SAHSU annual renewal and extension

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

[1 paragraph unchanged] The purpose of this renewal is to extend the current agreement for a further 3 years and to request the Annual refresh of HES APC, HES CC, ECDS and HES-ONS mortality (AR 2021/22, 2022/23 and 2023/24) for the on-going studies requiring the data. [8 paragraphs unchanged] The additional data required are HES Admitted Patient Care (APC), HES Critical Care (CC), HES Emergency Care Data Set (ECDS) and HES-linked mortality (annual refreshes of 2021/22, 2022/23 and 2023/24) to allow SAHSU to continue their on-going programme of work. Justification for accessing the data: Justification for requesting the data: [20 paragraphs unchanged] SAHSU will use the GDPPR data to look at long-term exposure to [12 words unchanged] on COVID-19 mortality. This study will build on the current research that our the team is investigating on the effect of long-term exposure to air pollution [48 words unchanged] the reported effects can be attributed to certain comorbidities. The study will: [11 paragraphs unchanged] SAHSU have a single section 251 support in place to cover the above. Any project which [39 words unchanged] and therefore an amendment would be put before NHS England for consideration. [7 paragraphs unchanged] Data will be accessed by individuals with an honorary contract with ICL. The individuals will act as an agent of ICL at all times under supervision from employees of ICL. Aside from these individuals, access is restricted to employees or Masters/PhD students of ICL who have authorisation from the Principal Investigator.

Processing activities

All processing activities are completed within the SAHSU Secure Research Systems (SSRS) facility which forms part of the Imperial College London (ICL) Secure Enclave trusted research environment (ISO 27001 certified) - an environment which is isolated from the "internet" and ICL services (email, network drives, one drive etc). The Secure Enclaves is an isolated environment within the Imperial College network, operated by Virtus SDC Ltd. The servers at Virtus SDC are owned and managed by Imperial College London in a dedicated area of the Virtus SDC data centre. Imperial do not have any shared racks with other organisations and operate their own switches. Access into the Imperial area is via swipe cards, CCTV covers the area and is monitored by Imperial and Virtus staff (24 hour). Servers can only be accessed by approved users who are appropriately trained people at Imperial College London. To access the Imperial servers swipe card access is required, and live logging and alerts of that access are available. All processing activities are completed within the dedicated SAHSU servers which are part of the Imperial College London (ICL) Certified Secure Research Environment (CSRE) - an ISO27001 certified environment which is isolated from the "internet" and ICL services (email, network drives, OneDrive etc). Access to the servers is controlled by Imperial ICT staff and heavily restricted. Virtus staff cannot enter the Imperial Cages without first seeking permission from Imperial. Permission is granted based on the need to enter and is not “ongoing” access (with the exception of “emergency” access, such as fire prevention). All access logs are recorded and made available to Imperial. The CSRE is an isolated environment within the Imperial College network, operated by Virtus SDC Ltd. The servers at Virtus SDC are owned and managed by Imperial College London in a dedicated area of the Virtus SDC data centre. Imperial do not have any shared racks with other organisations and operate their own switches. Access into the Imperial area is via swipe cards, CCTV covers the The SSRS facility is split into two different enclaves/zones:(1) holding identifiable data and (2) holding processed minimised (to a small geographic area under specification of the study) and pseudonymised data. All processing, storage and analysis of patient level data are completed within these 2 enclaves. By default remote users have only "screen view" access of the data. Users within the office can only access the SAHSU servers through a dedicated client workstation that sits alongside their main college PC. area and is monitored by Imperial and Virtus staff (24 hour). Servers can only be accessed by approved users who are appropriately trained people at Imperial College London. All access logs are recorded and made available to Imperial. The data recipient will access the NHS England's Secure Electronic File Transfer service (SEFT), from a specified ICL office using a secured client workstation, download and copy the data extracts to the SAHSU Research database residing within the SSRS facility. The data extracts include a limited set of identifiable (date of birth, date of death, NHS number and postcode) and special categories of personal data. The SAHSU facility is split into two different enclaves/zones:(1) holding identifiable data and (2) holding processed minimised (to a small geographic area under specification of the study) and pseudonymised data. The research database resides within the identifiable enclave/zone of the SSRS which is restricted to the database team for loading, processing, and to perform data linkages with spatial, socioeconomic and environmental exposure data using the requested identifiers. Once the purpose for requesting identifiers has been carried out, they are removed and stored separately from the clinical/administrative data within the database. However, the identifiers may be accessed again e.g., when environmental studies which require linkage to exposure data demand for more precision to the place of residence, in which case the database team will access the patient identifier to complete further linkages for those studies. All processing, storage and analysis of patient-level data are completed within these two enclaves. By default, users have only "screen view" access of the data. The data recipient will be a member of the SAHSU database team who will access the NHS England's Secure Electronic File Transfer service (SEFT) from an ICL managed device. The requested data will be downloaded to the SAHSU identifiable enclave. Health data are linked with spatial, socio-economic and environmental exposure data which is vital for SAHSUs research studies. The focus of SAHSUs work is to investigate key public health issues associated with environmental factors at a small area level or high geo-spatial resolution. SAHSU ensures that patient re-identification is not possible whenever environmental data (e.g., high-resolution air pollution data) are spatially linked to a health dataset. In order to perform the spatial linkage, SAHSU implements a two-stage process: i) only the geographic identifiers (e.g. postcode unit, census output areas) is released to the researcher who spatially links the environmental data and hands this back to the database team; ii) the database team links the environmental data to the health data, removes the geographic identifier and hands the health data linked to environmental data back to the researcher for analysis. The requested data extracts include a limited set of identifiable data (date of birth, date of death, NHS number and postcode) and special categories of personal data. The research database resides within the identifiable enclave, which is restricted to the database team for loading, processing, and to perform data linkages with spatial, socioeconomic and environmental exposure data using the requested identifiers. Once the purpose for requesting identifiers has been carried out, they are removed and stored separately from the clinical/administrative data within the database. However, the identifiers may be accessed again e.g., when environmental studies which require linkage to exposure data demand for more precision to the place of residence, in which case the database team will access the patient identifier to complete further linkages for those studies. The separation of patient identifiable and clinical/administrative data occurs after the data have been processed, linked and quality checked. The database team has therefore created an enhanced pseudonymised version from the dataset that was originally received from NHS England. This pseudonymised version will then be used to create future extracts for SAHSUs research studies. SAHSU ensures that patient reidentification is not possible whenever environmental data (e.g., high-resolution air pollution data) are spatially linked to a health dataset. In order to perform the spatial linkage, SAHSU implements a two-stage process: i) only the geographic identifiers (e.g. postcode unit, census output areas) are released to the researcher who spatially links the environmental data and hands this back to the database team; ii) the database team links the environmental data to the health data, removes the geographic identifier and hands the health data linked to environmental data back to the researcher for analysis. The separation of patient identifiable and clinical/administrative data occurs after the data have been processed, linked and quality checked. The database team has therefore created an enhanced pseudonymised version from the dataset that was originally received from NHS England. This pseudonymised version will then be used to create future extracts for SAHSU’s research studies. [3 paragraphs unchanged] • They have signed the SAHSU CSRE Acceptable Use Policy and undertaken all mandatory data protection training. • Any request to access sensitive or patient identifiable data (date of birth and/or death) must be strictly necessary for the purpose required. All individuals accessing record level data are substantive ICL employees or registered students (including PhD and Masters students). SAHSU have implemented a “Student Letter Agreement For Access To NHS England Data” (in place of a substantive employment contract and approved for use by NHS England on 22.9.21) which they have to sign to indicate their obligations for accessing and processing personal data. All registered students (including PhD and Masters students) are additionally required to sign the Imperial College London (ICL) Terms and Conditions as part of their registration and enrolment process at the start of their course and the Secure Research Systems (SSRS) Acceptable Use Policy and Agreement as all other individuals do. Data will be accessed by substantive ICL employees authorised by the Principal Investigator, and: Researchers can request minimised (to a small geographic area defined by the study) pseudonymised data extracts. The database team will generate extracts for the research team based on the specifications provided as per their data requests. Data extracts are copied and made available to researchers in the minimised/de-identified enclave/zone of the SSRS where they have all the facilities to conduct their studies. All studies requiring analysis of individual-level data are conducted within the SSRS facility. • Undergraduate, Masters or PhD students enrolled with Imperial College London. Any student working with the Data held under this Data Sharing Agreement (DSA) must have completed relevant data protection and confidentiality training and are subject to Imperial College London s policies on data protection and confidentiality. Any students accessing the Data will do so under the supervision of a substantive employee of Imperial College London. Imperial College London would be responsible and liable for any work carried out by students. These students would only work on the Data for the purposes described in this DSA. Users requesting access to SAHSUs data must complete data protection training and have a good understanding of the sensitivities around using health administrative data, how to handle sensitive data safely, lawfully and responsibly. Even after data have been processed, analysed and research findings have been compiled, SAHSU recognise that there is a potential risk of disclosure from small numbers (e.g. rare disease in a small area or any other special circumstances are taken into account e.g., Longitudinal data, key variables, sample size, household surveys, and other published datasets) so statistical disclosure controls are applied to all research outputs in line with HES analysis guidelines and other national disclosure procedure guidelines i.e. obscuring small numbers that appear in aggregate tables so as to prevent reidentification. • Individuals holding an honorary contract under the supervision of a substantive employee of Imperial College London for the purposes described in this DSA only. Imperial College London must maintain records in a single location that cover the following details of each individual given access under an honorary contract: Only aggregate data with small number suppression can be taken out of the SSRS. By default, users cannot transfer result findings without approval of the Information Asset Owner/Administrator and approval can be limited to only files that have been approved by senior members of staff. - Their substantive employer; SAHSU understand that data linkage between health datasets is only permitted with explicit written permission from data providers and substantial amendments to SAHSUs NRES ethics and HRA/CAG approvals. - Their role in respect of the purpose for the processing specified in the DSA; To date, amendments to the section 251 support have been sought and granted for the following three projects which required specific data linkage: - The start date and end date of the duration in which the Data will be accessed by the individual under an honorary contract; 1. Traffic pollution and health in London; - The necessity for the Data to be accessed by the person(s) holding an honorary contract, instead of a substantive employee of an organisation named as controller or a processor in this DSA; 2. Incinerators; - Confirmation that an appropriate contract is in place which follows the relevant guidance and is countersigned by the substantive employer of the honorary contract holder. 3. Small area variation in coronary heart disease incidence, mortality and survival and their risk factors and determinants in England. Researchers can request minimised (to a small geographic area defined by the study) pseudonymised data extracts. The database team will generate extracts for the research team based on the specifications provided as per their data requests. Data extracts are copied and made available to researchers in the de-identified enclave where they have all the facilities to conduct their studies. All studies requiring analysis of individual-level data are conducted within the CSRE. Any projects requiring linkage beyond that covered by this application would also be subject to an amendment for NHS England's consideration which would also require support from ethics and be covered by an amendment to the current section 251 approval. Even after data have been processed, analysed and research findings have been compiled, SAHSU recognise that there is a potential risk of disclosure from small numbers (e.g. rare disease in a small area or any other special circumstances are taken into account e.g., Longitudinal data, key variables, sample size, household surveys, and other published datasets) so statistical disclosure controls are applied to all research outputs in line with HES analysis guidelines and other national disclosure procedure guidelines i.e. obscuring small numbers that appear in aggregate tables so as to prevent reidentification. Only aggregate data with small number suppression can be taken out of the CSRE. By default, users cannot transfer result findings without approval of the Information Asset Owner/Administrator and approval can be limited to only files that have been approved by senior members of staff. SAHSU understands that data linkage between health datasets is only permitted with explicit written permission from data providers and substantial amendments to the SAHSU NRES ethics and HRA/CAG approvals. Data will not be made available to any third parties other than those specified except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide. In addition to the data provided by NHS England, SAHSU also hold and continue to receive the following record level identifiable datasets: • Cancer registrations/incidences (England and Wales) • ONS deaths registrations • ONS birth and still births registrations • Previously NHS Numbers for Babies (NN4B) now Birth Notification data • National Pupil Database Microsoft Limited supply Cloud Services for Imperial College London and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by "Personnel" (as defined within the Data Sharing Framework Contract i.e.: employees, agents and contractors of the Data Recipient who may have access to that data). Data will not be made available to any third parties other than those specified except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide.

