Part 1: A Tool for Advancing from Data to Policy

Hosted by the National Environmental Health Association (NEHA)

in partnership with the Centers for Disease Control & Prevention’s
Public Health Law Office
 Montrece McNeill Ransom, JD, MPH

 Public Health Law Program, CDC

 Team Lead, Public Health Law Training and
Workforce Development
 In this capacity, she:
 Develops competency models
 Creates and delivers training in public health
law, and
 Oversees the workforce development
components of CDC’s first cooperative
agreement focused on building the legal
capacity of the public health workforce.

2
 An Introduction to Legal Epidemiology:
A Tool for Advancing Data to Policy

Montrece McNeill Ransom, JD, MPH

Moderator
Team Lead, Public Health Law Training and Workforce Development
Public Health Law Program, Office for State Tribal Local and Territorial Support

3
 CDC PHLP Disclaimer

 The contents of this presentation have not been formally disseminated

by the Centers for Disease Control and Prevention (CDC) and should
not be construed to represent any agency determination or policy.

 These materials are for instructional use only and are not intended as a
substitute for professional legal or other advice.

 Always seek the advice of an attorney or other qualified professional

with any questions you may have regarding a legal matter.

4
 CDC Public Health Law Program

 Mission is to advance the use and understanding of law as a public

health tool
 Public health law increasingly recognized as a vital and essential
component of public health practice
 Public Health Law Program is part of a network of partners
● Representatives from federal, state, and local governments
● Academic and private organizations
● Focus on implementing public health law strategies

cdc.gov/phlp/index.html
5
 Early Example of a Legal Public Health Intervention

Outbreak of cholera in London, 1854

Caused 616 deaths

Effort led by Dr. John Snow, resulted

in local council deciding to remove
the pump handle

The Broad Street pump handle, Soho neighborhood in London, England

6
 New York City Before Sanitation Reform:
Varick Street in 1890s

7
 New York City After Sanitation Reform

8
 Social Determinants of Health

3 miles could equal up to 13-year life span difference

Life Span
for Given
Location

Kansas City, Missouri Minneapolis and St. Paul, Minnesota

rwjf.org/en/library/articles-and-news/2015/09/city-maps.html
10
Maintaining healthy
housing
Creating transportation infrastructure
 Law As a Social Determinant of Health

Public Health Legal

Law Practice Epidemiology

Legal epidemiology is the study of law as a factor in the cause,

distribution, and prevention of disease and injury in a population

Burris S, Ashe M, Levin D, et al. Annu Rev Public Health. 2016;37:135-48.

13
Studying law and
policy
 State constitution
 Statutory titles
– Title 16: Health and
Safety
– Title 22: Municipalities
 Links to regulations filed
and administrative code
 Legal Epidemiology

Legal Language Authorizing Involuntary Decontamination in Emergency

Response to Radiological Incidents, by State and Select Cities

 We use legal epidemiology to

● Understand trends in law
● Study the impact and
effectiveness of laws on health
● Inform and support best
practices
● Develop an evidence base of
what works
Express Language Narrow Language
Broad Language Limited Biologics Language

www.cdc.gov/phlp/docs/php-radioactive.pdf
15
 Tara Ramanathan, JD, MPH

 Public Health Law Program, CDC

 Specializes in state and local government
law related to emerging public health
issues
 Serves as the lead for the program’s
Research Initiative and works to develop
innovative and rigorous legal
epidemiology methods and guides for the
field

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 Jennifer Black, JD

 2017 Graduate-Emory University School

of Law
 Extern, Public Health Law Program, CDC
 Student Attorney, Turner Environmental
Law Clinic
 Former Intern, National Institute of
Environmental Health Sciences
 Student Advisory Committee, Emory
Global Health Initiative

