health NT Department of Health and
Community Services

47
Appendix B
Evaluation of Existing International

Environmental Health Surveillance Systems
June 2008
Narelle Mullan
Department of Health
Western Australia
Dr. Jane S. Heyworth

School of Population Health
The University of Western Australia
Western Australia
48
Table of Contents
1 Evaluation objective 51
2 Process of evaluation 52
3 Choice of existing surveillance systems 53
4 International investigation results 54
4.1 European world health organisation: environmental and health

information system 54
4.2 Czech republic: environmental health monitoring system 58
4.3 United kingdom, imperial college: rapid inquiry facility 62
4.4 Scotland, health protection scotland: environmental health surveillance system 64
4.5 United states of america, centers for disease control and prevention:
environmental public health tracking (epht) 68
5 Summary of findings 79
6 References 80
49
List of Tables
Table 1: Data Content Areas of ENHIS 56
Table 2: Resources Associated with ENHIS 56
Table 3: Data Content Areas of the Czech Republic Monitoring System 60
Table 4: Resourcing Associated with the Czech Republic Monitoring System 60
Table 5: Data Content Areas of the UK Rapid Inquiry Facility 63
Table 6: Resources Associated with the UK Rapid Inquiry Facility 63
Table 7: Data Content Areas of the Scottish EHS3 66
Table 8: Resources Associated with the Scottish EHS3 66
Table 9: Data Content Areas of the CDC EPHT 71
Table 10: Recourses Associated with the CDC EPHT 72
Table 11: Data Content Areas of EPHT States 75
Table 12: Resources Associated with EPHT States 76
Table 13: Summary of Focus Areas of EPHT States 76
List of Figures
Figure 1: Process of Evaluating Environmental Health Surveillance Systems 52
Figure 2: Government Structure Covered by ENHIS 55
Figure 3: Government Structure Covered by the Czech Republic Environmental
Health Monitoring 59
Figure 4: Governmental Structures Covered by the Rapid Inquiry Facility 62
Figure 5: Government Structure Covered by the Scottish EHS3 65
Figure 6: Concept of the CDC Environmental Public Health Tracking 68
Figure 7: Grantee States and Centers of Excellence in the CDC EPHT Program 69
Figure 8: Government Structure Covered by the CDC Environmental
Health Public Tracking 70
50
1 Evaluation Objective
The objective is to conduct an evaluation of existing environmental health surveillance systems
in order to gain further understanding on the successes and difficulties that Australia may face
in developing their own environmental health surveillance system and to identify potential
frameworks relevant to the Australian setting.
The Commonwealth Department of Health and Ageing (DoHA) in Australia, the national health
agency, has requested this evaluation. DoHA specified that both National and State requirements
be considered when examining the surveillance systems. Commonwealth need is summarized
in the following statement from the 2007-2010 Strategic Plan [Department of Health and Ageing,
2007]:
“Creating a nationally co-ordinated environmental health knowledge base

that will inform decision-making.”
Representatives of the Commonwealth and from each State had previously identified specific
issues that they wanted a nationally coordinated environmental health knowledge base to inform.
These issues included to:
1. Identify and prioritise current and emerging problems;
2. Help to specify safe exposure limits;
3. Assist in the development of guidelines and standards;
4. Define, evaluate and compare environmental health interventions;
5. Meet the needs and expectations of the community;
6. Inform the community and stakeholders;
7. Provide a rational framework for discussion and debate; and
8. Guide the research and development needed for the future.
Whilst the overall aim and systems were different for each surveillance systems reviewed, certain
aspects of each informed the above issues. Four general areas of interest were identified and
considered in the evaluation, each relating back to Australian issues listed above:
a) Primary data collections (issues 2, 3, 5)
b) Assessment and appraisal of issues (issues 2, 4, 5)
c) Research and development (issues 1, 2, 3, 8)
d) Reporting methods (issues 5, 6, 7)
e) Communication between agencies (issues 5, 6)
51
2 Process of Evaluation
The project team, based on recommendations from the Health Canada [Health Canada, 2004],
determined a series of questions that addressed the overarching framework of each system,
rather than specifics on the type of indicators considered. Where possible, questions were
proposed to the system’s management team, or alternatively sourced from literature. Figure 1
outlines the process of evaluation. All consultation was undertaken between January and April of
2008, therefore results reflect the systems at this time.
Figure 1 Process of Evaluating Environmental Health Surveillance Systems
Identify Environmental Health

Surveillance System
Describe the System

Major Stakeholders
Data Content and Sources
Identify Resources
Funding
Personnel
Technology
Evaluate
Primary data collections
Assessment and appraisal
Research and development
Communication
Summary and Discussion
52
3 Choice of Existing Surveillance Systems

The project team in Western Australia already had contacts with organisations with existing
programs overseas prior to commencing this feasibility study. In addition to these, a primarily
internet-based literature search was conducted, which highlighted several other systems.
Consultation with individuals with expertise in environmental surveillance in Europe and the USA
also led to the identification of further existing environmental health surveillance activities.
The majority of systems were located within Government Agencies, resulting in formal
documentation being unavailable in the public domain or published environment/health journals.
Therefore, obtaining the data and information required for an evaluation involved interviews with
key personnel, either in person or by telephone.
The countries, organisations and systems included in this evaluation are:
1. Europe, World Health Organisation (Environment and Health Information System)

2. Czech Republic, National Institute of Public Health (Environmental Health Monitoring
System)
3. United Kingdom, Imperial College of London (Rapid Inquiry Facility)
4. Scotland, Health Protection Scotland (Environmental Health System 3)
5. United States of America, Centers for Disease Control and Prevention (Environmental
Public Health Tracking) and associated Health Departments and Universities.
53
4 International Investigation Results

This section provides details on each of the environmental health surveillance systems
examined. In describing each system, standard graphics and tables have been provided. The first
is a figure which shows a common government structure, with a circle highlighting the agencies
covered by each system. Secondly a table listing the data content areas covered is provided,
and thirdly a table of resources associated with each system is included. This is followed by a
summary of the findings.
Not all systems were labelled as “surveillance” in their respective country and often were referred
to as information systems or tracking programs. However, the objectives of these systems
were examined and were closely aligned with Australia’s requirements and they were therefore
considered for this report.
4.1 European World Health Organisation: Environmental and