Expected output

[3 paragraphs unchanged] SAHSU communicate their research work directly to the public through high-impact events such as the annual Great Exhibition Road Festival, and various science events at local and regional levels. These events offer an opportunity to engage with the public and to share the work undertaken by the Unit. SAHSU have a dedicated page for Patient and Public Involvement (PPI) on the website. (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/patient-and-public-involvement-ppi/). The page has been updated with examples of public engagement and involvement in the PHICAZ project which is investigating the public health impacts of the clean air zones in London. Public Community Involvement Engagement The Study Team ensure that active public engagement and Participation (PCIE) community involvement is also undertaken by researchers both at a unit level, and within their individual research projects. These activities are designed studies. This is done with a proactive approach to make the study accountable, transparent, and undertaken relevant to reflect the specific needs of the research study public and a range of approaches have been taken. The overall ambition is to ensure that the public and community voice impacts our research projects. the research. At a unit level, SAHSU research continues to involve two members of the public as members of the UKHSA-SAHSU Liaison Committee to ensure that there is a strong public voice in the approval of the research studies. The UKHSA-SAHSU Liaison Committee meets twice a year to identify new areas of work and to review and approve projects using data from the SAHSU research database. SAHSU communicate its research work directly to the public through high-impact events such as the annual Great Exhibition Road Festival, and various science events at local and regional levels. These events offer us an opportunity to engage with the public and to share information about the research with them. [1 paragraph unchanged] September 2021: Presentation of the Reduced Noise Impacts on Short-Term Aircraft Noise and Cardiovascular Outcomes (RISTANCO) to the Joint MRC Centre and HPRU Public Community Oversight Group (PCOG) which has a representation from patient groups, public health practitioners, Non-Governmental Organisations (NGOs), government and industry. RISTANCO aims to investigate the short-term impact of aircraft noise on cardiovascular morbidity and mortality. The purpose of the public engagement was to better understand how researchers can best present the results of this project to the general public and begin thinking about the potential interventions that might result. The PCOG offers advice on research plans, protocols, and materials. The PCOG has also been set up to support researchers to assess the impact of Public Community Involvement Engagement and Participation (PCIEP) in their work. • Arowosegbe O and Davies B presented the PHICAZ project as part of the 2024 Imperial College Great Exhibition Road Festival, 15-16 June 2024. An activity was designed to engage with children who visited the SAHSU stand about the new London Ultra Low Emission Zones (ULEZ) policy and its impact on population health and the environment. January 2021 - The air quality health and economic costs and benefits of a zero-carbon UK study: SAHSU researchers ran a focus group with members of the public to feed into the study design of a project looking at the health impacts of government policy scenarios to meet its net-zero carbon emissions climate change target by 2050. • Blangiardo M and Parkes B hosted a ‘stick or switch’ activity developed by the Royal Statistical Society to introduce the concept of conditional probability based on a fun game as part of the 2024 Imperial College Great Exhibition Road Festival, 15-16 June 2024. Details of our research programme and outputs are published on the SAHSU website: (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/). • Cai Chang and members of the Imperial Patient Experience Research Centre (PERC) took part in a ‘Community Involvement Research Event’ at West Acton Community Centre, Ealing for patients and carers, 10 October 2024.The event was a pop-up informal café where community members could join sessions of their choice from a “menu” of various research projects including the SAHSU PHICAZ project. SAHSU also contributes to public involvement through: Wider Engagement – MRC Centre (environment-health.ac.uk): Details of the research programme and outputs are published on the SAHSU website: (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/.)

