Understanding public perceptions about environmental health hazards, exposures, and health impacts can help environmental public health practitioners to target and prioritize community activities, policy needs, and communication strategies. The online cross-sectional 2013 summer wave of the ConsumerStyles survey sampled U.S. adults and used questions from the Centers for Disease Control's Environmental Public Health Tracking Program to measure public awareness of governmental efforts to track environmental exposures and links to health impacts, as well as perceptions of environmental health issues. Unadjusted and adjusted logistic regressions examined the associations between demographic characteristics and level of awareness of government environmental public health efforts or level of concern about health risks associated with environmental pollutants. Responses were received from 4033 participants, yielding a response rate of 66.0%. More than half of respondents (57.8%) noted concerns about health risks from environmental pollutants. More than one-third (40.0%) of respondents reported awareness of government efforts. Nearly 40% of respondents felt that none of the health impacts listed in the survey were related to environmental issues. Multiple logistic regression models showed that non-Hispanic blacks, other races, females, people with a college or higher education, and people living in the Midwest or South regions were more likely than their counterparts to be concerned about how the environment affects their health. Future work should focus on improving risk communication, filling the information gap on environmental health issues, and understanding how perceptions change over time.

INTRODUCTION: Poor air quality affects respiratory and cardiovascular health. Information about health risks associated with outdoor air quality is communicated to the public using air quality alerts. This study was conducted to assess associations of existing respiratory and heart disease with three aspects of air quality awareness: awareness of air quality alerts, discussing with a health professional strategies to reduce air pollution exposure, and avoiding busy roads to reduce air pollution exposure when walking, biking, or exercising outdoors. METHODS: During 2014-2016, a total of 12,599 U.S. adults participated in summer waves of the ConsumerStyles surveys and self-reported asthma, emphysema/chronic obstructive pulmonary disease, heart disease, and each aspect of air quality awareness. In 2017, associations between each health condition and air quality awareness were estimated using log binomial and multinomial regression. RESULTS: Overall, 49% of respondents were aware of air quality alerts, 3% discussed with a health professional strategies to reduce air pollution exposure, and 27% always/usually avoided busy roads to reduce air pollution exposure. Asthma was associated with increased prevalence of awareness of air quality alerts (prevalence ratio=1.11, 95% CI=1.04, 1.20), discussing with a health professional (prevalence ratio=4.88, 95% CI=3.74, 6.37), and always/usually avoiding busy roads to reduce air pollution exposure (prevalence ratio=1.13, 95% CI=1.01, 1.27). Heart disease was not associated with air quality awareness. CONCLUSIONS: Existing respiratory disease, but not heart disease, was associated with increased air quality awareness. These findings reveal important opportunities to raise awareness of air quality alerts and behavior changes aimed at reducing air pollution exposure among adults at risk of exacerbating respiratory and heart diseases.

Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of health data for the planning, implementation, and evaluation of public health practice and is an important component in assessing the function of public health.1 In 2000, a Pew Environmental Health Commission's report highlighted the lack of surveillance data and information to monitor the burden of environmentally related disease and the need to improve our understanding of the links between environmental hazards and chronic diseases.2 In response, the National Environmental Public Health Tracking Program (Tracking Program) at the Centers for Disease Control and Prevention (CDC) was developed in 2002. Since its inception, the Tracking Program has worked closely with a community of funded state and local health departments to build capacity and infrastructure to develop the National Environmental Public Health Tracking Network (Tracking Network), an integrated network of environmental health surveillance data at the local, state, and national levels. Application of these data is key to support evidence-based decision making and public health actions within state and local programs to help promote healthy and informed communities. Now in its 15th year, the Tracking Program continues to enhance the infrastructure of the Tracking Network to support more consistent use of its data and program resources to help inform public health actions, with the ultimate goal of reducing the burden of environmentally related health conditions. | This special issue of the Journal of Public Health Management & Practice offers a unique examination of the breadth of work by CDC and its partners in the Tracking Program, with a focus on how the Tracking Network and program resources have been utilized to support environmental public health practice and inform specific public health actions. Wilson and Charleston3 first provide an overview of the Tracking Program's history and development and how support from the Tracking Program can improve environmental public health practice at the state and local levels. Eatman and Strosnider4 then discuss the process that is taken to monitor public health actions, which serves as a performance measurement for the Tracking Program. They provide 3 case studies to highlight the diversity of actions taken by tracking partners. More than 400 public health actions have been finalized by the Tracking Program since 2005, thereby illustrating the opportunities for our partners to use the data and resources to help address the environmental public health needs at the state and local levels. Zhou et al5 then provide an initial examination of standardized approaches for estimating the monetary value of different health outcomes, for both generating additional information to support environmental health decision making and evaluating the costs and benefits of public health actions informed by the Tracking Program and its partners. Lucas-Pipkorn and Tuomi6 provide the last article at the national level and describe efforts by the Tracking Program to address gaps in the Tracking Network by developing new partnerships between the Tracking Program, state health departments, and tribal communities.