Health Information System
The objective of the European Enviornmental and Health Information System (ENHIS) is to
create a comprehensive information and knowledge system, which will generate and analyse
environmental health information to support relevant policies in Europe, including those
addressing children. The ENHIS project is an indicator-based system which operates at a
regional scale examining European regional health issues. ENHIS is structured such that the
WHO co-ordinates the collation of information from European countries where the indicator of
interest is currently being reported at an international level, e.g., EUROSTATE, UN. For the
majority of indicators the data utilised are published and publicly available. The results from
ENHIS are communicated to stakeholders through a series of factsheets (see Appendix D for an
example).
ENHIS assists countries in building their capacity to operate and upgrade existing national
monitoring systems, and fosters participation in international networks to integrate health aspects
better in other policy areas (World Health Organisation 2008). The ENHIS system enables users
to make comparisons of countries’ progress towards the targets set in the Europe-wide action
programs and to exchange knowledge and good practices for the benefit of public health and the
environment. Figure 2 depicts how ENHIS fits into the governmental structure framework.
54
Figure 2 Government Structure Covered by ENHIS
National Environmental Federal

Health Agencies
State Environmental
Health
State Environmental State Department Local Government

Agencies of Health Authorities
Stakeholders
Stakeholders include the 18 countries within the World Health Organisation (WHO) European
Region, the Directorate General for Health and Consumer Affairs, the European Commission and
the European Union. A challenge has been that Environment and Health are separate portfolios
in many Ministries and therefore compete for resources. Each individual country’s Health and
Environmental Departments, as well as other local environmental and health agencies and
hospitals are also stakeholders.

A significant amount of research has been undertaken by WHO to identify the most appropriate
environmental health indictors. However, Data have been sourced from pre-existing European
data, which is usually published and publicly available at the international level, e.g.,
EUROSTATE, IRAC, UN, European Environment Agency. Therefore, there are minimal barriers
with regard to data provision. ENHIS produces reports for 29 indicators on environmental health
which cover both exposures and health outcomes and fall into the following content areas:
55
Table 1 Data Content Areas of ENHIS
Environmental health
Air quality gastrointestinal diseases
Food safety cancer
Chemical safety cardiovascular disease
Water and sanitation respiratory diseases
Mobility and transport overweight and obesity
Housing injuries
Uv and ionizing radiation developmental disorders
Occupational hazards
The ENHIS project also includes collecting detailed information on country-specific policies and
policy evaluation in environmental health. This inventory is available as a stand-alone database
providing valuable details of the different policy approaches. Where available, this detail is also
made available within each of the above content areas.
Resources
The following table summarises the resources that are currently being utilised for maintenance
and on-going development of the ENHIS program by the World Health Organisation.
Table 2 Resources Associated with ENHIS
Resourcing component of interest enhis

Funding 2.2mil euro

Program budget and source (60% Eu, 40%in-kind from

member countries)

Personnel
Team size 5
Program manager 1
Epidemiologist 1
Biostatistician
Environmental health expert 1
Gis developer
Database manager 1
Programmer
Communication experts
Technology
Desktop yes
Web portal yes
Web application no
Spatial technology no
56
Areas of Interest to Australia
Primary Data Collections

ENHIS assists countries in building their capacity to operate and upgrade existing national
monitoring systems, and fosters participation in international networks to integrate health aspects
better in other policy areas outside of environmental health. The system also encourages
member states to improve methods of data collection, extend data collection and develop
their own systems to detect regional differences. There is evidence of this occurring both at
the country level (data of drinking water quality improved in several countries after release of
indicators) and at the regional level. For example, Norway has indoor air quality surveillance
which, after being included in the ENHIS program, resulted in WHO adopting this as a
recommendation. In addition, data on environmental health policies in each country is published,
enabling a comparison of environmental health strategies.
Assessment and Appraisal of Issues

Individual countries manage the data collections and therefore minimal assessment of the data is
conducted at the regional level that ENHIS operates. Appraisal of the issues occurs, comparing
countries or regions within Europe. An assessment of policy-relevant information as well as policy
evaluation is collected for each country and is a unique approach to indicators. It allows the
WHO to monitor changes in policy adoption over time.
Research and Development

A useful component of the fact sheets is a collation of additional references that are relevant to
each issue. The involvement of research institutes or country-specific government agencies in
collating and publishing these factsheets encourages stakeholder involvement in the program
and timeliness of results.
Reporting Method
Series of fact sheets available in hard copy or downloadable from the Internet (www.enhis.org).
Communication Between Agencies

ENHIS has improved communication of environmental health issues at the Ministerial level. It
also provides comprehensive background information for members of the public to access.
Discussion
ENHIS is not about detecting new associations, rather documenting the situation for which there
are known links/associations between health and exposures. In some cases there are significant
data gaps for exposures and the reliance on publicly available data results in a time delay and
therefore lack of relevance for local action purposes. However, over time these gaps will lessen
through inherent pressure for countries to at least meet the minimum requirements for data
collection. A method of data collection whereby each state collates the information from other
states into the production of one or more factsheets would be a feasible model for a national
57
system in Australia. Without such arrangements, an information system such as ENHIS could
suffer from a lack of involvement in the processes and outcomes, therefore making it harder to
make improvements to environmental health. Cooperation between Health and Environment
Ministries in each state would be required in order to make local staff available.
4.2 Czech Republic: Environmental Health Monitoring System

The Environmental Health Monitoring System has been in place in the Czech Republic since
1994. This is a comprehensive system that involves the collection, processing and evaluation of
data on environmental contaminants and their impact on population health. The system involves
collecting indicator data concerning human exposures to environmental risk factors and selected
linked health effects and bio-monitoring.
Under the guidance of the WHO Environmental Health Centre and the methodology provided
by the project ENHIS, the Czech Republic has been seeking to establish a cross-sectional
membership network and to develop further environmental health monitoring. Factsheets, such
as that on population exposure to particulate matter, are being released on a regular basis to
inform environmental health policy better.
The aim of the Monitoring System is to provide high quality background data for decision-making
by the national and local authorities in the fields of health-care policy, health risks management
and control, and environmental protection. These data will be relied upon in the specification of
legislative measures, for establishment and adjustment of pollutant limits and for informing the
interested public [National Institute of Public Health, 2006].
58
Figure 3 Government Structure Covered by the Czech Republic Environmental Health

Monitoring

Health Agencies
State Environmental
Health

Stakeholders
The Monitoring System has been implemented in 30 cities including the capital Prague, regional
capitals and selected former district cities. Not all subsystems of the Monitoring System have
been in operation in all cities for economic and technical reasons. The National Institute of Public
Health in Prague co-ordinates the program. The Ministry of Health, National Institute of Public
Health, Ministry of Environment, Agency of Nature and Conservation, Landscape Protection,
Czech Hydro Meteorological Institute, local agencies and community organisations are all
involved.