Expected measurable benefits

[9 paragraphs unchanged] Health impact of living near a biomass-fuelled electricity generating installation: Examples detailing potential benefits from SAHSU's new and on-going studies, including examples of research, surveillance, commissions and methodology development: This project aims to focus on possible health complications associated with biomass burning to improve SAHSU's understanding of adverse effects of wood biomass burning in industrial facilities on the health of local populations. The results are expected to inform local and national public health decisions as well as future regulations. • Public Health Impacts of Clean Air Zones (London ULEZ): The Greater London Authority launched an Ultra Low Emission Zone (ULEZ) in central London in April 2019. This flagship public health intervention is intended to improve air quality (by lowering NO2 and PM), reduce congestion and deliver health benefits. The ULEZ has been extended to Inner London in 2021 and will be further extended to Greater London in 2023. The behavioural changes enforced by the COVID-19 lockdowns and wider responses to the pandemic had major impacts on traffic patterns, air quality and healthcare utilisation since the introduction of the ULEZ. This research will evaluate the health impacts of the ULEZ and the effect of COVID on the ULEZ associated impacts. This project is part of a larger programme of research into the impacts of clean air zones. The proposed epidemiological analysis will: a) describe inequalities in healthcare utilisation during the COVID pandemic in communities within and outside the ULEZ; b) examine trends in non-communicable diseases, pre-and post-ULEZ implementation, using routinely collected health data; c) evaluate exposure-response functions at a very fine geographical resolution, focusing on multimorbidity and deprivation at different time intervals (pre-post pandemic; pre-post ULEZ etc.), d) The goal of this research is to provide a comprehensive assessment of the impact of the London ULEZ on health. The project will use NHS England HES England; Inpatient and A&E; HES-ONS Linked Mortality; Birth and death registrations. Health effects of aircraft noise • Associations between wastewater measurements of chemicals of emerging concerns (CECs) and health outcomes in Greater London: Wastewater-based epidemiology (WBE) has proven to be a successful tool to monitor infection levels of SARS-CoV-2 in a population. Beyond infections, it is clear that the pandemic has had a profound effect on populations across the world and on their health. The aim of this project is to explore associations between routine WBE measurements for pharmaceuticals, lifestyle markers and chemical toxicants being made in Greater London (and potentially other major cities in England (e.g., Liverpool)) - and specific health outcomes, including mental health. The Study Team hypothesis is that precise WBE data might provide an early-warning system, which could help planning health resource usage. The analysis of pre- and post-pandemic associations might also prepare for future (viral) pandemics. The project will use: NHS England HES admitted patient care; ONS death registrations Following the findings from the SAHSU study on the health impacts from aircraft noise around Heathrow airport, published in the British Medical Journal in 2013, allow for a better understanding of the health problems caused by noise from aircraft in London. A follow-on study funded by the Medical Research Council on Aircraft Noise and Cardiovascular Outcomes (ANCO) is currently expanding SAHSU’s previous study to include all major airports in the UK. The focus is on long-term exposure to aircraft noise and cardiovascular-related hospital admissions and mortality. • Health impact of living near a biomass-fuelled electricity generating installation: The UK is shifting electricity generation towards “renewable” energy sources including biomass. DEFRA (2017) advise that burning biomass “could have adverse air quality impacts”, particularly through PM and NO2 associated health outcomes, including acute exacerbations of asthma and COPD. Based on modelled ground-based exposures to air pollutants, the SAHSU Team will investigate potential health impacts near biomass electricity generating installations in England and Wales using spatio-temporal epidemiological methods applied to SAHSU data. The aims of this project are: i) to assess the health impacts of living near biomass electricity generating installations; ii) to undertake a literature review and, if appropriate, a meta-analyse on the health impact of biomass-burning and health, in particular respiratory disease; iii) to identify existing data on air pollution modelling of emissions from power stations fuelled by biomass burning for use in epidemiological models; iv) to quantify health risks around selected biomass-burning facilities; and v) to feed results into policy for the management and control of installations carrying out biomass burning for power generation. The project will use: NHS England HES England; Inpatient and A&E data. The results are expected to inform local and national public health decisions as well as future regulations. In addition, SAHSU are studying the effects of short-term exposure to aircraft noise acute cardiovascular hospital admissions and mortality events via the NIHR funded study - Reduced Noise Impacts of Short-Term Aircraft Noise (RISTANCO). This study aims to also examine potential mitigation strategies through respite periods. These studies findings are expected to contribute to the evidence base to help better define the burden of environmental noise on health and improve health impact assessment for major infrastructure changes such as the proposed new runway at London Heathrow and expansions or other major airports. • Shingles vaccination. The potential of herpes zoster vaccination in reducing geographic and socioeconomic inequalities in dementia incidence: The overall objective of this project is to assess the potential of a public health intervention to reduce geographic and socioeconomic inequalities in dementia incidence in England. This project will focus on herpes zoster vaccination as a case study. The aim of this project is, therefore, to estimate the extent to which geographic and socioeconomic inequalities in dementia incidence in England could be reduced through herpes zoster vaccination. The project will use NHS England HES: Admitted patient care and emergency care and ONS mortality data. Evaluate the burden of climate-related respiratory disease using high-resolution spatiotemporal models: An example of a recently completed SAHSU project that has clearly demonstrated public benefit by informing national Government health policy statements is: This work aims to be be one of the first such projects to provide an integrated framework to quantify the health effects and costs of temperature changes in the UK on a nationwide level at a small-area scale. The methodology can be transferable to other drivers of disease affected by climate change such as infectious diseases in more vulnerable areas such as developing countries. • COMARE - Reports on childhood cancer incidence around nuclear installations in England, Wales and Scotland: This project examined rates of childhood cancers in neighbourhoods around nuclear installations in England, Scotland and Wales. The work was requested by the Committee on the Medical Aspects of Radiation in the Environment (COMARE) as part of ongoing surveillance of these facilities. The SAHSU Team examined rates of new cancers (incidence) of all childhood cancers and specific subtypes such as leukemia and lymphomas in the vicinity (within 25km) of 49 sites regulated by the Office for Nuclear Regulation, including 10 decommissioned and five partially operational installations. compared rates near sites with national and regional rates to determine if there is any excess. The Study Team also performed statistical tests to investigate whether there are clusters of cancers near sites. Analyses took into account population and socio-economic characteristics of areas that may influence childhood cancer rates. A statistical framework for the apportionment of particulate contaminants and their health effect determination: Bethan D et al. International Journal of Epidemiology, 54 (4), August 2025, dyaf107, https://doi.org/10.1093/ije/dyaf107. Air pollution is a major public health concern. It is linked to common non-communicable diseases, including asthma, lung cancer, heart attacks and strokes. This study aims to help SAHSU understand more about which sources of air pollution are the most harmful to the health of children and the elderly in London. This information aims to support the design of strategies to control and reduce air pollution that target the most harmful sources. The result findings may help focus public health efforts to reduce air pollution exposure in the population by enabling targeting of control efforts to the sources that mostly contribute to the harmful effects of air particles. This study aim is to help answer the question: does air pollution coming from different sources have different level of toxicity for the population? The study particularly considers vulnerable groups like children and the elderly. • The COMARE statement of June 2025 was informed by the results of this SAHSU project. MPH: The double burden of smoking and air pollution in England: “The newly published SAHSU study by Davies et al evaluated cancer rates for children 0 – 14 years of age living in the vicinity of 28 nuclear installations in England, Scotland and Wales between 1995 and 2016, showing no statistically significant increases for childhood leukaemia and NHL, central nervous system tumours and other solid tumours. In welcoming the findings of this detailed study, COMARE agrees with the authors that continued surveillance of childhood cancer rates is warranted.” See: https://assets.publishing.service.gov.uk/media/687747ac352c290d20dcaee8/COMARE_statement_on_the_SAHSU_publication_July_2025.pdf. The findings from this study may be useful to Local Authorities in providing information on how tobacco smoking and air pollution are affecting the health of local populations which can be used to decide on local priorities. SAHSU hope to produce maps of England that show the levels of air pollution, people who smoke and health outcomes for each Local Authority. The project team hope to use statistical models to explore how air pollution and tobacco smoking are related to each other and to the health outcomes. By exploring the links of smoking and air pollution with health outcomes and how they interact with each other, and by identifying areas in England with significant burden of diseases related to these factors, results are expected to provide supporting evidence to inform interventions such as to cease smoking and reduce second hand smoke targeted at local authorities that mostly need them. Air pollution Health Impact Assessment: Housing quality is a key socio-economic determinant of health and its associations with health are well-established. This project aims to estimate the associations of poor thermal comfort and health in London and examine how these differ across the socio-economic spectrum. The Environment Research Group, in collaboration with SAHSU, has an ongoing work programme to estimate health impacts of air pollution to provide support and evidence to national and local governments. The results of these short-term projects are expected to generate evidence on the health benefits of specific policies, for example, as input to cost-benefit analyses. Burden calculations hope to draw attention to the size of the air pollution problem in a particular area which in turn can act as motivation for further reductions in air pollution. Ultimately the aim is to encourage the adoption of policies by Defra and local authorities to reduce air pollution concentrations throughout the country and reap the health benefits that may bring to the public. PhD: Housing Quality and Health: This study aim to provide evidence needed to better understand the impacts of poor thermal comfort on health at the small area level, in order to identify existing hotspots and inequalities for the development of more effective and targeted housing policies. The origin of this projects lies within the Wellcome Trust-funded Pathway to Equitable Healthy Cities with existing links to Directors of Public Health, who are expected to help with facilitating policy impact. The air quality health and economic costs and benefits of a zero carbon UK: The project is expected to highlight policies to reduce greenhouse gas emissions that are also optimal for reducing air pollution concentrations and thus air pollution health impacts. The project is designed to feed into a cost-benefit analysis that aims to ensure that costs to the economy in paying for policies to reduce air pollution and greenhouse gas emissions are balanced against the monetised benefits of reduced impacts on health. Effects on health inequalities hope to also be analysed highlighting whether targeted action may be needed to give additional protection to deprived groups. Health Impact Assessment of air pollution on asthma in London (2): Result findings are expected to be used by Greater London Authority as evidence to establish the health impact of air pollution on asthma exacerbation in London and to derive appropriate strategies to inform and protect the general population and specific vulnerable groups. This is of particular importance with regards to the extension of the Ultra-Low Emission Zone in autumn 2021 and the London Environmental Strategy. In the longer term, methods developed as part of this project can be used for future incorporation of benefits of reductions in asthma outcomes within cost-benefit analysis of London-wide policies to reduce air pollution. MSc: Greenspace exposure and health – a question of scale: Result findings may have important implications for urban planning and policies related to green space accessibility and availability for the general population. Information about the appropriate scale at which greenspace provision should be prioritised to consequently have important benefits to the local population in providing spaces for physical activity and social contact. PhD: Impact of the London Ultra Low Emission Zone on health outcomes across the life course: Implementation of ULEZ-like zones is currently being actively considered by several UK cities. However, the current evidence regarding the health impacts of such zones is unclear. The outcomes of this study, with respect to clinically meaningful health benefits, hope to provide evidence for the role of similar zones in air pollution policy in London and elsewhere and also on the impact of the ULEZ on health outcomes across the life course, and whether these differ by socio-economic or demographic factors. The findings are expected to be written up in a PhD Thesis, presented at conferences/meetings and published in academic papers. Long term exposure to air-pollution and COVID-19 mortality: The role of pre-existing conditions: The results are expected to provide information about COVID-19 populations with worse prognosis and highlight the importance of the existing air pollution regulations. Spatio-temporal patterns in excess mortality and morbidity in England during Covid-19 pandemic: The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there may be adverse consequences on non-COVID-19 morbidity and mortality. Understanding effect modifiers of the relationship between health and exposure to urban green and blue space: This project aim is to develop new exposure metrics to assess health effects of green/blue space. Research findings hope to advance SAHSU's understanding of which factors are driving or influencing the relationship between green/blue space and health. Knowledge gained from the results on the drivers that potentially change the magnitude and direction of any health effects are essential to guide efficient policies both at the local level (e.g., tree planting scheme in city) and national level (e.g., recommendations on available green/blue space per person). Evaluating the burden of climate-related respiratory disease using high resolution spatiotemporal models: This work hopes to provide an integrated framework to quantify the health effects and costs of temperature changes in the UK on a nationwide level at a small-area scale. SAHSU hopes to communicate the results among public health experts and the public via a website. This methodology aims to be transferable to other drivers of disease affected by climate change such as infectious diseases in more vulnerable areas such as developing countries. A natural experiment of the Western Extension to the London Congestion Zone (WEZ): The WEZ is one example of road user charging, or systems of making motorists pay directly to drive within a certain area. These schemes are being considered in a range of areas in England, including Bath, Bristol and Sheffield. This project hopes to provide information on the health impacts of such schemes and give clues as to how they can best improve health. This research findings are expected to provide information on the air pollution and hospital admissions before, during, and after use of the WEZ. Asthma admissions and grass pollen counts, levels and potency in London and its surroundings: Airborne outdoor pollen is a major cause of asthma hospital admissions. Using unique pollen data available in London, this project aims to test the hypotheses that asthma hospitalizations increase with increasing airborne allergen levels, and that this association is underestimated by current exposure assessment methods based only on pollen counts. The results of this research may be useful for clinicians, patients and researchers (understanding risks and how to reduce them) as well as government and public health policymakers (i.e., may suggest the need for improved monitoring of allergens in the air). Given that future urbanization and climate change is expected to lead to important changes in how and which plants grow in our cities (and potentially how they interact with air pollutants), it is important to understand these relationships so the people in the UK may get the right information to protect themselves from asthma attacks. Health risks in the area exposed to the plume from the October 2000 chemical fire at CSG in Sandhurst, Gloucestershire – A small-area study update: Beyond improving SAHSU's understanding of the potential long-term health impact of this incident, it is likely that this work may contribute to provide updated evidence and hopefully reassurance to the local communities. Research findings are expected to be shared with stakeholders and the local community. Geographic inequalities in Acute Myocardial Infarction (AMI) case-fatality in hospitalised patients in England: the role of multi-morbidity: The findings hope to directly inform planning decisions about the common profiles of AMI patients that visit England’s hospitals, and their relative chances of survival versus death. Pathways to equitable health cities: Research findings are expected to provide the evidence underpinning actions and policies at the city level that aim to create liveable, sustainable and healthy environments, and effective public services for all. This study being inherently solution-oriented hope to directly inform actions that influence people’s health. In London, SAHSU hopes to work with the UK Health Security Agency and the Greater London Authority to address and inform contemporary policy choices. PhD: Time series analysis of air pollution: Results aim to be summarised in a publication and the results from daily spatio-temporal model are expected to be shared with the academic community, stakeholders and the public. The outcome of this study may further provide evidence of the acute adverse effects of air pollution, using refined air pollution estimates that can better represent exposure levels. The study also aims to produce air pollution surface maps of Great Britain, to help identify the ‘hotspots’ of polluted areas, and provide evidence and assistance in policy-making. Results aim to be summarised in a publication and the results from daily spatio-temporal model are expected to be shared with the academic community, stakeholders and the public. Impact of environmental inequities on health in England: Results are expected to provide a comprehensive picture of the effect of deprivation and environmental exposures on disease burden in Great Britain and how this has changed over time. This may also provide an important baseline to which future trends can be compared to and further highlighting areas of specific need for policy intervention and to better tailor policies aimed at tracking heath inequities. Small area variation in Coronary Heart Disease (CHD) event rates, mortality and survival in England: Results are expected to be a cross-sectional estimates of small area CHD event rates and survival. The final part of the project aims to examine the socioeconomic and health service correlates of the variations seen and hope to suggest possible interventions to reduce the overall burden of CHD as well as its inequalities. Health Inequality: Result findings are expected to demonstrate how the combination of social determinants and public health and health service policies are affecting health inequalities and where the largest needs for interventions are in order to help protect the health of the worst-off ensuring that no one is left behind in SAHSU's efforts to improve the public’s health. Childhood type 1 diabetes(T1D): re-admissions and co-morbidities: The results of these additional analyses hope to improve SAHSU's understanding of clinical presentation of Type 1 diabetes (T1D), the management of the disease, and associated co-morbidities, and how the wider environment might influence these, for example, by providing insight into the environmental and care factors which associate with T1D re-admission and/or co-morbidity. Air Pollution Mixtures -Tools for characterising multi-pollutant patterns of exposure for use in environmental health studies: Results are expected to provide further evidence on health effects of air pollution, including on metals exposures, which have been relatively little studied to date. The methodological component of the work aims to investigate whether looking at combinations of pollutants in this way gives better predictions of health risks than standard epidemiological techniques. Results may be relevant to air pollution regulation to protect public health and also provide information about environmental justice. Climate and climate change: In order to quantify the health impacts of climate change and the benefit of specific adaptation measures risk assessment models are required to consider how the effects of temperature on human health vary geographically and as a function of socio-demographic, environmental, and healthcare factors. These models can be used to assess how individuals and communities may adapt to climate change through modifying such environmental and healthcare determinants. Peer reviewed publications of the methods and results are expected to be the main outputs, the timeline depending on further funding being obtained. Analysis of HES inpatient data for Carbon Monoxide (CO) hospital admissions in England: Integration of information on population exposure and health effects aim to support an overall estimate of disease burden from CO in the national population, and support work on Environmental Public Health Tracking led by the UK Health Security Agency to help prevent CO poisoning cases. The outputs of the project are expected to be published in peer-reviewed journals during the course of the study and after completion. All SAHSU’s projects are aligned with the Terms of Reference of the SAHSU programme, which includes addressing environmental and health issues. All projects have been approved by the UKHSA Programme Board, which includes membership from the Department of Health and Social Care. In order to assist with standardising approaches across application processes, SAHSU have offered membership of the approving group to the Data Access Request Service at NHS England.