OBJECTIVE: Short-term exposure to ground-level ozone has been linked to adverse respiratory and other health effects; previous studies typically have focused on summer ground-level ozone in urban areas. During 2008-2011, Sublette County, Wyoming (population: ~10,000 persons), experienced periods of elevated ground-level ozone concentrations during the winter. This study sought to evaluate the association of daily ground-level ozone concentrations and health clinic visits for respiratory disease in this rural county. METHODS: Clinic visits for respiratory disease were ascertained from electronic billing records of the two clinics in Sublette County for January 1, 2008-December 31, 2011. A time-stratified case-crossover design, adjusted for temperature and humidity, was used to investigate associations between ground-level ozone concentrations measured at one station and clinic visits for a respiratory health concern by using an unconstrained distributed lag of 0-3 days and single-day lags of 0 day, 1 day, 2 days, and 3 days. RESULTS: The data set included 12,742 case-days and 43,285 selected control-days. The mean ground-level ozone observed was 47+/-8ppb. The unconstrained distributed lag of 0-3 days was consistent with a null association (adjusted odds ratio [aOR]: 1.001; 95% confidence interval [CI]: 0.990-1.012); results for lags 0, 2, and 3 days were consistent with the null. However, the results for lag 1 were indicative of a positive association; for every 10-ppb increase in the 8-h maximum average ground-level ozone, a 3.0% increase in respiratory clinic visits the following day was observed (aOR: 1.031; 95% CI: 0.994-1.069). Season modified the adverse respiratory effects: ground-level ozone was significantly associated with respiratory clinic visits during the winter months. The patterns of results from all sensitivity analyzes were consistent with the a priori model. CONCLUSIONS: The results demonstrate an association of increasing ground-level ozone with an increase in clinic visits for adverse respiratory-related effects in the following day (lag day 1) in Sublette County; the magnitude was strongest during the winter months; this association during the winter months in a rural location warrants further investigation.

CONTEXT: Exposure to elevated concentrations of traffic-related air pollutants in the near-road environment is associated with numerous adverse human health effects, including childhood cancer, which has been increasing since 1975. Results of individual epidemiologic studies have been inconsistent. Therefore, a meta-analysis was performed to examine the association between residential traffic exposure and childhood cancer. EVIDENCE ACQUISITION: Studies published between January 1980 and July 2011 were retrieved from a systematic search of 18 bibliographic databases. Nine studies meeting the inclusion criteria were identified. Weighted summary ORs were calculated using a random effects model for outcomes with four or more studies. Subgroup and sensitivity analyses were performed. EVIDENCE SYNTHESIS: Childhood leukemia was positively associated (summary OR=1.53, 95% CI=1.12, 2.10) with residential traffic exposure among seven studies using a postnatal exposure window (e.g., childhood period or diagnosis address) and there was no association (summary OR=0.92, 95% CI=0.78, 1.09) among four studies using a prenatal exposure window (e.g., pregnancy period or birth address). There were too few studies to analyze other childhood cancer outcomes. CONCLUSIONS: Current evidence suggests that childhood leukemia is associated with residential traffic exposure during the postnatal period, but not during the prenatal period. Additional well-designed epidemiologic studies that use complete residential history to estimate traffic exposure, examine leukemia subtypes, and control for potential confounding factors are needed to confirm these findings. As many people reside near busy roads, especially in urban areas, precautionary public health messages and interventions designed to reduce population exposure to traffic might be warranted.

Traffic-related air pollution is a main contributor to unhealthy ambient air quality, particularly in urban areas with high traffic volume. Within urban areas, traffic is a major source of local variability in air pollution levels, with the highest concentrations and risk of exposure occurring near roads. Motor vehicle emissions represent a complex mixture of criteria air pollutants, including carbon monoxide (CO), nitrogen oxides (NOx), and particulate matter (PM), as well as hydrocarbons that react with NOx and sunlight to form ground-level ozone. Individually, each of these pollutants is a known or suspected cause of adverse health effects. Taking into consideration the entire body of evidence on primary traffic emissions, a recent review determined that there is sufficient evidence of a causal association between exposure to traffic-related air pollution and asthma exacerbation and suggestive evidence of a causal association for onset of childhood asthma, nonasthma respiratory symptoms, impaired lung function, all-cause mortality, cardiovascular mortality, and cardiovascular morbidity.