The majority of the health statistics are sourced from the Ministry of Health, including the EPIDAT
information system for the mandatory reporting of the occurrence of infectious diseases, and
hospital and health registry data. The Czech Hydro-meteorological Institute provides some of the
environmental monitoring data.
59
Table 3 Data Content Areas of the Czech Republic Monitoring System
Air pollution dietary exposure to contaminants

Drinking water pollution biological monitoring
Noise health and well-being statistics
Toxic pollutants
Contamination of urban soil
Occupational environment

Resources Required
The following table summarises the resources that are currently being used for the maintenance
and on-going development of the monitoring program.
Table 4 Resourcing Associated with the Czech Republic Monitoring System
Resourcing component of interest czech system

Funding government of the
source czech republic
Personnel
Team size 4
Program manager 1
Epidemiologist 1
Biostatistician
Gis developer
Database manager 1
Programmer
Technology
Desktop yes
Web portal yes
Web application no
Spatial technology yes
60

There are close links between the primary data custodians, which has resulted in software and
database compatibility from the laboratory, data custodian and monitoring system. The numbers
of locations from which samples are being taken and statistics gathered has increased since
the program started 13 years ago. The extent to which the system has influenced the type of
information collected has not been possible to determine.

The annual reports produced are comprehensive in that each environmental health issue
provides the appraisal of all available datasets with an overview of differences both within Czech
Republic and over time. Where possible a health risk assessment is included for the issue being
considered. In cases where a direct health risk assessment is not possible ‘partial conclusions’
are documented. This information is valued by government agencies and key stakeholders.
Data from the reports and the monitoring system have been used in health impact assessment
and environmental impact assessment of various activities, constructions and projects [National
Institute of Public Health, 2006].

With the progressive development of the Monitoring System, specialized studies were designed
in agreement with Resolution No. 369/1991 of the Government of the Czech Republic. These
studies extend the existing monitoring results and deal with issues lying beyond the framework
of the basic tasks of the Monitoring System, but whose solution is necessary for the monitoring
activities to continue. The results are being published in the form of either monitoring reports or
scientific papers [National Institute of Public Health, 2006].
Reporting Method
The National Institute of Public Health produces both a technical report and annual summary
report which they make available via the Internet.
Communication Between-Agency Communication

There are 30 cities participating as part of the monitoring subsystems. Over the course of
ten years of routine operation of the Monitoring System, both the number and structure of its
participants have remained unchanged, meaning that the system can be considered as stabilised
and regular in terms of the scope of the monitoring activities.
Discussion
This system is managed by the Public Health Institute, rather than within the Department of
Health. It has the advantage of being a Government Agency but with a degree of independence
that is advantageous in establishing cross-agency relationships. It is also supported by public
health legislation, which provides funding security and value for all government agencies
involved.
61
4.3 United Kingdom, Imperial College: Rapid Inquiry Facility

The Rapid Inquiry Facility (RIF) has been developed by the Small Area Health Statistics Unit
(SAHSU) at the Department of Epidemiology and Public Health within Imperial College, London.
The RIF is an automated software computer tool which extends the ESRI® ArcGIS functions,
and uses both database and geographic information system (GIS) technologies (Small Area
Health Statistics Unit 2007). The purpose of the RIF is to address and facilitate responses to
epidemiological and public health questions in a timely manner using routinely collected health,
population and environmental hazard data.
The RIF can perform risk analysis for hazardous sources and can be used for disease distribution
mapping. In addition, it is now possible to import detailed exposure data, such as output from
dispersion modelling.
Figure 4 Governmental structures covered by the Rapid Inquiry Facility

University
Health Agencies
State Environmental
Health
State Environmental State Department

Agencies of Health
Stakeholders
Stakeholders include the Imperial College in London, Health and Environmental Federal, State
and community government and non-government agencies.

The RIF system is designed to consider chronic diseases on a regular basis and environmental
exposures as required. All NHS hospital data are collated and cleaned at Imperial College,
environmental data are obtained from the Health Protection Agency and the Department of
Environment. The datasets available fall into these broad categories:
62
Table 5 Data Content Areas of the UK Rapid Inquiry Facility

Toxic sites hospital morbidity
Landfill sites mortality
Cancer
Environmental exposures as required
Resources
Table 6 Resources Associated with the UK Rapid Inquiry Facility
Resourcing component of interest RIF

Funding department of health and
source department of environment
Personnel
Team size 10
Program manager 1
Epidemiologist 2
Biostatistician 1
Gis developer 1
Database manager 2
Programmer 1
Technology
Desktop yes
Web portal NO
Web application no

Data cleansing and data linking has been conducted by SASHU staff. They have contributed
a lot of resources to improving the links within hospital admissions. This has added immense
value to the database; however, this enhanced version remains within the University and is not
systematically fed back to the Health agency. In addition, other research agencies do not have
access.
63

The ability to conduct assessments on a large range of complex issues has been greatly
improved. Issues raised by government departments or the public can be addressed within a
shorter time frame and with confidence as a result of the Rapid Inquiry Facility.

Having access to the routinely collected health statistics and investing large resources into the
data management of these datasets has given the SAHSU at Imperial College the opportunity to
conduct detailed and world-leading research on environmental health issues. The development of
small area spatial statistics has been widely applied and their knowledge of these techniques has
been shared with the global community via published journal articles, reports and short courses.
Reporting Method
Final product showing map of relative rates aids communication between all parties. Study
results have been documented in articles published in peer-reviewed journals.