Unchanged: Benefits reported.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

The purpose of this renewal is to extend Small Area Health Statistics Unit (SAHSU) at Imperial College Programme Level Agreement for a further 3 years and to request additional annual refresh of Hospital Episode Statistics (HES) data. The Small Area Health Statistics Unit (SAHSU) currently holds Hospital Episode Statistics (HES) data in the form of Admitted Patient Care (APC), Critical Care (CC), Accident & Emergency (A&E), Emergency Care Data Set (ECDS), HES-linked mortality data and GPES (General Practice Extraction Service) data for pandemic planning and research (GDPPR). Some data extracts include identifiable and sensitive data (NHS Number, Postcode, Date of Death and Date of Birth) under this agreement. Identifiable data is justified due to the need to link particular data sets, minimised per project, to enable specific project datasets that answer particular research questions in line with the objectives listed. The Small Area Health Statistics Unit (SAHSU) is based within the Department of Epidemiology and Biostatistics at Imperial College London (ICL). SAHSU now form a core part of the MRC Centre for Environment and Health at ICL. The purpose of this renewal is to extend the current agreement for a further 3 years and to request the Annual refresh of HES APC, HES CC, ECDS and HES-ONS mortality (AR 2021/22, 2022/23 and 2023/24) for the on-going studies requiring the data. SAHSU is based within the Department of Epidemiology and Biostatistics at Imperial College London (ICL). SAHSU now forms a core part of the Medical Research Council (MRC) Centre for Environment and Health at ICL. SAHSU was established in 1987 as a recommendation of the Black Inquiry into the incidence of leukemia leukaemia and lymphoma in children and young adults near the Windscale/Sellafield nuclear power [35 words unchanged] a highly specialised area of work requiring excellence in computing, database management, Geographical Geographic Information Systems (GIS), statistics, environmental exposure assessment and epidemiology. The set of skills and expertise that has been established and built up in at SAHSU being a unique is an invaluable resource both nationally and worldwide. SAHSU hold holds comprehensive sets of health, demographic, and a range of environmental data at high spatial resolution. SAHSU has a no-cost funding in place by the UK Health Security Agency (UKHSA)to contribute to public health in the UK. SAHSU receives funding from research funders and charities, including UK Research and Innovation (UKRI), the National Institute of Health Research (NIHR), Health Data Research UK (HDRUK), Wellcome Trust, British Medical Association (BMA) and Cystic Fibrosis Trust. The funders are not involved in study design, data collection, management, analysis and interpretation, or the decision to submit for publication. UKHSA provides governance oversight and approval to SAHSU's research portfolio as described in the HRA CAG and REC approvals. UKHSA is a research collaborator via the NIHR HPRUs. SAHSU does not receive funding from UKHSA. Funders do not determine the means and purpose of processing the data. Since its inception, SAHSU has been funded by the Government, initially by the Department of Health and since 2009 in collaboration with the Medical Research Council (MRC) as part of the MRC and Health Protection Agency (HPA) and latterly MRC-Public Health England (PHE) Centre for Environment and Health. This funding arrangement has been extended until 30 November 2022 to allow work to continue during the transition from PHE to UK Health Security Agency. SAHSU and UKHSA are currently developing a governance framework to replace the no-cost extension to the MRC-PHE programme grant. Most SAHSU studies are funded through peer-reviewed grants from research councils such as National Institute for Health Research (NIHR) Health Protection Research Units, the Medical Research Council, Health Data Research UK, Wellcome Trust and charities e.g., the Cystic Fibrosis Trust. SAHSU also has a no-cost funding extension in place with the UK Health Security Agency (UKHSA). [1 paragraph unchanged] Microsoft Limited supply Microsoft defender for cloud, anti-malware service for Imperial College London and are therefore listed as a data processor. They provide support for the system, but do not access data. [2 paragraphs unchanged] Data Required: [10 paragraphs unchanged] To deliver against these the Terms of Reference, SAHSU utilise the research database to meet the following purposes: Purpose 1 - Maintenance of the SAHSU health research database: database At the core of the overall programme of work is the maintenance of the SAHSU research database. database, which combines multiple datasets and has both ethics and section 251 approvals in place. A particular strength is the maintenance of historic data, which allows us SAHSU to examine long term trends and the use of data at high spatial resolution (postcode (address and address), postcode), which are crucial for studies of environmental exposures determined by spatial location e.g., electromagnetic field exposure arising from proximity to an overhead power line. line; noise pollution arising from residential proximity to aircraft flight paths. Purpose 2 - To carry out a programme of research projects and studies: studies The research programme includes both methods, methods development and investigation of priority questions in environment and health. A key aim is to improve the science base underlying the translation of knowledge on the effects of the environment on health into policy. SAHSU conduct conducts national research studies on environmental factors that may affect health ranging from exposures to e.g., electromagnetic fields to (such as from mobile phone base stations), traffic-related air pollution and pollution, road and aircraft noise, water contaminants, waste disposal, green and blue space, using nationally collected patient data including mortality, hospital admissions, cancer registrations and births data. Additional small area small-area analyses are conducted that help support the general remit of the unit e.g., investigating differential hospital admission rates in ethnically diverse neighbourhoods. SAHSU provide provides national expertise in clusters cluster detection and small area small-area statistical methods and has close links with the UK Health Security Agency including input into their environmental public health tracking programme and surveillance activities. Purpose 3 - To build up reliable background information on the distribution of environmental exposure, socio-economic exposures, socioeconomic data and disease amongst small areas: areas SAHSU have developed an extensive collection of environmental exposure data including air pollution, electromagnetic fields, traffic noise and industrial installations that we hold at high spatial resolution (e.g., less than 100m resolution). This is linked to pseudonymised health data extracts as needed in approved studies - all SAHSU studies are controlled via the UKSHA-SAHSU Liaison Committee [a]. SAHSU have developed an extensive collection of environmental exposure data e.g., air pollution, magnetic fields, environmental noise, that SAHSU hold at high spatial resolution, together with geographically-referenced health data as needed in approved studies - all SAHSU studies are approved via the UKHSA -SAHSU Liaison Committee. New studies are formally presented and discussed at Liaison Group meetings every six months to ensure full oversight. The funders review is to ensure that the project being proposed falls within the remit of the funding. The ideas for some studies are formulated by the funder however it is SAHSU that determines the means and purpose of processing for the projects. An example of this work is the Environment and Health Atlas for England and Wales, which included 14 conditions (nine cancers) at small area level (website http://www.envhealthatlas.co.uk/homepage/ and OUP book: Hansell AL, Beale LA, Ghosh RE, Fortunato L, Fecht D, Jarup L, Elliott P. The Environment and Health Atlas for England and Wales. Oxford University Press, April 2014, Oxford, UK). In 2021, SAHSU has collaborated with DISCOVER-NOW Health Data Research UK (HDR-UK) Hub for Real-world evidence synthesis to link modelled long-term air pollution exposure to participants in North West London 's Whole Systems Integrated Care (WSIC) record at the individual level based on residential postcode. This data will be used moving forward to study the impact of air pollution on health outcomes. Purpose 4 - To develop methodologies methodology for analysing and interpreting health outcomes related to small areas: areas Some of SAHSU’s SAHSU's studies are methodological, relating to - for example, example statistical uncertainty in observed health risks in areas relating to the choice of spatial boundaries or uncertainties in the population estimates; estimates, development of methods to detect clusters of disease in time and space (surveillance); (surveillance); development of methods to better adjust for lifestyle factors in health risk analyses by using risk scores constructed at area-level from cohort datasets and surveys in our analyses of hospital admissions and mortality. Purpose 5 - To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups: groups SAHSU participate participates in national and international scientific meetings and provide provides training to the UK Health Security Agency (UKHSA) UKHSA and internationally including to the US Centers Centres for Disease Control (CDC) in the use of small area analysis for public health purposes. SAHSU use aggregate non-disclosive data i.e., small numbers supressed in outputs, presentations and training. Purpose 6 - To provide rapid ad-hoc ad hoc support to the UK Health Security Agency (UKHSA) UKHSA and the Department of Health and Social Care (DHSC) DHSC about unusual clusters of disease, particularly in the neighbourhood of industrial installations: Such work is carried out on the instruction of the DHSC or UKHSA and approved by the Director of SAHSU. By its nature, such requirements cannot be detailed in advance, but the only outputs provided to DHSC and UKSHA would be aggregated with small numbers suppressed. installations SAHSU have developed the Rapid Inquiry Facility (RIF) which is an automated software tool that uses both a database and Geographic Information System (GIS) technologies to rapidly address epidemiological and public health questions using routinely collected health and population data. This allows SAHSU to respond rapidly, with expert advice to ad hoc queries from the funding departments about unusual clusters of disease, particularly in the neighbourhood of industrial installations. The RIF can perform risk analysis around putative hazardous sources and can be used for disease mapping. It generates standardised rates and relative risks for any given health outcome, for specified age and year ranges, for any given geographical area. This facility was initially designed as a tool for SAHSU staff to analyse routinely collected health data in relation to environmental exposures. The software has public health utility and was further developed as part of the European Health and Environment Information System project and as part of the US Centers for Disease Control environmental public health tracking programme. For use within SAHSU, the RIF software will sit within the SAHSU Secure Research System facility. Such work is carried out on the instruction of UKHSA or DHSC and is approved by the Director of SAHSU. By its nature, such requirements cannot be detailed in advance, but the only outputs would be aggregate with small numbers suppressed and provided to DHSC and UKHSA. In all cases data are either extracted using the Rapid Enquiry Facility (RIF) - see below - or by the database team. SASHU currently hold a limited set of confidential/sensitive patient information: date of birth, date of death, address, postcode, NHS number. Confidential/sensitive patient information is only accessible to the database team. Researchers only have access to minimised and de-identified data. Dates of birth and death are required for temporal analysis. They are only used by the database team to link to temporal exposure data and researchers receive age in month/years. Postcodes are used for geospatial data linkage across environmental, administrative geographies and socio-economic datasets. NHS numbers are used for linkage; either within