International Conference of the Central and Eastern European Chapter of the International Society...

International Conference of the Central and Eastern European Chapter International Conference of the Central and Eastern European Chapter of the International Society for Environmental Epidemiology, of the International Society for Environmental Epidemiology,

Celadna, Czech Republic, 26-29 November 2007Celadna, Czech Republic, 26-29 November 2007

Development of Environmental Health Development of Environmental Health Information System in Central and Information System in Central and

Eastern EuropeEastern Europe

Dafina DalbokovaDafina Dalbokova

World Health OrganizationWorld Health Organization

Regional Office for EuropeRegional Office for Europe

On behalf of ENHIS project groupOn behalf of ENHIS project group



This presentation:

• Development of European EH Information System (ENHIS): highlights

• Assessment of children’s EH by CEHAPE RPG: situation in Central and Eastern Europe and need for a system

• Next steps and actions needed to advance the EH information system in Central and Eastern Europe

Development of Environmental Health Information System in Central and Eastern Europe

ENHIS – European EH information system: partners

The product of EC-DG Sanco co-sponsored projects: ENHIS (2004 - 5) (SPC2003112) ENHIS 2 (2005 - 7) (SPC2004124)

International process to develop EH Information System in International process to develop EH Information System in Europe, 2004-2007Europe, 2004-2007

Defining the scope of the system Covering four CEHAPE RPGs Focus on health related exposures, health effects and actions

Screening for: policy relevance scientific evidence feasibility

Development of methodological guidelines Testing of methodology Evaluation of the process by the MS Implementation

EC-DG Sanco co-sponsored projects coordinated by WHO: ENHIS (2004 - 5) (SPC2003112) – 12 partner MS ENHIS 2 (2005 - 7) (SPC2004124) – 20 partners from 19 MS

Eight key meetings (18-29 MS represented)

Progress reports to EC H&E Working Party and EEHC

ENHIS was launched at the Intergovernmental

Mid-term Review meeting between the Fourth

and the Fifth Ministerial Conferences on

Environment and Health

(Vienna, 13-15 June 2007)

Endorsement and support from the MS

Children exposure and health effects: main linkages Children exposure and health effects: main linkages

Air pollution

Unsafe water and

sanitation

Chemicals and

heavy metals

Physical agents

Unsafe housing

Mobility and

transport

Child labour

Respiratory diseases

Gastrointestinal

diseases

Neurodevelopmental

disorders

Cardiovascular

disorders

Cancer

Injuries

Effects on

reproductive health

?

?

Scope of the ENHIS information: evidence on the linkages & the interventions

CE

HA

PE

Reg

ion

al Prio

rity Go

als I,II,III,IV

Core set of indicators: Country coverage and Core set of indicators: Country coverage and data sourcesdata sources

0

10

20

30

40

50

60

1.1 1.2 1.3 1.4 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3.1 3.2 3.3 3.4 3.5 3.6 3.7 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8

Indicator code

Co

un

try

co

ve

rag

e p

er

ind

ica

tor

RPG1 RPG4RPG3RPG2

RPG1• Case studies• Eurostat• WHO/ UNICEF JMP• DG Env; EEA

RPG2• WHO MDB• WHO HBSC• ENHIS Survey

RPG3• ISAAC• WHO MDB• EEA AirBase• GYTS Survey• Eurostat (SILC)• World Health Statistics• WHO Tobacco DB

RPG4• ACCIS IARC• GLOBOCAN• WHO POP Survey• EU SCOOP project• Case studies• EC DG JRC• Eurostat • ENHIS Survey

European EH information system productsEuropean EH information system products

Methodology for 26 core indicators

International and national data

bases

Data from surveys

Analysis and assessment

(including HIA)

26 FACT SHEETS

http://www.enhis.org

http://euro.who.int/document/E90767.pdf

http://www.enhis.org/

Building EH information base: indicator fact sheetBuilding EH information base: indicator fact sheet

Standardized format (4 pages)

Sections:

• Indicator name, definition• Key message & rationale• 1-2 charts (with description)• Health and environment context• Policy relevance and context• Assessment (including HIA)• Meta-data (data-about-data)• References

Sections available on the WWW

PDF printout available

Updated with new/ more info

Effective use and re-use of information

ENHIS web: options for access to data/ informationENHIS web: options for access to data/ information