The current arrangements do not require the health and environmental agencies to interact any
more than before the system was in place. Interaction between the health agencies and the
University has improved greatly and therefore key personnel would have a greater understanding
of environmental health modeling and risk assessment.
Discussion
This is a health outcome assessment tool rather than a system which allows for ongoing tracking
of environment and health. It is reactive rather than proactive for a number of reasons. While the
intention was to be able to respond to government queries as they arose, the reality is that this
has been successful mainly when there are good data, usually collected for a one-off purpose.
Good publications have resulted from the work at Imperial College and statistical approaches
to analysing the relationship between area level exposures and health outcomes have certainly
improved.
RIF is an excellent tool but if enhancements remain the property of the University then it be more
challenging to influence longer-term improvements to primary data collections. It is relevant to
the Australian setting if used within those environmental and/or epidemiology branches. Recently
epidemiologists within government programs in Europe and the USA have both considered the
RIF software as an appropriate surveillance tool.
4.4 Scotland, Health Protection Scotland: Environmental Health

Surveillance System
The Environmental Health System for Scotland (EHS3) has been funded by the Scottish
Executive since 2003. It is currently funded by the Scottish Executive Environment and Rural
Affairs Department (SEERAD). The creation of EHS3 falls into three stages:
64
Phase 1 – an initial “pilot” stage (completed in 1998)

Phase 2 – an “extended pilot” stage incorporating a detailed evaluation of environmental data
Phase 3 – a final stage during which the project was rolled out to Scotland as a whole.
EHS3, in its completed form, will be an ongoing multi-agency collaboration involving area
NHS boards, NHS Information & Statistics Division, local authorities, the Scottish Environment
Protection Agency, Water Authorities and other relevant agencies. Its purpose will be to collect,
hold and, as appropriate, analyse and interpret environmental and health data throughout
Scotland.
Much of these data are currently available but are under-utilised. In keeping with the principles
of surveillance, data gathering will be ongoing and regular outputs will be agreed which will
inform policy and action to promote improved environmental standards and public health. With
appropriate development, the system will also have potential as a predictive tool for managing
environmental fluctuations in demand for NHS services.
Figure 5 Government Structure Covered by the Scottish EHS3

Health Agencies
State Environmental
Health

Stakeholders
Scottish Executive Environment and Rural Affairs Department, Health Protection Scotland,
Scottish Centre for Infection and Environmental Health, Scottish Environmental Protection
Agency, Scottish Water, Scottish local authorities, Keep Scotland Beautiful.
65
Data Sources and Content

In this system, environmental data are sourced on a regular basis. The content areas given
initial priority are listed in the table below:
Table 7 Data Content Areas of the Scottish EHS3
Environmental health (initial areas of interest)

Air quality respiratory conditions

Water quality cerebrovascular disease

Radiation circulatory system disease
Noise malignant neoplasm
Mobile phone masts
Cooling towers
Landfill sites
The Scottish local authorities provide data on a range of environmental parameters including air
quality, noise complaints and radiation. Scottish Water provides data on drinking water quality
based on regulation water sampling at both treatment plants and consumers’ homes.
Resources Required
Table 8 Resources Associated with the Scottish EHS3
Resourcing component of interest ehs3

Funding scottish government
source
Personnel
Team size 3
Program manager 1
Epidemiologist 1
Biostatistician
Gis developer
Database manager
Programmer
Technology
Desktop yes
Web portal yes
Web application no
66

Initial consultation enabled gaps in the quality and completeness of data to be identified.
However, since then the data provided are from routinely collected information and additional
fields or coverage have not been requested.

A range of environmental health hazards and incidents are addressed in a weekly Scottish Health
Protection report. Whilst not every issue is covered each week, regular reports are published of
data, sitting alongside the reporting of communicable disease and disaster planning information.

Operating from within the Scottish Health Protection Agency has meant that this program has not
aimed to conduct any detailed research examining the links between environmental and health
data.
Reporting Method
Regular contributions to the Health Protection Agency fortnightly newsletter

Initially the project team, consisting of a program manager, epidemiologist and an environmental
health advisor, was required to visit each agency and negotiate data-sharing agreements. This
has appeared to be successful with external agencies now reguarly contributing information to
the system.
Discussion
The Scottish system framework closely matches the operations that currently exist at the State
level of environmental health in Australia. The close working relationship with local authorities
and other State agencies and the need to bring datasets into a single information system are
similar to Australian requirements. The focus is more on gathering environmental data, with
health information being collated as required.
In a presentation of the system, several key factors were listed to ensure continuing progress of
the Scottish EHS3:
Joint ownership of the project

Shared commitment
Staged approach
Consensus on inputs and outputs
Realistic expectations
67
4.5 United States of America, Centers for Disease Control and

Prevention: Environmental Public Health Tracking (EPHT)
The CDC govern the US National Environmental Public Health Tracking Program, which is
a multi-disciplinary collaboration that involves the ongoing collection, integration, analysis,
interpretation and dissemination of data from environmental hazard monitoring, human exposure
surveillance and health effects surveillance (Centers for Disease Control and Prevention 2006).
The program began in 2001 after a Health Commission report was released indicating there was
a lack of co-ordination in public health when dealing with environmental health threats.
The CDC has been developing the tracking network (due for implementation in September
2008), an on-line database of information, which forms the cornerstone of the tracking program.
The tracking network provides information which can be disseminated throughout the national
network to public health professionals, for improving environmental health policy and practice
(Centers for Disease Control and Prevention 2006).
Figure 6 Concept of the CDC Environmental Public Health Tracking
The CDC used the initial funding ($17.5 million) granted in 2002 to fund 17 states, three local
health departments and three schools of public health to begin development of tracking programs
and to expand capacity in environmental public health at state and local levels (Centers for
Disease Control and Prevention 2003). The idea was to develop state health surveillance first,
then attempt to link state data through the national surveillance network.
68
Figure 7 Grantee States and Centers of Excellence in the CDC EPHT Program
Having spent the last five years establishing formal networks between environment and health
agencies within participating states, the National Tracking Network (i.e., the web portal tool) was
to be launched in September 2008. When completed, the fully developed EPHT program will
connect electronic data sources from health and environmental agencies, provide the tools to
analyse and link these data, and display the final information in an intelligent way to those who
need to see it (Florida Department of Health, 2007). Overall, the program’s goals are to:
(1) Build a sustainable national and state EPHT network,
(2) Increase EPHT capacity,
(3) Disseminate credible information regarding environmental hazards
(4) Advance environmental public health science and research, and
(5) Bridge the gap between public health and the environment.
69
Figure 8 Government Structure Covered by the CDC Environmental Health Public