datasets or between datasets. For linkage between datasets further approvals are required from NRES, HRA CAG and data providers. SAHSU will use the GDPPR data to look at long-term exposure to air-pollution and COVID-19 mortality and to quantify the effect of pre-existing conditions on COVID-19 mortality. This study will build on the current research that our team is investigating on the effect of long-term exposure to air pollution on COVID-19 mortality. The role of long-term air-pollution exposure on COVID19 mortality has sparked discussion in the scientific community, including their recent study: (https://www.sciencedirect.com/science/article/pii/S0160412020322716?via%3Dihub). Nevertheless, long-term exposure to air-pollution can trigger certain comorbidities (e.g. hypertension, stroke, Chronic obstructive pulmonary disease) which are known to increase COVID19 mortality, hence the reported effects can be attributed to certain comorbidities. The study will: SAHSU request national data to provide any ad-hoc rapid response required by UKHSA. Given that UKHSA coverage is across England, and the requirements cannot be predicted in advance, national data is required given that response times do not permit time to request, receive and process individual extracts of data. 1. Identify which comorbidities increase COVID-19 mortality. Historical data is also essential to enable SAHSU to obtain longitudinal data on prior admissions for patients for example to identify a patient’s first admission for a particular diagnosis. Access to historic data has enabled SAHSU to examine long term trends and use of data at high spatial resolution (postcode), which are crucial for studies of environmental exposures determined by spatial location e.g., electromagnetic field exposure arising from proximity to an overhead power line. Risk modelling also requires access to data items on prior patients’ admissions including previously recorded co-morbidities. 2. Re-assess the effect of air-pollution after accounting for the comorbidities identified. [a] UKHSA's representation on the UKHSA-SAHSU Liaison Committee is to provide oversight in managing the governance aspects of the SAHSU database and the research infrastructure ensuring studies falls within the remit of the agreed terms of references. The UKHSA-SAHSU Liaison Committee that has a Terms of Reference document describing the purpose, scope, membership and authority of the committee. Specifically, proposed SAHSU projects are approved by the SAHSU Director or Deputy Director, presented to the UKHSA-SAHSU Liaison Committee for minuted approval and subsequently ratified by the UKHSA Environmental Public Health Programme Board, attended by a member of the DHSC, via minuted approval. Approval is subject to the research or surveillance being needed to support the public health function of UKHSA or the devolved administrations and falling within SAHSU’s agreed remit. Approved studies are then adopted onto the SAHSU portfolio. The UKHSA-SAHSU Liaison Committee meeting is held twice a year and chaired by UKHSA. These meetings inform UKHSA, DHSC, stakeholders from public health bodies in the devolved administrations (Public Heath Wales, Welsh Government, Welsh Cancer Intelligence and Surveillance unit, Health Protection Scotland, Scottish Government, Northern Ireland Government) and data providers (including NHS Digital, Office for National Statistics) of SAHSU’s work programme and support SAHSU’s governance requirements. 3. Adjust for a series of confounders, such as age, sex, ethnicity, access to healthcare, deprivation and the spread of the disease.’ The lawful basis for processing data under GDPR has been reviewed and been assessed as acceptable. Imperial College London process data under Article 6(1)(e): "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller" as they are a public Authority. The Data Protection Act 2018 s7(1) (a) defines 'public bodies' for the purpose of the GDPR as "a public authority as defined by the Freedom of Information Act 2000". The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means anybody which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists "Maintained schools and further and higher education institutions" as public authorities. The processing of GDPPR data is restricted to COVID-19 purposes only. Additionally, Imperial College London process the Special Category Health Data under Article 9(2)(j): "processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject" as the data are required for research purposes in the public interest - meeting the conditions in the DPA 2018 Schedule 1 Part 1 (4) - which GDPR Recital 52(2) determines is an appropriate derogation from the prohibition on processing special categories of personal data. The Rapid Enquiry Facility (RIF) is an automated software tool that uses both database and Geographic Information System (GIS) technologies to rapidly address epidemiological and public health questions using routinely collected health and population data. This allows SAHSU to respond rapidly, with expert advice about unusual clusters of disease, particularly in the neighbourhood of industrial installations. The RIF can perform risk analysis around putative hazardous sources and can be used for disease mapping. It generates standardised rates and relative risks for any given health outcome, for specified age and year ranges, for any given geographical area. This facility was initially designed as a tool for SAHSU staff to analyse routinely collected health data in relation to environmental exposures. The software has general public health utility and was further developed as part of the European Health and Environment Information System (EUROHEIS) project and as part of the CDC environmental public health tracking programme. A newer version of the Rapid Enquiry Facility (RIF) software is expected to be re-developed which will allow SAHSU to test on various scenarios to help detect clusters or increased rates of disease near industrial installations. As a result of the RIF software expected to be re-developed, SAHSU have been doing less on this function (due to less capacity/resources availability), but SAHSU are expecting to be doing more in the near future. As an example of the most recent request, SAHSU have responded to a request from the Committee on the Medical Aspects of Radiation in the Environment (COMARE) to use the RIF to provide ongoing surveillance of cancer around nuclear power stations using cancer registrations. Approval of individual projects UKHSA is a research collaborator via the NIHR HPRUs. SAHSU does not receive funding from UKHSA. UKHSA's representation on the UKHSA-SAHSU Liaison Committee is to provide oversight of the use of the UKHSA funding ensuring that it is being used within the remit of the funding agreement. Most SAHSU studies are funded through peer reviewed grants from research councils such as UKRI, HDRUK, NIHR and the Wellcome Trust and other charities e.g., the Cystic Fibrosis Trust. Even though, UKHSA do not have any decision-making responsibilities over the project initiations within the SAHSU unit and are therefore not considered a Data Controller. Project/study initiations are done by researchers within SAHSU. All new studies using SAHSU data must be approved as a 'SAHSU-study'. To do so, researchers must provide a project outline detailing the project rational, its relevance to patients and the public (i.e., health and/or social care) and which data will be required. The study can then be approved by either the Director or Deputy Director under consideration of SAHSU's overall programme terms of reference and whether the study is adequately covered by SAHSU's existing ethical approval and if not, separate ethical approval must be sought. Once approved internally, the project will be introduced to UKHSA via the UKHSA-SAHSU Liaison Committee which will provide confirmation that the project falls within the UKHSA-SAHSU’s programme of work and then forwarded to get formal approval from the appropriate UKHSA programme board attended by a member of DHSC (e.g., Environmental Hazard Board). UKHSA do not have access to SAHSU’s data. SAHSU have a single section 251 support in place to cover the above. Any project which may have additional requirements (for example to require the linkage of an additional dataset beyond that previously agreed) must seek an amendment to the existing s251 and ethics approvals. It would also be outside the scope of this application, and therefore an amendment would be put before NHS England for consideration. This data request justification for a national dataset is based on the following core infrastructure work, the Rapid Inquiry Facility (RIF) and for Surveillance Methodology based projects. The RIF study facilitates spatial epidemiological analyses, relating spatial and non-spatial data. Two types of analysis can be carried out with the RIF: risk analysis around putative hazardous sources and disease mapping. The RIF calculates and can map rates and relative risks either by distance around one or more selected point, line or area sources, or groups of areas defined by exposure levels. Previous versions of the RIF have been widely disseminated, and used by public health departments in the USA, Canada and Europe. Redevelopment of the RIF is currently paused due to funding constraints. Version 4.0 will be freely available for application in any public health setting and with particular usefulness in initial epidemiological investigations of potential clusters of disease, in relation to environmental contamination such as around industrial sites, and disease surveillance. SAHSU are hoping to work with UKHSA and CDC retesting, refining the software and implementation. SAHSU surveillance methodology work includes the development of space-time clusters [c] methods suitable for surveillance of all cancers at small area-level. As part of this development SAHSU would look at space-time clusters at small- area level of not only single cancers, but cancers that might be plausibly linked to specific environmental exposures, such as smoking-related cancers and endocrine disruptor-related cancers. For example, SAHSU are just planning a study to evaluate the potential of machine learning methods for application to high-dimensional administrative health data and to apply this to the SAHSU datasets. SAHSU have a Non-Communicable Disease Surveillance study funded by the Wellcome Trust to investigate use of hospital data for non-communicable disease surveillance [b] Space-time clusters - Data has both a spatial and a temporal context: everything happens someplace and occurs at some point in time and this analysis can define neighbour relationships using both spatial and temporal aspects of data and recognising where there are clusters of these relationships occurring. SAHSU has a particular national responsibility in carrying out environmental health surveillance of the population in relation to environmental contaminants and point sources of industrial pollution, based on routinely collected health data. Having national data will enable SAHSU to provide an ad-hoc rapid response to UKHSA. Given that UKHSA coverage is across England, and the requirements cannot be predicted in advance, national data is required given that response times do not permit time to request, receive and process individual extracts of data. Historical data is also essential for all projects to enable SAHSU to obtain longitudinal data on prior admissions for patients. The lawful basis for processing data under GDPR has been reviewed and assessed as acceptable. Imperial College London process data under Article 6(1)(e): "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller" as they are a public Authority. The Data Protection Act 2018 s7(1) (a) defines 'public bodies' for the purpose of the GDPR as "a public authority as defined by the Freedom of Information Act 2000". The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means anybody which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists "Maintained schools and further and higher education institutions" as public authorities. Additionally, Imperial College London processes the Special Category Health Data under Article 9(2)(j): "processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject" as the data are required for research purposes in the public interest - meeting the conditions in the DPA 2018 Schedule 1 Part 1 (4) - which GDPR Recital 52(2) determines is an appropriate derogation from the prohibition on processing special categories of personal data.