RATIONALE: Information on how ambient air pollution affects susceptible populations is needed to ensure protective air quality standards. OBJECTIVES: To estimate the effect of community-level ambient particulate matter (PM) and ozone (O(3)) on respiratory symptoms among primarily African-American and Latino, lower-income asthmatic children living in Detroit, Michigan and to evaluate factors associated with heterogeneity in observed health effects. METHODS: A cohort of 298 children with asthma was studied prospectively from 1999 to 2002. For 14 days each season over 11 seasons, children completed a respiratory symptom diary. Simultaneously, ambient pollutant concentrations were measured at two community-level monitoring sites. Logistic regression models using generalized estimating equations were fit for each respiratory symptom in single pollutant models, looking for interactions by area or by corticosteroid use, a marker of more severe asthma. Exposures of interest were: daily concentrations of PM<10mcm, <2.5mcm, and between 10 and 2.5mcm in aerodynamic diameter (PM(10), PM(2.5), and PM(10-2.5) respectively), the daily 8-hour maximum concentration of O(3) (8HrPeak), and the daily 1-hour maximum concentration of O(3) (1HrPeak). RESULTS: Outdoor PM(2.5), PM(10), 8HrPeak, and 1HrPeak O(3) concentrations were associated with increased odds of respiratory symptoms, particularly among children using corticosteroid medication and among children living in the southwest community of Detroit. Similar patterns of associations were not seen with PM(10-2.5). CONCLUSIONS: PM(2.5) and O(3) at levels near or below annual standard levels are associated with negative health impact in this population of asthmatic children. Variation in effects within the city of Detroit and among the subgroup using steroids emphasizes the importance of spatially refined exposure assessment and the need for further studies to elucidate mechanisms and effective risk reduction interventions.

OBJECTIVES: Unintentional, non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. A comprehensive national CO poisoning surveillance framework is needed to obtain accurate estimates of CO poisoning burden and guide prevention efforts. This article describes the current national CO poisoning surveillance framework and reports the most recent national estimates. METHODS: We analyzed mortality data from the National Vital Statistics System multiple cause-of-death file, emergency department (ED) and hospitalization data from the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample and Nationwide Inpatient Sample, hyperbaric oxygen treatment (HBOT) data from HBOT facilities, exposure data from the National Poison Data System, and CO alarm prevalence data from the American Housing Survey and the National Health Interview Survey. RESULTS: In the United States, 2,631 UNFR CO deaths occurred from 1999 to 2004, an average of 439 deaths annually. In 2007, there were 21,304 (71 per one million population) ED visits and 2,302 (eight per one million population) hospitalizations for confirmed cases of CO poisoning. In 2009, 552 patients received HBOT, and from 2000 to 2009, 68,316 UNFR CO exposures were reported to poison centers. Most nonfatal poisonings were among children (<18 years of age) and females; hospitalizations and deaths occurred more frequently among males and elderly people (>65 years of age). More poisonings occurred during winter months and in the Midwest and Northeast. CONCLUSIONS: UNFR CO poisoning poses a significant public health burden. Systematic evaluation of data sources coupled with modification and expansion of the surveillance framework might assist in developing effective prevention strategies.

OBJECTIVES: We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies. METHODS: This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States. RESULTS: We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset. CONCLUSIONS: Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention. (Am J Public Health. Published online ahead of print August 16, 2012: e1-e7. doi:10.2105/AJPH.2012.300674).

OBJECTIVE: Unintentional carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States. Most poisoning cases occur in residential settings and a working CO alarm may prevent many of these events. The use of a CO alarm is mandated in many parts of the country; however, little is known about the compliance and adoption of such ordinances at the population level. This study determined the prevalence of residential CO alarm and awareness of a 2001 CO alarm ordinance in Mecklenburg County, North Carolina in 2009. METHODS: A random sample of households stratified by housing type (eg, single-family homes, multifamily homes) was included in a cross-sectional survey conducted. One adult respondent from each household was administered a questionnaire that included information on sociodemographic and household characteristics, presence of a CO alarm, and CO alarm ordinance awareness. Data were analyzed using multivariate stratified conditional logistic regression. RESULTS: Among 214 participating households (response rate, 23.4%), 145 (67.8%) reported having a working CO alarm and 79 (36.9%) of the respondents were aware of the CO alarm ordinance. Respondents who were aware of the ordinance had 9 times higher odds (95% confidence interval, 3.3-25.9) of having a CO alarm than those who were unaware. Also, households with an attached garage had more than 2 times higher odds (95% confidence interval, 1.0-6.2) of having a CO alarm than those without an attached garage. Awareness of the CO alarm ordinance was not associated with any sociodemographic (eg, age, sex, race, education, income) or household (eg, home ownership, home construction year) characteristics. CONCLUSIONS: Carbon monoxide alarm prevalence in Mecklenburg County households was higher than the national average and was associated with CO alarm ordinance awareness. Public health efforts might benefit from regulations aimed at population-level adoption of preventive health behaviors.