Health Impact

Assessment

Environmental Burden of Disease

estimates by countrywww.who.int

Environment and health issues

Health effects of the environment

Country profiles

Environment and health policy

Methods and tools

Links

http://www.who.int/

ENHIS web: country profilesENHIS web: country profiles

WHO Environmental Burden of DieseaseWHO Environmental Burden of Diesease

(ENHIS):(ENHIS):



This presentation:





EH situation assessment 2000-5: EH situation assessment 2000-5: CEHAPE RPG ICEHAPE RPG I

Access to public water supply: for <40% of population of rural areas of some MS

House connected to sanitation facilities: <50% of population in rural areas of some MS

0 20 40 60 80 100

AustriaCyprus

DenmarkFranceIceland

NetherlandsNorwaySweden

SpainSwitzerland

LuxembourgUnited Kingdom

GermanyIreland

ItalyMalta

PolandSlovakiaFinland

Czech RepublicHungaryBelgium

Bosnia and HerzegovinaEstoniaGreece

BulgariaCroatia

ArmeniaSerbia and Montenegro

LatviaLithuania

Russian FederationPortugalUkraineAlbania

UzbekistanGeorgiaTurkey

TurkmenistanKyrgyzstanKazakhstan

TajikistanBelarus

AzerbaijanRomania

Republic of MoldovaAndorraMonaco

Proportion of population (%)

Rural houseconnection

Urban houseconnection

0

10

20

30

40

50

60

70

80

90

100

Sp

ain

Sw

ed

en

Ne

the

rlan

ds

Sw

itze

rlan

d

Au

stria

Cze

ch R

ep

ub

lic

Fin

lan

d

Slo

vaki

a

La

tvia

Est

on

ia

Lith

ua

nia

Cro

atia

Alb

an

ia

Bo

snia

an

d H

erz

eg

ovi

na

Ru

ssia

n F

ed

era

tion

Bu

lga

ria

Arn

en

ia

Be

laru

s

Ukr

ain

e

Hu

ng

ary

Se

rbia

Po

lan

d

Ge

org

ia

Ro

ma

nia

Ka

zakh

sta

n

Pro

po

rtio

n o

f p

op

ula

tion

(%

)

Urban

Rural

CEHAPE RPG I: Gastro-intestinal diseases and safe water and sanitation

EH Situation 2000-5: CEHAPE RPG IEH Situation 2000-5: CEHAPE RPG I

0

2

4

6

8

10

12

Year

Nu

mb

er o

f o

utb

reak

s

Waterborne outbreaks recorded in Finland, 1980-2004

compulsory monitoring

Role of improved surveillance and monitoring:

Reveals under-reported morbidity

Reduces risks

Bathing water quality in Portugal: 1995-2005

No harmonized surveillance of water-borne diseases -> case examples;Only Croatia child-specific

EH situation assessment 2000-5:EH situation assessment 2000-5: CEHAPE RPG IICEHAPE RPG II

Non-traffic related injuries in early childhood: Over 75,000 deaths per year >10x disparities in death rates between MS Large differences between MS in causes – use info to focus risk reduction

Policies can reduce the risk

0% 20% 40% 60% 80% 100%

Greece*Estonia

United KingdomAustria

Sw eden*Sw itzerland**

Germany*Ireland*

SloveniaSpain*

KazakhstanBulgariaFinland

Italy*Croatia

RussianMalta

CzechiaUkraine

AzerbaijanArmeniaFrance**Portugal

Slovakia**RomaniaNorw ay*Albania*

LatviaRep.of Moldova

LithuaniaHungary

PolandGeorgia*Belarus*

TFYR Macedonia**Kyrgyzstan

Turkey*Uzbekistan**Netherlands

drow ning falls burns poisoning

CEHAPE RPG II: Injuries and physical activity by supportive and safe environments

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

10-14 (Netherlands,Finland, Slovakia,Czech Republic,Greece, Austria,France, Sw eden)

6-9 (Bulgaria,Hungary, Lithuania,Romania, Portugal,

Italy, Poland,Slovenia, Malta)

0-5 (Croatia, Albania,Uzbekistan, Estonia,

Spain)

Scor

e of

pol

icy

indi

cato

r

Mortality from non-traffic related unintentional injuries (per 100,000)

EH Situation 2000-5: CEHAPE RPG IIEH Situation 2000-5: CEHAPE RPG II

Road traffic related injuries, age <25: Over 32,000 deaths per year >5x inequality in death rates between MS