17
Centers for Disease Control and Prevention

Legal Epidemiology: How to Study the Impact of Law

Tara Ramanathan, JD, MPH

Team Lead for Research and Translation
Public Health Law Program

May 10, 2017

Social determinants
of health
 Resource availability
 Healthcare access
 Public safety
 Social support
 Natural environment
 Worksites and schools
 Physical barriers
 Economic status
 Many more!
Social determinants
of health



Resource availability
Healthcare access
Public safety
MD



Social support
Natural environment
Worksites and schools
DC



Physical barriers
Economic status
Many more!
VA
 What is legal epidemiology?
 The scientific study of law as a factor
in the cause, distribution, and
prevention of disease and injury in a
population
– Legal mapping
– Legal evaluation
– Research innovation
Defining legal mapping
 Comparative law analyses on topics
important to health
– Legal assessments can show
differences in law at one point
in time
– Policy surveillance can show
changes across jurisdictions
over time
Ebola Screening and Monitoring Policies for Asymptomatic Individuals
Based on policies found by PHLP as of December 2, 2014*
WA

MT ME
ND

OR MN VT
NH
ID WI NY MA
SD
WY MI RI

PA CT
IA
NE NJ
NV
OH
IL IN DE
UT
MD
CO WV
VA DC
CA KS MO KY

NC
TN
AZ OK
NM AR SC

MS AL GA

TX

AK LA

FL

HI

Policy as compared to CDC guidance:

*Map illustrates policies that

American Samoa More restrictive were known to PHLP as of the

date indicated. In some
instances, states amended their
Guam Equal policies after communication
between the state and PHLP,
Northern Mariana Islands Less restrictive after states sent policies PHLP
had previously not located, or
Puerto Rico Unclear if more, equal, or less restrictive states added new language that
was not found by PHLP until a
later date.
U.S. Virgin Islands No policy found
12/2/14
Ebola Screening and Monitoring Policies for Asymptomatic Individuals
Based on policies found by PHLP as of January 13, 2015*
WA

MT ME
ND

OR MN VT
NH
ID WI NY MA
SD
WY MI CT RI

IA PA
NE NJ
NV
OH
IL IN DE
UT
MD
CO WV
VA DC
CA KS MO KY

NC
TN
AZ OK
NM AR SC

MS AL GA

TX

AK LA

FL

HI

Policy as compared to CDC guidance:

*Map illustrates policies that

American Samoa More restrictive were known to PHLP as of the

date indicated. In some
instances, states amended their
Guam Equal policies after communication
between the state and PHLP,
Northern Mariana Islands Less restrictive after states sent policies PHLP
had previously not located, or
Puerto Rico Unclear if more, equal, or less restrictive states added new language that
was not found by PHLP until a
later date.
U.S. Virgin Islands No policy found
1/13/2015
Ebola Screening and Monitoring Policies for Asymptomatic Individuals
Based on policies found by PHLP as of February 5, 2015*
WA

MT ME
ND

OR MN VT
NH
ID WI NY MA
SD
WY MI CT RI

IA PA
NE NJ
NV
OH
IL IN DE
UT
MD
CO WV
VA DC
CA KS MO KY

NC
TN
AZ OK
NM AR SC

MS AL GA

TX

AK LA

FL

HI

Policy as compared to CDC guidance:

*Map illustrates policies that

American Samoa More restrictive were known to PHLP as of the

date indicated. In some
instances, states amended their
Guam Equal policies after communication
between the state and PHLP,
Northern Mariana Islands Less restrictive after states sent policies PHLP
had previously not located, or
Puerto Rico Unclear if more, equal, or less restrictive states added new language that
was not found by PHLP until a
later date.
U.S. Virgin Islands No policy found
2/5/2015
Ebola Screening and Monitoring Policies for Asymptomatic Individuals
Based on policies found by PHLP as of August 31, 2015*
WA

MT ME
ND

OR MN VT
NH
ID WI NY MA
SD
WY MI CT RI

IA PA
NE NJ
NV
OH
IL IN DE
UT
MD
CO WV
VA DC
CA KS MO KY

NC
TN
AZ OK
NM AR SC

MS AL GA

TX

AK LA

FL

HI

Policy as compared to CDC guidance:

*Map illustrates policies that

American Samoa More restrictive were known to PHLP as of the

date indicated. In some
instances, states amended their
Guam Equivalent policies after communication
between the state and PHLP,
Northern Mariana Islands Less restrictive after states sent policies PHLP
had previously not located, or
Puerto Rico Unclear if more, equivalent, or less restrictive states added new language that
was not found by PHLP until a
later date.
U.S. Virgin Islands No policy found
8/31/15
Data collection: law and policy
 Database examples Develop
– Westlaw, Lexis, Bloomberg search string
– Municode
– Government websites
 Iterative legal database search
– Standardized search strings
– Objective: minimize false negatives
Refine Review
– Refine terms with defined search terms results
inclusion and exclusion criteria
Data analysis: law and policy
 Questions are a measurement tool Develop
questions
– Every law is measured with same
ruler
– Iterative question creation
– Expert review Refine Test
 Reliability and validity are critical
– Redundant coding
– Discrepancy analysis
Analyze
reliability and
validity
 Polar Graph on State School Vaccination Exemptions Law
www.cdc.gov/phlp/publications/topic/vaccinations.html

Legal evaluations
 Comparative analyses
of legal data with
health, cost, or systems
data
• Associational studies can
use existing datasets
• Qualitative studies can
engage stakeholders
 Correlations of laws to identified health objectives
40
35

35
Total Laws Relating to HIEs and HIOs as of Jan. 2014 (SIM States)

30

Laws Related to HIT Oversight by State as of Jan. 2014

30

R² = 0.33 25

25

20
20

15
15

10
10

5 5
R² = 0.11

0 0
0 20 40 60 80 100 120 140 160 180 200 0 10 20 30 40 50 60 70 80 90 100
% change in the number of non-federal acute care hospitals that electronically exchanged health information with outside ambulatory Percent of eligible Stage 2 hospitals’ electronic reporting of laboratory results, syndromic surveillance and immunizations to local
providers or hospitals by U.S. state (2010-2014) public health agencies, as reported through the Medicare EHR Incentive Program in 2014
Qualitative evaluations to examine impact
Example of
Evaluation Results
 There are many
“perceived” legal barriers
to data use and release
– Not all are actual legal
prohibitions
Example of
Evaluation Results
 Three approaches to
perceived barriers
– Apply conservative
data use policies
– Identify legal
solutions
– Identify
technological
solutions
 What Can States and Territories Learn From Legal Epi Studies?

Legal Mapping Legal Evaluation

Legal Assessments Policy Surveillance Associational Studies Investigational Studies
What do laws say How do laws across Do trends in law What impact does the
across jurisdictions on jurisdictions change relate to trends in law have on health,
a topic over time? health? cost, and the health
system?
For more on legal epidemiology:
 Submit a technical assistance request to PHLP at
www.cdc.gov/phlp/technicalassistance or email us at
phlawprogram@cdc.gov.
 Visit our website to learn about our program and available
resources: www.cdc.gov/phlp.
 Subscribe to the CDC Public Health Law News at
www.cdc.gov/phlp/news/current.html.
Centers for Disease Control and Prevention

Exploring Biomonitoring Issues in Law and Policy

Jennifer Black, JD
Legal Extern

Public Health Law Program

Office of State, Tribal, Local and Territorial Support
Centers for Disease Control and Prevention

May 10, 2017

Why is law important to biomonitoring?
Why is law important to biomonitoring?
Why is the law important to biomonitoring?
 Minnesota
144.996 ENVIRONMENTAL HEALTH TRACKING; BIOMONITORING.
Subd. 2. Biomonitoring. The commissioner shall:
(1) conduct biomonitoring of communities on a voluntary basis by collecting and analyzing biospecimens, as appropriate, to
assess environmental exposures to designated chemicals;
(2) conduct biomonitoring of pregnant women and minors on a voluntary basis, when scientifically appropriate;
(3) communicate findings to the public, and plan ensuing stages of biomonitoring and disease tracking work to further develop
and refine the integrated analysis;
(4) share analytical results with the advisory panel and work with the panel to interpret results, communicate findings to the
public, and plan ensuing stages of biomonitoring work; and
(5) submit a biennial report to the chairs and ranking members of the committees with jurisdiction over environment and health by
January 15, beginning January 15, 2009, on the status of the biomonitoring program and any recommendations for improvement.