Tracking

Health Agencies
State Environmental
Health

Stakeholders
Federal stakeholders include the Centers for Disease Control and Prevention, Environmental
Protection Authority (EPA), National Aeronautics and Space Agency (NASA) and United States
Geological Survey (USGS). Other stakeholders include the Agency for Toxic Substances and
Disease Registry, Health Care Organisations, Non-government Organisations, Universities, State
Agencies, Local Agencies and other Community Groups and Members:
Association of Public Health Laboratories
Association of State and Territorial Health Officials
Council of State and Territorial Epidemiologists
Environmental Council of the States
Environmental Protection Agency
National Association of County and City Health Officials
National Aeronautics and Space Administration: Earth Science Enterprise
National Conference of State Legislatures
National Environmental Health Association
Physicians for Social Responsibility
Small Area Health Statistics Unit of Imperial College London
Trust for America’s Health.
70
Data Sources and Content

For the implementation phase of the tracking network, eight data content areas were selected.
These areas include:
Table 9 Data Content Areas of the CDC EPHT
Environmental health coontent areas

Air monitorin
Birth defects
Cancer
Carbon monoxide poisoning
Childhood lead
Drinking water
Hospitalisations
Reproductive health outcomes
Within each of the eight content areas, nominated measures have been identified as priority
for collation at the National level. The tracking network will use a core set of health, exposure
and hazard measures for the tracking network and nationally consistent data to support the
development of these measures. The data will be sourced at the state level from environment
and health agencies and passed upwards to the federal tracking system. Partner data, such as
that from the EPA’s air quality monitoring system or CDC health registries and national surveys,
will also be accessible through the tracking network as interoperability is established.
71
Resources
Table 10 Recourses Associated with the CDC EPHT
Resourcing component of interest ehs3

Funding US Congress
source
Personnel
Team size 21
Program manager 3
Epidemiologist 4
Biostatistician
Gis developer 2
Database manager 4
Programmer 4
Communication experts 3
Technology
Desktop yes
Web portal yes
Web application YES

Given the framework of government that this system must cope with, it is unrealistic to expect
the National Tracking Team to have influence over primary data collections. However, they do
provide a strong advisory role to tracking teams at the state level on improvements. The national
team has directed resources and energy towards improving national data collections, by clarifying
minimum dataset and data quality. There have also been opportunities to fund personnel within
other areas of the CDC, for example cancer, which builds trust and improves communication with
other Federal data custodians.

Once the national network is functional then state-level users with the appropriate security
access will be able to gather information from the CDC regarding environmental health issues
for comparison with other states (benchmarking). Environmental health issues that span across
borders will be able to be dealt with in a more co-ordinated fashion.
72

The research and development associated with the National Tracking Program surrounds
the transfer of data and information electronically without compromising on security and
confidentiality. The CDC has had cooperative agreements with three Academic Centers of
Excellence since 2002. The purpose of the program is to provide expertise and support to
State and local health departments in (1) the development and utilization of data from state and
national environmental public health tracking (surveillance) networks and (2) the investigation
of the potential links between health effects and the environment. The Partner Universities have
published their experience and findings in scientific papers and numerous presentations to state
grantees and the national team. Initial research by these Centers highlighted how important data
standards and collection methods were prior to detailed analysis and linkage.
Reporting Method
An on-line tracking network portal system is being developed. The tracking network, the tracking
programs user interface, will provide various levels of access to users depending on their role
and purpose. A user of the tracking network will by default be granted access to public use
information. Access to more sensitive information will be granted by the data owner/steward,
with different access rights possible. In terms of data regulation issues, data will need to be re-
released for use in some circumstances.

The National team has invested resources in experienced staff, professional writing and high
quality products for the purpose of communication. There are several key audiences and
advocacy to professional associations and external agencies is a high priority for the Tracking
Program.
4.5.1 EPHT State Grantee Comparison

The goal of each Grantee State is to develop a system that enables linkage, monitoring and
reporting of health effects and environmental hazards and exposure data, whilst also providing
the CDC with data for the National EPHT Program. Grantee states have had funding since 2003
to build capacity in this area and/or manage projects that demonstrate the potential of linking the
hazard, exposure and health data together (often called pilot projects).
This section aims to highlight that, within the CDC contractual requirements, there were
differences in how each State has managed the program, dependent upon the local context.
Approaches were also dependent on situations often beyond the control of each team, with
some being further advanced in this field at the time of grants being awarded. The four States
presented here as examples are California, Utah, Florida and Oregon.
Stakeholders
A requirement of initial grant recipients was that they develop partnerships with local, tribal, state,
federal government; health care providers; non-governmental organisations; and private for profit
and non-profit groups whose participation is critical to the success of the program. Secondly, a
formal partnership between state health and environmental agencies for the development of the
system had to be established.
73
All four states managed these partnerships by establishing advisory groups/councils. It is

common for these groups to include the following state-based agencies:
Environmental Protection Agency
Department of Environmental Quality
Office of Vital Records
Cancer Registry
Center for Health Statistics
Death Registry
Public Health Associations
Behavioural Surveillance System
CDC
Local (County-level) Health Departments
Universities.
Advisory groups assisted with the development of the program, ensuring that it was compatible
with national standards, evaluated findings and recommends priorities. They were involved
across all stages of the program development.
Worth noting is that California has gone to great lengths to include as stakeholders those
from external agencies, and private and not-for-profit sectors. This includes the University of
California, University of Berkeley, local public health and environmental officials, community-
based and non-governmental organisations, environmental advocacy groups and the public.
Also, Utah has recently created an EPHT Network Web Board, which allows authorised users
to organise and readily access information, manage documents and share calendars from
anywhere and at any time. It is designed to enhance communications between stakeholders and
the program staff.
Oregon has had a focus on including local health departments on advisory groups and co-
ordinating mini-grants to local health departments recognising the need to build capacity at the
primary data collection level. The intention of Oregon EPHT to improve communications and data
access for local counties is similar to the relationships that an Australian environmental health
surveillance system will need to consider. It highlights the important work that local counties
conduct and benefits of keeping them informed. Useful lessons to be learnt from this group and
including the immediate benefits back to a key stakeholder.
74
Data Content Areas