Particulate matter and ozone are two well-characterized air pollutants that can affect health and are monitored by the U.S. Environmental Protection Agency (EPA). Particulate matter (solid or liquid particles suspended in the air) varies widely in size and chemical composition and can include smoke, fumes, soot, and combustion by-products, as well as natural particles (e.g., windblown dust, pollen, and sea salt) (1,2). Particulate matter therefore represents a complex class of air pollutants that differ from other gaseous air pollutants (e.g., ozone). The transport and effect of particulate matter, both in the atmosphere and in the human respiratory tract, are governed principally by particulate size, shape, and density. Individual particles are characterized by their equivalent aerodynamic diameter: coarse particulate matter (2.5--10 µm); fine particulate matter, or PM2.5 (0.1--2.5 µm); and ultrafine particulate matter (<0.1 µm). Ozone is a gas that occurs naturally in the stratosphere, approximately 10--30 miles above the earth's surface, protecting the earth from the sun's ultraviolet rays. Ozone also exists at ground level and is the primary component of smog. At ground level, ozone is created when specific pollutants react in the presence of sunlight. In urban areas, vehicular and industrial emissions are chief contributors to ozone production. Ground-level ozone adversely affects health and damages the environment. | | The association between outdoor particulate matter concentrations and acute and chronic adverse health outcomes includes premature death, lung cancer, exacerbation of respiratory and cardiovascular disease, and increased risks for cardiovascular morbidity (e.g., myocardial infarction and arrhythmia) (1--6). Data indicate that fine particulate matter is the size fraction most strongly associated with these observed health effects (1--7). Populations most susceptible to these exposures include older adults and children, as well as persons with heart and lung disease. National Ambient Air Quality Standards (NAAQS) were set forth in the Clean Air Act Amendments of 1970* requiring EPA to set air quality standards for specific pollutants, such as PM2.5 and ozone, to protect the health of the general public, as well as that of sensitive populations. States that do not meet the standards are subject to additional regulatory requirements and must develop a state implementation plan to meet the standards. State implementation plans might include control requirements and limits on emissions. In 2006, on the basis of increasing evidence of the effects of PM2.5 on human health, EPA revised its 24-hour NAAQS from 65 µg/m3 to 35 µg/m3. Throughout the United States, PM2.5 concentrations have been decreasing; more counties were in compliance with national pollution standards as of 2008 compared with previous years (8). During 2001--2008, the average annual and 24-hour PM2.5 concentrations declined by 17% and 19%, respectively (8).

BACKGROUND: Unintentional carbon monoxide poisoning is preventable. Severe cases are often referred for hyperbaric oxygen treatment. To guide prevention efforts and treatment practices, this study provides some of the most detailed current information about patients with carbon monoxide poisoning who have been treated at hyperbaric facilities across the United States and the circumstances surrounding their exposures. This study can help improve efforts to prevent carbon monoxide poisoning and enhance treatment practices. METHODS: From August 2008 to January 2010, nonidentifiable, patient-level data were reported by 87 hyperbaric facilities in 39 states via an online reporting system. This reporting system was developed collaboratively by the Undersea and Hyperbaric Medical Society and the Centers for Disease Control and Prevention. RESULTS: Among the 864 patients reported to receive hyperbaric oxygen treatment for unintentional, non-fire-related, carbon monoxide poisoning, most of the patients were white men aged between 18 and 44 years. Only 10% of patients reported the presence of a carbon monoxide alarm at their exposure location, and 75% reported being part of a group exposure. Nineteen patients (2%) reported a prior carbon monoxide exposure. About half (55%) of the patients treated were discharged after treatment; 41% were hospitalized. CONCLUSIONS: The findings in this report expand the knowledge about patients with carbon monoxide poisoning. These results suggest that prevention efforts, such as educating the public about using carbon monoxide alarms and targeting the most at-risk populations, may help reduce the number of exposures, the number of persons with chronic cognitive sequelae, and the resulting burden on the health care system.

