GIS Takes Flight In Public Health Sector

By Ed McKenna

Geographic information systems are becoming vital tools for scientists and public health officials investigating the cause and spread of deadly diseases around the world.

Officials at the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry, both in Atlanta, are using GIS to monitor the spread of a host of diseases, including polio, malaria, dengue fever, Guinea worm and Lyme disease, said Chuck Croner, a geographer and survey statistician with the CDC.

The agencies also are conducting studies using GIS into the risks for childhood lead poisoning, underimmunization, commercial fishing injuries and fatalities, exposures to pesticides and chemical releases, he said.

In addition, GIS is now slated to play a large role in cancer research, with the National Cancer Institute preparing to build a prototype system for the Long Island Breast Cancer Project study. Based in Bethesda, Md., the National Cancer Institute is a component of the National Institutes of Health.

The growing use of GIS in public health is stoking an already robust software, services and data market, valued at about $3 billion worldwide last year, according to David Sonnen, senior GIS analyst for International Data Corp., Framingham, Mass.

GIS software sales worldwide grew about 11 percent last year to $986 million, he said. In 1999, software sales are expected to reach $1.2 billion, he said, adding that the market is projected to grow about 20 percent per year over the next five years.

IDC has not yet tallied forecasts for the services and data markets but expects solid growth in both, Sonnen said. Geographic information systems are computer systems capable of assembling, storing, manipulating, and displaying geographically referenced data.

The leading software vendor in the public sector market is Environmental Systems Research Institute (ESRI), Redlands, Calif., said Sonnen. Other key vendors include Intergraph Corp., Huntsville, Ala., and MapInfo, Troy, N.Y.

Long used in public safety and land management programs, "the idea of using GIS to study public health issues is really just beginning to blossom," said Elizabeth Harper, director of marketing for Applied Geographics Inc., a Boston-based environmental and GIS consulting firm.

It may be a new market, but it is already boosting vendors' bottom lines.

"Governments worldwide are spending a lot of money" for GIS in the public health area, said Bill Davenhall, manager of the health solution group at ESRI. "The greatest use of our product is in epidemiology," he said, noting that sales for public health uses represented about 10 percent of total sales, or $30 million, last year.

A number of factors are driving GIS expansion into public health, said Croner. For one, the Clinton administration's National Spatial Data Infrastructure initiative has begun to take hold, providing for more uniform and efficient use of the technology. President Clinton issued an executive order in April 1994 directing federal agencies to work with state and local governments and the private sector to develop the data infrastructure.

The growth of Web-based technology is another catalyst, spawning many new opportunities for federal, state and local governments and even neighborhoods to use GIS, Croner said.

"We are finding that GIS is empowering many professionals and nonprofessionals to examine health conditions in their own community," he said.

On another level, Global Positioning System technology has boosted the capability of GIS for disease surveillance missions. The satellite-based navigation system can provide precise location information for detailed maps of at-risk environments, he said.

What's more, GIS has become more accessible, said Tim Rogan, director of business development for Averstar Inc.'s Geospatial Services Group, Portland, Ore. In its early days, it was a back-room technology with agencies relying on a small cadre of trained people to do GIS analysis, he said.

"Now it's gone to the desktop and it is imbedded, so a researcher can use it without having to be a GIS specialist," Rogan said.

Researchers can download a rudimentary DOS-based mapping system from the CDC Web site at no cost. Designed at the CDC with help from the World Health Organization, Epi Map was added to the agency's EPI Info database tools in 1991 and made available on the Web in 1994, said Andrew Dean, chief of Epi Info development team at the center.

The CDC is developing a more robust Windows version, called Epi Map 2000, which will use ESRI GIS as its main engine, said Dean. The agency may distribute the product without restriction so long as it accompanies Epi Info, he said.

Since its introduction in 1985, EPI Info has proven popular in the United States and worldwide. At least 42 states are using Epi Info to maintain their disease statistics and report them to CDC online every week, Dean said.

Among the states using Epi Info is Maryland. Working with the Maryland Department of Health and Mental Hygiene in 1995, Jay Devasundaran, an epidemiologist with the department, designed a mapping system using ESRI GIS for state health personnel to use.

That program has been used to display communicable disease levels in the state of Maryland by county and zip code, Devasundaran said.

Devasundaran, who joined St. Mary's County, Md., Health Department as epidemiologist last year, is now working on a project that will use GIS to help combat lead poisoning in children in the county.

Many other states and localities are following suit.

For example, the Florida Department of Agriculture is looking to use a new program from Advanced Computer Resources, Nashua, N.H., that uses MapInfo's GIS to help monitor the state's disease-spreading mosquito population.

Advanced Computer Resources plans to begin selling the systems this fall, said Matt Leo, senior database consultant with the company.

Developed under Small Business Innovative Research grants from the CDC, the application will support all the day-to-day operations of the mosquito control districts, said Leo. The company has two test sites in Florida and expects to provide the systems statewide before the end of the year.

Later this year, geographic information system technology will be used to study the above-average incidence of breast cancer on Long Island, N.Y. The Long Island Breast Cancer Project study was mandated by Congress in 1993.

The National Cancer Institute sees the Long Island study as a model for future cancer studies nationwide, said Rogan. The institute expects to award a contract for the project next month. Competing for the contract are teams led by Averstar and Applied Geographics, according to industry sources. Both contractors will use ESRI GIS.

Estimated to be worth $3 million, the project is divided into two phases. The first, which will last two years, is devoted to "building up the data and implementing some of the geographic analyses," said Harper of Applied Geographics.