Table 11 Data Content Areas of EPHT States

Data content area california utah florida oregon
Environmental
Air quality n n n n
Pesticides n
Water quality n n n n
Hazardous waste n n n
Solid waste n
Radiation n
Exposure to metals n
Persistent organic compounds n
Tobacco smoke n
Radon n
Mold n
Asbestos n
Volatile organic compounds n
Co poisoning n
Health
Respiratory disease n n n
Adverse health outcomes n n
Cancer n n n n
Myocardial infarction n
Diabetes n
Neurodevelopmental outcomes n
Autoimmune disorders n
Kidney disease n n
Neurological disease n n
Co deaths and hospitalisations n n
Lead poisoning n n n n
Occupational illness n
Perinatal mortality n
Birth defects n n n n
n = data available for national network

n = data partner identified, not yet available
75
Resources Required
Table 12 Resources Associated with EPHT States
Resourcing component of interest california utah florida oregon

Personnel
Team size
8 4 4 7
Program manager
1 1 1 1

Principal investigator
Epidemiologist 2 1 1 1
Biostatistician
Research analyst 2
Environmental health expert 1 1
Gis developer 1 1 1
Database manager 1
Programmer
Communication experts 1 1 1 1
Technology
Desktop yes yes yes no
Web portal yes yes yes yes
Web application yes yes no no
Spatial technology yes yes yes yes


Each state in this evaluation was examined for how they delivered in those areas of interest to
Australia is summarised in Table 13. The number of dots within each grid cell denotes the extent
to which each state has focused on certain aspects of surveillance, relative to each other. It is a
subjective opinion and intended to show the strengths of each program, low dot numbers do not
equate to poor performance.
Table 13 Summary of Focus Areas of EPHT States
Area of interest to australia california utah florida oregon

Primary data collection lll ll ll ll
Appraisal and assessment of issues ll lll ll ll
Research and development lll l l l
Reporting methods ll ll ll ll
Communication between agencies lll l ll lll
76
California has shown some good examples of influencing the primary data collections, as a result
of regular advisory group meetings and high level of participation in the pilot projects. One of
the key areas in which data collections have improved is by offering a geocoding service to data
custodians. The enhanced spatial information was returned to the custodians, therefore providing
them with analysis and visualisation tools previously unavailable. This also meant that the EPHT
team had greater control over standardising the datasets of interest to the project. Participation in
two very detailed research projects, on the subject of adverse birth outcomes and asthma, gave
partners to the California program an understanding of how valuable their data is to the long-term
objectives of EPHT.
In contrast, Utah has worked closely with other sections of the Health Department to present key
data sets in the existing on-line reporting tool developed for public health. They also invested
time and resources into the desktop software package RIF (from the Small Area Health Statistics
Unit in London) to manage routinely collected health information. As a result their ability to
address a range of health issues quickly and to a wide audience has improved. However, there
has been minimal influence over primary data collections with this more technically focused
Tracking Program.
Florida has also created workgroup committees which provided technical expertise on data
issues for agencies such as the Office of Vital Statistics and the Registries including the Florida
Cancer Data System and the Florida Birth Defects Registries. This state has influenced primary
data collections with the establishment of a birth defects registry since the EPHT has requested
this measure in its national network.
All states have staff dedicated to epidemiology and communications, recognising that the two
roles are very different and valuable in their own right. The communication specialists aid in
building awareness of the programs across all agencies and the public, and the epidemiologist is
on the team to consider data in a scientifically rigorous manner once it arrives.
4.5.2 EPHT Centers of Excellence