EH situation assessment 2000-5:EH situation assessment 2000-5: CEHAPE RPG IICEHAPE RPG II

Physical activity: Excess body weight & obesity: in 5% to 35% of children Over 50% of children not sufficiently active Policy implementation varies among countries

Degree of implementation of 12 policies to reduce excess body weight andobesity in children, 2005 - 2006

EH situation assessment 2000-5: CEHAPE RPG IIIEH situation assessment 2000-5: CEHAPE RPG III

Respiratory diseases in children: Asthma: prevalence >15% in many MS ARI mortality – 100x differences between the MS

0.01 0.1 1 10

Kyrgyzstan

Romania

Republic of Moldova

Bulgaria

Albania

Slovakia

The former Yugoslav Republic of Macedonia

Lithuania

Hungary

Latvia

Malta

Poland

Czech Republic

Portugal

Estonia

Greece

United Kingdom

Ireland

Slovenia

Italy

Finland

Spain

Germany

France

Switzerland

Norway

Netherlands

Sweden

Austria

Average number of post-neonatal deaths due to respiratory diseases per 1000 live births

Post-neonatal ARI mortality

(log scale)

CEHAPE RPG III: Respiratory diseases and outdoor and indoor air quality


Exposure to outdoor air pollution (particles)

PM10 level > AQG for 90% children in

WHO/Euro

No improvement in urban air quality

in the current decade

No data on air quality for 43% of population

in the Region


Indoor air exposures

Environmental Tobacco Smoke

Over 50% children exposed to ETS at home No data on children exposure to ETS in West

Policies to reduce children’s exposure to ETS

in public places exist in most MS but smoking

ban still insufficient

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Health care facilities

Education facilities

Bars and restaurants

Theatres and cinemas

Public transport

Advertisement of cigarettes

Sale of tobacco to minors

Proportion of countries

ban restriction no restriction no data

Proportion of WHO/Euro MS implementing policies to reduce exposure of children to ETS

0 10 20 30 40 50 60 70 80 90 100

Czech Republic

Lithuania

Tajikistan

Republic of Moldova

Kyrgyzstan

Slovenia

Bulgaria

Ukraine

Kazakhstan

Russian Federation

Belarus

Slovakia

Estonia

Hungary

Albania

Poland

Turkey

Romania

Armenia

The former Yugoslav Republic of Macedonia

Croatia

Georgia

Serbia and Montenegro (Montenegro)

Serbia and Montenegro (Serbia)

Proportion of 13–15-year-olds exposed to ETS (%)


Indoor air exposures (cont’d)

Current exposure to ETS contribute to an additional 10,380 asthma attacks in a city with 20,000 children aged 0-14 yrs and 3% of asthma prevalence and 300 asthma attacks per child x year

Mould and Dampness

No data on exposures in the school environment!!

http://www.ibsb.ro/images/school.JPG

EH situation assessment 2000-5: CEHAPE RPG IVEH situation assessment 2000-5: CEHAPE RPG IV

0 2 4 6 8 10 12 14 16 18

GreeceBulgaria

RomaniaLatvia

PortugalPoland

SlovakiaHungary

SpainEstonia

ItalyFinland

Czech RepublicGermanySlovenia

IrelandUnited Kingdom

LithuaniaSwedenFrance

NetherlandsDenmark

AustriaNorway

SwitzerlandIceland

Num

ber

of c

ases

per

100

000

per

yea

r

Males Females

Melanoma incidence rates (age <55) high in N and W Europe

Implementation of actions to reduce children excessive exposure to UV in 26 MS

CEHAPE RPG IV: An environment free of hazardous chemicals and other hazards

Excessive exposure to UV

0 5 10 15 20 25 30

Sweden, 7–11, 1995–2001

Sweden, 3–19, 1991–1994

Germany, 3–14, 2003–2006

Germany, 6–14, 1990–1992

Israel, 1–10, 1998–2000

France, 0.5–6, 2002–2004

France, 1–6, 1995–1996

Czech Republic, 8–11, 1996–2001

Hungary, 4–6, 2006

Hungary, 4–6, 1996

Poland, 2–7, 1993–1999

Russian Federation, 2–6, 1997

Romania, 1–9, 1999–2000

TFYR Macedonia,* 10–14, 2004

TFYR Macedonia,* 10–14, 2001–2003

Bulgaria, 6–15, 2003

Bulgaria, 6–15, 1999–2003

Geometric mean of PbB (µg/dl)

0

5

10

15

20

25

30

35

40

Net

herla

nds

Spa

in

Ger

man

y

Finl

and

Cze

ch R

ep.