Data sets mandated for the program include geo-coded, population-based cancer incidences and mortality data, New York State Department of Health incidence data and Environmental Protection Agency toxic chemical release inventory, national air toxic information and land view data.

The Long Island project mirrors in many ways a study begun in 1995 probing the cause of above-average incidence of breast cancer on Cape Cod, Mass., said Harper. Applied Geographics is working as a subcontractor on that project to the Silent Spring Institute, a Newton, Mass.-based, non-profit organization founded by community activists.

Funded by the state of Massachusetts, the institute has an operating budget of $7 million through 2001, said Julia Brody, executive director of Silent Spring Institute.

"GIS technology has a number of significant strengths for a study of breast cancer etiology," said Brody. "Breast cancer has multiple causes, and the GIS allows us to incorporate multiple factors in a single analysis." The system also can plot historical data. "In the study of cancer, which has long latency, it is very important to have a source of historical data," she said.

Also, GIS provides information that women themselves would not know, Brody said, noting that "a typical epidemiological study might interview women, but you can't ask them what was in their drinking water." While its use in epidemiological studies is growing, GIS is probably most widely used in the health sector to look at patterns of where people have to go to get medical services, said Rogan

For example, ESRI provided the Women, Infants and Children program with GIS and enlisted Chris Austin, president of GeoHealth Inc., Redlands. Calif., to train the staff to use the program to find information, such as how to plot where their clients come from, where their clinics are and the available bus routes.

At GeoHealth, Austin devised BodyViewer, which uses ESRI GIS to graphically map the body's systems, allowing health care professionals to more easily visualize and analyze the more than 14,000 ICD-9 codes used worldwide as identifiers of various ailments.

Rather than a list of numbers, BodyViewer presents a computerized picture of the body with its organs. The users, which could include hospitals or insurance companies, can click on a particular organ and receive a map of reported ailments related to that organ.

"We made a special category for public health that visualizes the mode for transmission of communicable diseases rather than the body," he said. For example, a picture of a rat shows diseases spread by rodents, he said, noting you can click on the rat and see a map illustrating incidences of the diseases.

Austin, who has given the software to Missouri to use on a trial basis, also has had discussions with the CDC and with state and local governments about the use of GIS tools.

By Ed McKenna



The Environmental Protection Agency will provide a strong supporting role in helping to develop the geographic information system for the Long Island Breast Cancer Project.

The National Cancer Institute also may tap the agency's vast experience in using advanced mapping tools as it develops its geographic information system.

EPA uses the technology at virtually every level of its operations. When remediating a Superfund location, for example, a separate GIS database is compiled for that site, said Bruce Rundell, a senior geologist with the EPA in Philadelphia.

On a practical level, the GIS becomes a central data repository. "We collect so much data, it is good to have it all in one spot [rather than having] tons and tons of data on paper. That is hard to dig up," he said.

The GIS also serves as an analytic tool to help with basic decisions, such as how much dirt to move or whether to take ground water samples on a regular basis when monitoring the site, he said.

Rundell opted to use an Intergraph Corp. GIS primarily because of its 3-D visualization capability, he said. "We do a lot of soil borings and ground water investigations" that require 3-D visualization, he said.

The Intergraph GIS was purchased under the Naval Facilities Engineering Command's Installation Management/Facilities CAD-2 contract, which was awarded in 1993 and is slated to run for 12 years.

Intergraph shares the contract with Cordant Inc. of Reston, Va. The contract provides for computer-aided design and drafting, GIS and computer-aided facility management to support Navy and other Defense Department and civilian agency facilities engineering requirements.

At the EPA's 10 regional facilities, GIS is used to address broader issues. In Region 5, for example, the Fully Integrated Environmental Location Decision Support, or FIELDS, system includes GIS and Global Positioning System technology to monitor conditions, especially contaminated sediment, in Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin .

The system is used to help prioritize sites, map historical contamination, discover new hot spots, estimate cleanup volumes and mass and assess sediment-based risk. It not only helps design studies to analyze data but also speeds up decision making, said Howard Zar, senior environmental scientist with the EPA in Chicago.

It has become routine for an EPA worker to go to a site armed with a laptop computer to access FIELDS, Zar said. Workers can do sampling on the site and enter the data right away, and, with the aid of GPS, "one can enter the exact location of that data and instantly know what kind of information one is getting," he said.

At the agency's headquarters in Washington, the data collected in the field is fed into the agency's Envirofacts Warehouse, which provides agency data to EPA employees and the general public via the Web.

In February, the agency added an application called EnviroMapper, which includes an ESRI GIS, to Envirofacts, allowing users to access spatial data.

EnviroMapper "allows you to see clusters of facilities in any geographic area that you want to drill down into," said Pat Garvey, director of Envirofacts. The application allows users to view spatial data at the national, state, and county levels.

Development of Envirofacts actually began 10 years ago under the Mission-Oriented Systems Engineering Support (MOSES) contract, said Delroy Ward, assistant vice president and project manager for the Envirofacts project at Science Applications International Corp. in Arlington, Va. SAIC, which was the prime contractor on the original 1991 MOSES contract worth about $215 million, also won the follow-on contract in 1998. It is worth about $270 million.

The original idea was to bring together all of the agency's various databases, Garvey said, noting the databases had previously been stovepipe systems. Four years ago, it was decided to use the Web as a single access point for the database, which went live on the Internet in March 1995, he said.