Tulane University Center for Applied Environmental Public Health is one of four Academic
Partners for Excellence (APEX) in Environmental Public Health Tracking funded by the Centers
for Disease Control and Prevention (CDC) to assist in the development of the nationwide
environmental public health tracking network to further the understanding of the relationship
between health and the environment. Consultation with Tulane University highlighted the
importance of data standards and management within a national tracking program. Their
experience has shown that government agencies have the mandate to collect data but
predominantly in a regulatory role and the focus of reporting is whether results were above
or below the standard. Data is also stored in a myriad of different ways which meant that
considerable resources were being used to clean and influence data collection methods, prior to
any modelling of exposures and health outcomes.
It appeared that while there were research benefits to be gained from the collation of national
datasets, the timeframes involved were under-estimated and the need to set realistic and long
timelines was reinforced. In addition, the relationship with state agencies and involvement in
working groups examining standards and sharing protocols was valuable as researchers were
able to advise such groups on data requirements. Sustained funding was also a concern as the
research programs are currently very dependent on the CDC contract.
77
Discussion
The Environmental Public Health Tracking is the largest of all systems examined and has the
support, both financially and conceptually, of the highest level of Government in the United
States. This has enabled the CDC to expand the team of experts working on the program and
allowed them to plan for long-term sustainability of the program. The program has also been able
to engage experts both within the US and internationally to contribute to the development. This
willingness to learn from existing work in the field and encourage each state to share knowledge
has resulted in a national network that Australia should consider aiming towards.
While there are only 16 of the 52 US states participating in the EPHT program, the CDC plans to
develop the tracking network for these 16 states and then expand the capacity so that eventually
it can become a nation-wide program. These future plans for expansion are dependent on
increased funding from the US Congress and changes in government can result in an element of
risk for the EPHT program. Recognising this vulnerability, the CDC EPHT team have invested in
a communication’s team at the national level who develop material and increase the profile of the
program to public health advocacy groups and other government agencies.
The tracking program currently covers eight content areas within environmental health and has
spent considerable resources developing a technical infrastructure capable to securely passing
data on these eight content areas from state to federal databases. The number of issues covered
by the program is expected to increase over time.
78
5 Summary of Findings
The evaluation has meant that Australia now has some tangible examples of environmental
health surveillance systems that have been successful in their various countries. There are
aspects of each that have informed the wider feasibility study. Some key points from the
international evaluation are:
There was a common objective to improve government’s ability to detect linkages between
environmental hazards and health outcomes and to monitor changes over time and place.
The models differed in which level and types of agencies were involved.
Stakeholders, both within and outside of environmental health, and good communication
were crucial to success of each program.
Common to all was an agreement between the Federal Health and Federal Environment
Departments to participate. Majority of programs established a Memorandum of
Understanding between the Health and Environment Departments, signed by respective
Ministers.
With the exception of RIF, all data systems were housed and managed within Government
Health Agencies.
Funding Sources were often external to Environmental Health Departments.
Personnel associated with the systems included managers, epidemiologists, health
information (data), spatial technology and communication experts.
Spatial technology was common to all systems as a method of presenting the results of a
surveillance system. However, there was varying levels of use of spatial databases and
spatial analysis of environmental health issues.
Improved intergovernmental and community collaboration was evident in all programs,
particularly the California EPHT program who have built an open and trusting network of
stakeholders. Other examples of improvements to environmental health activities include
the creation of a birth defects registry in Florida and improved access to information to
inform public health plans, health risk assessments and research projects for all countries
considered in this evaluation.
The all encompassing US model, covering all levels of government is a feasible goal for Australia
in the long-term. In building towards that goal, a hybrid between the federal level WHO model
and Scottish/Oregon state-level models is suggested. It will involve developing a program of
surveillance within several states of Australia, assessing their effectiveness and then deciding on
the prospects of an implementation across the country. The states involved will assess whether
data standards related to the hazards, exposures and health outcomes are adequate for analysis
of environmental health issues nationally.
79
6 References
Centers for Disease Control and Prevention (2003). Environmental Public Health Tracking Program:
Closing America’s Environmental Public Health Gap. Atlanta, CDC.
Centers for Disease Control and Prevention. (2006). “CDC’s National Environmental Public Health
Tracking System: National Network Implementation Plan.” from
http://www.cdc.gov/nceh/tracking/pdfs/nnip.pdf.
Department of Health and Ageing, “National Environmental Health Strategy 2007-2012”, Office of Health
Protection, Editor. 2007.
Florida Department of Health, 2007 “Integrating Data for Improved Public Health Surveillance: The
Environmental Public Health Tracking Network.” from http://www.doh.state.fl.us/Environment/programs/
Environmental_Public_Health_Tracking/Florida_EPHT_Whitepaper.pdf
Health Canada, Population Health Branch (2004). “Framework and Tools for Evaluating Health
Surveillance Systems” from http://www.phac-aspc.gc.ca/php-psp/pdf/i_Surveillance_Evaluation_
Framework_v1.pdf
National Institute of Public Health, Prague (2006) “Environmental Health Monitoring System in the Czech
Republic”, from http://www.szu.cz/uploads/documents/chzp/souhrnna_zprava/szu_07an.pdf
Small Area Health Statistics Unit. (2007). “The SAHSU Rapid Inquiry Facility (RIF)- a tool for environmental
public health tracking.” Retrieved 16/01/2008, 2008, from
http://www.sahsu.org/sahsu_related_studies.htm#RIF.
World Health Organisation. (2008). “European Environment and Health Information System.”
Retrieved 04/03/2008, 2008.
80
Appendix C
Example of Fact Sheet from WHO Environmental and Health Information System
81
82
83
84
85
86
87
88
Appendix D
Meeting on Environmental Health Surveillance to discuss
State and Local Government Web Portal Requirements
Fremantle, June 2008
Agenda
1. Welcome and Introduction
2. Meeting Objective
3. Discussion covering the key aims:
a. Decision Making
b. Communication
c. Tracking Change
4. Summary and General Comments
Attendees

Name Organisation

Brendan Ingle Environmental Health, City of Mandurah
Rod Nowrojee Environmental Protection Authority
Michelle Swann Environmental Protection Authority
Narelle Mullan Science & Policy Unit, EHD, DoH
Amber Douglas Mosquito Borne Disease Control, EHD, DoHealth
Zachary Alach Science & Policy Unit, EHD, DoH

Background
This meeting was held as part of a short-term study into the potential for Australia to develop
an environmental health surveillance system. A review of similar systems internationally has
highlighted the complexities of agencies involved and the need for collaborations at the Federal
level to set an example for other levels of government to follow. While there had been a strong
focus on the partnerships required, attention also needs to be been given to what other aspects a
surveillance system should be addressing.
In addition to formal partnerships, the following aspects were found common to successful
national environmental health surveillance systems:
A strong research capacity
Utilisation of spatial technology
A web-portal as end product.
89
At previous meetings of the W.A. Reference Group there was general acceptance among
participants on the proposed partnership model, support for increased research capacity and an
assumption that spatial technology has evolved significantly and now available for projects such
as this. However, some members required clarification around the content of the web-portal,
ensuring its relevance to both State and Local Government. It was agreed that the web-portal be
the subject of separate meeting.
Meeting Objective
A small meeting between the local government representative and State Government Health and
Environment agencies was held in Fremantle on the 24th of June 2008. The meeting objective
was to:
Determine the style and content of an environmental health surveillance

web-portal for state and local government.
Participants spent some time discussing how a web-portal would aid the following:
1. Decision-making for managers;
2. Communication between local and state government; and
3. Tracking changes in hazards, exposures and disease over time.
Outcomes
There was general consensus that a web-portal can contain information beyond the
results of monitoring or disease rates. Given the wide range of issues of interest to those
managing environmental health issues, a web-portal can also be used a reference guide
and communication tool for managers. Information that decision-makers in local and state
government agencies require is not always based on specific monitoring at a particular site.
The meeting highlighted that:

the web-portal is an opportunity to educate local governments on the priority for
environmental health at the national and state levels,
conceptual decision making tools that allow comparisons between disparate environmental
health themes (e.g. food safety vs air quality) in a qualitative manner can assist, particularly
when detailed data is unavailable,
a two-way flow of information was important; state agencies has valuable data and
knowledge that should be shared with local government and visa versa,
a meta-data collection of past and present projects of relevance to environmental health,
referenced in both space and time would be useful,
the finest resolution of data should be collected and varying levels of secure access
granted to end-users (rather than pre-defined boundaries),
one agency should develop a template for a web-portal that can be used across all
jurisdictions in Australia and be careful not to duplicate or replace existing Intranet and
Internet sites for the State Environmental Health Branches.
90
Recommendations
The following recommendations will be considered in the final Commonwealth report:
1. There is continued support for developing a web-based resource for surveillance of
environmental health issues at the State level, allowing for a degree of flexibility in priorities
for jurisdictions across Australia.
2. Concept mapping for decision making will continue to be developed in W.A. with the
intention of a providing a demonstration to local government within the coming 12 months.
3. The web-portal should include a metadata search that returns monitoring or disease data
where available/appropriate or alternatively expert opinion in the form of published reports,
established guidelines and policies on environmental health issues.
4. The design should be flexible enough to present and search detailed monitoring and
health indicators or more detailed datasets when it becomes available (with appropriate
restrictions to protect confidentiality).
Ideas and Notes
WHO ISSUES IDEAS