Slo

vak

Rep

.

Ukr

aine

Nor

way

Cro

atia

Hun

gary

TEQ

(pg/

g fa

t)

198819932002

EH situation assessment 2000-5: CEHAPE RPG IVEH situation assessment 2000-5: CEHAPE RPG IV

Exposure to hazardous chemicals

Decrease of lead exposure due to un- leaded fuels (but plumbing and local industries continue to be of concern)

POPs exposure – the lowest safety margins – monitoring is warranted

Dioxins in human milk

Pb in blood

Implications for human bio-monitoring

Children’s health and the environment in Europe: Children’s health and the environment in Europe: Main messagesMain messages

Health-related environmental conditions around 2004-5:

Big inequalities in health and exposure:– between various parts of the European Region of WHO– between various population groups within the Member States

Substantial differences in policy addressing the risk

Data availability:

International reporting (WHO, EEA, EUROSTAT) facilitates access of

MS to the standardized data for national and international analyses Improved surveillance reveals „unnoticed“ problems Internationally coordinated population-based surveys are important

source of the most relevant data

The need for a system in CEE



This presentation:





On the horizon - 2009

Fifth Ministerial Conference on EH (Rome, fall 2009)

Maintenance of the system -> its ability for policy monitoring & evaluation

• Improvement of geographical coverage (53 WHO/EURO MS)• National extensions of the system (sub-national data; country-specific indicators) & of the EH information network (incl. extension within countries)

Extension of thematic scope to address emerging issues (e.g. climate change)

European Environmental Health Information System: European Environmental Health Information System: integrating regional and local levelintegrating regional and local level

Population groups Adapted from CIHR-IPPH conceptual framework of population health, Annu. Rev. Public Health, 2006, 27

Scal

e

International & National

Local

Generic

Specific

EH ri

sks

Web-based, secure information system that exists at the local, regional,

and national/ international levels System consisting of distributed information systems & a network Enhance the use & re-use of existing data

ENHIS Network – Important system resourceENHIS Network – Important system resource

Responsive partner institutions –mechanism for transfer of knowledge to the MS

Several national workshops on ENHIS: e.g. Slovakia,

Spain, Hungary, Czech Republic …

Increased capacity in preparation & use of EH

information in policy debate in a national context ->

10+ national indicator fact sheets under way

Maintaining communication links getting “everybody on the same page”; ENHIS SharePoint: e-networking & common info space

Member States consider advancing national systems building on ENHIS with network as important resource (possible proposal in early 2008 under EC health action programme 2008-2013)

Join the ENHIS network!!

Activities & needs to advance national EH Activities & needs to advance national EH information systems: together we can make it!!information systems: together we can make it!!

Evaluating of the prospects for development of national EH

information systems using the WHO/ ENHIS methodology

Mapping your own country needs in strengthening public health

capacities -> tailor WHO activities both on technical & policy site

Looking for mechanisms and resources for joint technical projects

Initiated effort on farther transfer of the system in South East

Europe (WHO meeting, Bucharest, 12-13 November 2007)

Necessary actions:

Take an active part in creating a national EH information network

(incl. your country ENHIS partner) to link people, projects,

institutions to the ENHIS one

WHO:

Activities & needs to advance national EH Activities & needs to advance national EH information systems: together we can make it!!information systems: together we can make it!!

Necessary actions:

Stimulating the academia work on system improvement, a.o. conducting

studies using routine indicators and data

Capacity building: introducing EH surveillance in the academic curricula

Intervention studies and accountability research

Human bio-monitoring to improve our knowledge of H-E links

Remote sensing for environmental monitoring and GIS

Research:



Thank youThank you

Background information about the SystemBackground information about the System

Overview of children’s environmental health indicatorsOverview of children’s environmental health indicators

Children vulnerability to environmental hazardsChildren vulnerability to environmental hazards

Unique exposure pathwaysTransplacentalBreastfeeding

Exploratory behaviours leading to exposuresHand-to-mouth, object-to-mouthNon-nutritive ingestion

Stature and living zones, microenvironmentsLocation – lower to the groundHigh surface area to volume ratio

Children do not understand dangerPre-ambulatoryAdolescence – “high risk” behaviours

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