Subd. 3. Health data. Data collected under the biomonitoring program are health data under section 13.3805.
History: 2007 c 57 art 1 s 144
Biomonitoring Statutes and Regulations
 Legal issues:
– What is biomonitoring?
• What sources does it test?
• What substances matter?
• How are these substances
affecting humans?
– The environment?
CDC Biomonitoring Grantees: Focus of State Laws

 Definitions
 Mediums
monitored
 Hazards monitored
 Procedures and
techniques
 Public notification
Focus of State Laws:
Definitions of Biomonitoring/ Monitoring
 “Biomonitoring:”
– Identifying and measuring substances within
biological specimens.
• CA, CO, NM, UT
 “Monitoring:”
– Testing and observing substances to
determine compliance with environmental
health standards
• AZ, MA
 Both definitions: NJ
Focus of State Laws: Mediums Monitored

 Water:
– Drinking water
• AZ, CO, MA, NH, NJ, UT, NM
– Ground Water Discharge
• CO, MA, NM, UT (with exclusions)
– Swimming (MA)
– Coastal zone (NJ)
Focus of State Laws:
Mediums Monitored (cont.)
 Air and Soil:
– Broad Authority
• NM
– General Reporting of Substances
• AZ
– Specific Reporting of Substances
• CO and NH (Mercury)
Focus of State Laws: Hazards Monitored

 Waste Facilities
– CO, AZ, MA
 Nuclear/Radiation
– MA, UT, VA
 Coal/Mining
– VA
 Pesticides
– NJ, UT
Focus of State Laws: Hazards Monitored
 “Hazardous Material”
– CA, NM
 Metals
– CO, NH
 Other Chemicals
– AZ, CO, CA
Focus of State Laws: Procedures and Techniques

 Recording samples
– VA, NM
 Testing requirements
– CO, NJ
 Analysis requirements
– NM
 Other
– CA
Focus of State Laws: Public Notification

 Information: findings, notice

– CA, CO
 Engagement: access, citizen rights
– NJ, VA
 Consequences for noncompliance
– NH
Common characteristics
 Provisions appropriate to the region
– MA and NJ
 Laws setting a “floor”
 Mediums covered
 Unique attributes
 Industrial Inclusions
 Environmental vs. human testing
 Usage of “biomonitoring”
 Procedures, such as training of technicians or scientific methods
 Other?
 Thank You!
For more information, contact CDC
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.
57
 How Do We Use Law To Affect Social Determinants of Health?

Life Span
for Given
Location

rwjf.org/en/library/articles-and-news/2015/09/city-maps.html
58
 Virtual Town Hall Meeting:
Exploring the Legal Epidemiology Competency Model

Explore and offer feedback on a draft competency model to support public

health practitioners, lawyers, and policy experts working in this area

Hosted by: The Public Health Foundation

Date: Thursday, May 11, 2017- TOMORROW!
Time: 2-3:30pm EDT

For more information about this virtual meeting or to register, please visit the
PHF website or contact Janelle Nichols at jnichols@phf.org.

59
 Speaker Contact Information
Montrece McNeill Ransom, JD, MPH
mransom@cdc.gov

Tara Ramanathan, JD, MPH

tramanathan@cdc.gov
For more information, contact CDC
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348 www.cdc.gov Jennifer Black, JD
jblack2@cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.
 Thank you for participating!

Sign up for Part 2: A Tool for Evaluating the Impact of

Environmental Public Health Law
at http://neha.org/node/59017.