Processing activities

SAHSU currently holds - and continues to obtain - HES data in the form of Admitted Patient Care (APC), Critical Care (CC), Accident & Emergency (A&E), Emergency Care Data Set (ECDS) as well as Civil Registration mortality data which includes identifiable data (NHS Number, Home address and Date of Birth) under this agreement. All processing activities are completed within the SAHSU Secure Research Systems (SSRS) facility which forms part of the Imperial College London (ICL) Secure Enclave trusted research environment (ISO 27001 certified) - an environment which is isolated from the "internet" and ICL services (email, network drives, one drive etc). The Secure Enclaves is an isolated environment within the Imperial College network, operated by Virtus SDC Ltd. The servers at Virtus SDC are owned and managed by Imperial College London in a dedicated area of the Virtus SDC data centre. Imperial do not have any shared racks with other organisations and operate their own switches. Access into the Imperial area is via swipe cards, CCTV covers the area and is monitored by Imperial and Virtus staff (24 hour). Servers can only be accessed by approved users who are appropriately trained people at Imperial College London. To access the Imperial servers swipe card access is required, and live logging and alerts of that access are available. ******This is an amendment to request the addition of GPES data for pandemic planning and research (GDPPR) data set to the agreement to enable SAHSU to undertake COVID-19 related studies. **** Access to the servers is controlled by Imperial ICT staff and heavily restricted. Virtus staff cannot enter the Imperial Cages without first seeking permission from Imperial. Permission is granted based on the need to enter and is not “ongoing” access (with the exception of “emergency” access, such as fire prevention). All access logs are recorded and made available to Imperial. In the previous iterations of this agreement, the data recipient needed to be physically present in their office on Imperial College London (ICL) St Mary’s Campus to download/ upload the NHS Digital data extract files from the NHS Digital’s Secure Electronic File Transfer (SEFT) system to the server (located in the same building on St Mary’s Campus) within the Private network i.e. Secure Research Systems environment (SSRS). The SSRS facility is split into two different enclaves/zones:(1) holding identifiable data and (2) holding processed minimised (to a small geographic area under specification of the study) and pseudonymised data. All processing, storage and analysis of patient level data are completed within these 2 enclaves. By default remote users have only "screen view" access of the data. Users within the office can only access the SAHSU servers through a dedicated client workstation that sits alongside their main college PC. The move of ICL’s SSRS to the Virtus Data centre happened during the lockdown restriction period in May 2020. However, the ICL Security Manager looked at the NHS Digital requirements and considered that an improvement in the transfer process could be made. Instead of the data recipient coming in and using an ICL secure PC onto a hardware encrypted drive (USB) with a hardware PIN , they could connect remotely and securely to a server specifically designed for secure data transfers via a secure ICL remote device. The data recipient will access the NHS England's Secure Electronic File Transfer service (SEFT), from a specified ICL office using a secured client workstation, download and copy the data extracts to the SAHSU Research database residing within the SSRS facility. The data extracts include a limited set of identifiable (date of birth, date of death, NHS number and postcode) and special categories of personal data. NEW DATA DOWNLOAD METHODOLOGY The research database resides within the identifiable enclave/zone of the SSRS which is restricted to the database team for loading, processing, and to perform data linkages with spatial, socioeconomic and environmental exposure data using the requested identifiers. Once the purpose for requesting identifiers has been carried out, they are removed and stored separately from the clinical/administrative data within the database. However, the identifiers may be accessed again e.g., when environmental studies which require linkage to exposure data demand for more precision to the place of residence, in which case the database team will access the patient identifier to complete further linkages for those studies. The data recipient logs into a secure transfer server within ICL via pulse secure VPN from their ICL owned secure workstation which they use solely to connect to the Secure Enclave and the SSRS. This secure transfer server has all outgoing connections blocked apart from approved data providers transfer service. The data recipient then downloads the NHS Digital data extract files from SEFT direct to the enclave file transfer gateway to be collected from the SAHSU database server. The data recipient then connects to the SAHSU database server and moves the NHS Digital data extract files into the SAHSU Identifiable Enclave which holds the SSRS Database Server (Oracle Database[a]). No copies of files are kept during the transfer process and ICL uses a “shred” program to securely delete data in line with NHS Digital requirements. A USB drive (or any other removable storage device) is no longer used for data transfers. Health data are linked with spatial, socio-economic and environmental exposure data which is vital for SAHSUs research studies. The focus of SAHSUs work is to investigate key public health issues associated with environmental factors at a small area level or high geo-spatial resolution. SAHSU ensures that patient re-identification is not possible whenever environmental data (e.g., high-resolution air pollution data) are spatially linked to a health dataset. In order to perform the spatial linkage, SAHSU implements a two-stage process: i) only the geographic identifiers (e.g. postcode unit, census output areas) is released to the researcher who spatially links the environmental data and hands this back to the database team; ii) the database team links the environmental data to the health data, removes the geographic identifier and hands the health data linked to environmental data back to the researcher for analysis. No record-level identifiable or pseudonymised data is downloaded from the SSRS. Data manipulation of patient identifiable data is conducted within the SAHSU Identifiable enclave (as in Data flow) Database server only. Extractions of data from the SAHSU database are taken based on specifications provided by the researchers according to their study protocols. An extract is taken from the NHS Digital data in the database which may require linkage to geographic or environmental exposure data as per the study specification. The study extract is then pseudonymised - in case future linkage to more environmental exposure data may be required at a later stage or anonymised depending on the requirement of the study once the linkage has been performed by the database team. The database team copies the pseudonymised/anonymised data extract to the File Server - study folder which sits within the SSRS Minimised de-identified enclave to which the researcher is given access to via their VM Statistical server. Researchers do not have access to the ORACLE database server which is located within the SSRS “Identifiable Enclave” (refer to Data flow diagram). The researchers access and analyse the data from the File server project folder within the SSRS Minimised enclave. Individual level data are not allowed to be taken from the SSRS. Research Findings/aggregate data with small number suppression can be taken out of the SSRS for publications. The separation of patient identifiable and clinical/administrative data occurs after the data have been processed, linked and quality checked. The database team has therefore created an enhanced pseudonymised version from the dataset that was originally received from NHS England. This pseudonymised version will then be used to create future extracts for SAHSUs research studies. This new and improved data transfer methodology is now in use and the current lockdown data download process is that the data recipient logs into a secure transfer server within Imperial College London via pulse secure VPN (that checks on the status of the client’s workstation patches and anti-virus software) from a secure dedicated ICL owned remote device. This secure transfer server has all outgoing connections blocked apart from approved data providers' transfer service. The data recipient then downloads the NHS Digital files from SEFT direct to the enclave [b] file transfer gateway to be collected from the SAHSU database server. No copies of files are kept during the transfer process and they use the “shred” program to securely delete data in line with NHS Digital requirements. The method for downloading data from SEFT using a remote device will cease once the lockdown restrictions are over and authorisation for home working is no longer allowed. Researchers must follow the SAHSU governance process for requesting data extracts for their studies. The following checks are carried out prior to data extractions: [b] The Secure Enclaves are trusted research environments within ICL which are isolated from the “internet” and most ICL services (such as email, network drives). All communication into and out of the SSRS network is via gateways. These gateways control and monitor access to servers and file transfers. It is for this reason that the data recipient cannot connect directly to the SEFT server from a SSRS server. The gateways are not public facing, they can only be accessed by approved workstations within the college or remote clients with pulse VPN running. It was built and is controlled by the ICL Security Manager and is a Linux windows server running samba shares. It is dedicated to the Secure Enclaves. As well as recording the data transfers, it keeps copies of all files transferred (except raw data downloaded from data providers) so they can be audited for IG compliance with data sharing agreements and GDPR requirements. • Their studies have been approved by the UKHSA-SAHSU Liaison Committee. The study team data recipient will revert to only allowing approved workstations within Imperial College to access the transfer gateway. • They are under contract with Imperial College London. [a] Data are loaded to an Oracle Database with Advanced Security implemented. This allows us to protect data at the source using Transparent Data Encryption (TDE) by enforcing data-at-rest encryption in the database layer which prevent unauthorised access from bypassing the database and reading sensitive information directly from storage. After the data are encrypted, data are transparently decrypted for authorised users when they access the data. ORACLE Transparent Data Encryption (TDE) helps protect data stored on media (also called data at rest) in the event that the storage media or data file (i.e. the SAHSU Database and disk arrays) is stolen. To prevent unauthorised decryption, TDE stores the encryption keys in a security module external to the database, called a keystore - a built-in encryption key management that eliminates the complex task of managing and securing encryption keys. • They have signed the SAHSU Acceptable Use Policy and undertaken all mandatory data protection training. Only members of the database team have access to the Oracle database which holds patient-identifiable and sensitive data. Data loading, cleaning, validations, derivations, and any authorised data linkage are performed by the database team. • Any request to access sensitive or patient identifiable data (date of birth and/or death) must be strictly necessary for the purpose required. All extractions of data from the SAHSU database performed by the database team are all logged and cross checked by the database manager prior to extraction. *** All individuals accessing record level data are substantive ICL employees or registered students (including PhD and Masters students). SAHSU have implemented a “Student Letter Agreement For Access To NHS England Data” (in place of a substantive employment contract and approved for use by NHS England on 22.9.21) which they have to sign to indicate their obligations for accessing and processing personal data. All registered students (including PhD and Masters students) are additionally required to sign the Imperial College London (ICL) Terms and Conditions as part of their registration and enrolment process at the start of their course and the Secure Research Systems (SSRS) Acceptable Use Policy and Agreement as all other individuals do. The following checks are carried out prior to data extractions: Researchers can request minimised (to a small geographic area defined by the study) pseudonymised data extracts. The database team will generate extracts for the research team based on the specifications provided as per their data requests. Data extracts are copied and made available to researchers in the minimised/de-identified enclave/zone of the SSRS where they have all the facilities to conduct their studies. All studies requiring analysis of individual-level data are conducted within the SSRS facility. 1. The project has been approved by the SAHSU Liaison Committee; Users requesting access to SAHSUs data must complete data protection training and have a good understanding of the sensitivities around using health administrative data, how to handle sensitive data safely, lawfully and responsibly. Even after data have been processed, analysed and research findings have been compiled, SAHSU recognise that there is a potential risk of disclosure from small numbers (e.g. rare disease in a small area or any other special circumstances are taken into account e.g., Longitudinal data, key variables, sample size, household surveys, and other published datasets) so statistical disclosure controls are applied to all research outputs in line with HES analysis guidelines and other national disclosure procedure guidelines i.e. obscuring small numbers that appear in aggregate tables so as to prevent reidentification. 2. User is under contract with Imperial College London; Only aggregate data with small number suppression can be taken out of the SSRS. By default, users cannot transfer result findings without approval of the Information Asset Owner/Administrator and approval can be limited to only files that have been approved by senior members of staff. 3. Any access to sensitive or patient identifiable data e.g. (date of birth and/or death) has SAHSU understand that data linkage between health datasets is only permitted with explicit written permission from data providers and substantial amendments to SAHSUs NRES ethics and HRA/CAG approvals. to be necessary for the purpose required; To date, amendments to the section 251 support have been sought and granted for the following three projects which required specific data linkage: 4. SAHSU Acceptable Use Policy and Agreement has been signed; and the user has undertaken mandatory information governance training. Pseudonymised extracts are generated from the Oracle database and copied to the specific user folder on a research server within the “Private Network” which has a range of statistical software installed to enable them to do further analysis. Users requesting access to SAHSU’s data have had Information Governance training and have a prior understanding of the sensitivities around using administrative data, how to handle sensitive data safely, lawfully and responsibly. They are required to apply the rules and regulations for disclosure risk analysis for their studies outputs. All outputs will be aggregated with small numbers suppressed in line with NHS Digital’s Disclosure Control Procedure and the HES analysis guide. No record level will be transferred outside of England and Wales under this agreement, and is only processed and stored at the addresses given within this application and data provided under this agreement will not be shared with any third party. In addition to the data provided by NHS Digital, SAHSU also hold the following record level identifiable datasets: • Cancer registrations (England and Wales) • ONS deaths registrations • ONS birth and still births registrations • Previously NHS Numbers for Babies (NN4B) which is now Births Registration data • National Pupil Database SAHSU understand that linkage between datasets is only permitted with: • Approval via a substantial amendment to SAHSU ethics approval • Approval via a substantial amendment from Health Regulation Authority Confidentiality Advisory Board (HRA CAG) • Explicit written permission from the data providers concerned. *** GDPPR data - No linkage will be undertaken with the other health datasets SAHSU currently hold in their database (listed above). *** To date, amendments to the section 251 support have been sought and granted for the following three projects requiring specific data linkage: [3 paragraphs unchanged] Any projects requiring linkage beyond that covered by this application would also be subject to an amendment for NHS Digital's England's consideration which would also require support from ethics, ethics and be covered by an amendment to the current section 251 approval approval. All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data). In addition to the data provided by NHS England, SAHSU also hold and continue to receive the following record level identifiable datasets: Data under this agreement will be disseminated more frequently so that SAHSU are able to work on the most complete data to enable SAHSU to undertake COVID-19 related studies. • Cancer registrations/incidences (England and Wales) Staff accessing the record level data are substantive employees of Imperial College London or registered students (including PhD and Masters students) who have signed a legally binding data access contract (in place of a substantive employment contract) which has been approved for use by NHS Digital. Any other individual on a honorary contract will only be accessing data which has been aggregated with small numbers suppressed as per the HES analysis guide. • ONS deaths registrations All registered students (including PhD and Masters students) are additionally required to sign the Imperial College London (ICL) Terms and Conditions as part of their registration and enrolment process at the start of their course, the Facility of Medicine Code of Practice for Handling of health and social care research data, and the Secure Research Systems (SSRS) Acceptable Use Policy and Agreement. In addition, all students and substantive staff members undertake regular Data Protection training. • ONS birth and still births registrations The only data linkage to be undertaken will be that as outlined in the application any additional linkages would require an amendment to this agreement. • Previously NHS Numbers for Babies (NN4B) now Birth Notification data HES and ECDS DISCLOSURE CONTROL / SMALL NUMBER SUPPRESSION • National Pupil Database In order to protect patient confidentiality, when presenting results calculated from HES record level data, outputs will contain only aggregate level data with small numbers suppressed in line with HES Analysis Guide. When publishing HES data, you must make sure that: Microsoft Limited supply Cloud Services for Imperial College London and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data. · cell values from 1 to 7 are suppressed at a local level to prevent possible identification of individuals from small counts within the table. All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by "Personnel" (as defined within the Data Sharing Framework Contract i.e.: employees, agents and contractors of the Data Recipient who may have access to that data). · Zeros (0) do not need to be suppressed. · All other counts will be rounded to the nearest 5. [1 paragraph unchanged] ****GDPPR Disclosure Controls / Suppression Rules Whilst there are no specific GDPPR disclosure controls, outputs for public consumption should follow the Government (ONS) Statistical Service disclosure controls.  NHS Digital recommend that users review and follow the disclosure control guidelines as set out within the HES Analysis Guide. Some, but not all requirements are outlined below: Disclosure control only needs to be applied to values relating to individuals. No rounding or suppression is required for values not relating to individuals, such as a count of providers. No small number suppression is required for national totals. For any sub national geographies e.g. NHS Commissioning Region / Government Office Region or smaller, then the following apply: • Zeroes can be shown. • Values between 1-7 to be displayed as “*”. • Any other numbers rounded to nearest 5. • Percentages calculated from rounded values ****