Decision-Making LGA EH Managers • Diverse range of • Where funds are being
LGA Planners information required directed could be of interest
EH Officers • EH Input often too late • Spatial index of health
State EH Managers to influence decisions studies would be useful
EPA • Concept mapping as a • Ability to include health
State Environment tool economics in EH issues
State Planning • Allow access from important and web-portal
Federal Health all the potential could be a reference for such
perspectives – detail
flexibility important • State-based reference sites
such as on-line Spatial Atlas
should be included/linked
Communication LGA EH Staff • Obtaining evidence for • A tool to allow increase
State EH Staff EH Decisions advocacy of environmental
State Health • Expert reports often health would be great
State Environmental difficult to find and • Search engine of expert
State Planning reference opinion as well as datasets
Federal EH • Remoteness of LGAs • Web-portal should be time
Federal Environment in Australia saving and reduce the
• Transparent potential for conflicting
responsibilities messages to the public
• Need to educate LGAs • The delivery of health and
on Federal and State demographic information
priorities to local government would
• Ability to see similar be welcomed – must be
projects/programs in timely to include in proposed
other LGAs or States development applications
etc.
91
WHO ISSUES IDEAS

Tracking Changes LGA EH Management • The varying scales of • Cater for every end of the
State EH Management data collection data spectrum (Detailed
State Health Managers • Standards across through to general)
State Environment jurisdictions • Allow for different levels of
EPA • Issue of double secure access to enforce
Federal EH handling data and confidentiality
Dept of Planning analysing results – • Interest in an interactive
judging when should website where parameters
expert opinion or such as disease type/hazard
interpretations be used type/area and timeframes
instead can be selected.
• Access from various • Value and context added to
custodians the LGA sampling results
• Security levels for would be of interest to the
disease data LGA end-users.
• Aboriginal • Of all the examples of web-
environmental health portal, the Wildlife Disease
requires attention and Node was the most closely
tracking aligned with requirements
• Data flow must be discussed.
two-way: LGAs need
info on health and
demographics from
DoHealth as well as
enhanced monitoring
info (eg MBDC data).
92
Basic example of the initial web-portal content required ….
Environmental Health Surveillance Information Node
Decision Making Tools
(priority setting tools such as concept mapping and impact
assessment tools)
Environmental Health Indicators

(when consensus on indicators at the LGA level have been
research this section can provide access to indicators – detail
not covered in this meeting)
Maps and Data

(detailed reports and maps on monitoring and health data where
and when it is available – map capable of thematic or point based
information of results)
Web Resources
(link to relevant agencies related to environment and health
surveillance)
Australian Environmental Health Project Map

(a spatially referenced database of past and current
Surveillance Activities and Events environmental health projects – the map reference
(information to bring together jurisdictions on the subject of contains either a link to an agency or published report.
monitoring/indicators /tracking/surveillance) Searchable by hazard, disease or geography)
93
94
Surveillance
A Feasibility Study
November 2008
Prepared by
Narelle Mullan, Dr. Chantal Ferguson & Daniel Paech
11176 JAN’09 23650
Produced by Environmental Health Directorate

Department of Health 2009 Western Australia

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Environmental Health

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2 BACKGROUND AND CONCEPTS 12

3 AUSTRALIAN SURVEILLANCE ACTIVITIES 20

4 INTERNATIONAL ENVIRONMENTAL HEALTH SURVEILLANCE 25

5 AUSTRALIAN ENVIRONMENTAL HEALTH SURVEILLANCE 31

Table 2 Environmental and Health Factors Common to International Surveillance

Table 3 Summary of Potential Risks 39

Figure 2 Primary and Secondary Surveillance for Environmental Health 17

Figure 3 Environmental Health Surveillance Concept [51] 18

Figure 4 Partnership Frameworks for Australian Environmental Health Surveillance 32

Figure 5 Proposed Management Structure for National Environmental

Figure 6 Development Timeframe for National Environmental Health Surveillance 40

Abbreviations and Acronyms

OECD Organisation for Economic Co-operation and Development

In summary, the key findings of this study are:

Finding 1: Australian Environmental Health Surveillance is Feasible

Finding 2: Window of Opportunity

Finding 3: Technology Barriers Removed

Innovation in this field requires governments with an appropriate long-term vision.

Recommendation 1: Support and Commitment

Recommendation 3: Program Plan and Pilot Projects

Recommendation 4: Sustainable Funding Arrangements

1.1 Study Objective

Examine a range of potential environmental health surveillance systems for Australia

1.2 Study Purpose and Process

1.2.1 Australian Government Partners

1.2.2 Interstate Working Group

1.2.3 Western Australian Reference Group

1.3 Study Scope

This study provides:

1.4 Definition of Terms

Environmental health covers those aspects of human health determined by physical,

2 Background and Concepts

2.1 Environmentally Related Disease in Australia

2.2 Economic Costs of Environmentally Related Diseases

Table 1 Documented Cost of Seven Environmentally Related Diseases in Australia

Cost in 2001 Estimated Cost

2.3 Health Surveillance

Figure 1 Key Concepts of Health Surveillance

Legislation & Regulation

Source: Health Canada48

2.4 Environmental Health Surveillance

Figure 2 Primary and Secondary Surveillance for Environmental Health

Majority External Agencies Environmental Health Management

Figure 3 Canadian Environmental Health Surveillance Concept51

• Characteristic of • Identifiable health outcome

• What is released to • Prevalence of outcome can

• Who is exposed? • Populations can be

2.5 Surveillance versus Indicators

An environmental health surveillance system would incorporate aspects of environmental

2.6 Limitations of Environmental Health Surveillance

3 Australian Surveillance Activities

3.1 National Health Surveillance

3.1.1 National Chronic Disease Surveillance

3.1.2 National Health and Well-Being Surveillance

3.1.3 National Communicable Disease Surveillance

The Biosecurity Surveillance System (BSS) Program is an initiative of the Department of

Information sharing is a crucial component of OzFoodNet. Network members are expected to

3.2 National Environmental Surveillance

3.2.1 National State of Environment Reporting

3.2.2 National Pollutant Inventory

3.2.3 National Air Quality Database