BACKGROUND: Unintentional, non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States, but the overall hospital burden is unknown. This study presents patient characteristics and the most recent comprehensive national estimates of UNFR CO-related emergency department (ED) visits and hospitalizations. METHODS: Data from the 2007 Nationwide Inpatient and Emergency Department Sample of the Hospitalization Cost and Utilization Project were analyzed. The Council of State and Territorial Epidemiologists' CO poisoning case definition was used to classify confirmed, probable, and suspected cases. RESULTS: In 2007, more than 230 000 ED visits (772 visits/million) and more than 22 000 hospitalizations (75 stays/million) were related to UNFR CO poisoning. Of these, 21 304 ED visits (71 visits/million) and 2302 hospitalizations (8 stays/million) were confirmed cases of UNFR CO poisoning. Among the confirmed cases, the highest ED visit rates were among persons aged 0 to 17 years (76 visits/million) and 18 to 44 years (87 visits/million); the highest hospitalization rate was among persons aged 85 years or older (18 stays/million). Women visited EDs more frequently than men, but men were more likely to be hospitalized. Patients residing in a nonmetropolitan area and in the northeast and midwest regions of the country had higher ED visit and hospitalization rates. Carbon monoxide exposures occurred mostly (>60%) at home. The hospitalization cost for confirmed CO poisonings was more than $26 million. CONCLUSION: Unintentional, non-fire-related CO poisonings pose significant economic and health burden; continuous monitoring and surveillance of CO poisoning are needed to guide prevention efforts. Public health programs should emphasize CO alarm use at home as the main prevention strategy.

OBJECTIVE: Carbon monoxide (CO) poisoning is preventable, yet it remains one of the most common causes of poisoning in the U.S. In the absence of a national data reporting system for CO-poisoning surveillance, the burden of CO-related hospitalizations is unknown. Our objective was to generate the first national estimates of CO-related hospitalizations and to evaluate the use of a Web-based query system for public health surveillance. METHODS: The Healthcare Cost and Utilization Project's (HCUP's) 2005 Nationwide Inpatient Sample (NIS) data were used for CO-related hospitalization estimates. Data for confirmed, probable, and suspected cases were generated using the HCUPnet Web-based query system. We used data from 1993 through 2005 NIS to describe trends in CO-related hospitalizations. We used the Centers for Disease Control and Prevention's surveillance evaluation guidelines to evaluate the system. RESULTS: In 2005, there were 24,891 CO-related hospitalizations nationwide: 16.9% (n=4,216) were confirmed, 1.1% (n=279) were probable, and 81.9% (n=20,396) were suspected CO-poisoning cases. Of the confirmed cases (1.42/100,000 population), the highest hospitalization rates occurred among males, older adults (aged > or = 85 years), and Midwestern residents. CO-related hospitalization rates declined from 1993 through 2000 and plateaued from 2001 through 2005. The simplicity, acceptability, sensitivity, and representativeness of the HCUPnet surveillance system were excellent. However, HCUPnet showed limited flexibility and specificity. CONCLUSIONS: Nationwide, the burden of CO exposure resulting in hospitalization is substantial. HCUPnet is a useful surveillance tool that efficiently characterized CO-related hospitalizations for the first time. Public health practitioners can utilize this data source for state-level surveillance.

BACKGROUND: Wild game hunting is a popular activity in many regions of the United States. Recently, the presence of lead fragments in wild game meat, presumably from the bullets or shot used for hunting, has raised concerns about health risks from meat consumption. OBJECTIVE: This study examined the association between blood lead levels (PbB) and wild game consumption. METHODS: We recruited 742 participants, aged 2-92 years, from six North Dakota cities. Blood lead samples were collected from 736 persons. Information on socio-demographic background, housing, lead exposure source, and types of wild game consumption (i.e., venison, other game such as moose, birds) was also collected. Generalized estimating equations (GEE) were used to determine the association between PbB and wild game consumption. RESULTS: Most participants reported consuming wild game (80.8%) obtained from hunting (98.8%). The geometric mean PbB were 1.27 and 0.84mug/dl among persons who did and did not consume wild game, respectively. After adjusting for potential confounders, persons who consumed wild game had 0.30mug/dl (95% confidence interval: 0.16-0.44mug/dl) higher PbB than persons who did not. For all game types, recent (<1 month) wild game consumption was associated with higher PbB. PbB was also higher among those who consumed a larger serving size (≥2oz vs. <2oz); however, this association was significant for 'other game' consumption only. CONCLUSIONS: Participants who consumed wild game had higher PbB than those who did not consume wild game. Careful review of butchering practices and monitoring of meat-packing processes may decrease lead exposure from wild game consumption.