Expected output

SAHSU's proposed work will continue with the same themes of SAHSU’s programme of work agreed with Public Health England. SAHSU have a long record of publishing its research in high-quality peer-reviewed journals and presenting results at scientific meetings and conferences to inform policy and to empower public debate. SAHSU have attracted considerable interest in their work from the media, members of the public and work closely with UKHSA and Imperial College to respond appropriately. Where results are likely to be of particular interest, SAHSU put out a press release and, if necessary, hold a press conference. SAHSU research findings are fed back to relevant policy leads within PHE and other government departments and used to consider population health risks and to inform national public health policy. The study finding using the GDPPR data will be in the public interest and will benefit the health and social care as it will provide information about COVID-19 populations with worse prognosis and will highlight the importance of the existing air pollution regulations. SAHSU have a publication policy that includes sharing all publications with colleagues at UKHSA and the devolved administrations and a full list of publications is presented bi-annually to the UKHSA-SAHSU Liaison Committee and quarterly to the UKHSA Environmental Public Health Programme Board. Below are some examples of SAHSU’s studies which require HES and Civil Registration/Mortality Data: SAHSU research is presented to scientific advisory committees where it is of national interest e.g., their work on the surveillance of childhood cancers was considered by the Committee on the Medical Aspects of Radiation in the Environment (COMARE). **** NEW for Version 4 SAHSU communicate their research work directly to the public through high-impact events such as the annual Great Exhibition Road Festival, and various science events at local and regional levels. These events offer an opportunity to engage with the public and to share the work undertaken by the Unit. > Public Health Impacts of Clean Air Zones Public Community Involvement Engagement and Participation (PCIE) is also undertaken by researchers within their individual research projects. These activities are designed and undertaken to reflect the specific needs of the research study and a range of approaches have been taken. The overall ambition is to ensure that the public and community voice impacts our research projects. In 2021, SAHSU have commenced a programme of work, funded by a five-year MRC programme grant, to determine the impact of the London Ultra Low Emission Zone (ULEZ) on air quality, the composition of pollutants, health, health inequalities and multi-morbidities across the life-course. The ULEZ is a large-scale public health intervention targeting urban air pollution, principally from primary traffic emissions. It operates in the London Congestion Charge area and vehicles must either meet emission standards or pay a daily charge to drive within the area. Globally, air pollution is the leading environmental risk factor for mortality. A previous SAHSU collaboration on a health impact assessment estimated the 2010 mortality burden from PM2.5 and nitrogen dioxide (NO2) in London was approximately 141,000 life-years lost. The ULEZ is a large scale public health intervention and it is essential to evaluate its effectiveness in delivering the expected impacts on air quality and health. SAHSU are planning (with appropriate approvals) to use HES and civil registration data during the period of this DSA, to study the health outcomes in people within and outside the ULEZ (and pre/post implementation) to provide evidence to Public Health England, the Greater London authority, Local Authorities and other public health organisations to inform air pollution strategy including clean air zones. Examples include: > COVID-19 research September 2021: Presentation of the Reduced Noise Impacts on Short-Term Aircraft Noise and Cardiovascular Outcomes (RISTANCO) to the Joint MRC Centre and HPRU Public Community Oversight Group (PCOG) which has a representation from patient groups, public health practitioners, Non-Governmental Organisations (NGOs), government and industry. RISTANCO aims to investigate the short-term impact of aircraft noise on cardiovascular morbidity and mortality. The purpose of the public engagement was to better understand how researchers can best present the results of this project to the general public and begin thinking about the potential interventions that might result. The PCOG offers advice on research plans, protocols, and materials. The PCOG has also been set up to support researchers to assess the impact of Public Community Involvement Engagement and Participation (PCIEP) in their work. SAHSU is undertaking a programme of studies that apply spatio-temporal methodologies [a] to understand the role of the environment in vulnerability and resilience to the health impacts of the COVID-19 pandemic. SAHSU has published an analysis of the community factors associated with excess mortality during the first wave of the pandemic in England, and is currently working on a cross-country comparison of excess mortality that will generate hypotheses about the different national responses to the pandemic and will be of importance and relevance to public health policy in England. The GDPPR data and mortality data from NHS Digital will be used in a forthcoming study of the role of co-morbidities in the observed associations between COVID-19 mortality and air pollution. The findings of this work hope to be significant to the formation of air pollution policy. January 2021 - The air quality health and economic costs and benefits of a zero-carbon UK study: SAHSU researchers ran a focus group with members of the public to feed into the study design of a project looking at the health impacts of government policy scenarios to meet its net-zero carbon emissions climate change target by 2050. [a] Data has both a spatial and a temporal context, i.e. everything happens someplace and occurs at some point in time and this analysis can define neighbour relationships by analysing both spatial and temporal aspects of data. This provides a richer context. Details of our research programme and outputs are published on the SAHSU website: (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/). > Vulnerability to Climate Change: Inequalities in exposure, susceptibility and adaptation capacity in two metropolises The overall aim of this PHD study is to characterize the vulnerability to temperature changes of the citizens of Sao Paulo (Brazil), London and Greater Manchester (United Kingdom), from the perspective of their exposure, sensitivity and adaptation capacity, and to quantify the impact of these vulnerabilities on the temperature-related mortality and morbidity (i.e. hospital admission and A&E data) association, for all-cause and specific outcomes using data between 1990 and 2020 (when available). > Understanding effect modifiers of the relationship between health and exposure to urban green and blue space Despite a body of evidence linking green and blue space exposure to physical health benefits, specific effect modifiers of this association are currently understudied or unknown. The aim of this PhD project is to identify and assess important factors that might act as modifiers of the relationship between urban green/blue space and health. > A natural experiment of the Western Extension to the London Congestion Zone This project will use data on air pollution concentrations and hospital admissions between 2003 and 2014. Air pollution data (nitrogen dioxide and particulate matter) will be linked to residential addresses. This will allow SAHSU to examine exposure to air pollution before, during and after the implementation of the Western Extension Zone. SAHSU will assess all hospital admissions, and admissions for all respiratory and all cardiovascular diseases separately. These will be combined with population data to examine hospitalisation rates. SASHU hope to have one intervention group of the residents compared with two other groups: one from just outside the area and another similar in terms of deprivation. > Asthma admissions and grass pollen counts, levels and potency in London and its surroundings Airborne outdoor pollen is a major cause of asthma hospital admissions. Current exposure assessment methods rely primarily on daily changes in the number of airborne pollen counts and thus do not capture changes in the true biological allergenic potential of the air (i.e. allergen levels). Using unique pollen data available in London, this project will test the hypotheses that asthma hospitalizations increase with increasing airborne allergen levels, and that this association is underestimated by current exposure assessment methods based only on pollen counts. > Geographic inequalities in AMI case-fatality in hospitalised patients in England: the role of multi-morbidity The overall aim is to understand patterns of multi-morbidity in hospitalised AMI patients and their role in AMI mortality, nationally and sub-nationally. > Pathways to equitable health cities This project aims to understand the impacts of planning and policy actions on population health and on health inequalities, focusing on cities in five countries (Bangladesh, Canada, China, Ghana and the UK). SASHU hope to capture spatial inequalities in health focusing on mortality, hospitalisation, cancer incidence and birth outcomes (prematurity and birth weight) using methods from spatial and spatio-temporal statistics. SASHU hope to also use environmental epidemiological models to simulate how specific actions related to housing, neighbourhood design, transportation, sanitation, water and safety and health services impact population health, which will help inform planning and policy decisions. Their work is in close collaboration with the PHE. **** > Disease clustering SAHSU have commenced a programme of work to improve statistical methods assisting with detection of space-time disease clustering for chronic disease, including both new statistical techniques and use of machine learning. Funding sources to SAHSU include the Wellcome Trust, the Medical Research Council and Public Health England. This will be an important advance for chronic disease surveillance and feed into Public Health England health protection plans. SAHSU are commencing this work across a range of diseases and also want to expand this to consider groups of diseases to detect if there are clusters that might be linked to a common environmental risk factor e.g. endocrine disruptor chemicals, asbestos. SAHSU are currently working with hospital admissions and mortality separately. However, to fully detect severe cases but to avoid double-counting (people both admitted and dying of disease), SAHSU need to take into account both hospital admissions and mortality so need to be able to link across these datasets. >Cardiovascular health effects of aircraft noise exposure SAHSU have a programme of work funded by the Medical Research Council and by the National Institute of Health Research respectively to look at long-term and short-term effects of aircraft noise on cardiovascular disease. To fully detect impacts but to avoid double-counting of cases (people both admitted and dying of cardiovascular disease), SAHSU need to take into account both hospital admissions and mortality so need to be able to link across these datasets. Another advantage is that this increases the number of cases SAHSU can include in the analysis (as a significant proportion of cardiovascular deaths occur in people who have not previously been admitted to hospital with cardiovascular disease). > Small area variation in Ischemic heart disease incidence, mortality and survival and their risk factors and determinants in England Regional differences in mortality between different areas of England are well established and have been documented for over a century. It has, however, thus far been difficult to tackle these variations and they have become entrenched. Part of the difficulty can be attributed to the lack of outcome data, such that health and social care evaluations are often based on process indicators (such as number of procedures performed), rather than hard end-point outcomes such as mortality. Linkage of diagnostic data with end-point mortality outcomes provides a unique opportunity to overcome this obstacle and disentangle the underlying causes of regional variation in mortality. This should allow SAHSU to target interventions and health and social care policies to those areas with most need and directly monitor their impact on health inequalities. HES data and Civil Registration/Mortality data have the advantage of providing almost complete coverage of England - allowing for robust conclusions about regional variation which are not limited by data gaps. Evaluation of local and regional variation acquires increasing significance in the era of ‘any willing provider’ to ensure that patients are safeguarded from for-profit firms which may have a greater incentive to ‘cut corners’ in the provision of health and social care. Cancer services already apply a similar strategy to tackle variation though registry collections of incidence rates and careful follow up of outcomes. SAHSU focus on coronary heart disease (CHD) - the leading causes of death in men and second largest cause in women, although such a strategy can potentially be applied to any cause of morbidity and mortality. About one half of the regional differentials in mortality in England are accounted for by CHD, which can be divided into acute coronary syndrome (ACS) and chronic CHD. It is however unknown what proportion of the variance in ACS mortality among small area units such as wards or local authorities is due to differences in ACS event rates vs. treatment. Incidence of ACS, unlike incident cancer or sexually transmitted disease, is not comprehensively recorded in England. Thus, while circulatory diseases are one of the largest causes of death, very little is known about the differences between small areas in event rates or outcomes of ACS. This limits the evaluation of current preventive and health service interventions aimed at reducing coronary heart disease event rates and improving survival, especially in the worst-off regions. SAHSU have already used pseudonymised linked individual records of hospitalisation and mortality data to generate measures of ACS event rates and survival across local authority districts in England for 2006-2010. The linked data are cleaned so that individual records which appear in overlapping data sources are not double counted. Once outcomes have been attributed to each hospital admission, the data are fully de-identified and used to generate local rates of events. The data are then used in a geographically referenced statistical model, to minimise the impacts of statistical noise due to areas boundary effects, and to derive consistent and comparable quantification of ACS event rates and survival for small areas in England. Linkage permissions for this study ran out in 2010 and the mechanism for renewal was suspended whilst the new health and social care structures were bought into existence. The previous analysis is now out of date and would benefit greatly from the input of recent data to enable us to provide outputs which are relevant to the current health and social care service. > Cystic fibrosis project: This project is funded jointly by the UK Cystic Fibrosis (CF) Trust and the MRC Doctoral Training Programme at Imperial College London. It includes two registered degree-level studentships for a duration of 3.5 years. The research projects will focus on analyses of HES data of individuals diagnosed with cystic fibrosis, alongside data from the UK CF Trust’s Registry, in relation to environmental factors, including air pollution, to rigorously quantify possible causative interactions, with a particular focus on respiratory disease. It will be extremely useful to study the hospitalisation history (HES) of cystic fibrosis patients who died in order to potentially identify triggers or signals that could have helped prevent lethal complications. It will also be useful to study where patients have died, in relation to distances to CF care centres and hospitals. The HES/Civil Registration linkage will be useful to study cases potentially only diagnosed at death with cystic fibrosis. The UK CF Registry data is mostly based on annual reports, while HES will provide a more precise encounter-based source of information. > Carbon monoxide project: SAHSU is engaged in examining the population burden of carbon monoxide poisoning, with funding from the National Institute of Health Research Health Protection Research Unit in Health Impacts of Environmental Hazards and from Public Health England. SAHSU have published a paper on carbon monoxide hospital admissions (Ghosh et al, Journal of Public Health, 2015). SAHSU now propose to look at deaths and hospital admissions together - to determine what people who die of CO poisoning were previously admitted to hospital for and also what people admitted to hospital with CO poisoning go on to die of. This will help SAHSU identify if there are warning signals that could help better detection of CO poisoning and prevent deaths. There are growing concerns about the hidden burden of carbon monoxide poisoning in England and globally. Because most of the symptoms seen in patients who have been exposed to carbon monoxide poisoning are very common (e.g. headaches or dizziness), many cases are detected quite late or misdiagnosed. Linking HES and Civil Registration/Mortality data for patients who died from carbon monoxide poisoning or patients who were diagnosed with carbon monoxide poisoning relatively shortly before their death will help improve understanding of possible misclassifications or missed cases, and substantially contribute to reduce the burden of this preventable cause of poisoning. Specific outputs expected, including target date: There are three main types of output from this application :- 1. The maintenance of the research database, and associated record level pseudonymised extracts for use by individual researchers within SAHSU. Such extracts are delivered either through the RIF or the database team. This database will have the ability to provide data for the specific projects which have been approved as set out above. Note that all extracts are subject to the constraints within this agreement, eg: that data will only be held and processed at the processing / storage address. Such work is on-going through the lifetime of this agreement. 2. Individual project research outputs. All such outputs would be aggregate data, and be used within journal papers, research reports and results, presentations at conferences. Such research outputs would be placed into the public domain. Examples of previous outputs and projects are given below. 3. Individual analyses for Public Health England (PHE). Again, all such outputs would be in aggregated form, but would be provided directly to PHE. Future outputs from the study hope to be disseminated via peer reviewed publication and academic conferences presentations. All outputs from individual projects will aggregated with small numbers suppressed in line with the HES Analysis Guide. To confirm, no record level data is provided to any third party organisation and no commercial use is permitted.

Expected measurable benefits

SAHSU has a unique role to support Public Health England’s mission to protect the health and wellbeing of the population with respect to environment and health concerns. SAHSU delivers authoritative analyses of routine health statistics in support of public health policy, environment and health surveillance and environmental public health tracking. SAHSU's research programme aims to provide the evidence underpinning actions and policies that hope to create liveable, sustainable and healthy environments and effective public services for all and hopes to directly inform actions that influence people’s health. Part of the assessment/approval process for SAHSU studies is a consideration of the potential benefits and impacts of the findings and this information is included in the project descriptions in the public domain (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/current-research-projects/). The key points in demonstrating the benefit to health and social care are: The results of SAHSU studies are placed in the public domain via conference presentations, reports and peer-reviewed publications and are intended (and have been used) to inform decision making by public health and to national public health policy-makers. Results of studies also are directly shared with relevant Policy Leads within UKHSA and other government departments. SAHSU undertakes a programme of research, surveillance and cluster investigation, subject to funding from external sources, that includes both methods development and investigation of priority questions in environment and health (including social, economic and demographic factors) as approved through PHE governance. The governance is overseen by the PHE-SAHSU Liaison Committee. The key points in demonstrating the benefit to health and/or social care are as follows: The work of SAHSU helps progress PHE’s remit to protect the public’s health from public health hazards, particularly in relation to environmental hazards, and also in surveillance of non-communicable disease. For example SAHSU have published neighbourhood and postcode searchable maps in the SAHSU Environment and Health Atlas for England and Wales (www.envhealthatlas.co.uk) and published in recent years substantive studies on health effects of environmental air pollution and noise and future impacts of climate change on mortality. • The core SAHSU programme of work is agreed with and approved by the UK Health Security Agency and this includes work undertaken to assist UKHSA in fulfilling their duties In June 2021, SAHSU published a study exploring the community factors associated with vulnerability and resilience to excess mortality in the first wave of the COVID-19 pandemic in England (pre-printed in November 2020). SAHSU are currently progressing a similar study looking at environmental factors and health outcomes using hospital admissions as the outcome event. • Individual projects must be aligned with the Terms of Reference of the SAHSU programme, which includes addressing environmental, sociodemographic and health issues. A fundamental part of SAHSU’s work is the investigation of inequalities in environmental exposure and health. Findings from our studies are shared widely with stakeholders including PHE and feed into policy to reduce inequalities in health such as the Mayor of London’s Health Inequalities Strategy. Data analyses also indirectly support service development, for example, adapting national deprivation indices to better define inequalities in rural areas in collaboration with Directors of Public Health. • All projects are approved by the UKHSA-SAHSU Liaison Committee. In order to assist with standardising approaches across application processes, data providers are also invited to these meetings. The work of SAHSU attracts considerable interest from the media and from members of the public and work closely with PHE and Imperial College to respond appropriately. Some of the research studies are conducted as a direct response to public concerns e.g. the incinerators study investigating potential impacts of municipal waste incineration on birth outcomes and infant mortality, initiated in response to Public Health England request. • All projects are approved by the Environmental Public Health Programme Board at UKSHA, which includes membership from a representative of the Department of Health and Social Care. All SAHSU’s projects are aligned with the Terms of Reference of the SAHSU programme, which includes addressing environmental and health issues. All projects are approved by the PHE Programme Board, which includes membership from the Department of Health (DH). In order to assist with standardising approaches across application processes, SAHSU have offered membership of the approving group to the Data Access Request Service at NHS Digital. Benefits are achieved on an on-going basis, and it is difficult to outline specific target dates which are reliant on a range of factors both within and outside of SAHSU. Examples detailing potential benefits from SAHSU's new and on-going studies, including examples of research, surveillance, commissions and methodology development: Health impact of living near a biomass-fuelled electricity generating installation: This project aims to focus on possible health complications associated with biomass burning to improve SAHSU's understanding of adverse effects of wood biomass burning in industrial facilities on the health of local populations. The results are expected to inform local and national public health decisions as well as future regulations. Health effects of aircraft noise Following the findings from the SAHSU study on the health impacts from aircraft noise around Heathrow airport, published in the British Medical Journal in 2013, allow for a better understanding of the health problems caused by noise from aircraft in London. A follow-on study funded by the Medical Research Council on Aircraft Noise and Cardiovascular Outcomes (ANCO) is currently expanding SAHSU’s previous study to include all major airports in the UK. The focus is on long-term exposure to aircraft noise and cardiovascular-related hospital admissions and mortality. In addition, SAHSU are studying the effects of short-term exposure to aircraft noise acute cardiovascular hospital admissions and mortality events via the NIHR funded study - Reduced Noise Impacts of Short-Term Aircraft Noise (RISTANCO). This study aims to also examine potential mitigation strategies through respite periods. These studies findings are expected to contribute to the evidence base to help better define the burden of environmental noise on health and improve health impact assessment for major infrastructure changes such as the proposed new runway at London Heathrow and expansions or other major airports. Evaluate the burden of climate-related respiratory disease using high-resolution spatiotemporal models: This work aims to be be one of the first such projects to provide an integrated framework to quantify the health effects and costs of temperature changes in the UK on a nationwide level at a small-area scale. The methodology can be transferable to other drivers of disease affected by climate change such as infectious diseases in more vulnerable areas such as developing countries. A statistical framework for the apportionment of particulate contaminants and their health effect determination: Air pollution is a major public health concern. It is linked to common non-communicable diseases, including asthma, lung cancer, heart attacks and strokes. This study aims to help SAHSU understand more about which sources of air pollution are the most harmful to the health of children and the elderly in London. This information aims to support the design of strategies to control and reduce air pollution that target the most harmful sources. The result findings may help focus public health efforts to reduce air pollution exposure in the population by enabling targeting of control efforts to the sources that mostly contribute to the harmful effects of air particles. This study aim is to help answer the question: does air pollution coming from different sources have different level of toxicity for the population? The study particularly considers vulnerable groups like children and the elderly. MPH: The double burden of smoking and air pollution in England: The findings from this study may be useful to Local Authorities in providing information on how tobacco smoking and air pollution are affecting the health of local populations which can be used to decide on local priorities. SAHSU hope to produce maps of England that show the levels of air pollution, people who smoke and health outcomes for each Local Authority. The project team hope to use statistical models to explore how air pollution and tobacco smoking are related to each other and to the health outcomes. By exploring the links of smoking and air pollution with health outcomes and how they interact with each other, and by identifying areas in England with significant burden of diseases related to these factors, results are expected to provide supporting evidence to inform interventions such as to cease smoking and reduce second hand smoke targeted at local authorities that mostly need them. Air pollution Health Impact Assessment: Housing quality is a key socio-economic determinant of health and its associations with health are well-established. This project aims to estimate the associations of poor thermal comfort and health in London and examine how these differ across the socio-economic spectrum. The Environment Research Group, in collaboration with SAHSU, has an ongoing work programme to estimate health impacts of air pollution to provide support and evidence to national and local governments. The results of these short-term projects are expected to generate evidence on the health benefits of specific policies, for example, as input to cost-benefit analyses. Burden calculations hope to draw attention to the size of the air pollution problem in a particular area which in turn can act as motivation for further reductions in air pollution. Ultimately the aim is to encourage the adoption of policies by Defra and local authorities to reduce air pollution concentrations throughout the country and reap the health benefits that may bring to the public. PhD: Housing Quality and Health: This study aim to provide evidence needed to better understand the impacts of poor thermal comfort on health at the small area level, in order to identify existing hotspots and inequalities for the development of more effective and targeted housing policies. The origin of this projects lies within the Wellcome Trust-funded Pathway to Equitable Healthy Cities with existing links to Directors of Public Health, who are expected to help with facilitating policy impact. The air quality health and economic costs and benefits of a zero carbon UK: The project is expected to highlight policies to reduce greenhouse gas emissions that are also optimal for reducing air pollution concentrations and thus air pollution health impacts. The project is designed to feed into a cost-benefit analysis that aims to ensure that costs to the economy in paying for policies to reduce air pollution and greenhouse gas emissions are balanced against the monetised benefits of reduced impacts on health. Effects on health inequalities hope to also be analysed highlighting whether targeted action may be needed to give additional protection to deprived groups. Health Impact Assessment of air pollution on asthma in London (2): Result findings are expected to be used by Greater London Authority as evidence to establish the health impact of air pollution on asthma exacerbation in London and to derive appropriate strategies to inform and protect the general population and specific vulnerable groups. This is of particular importance with regards to the extension of the Ultra-Low Emission Zone in autumn 2021 and the London Environmental Strategy. In the longer term, methods developed as part of this project can be used for future incorporation of benefits of reductions in asthma outcomes within cost-benefit analysis of London-wide policies to reduce air pollution. MSc: Greenspace exposure and health – a question of scale: Result findings may have important implications for urban planning and policies related to green space accessibility and availability for the general population. Information about the appropriate scale at which greenspace provision should be prioritised to consequently have important benefits to the local population in providing spaces for physical activity and social contact. PhD: Impact of the London Ultra Low Emission Zone on health outcomes across the life course: Implementation of ULEZ-like zones is currently being actively considered by several UK cities. However, the current evidence regarding the health impacts of such zones is unclear. The outcomes of this study, with respect to clinically meaningful health benefits, hope to provide evidence for the role of similar zones in air pollution policy in London and elsewhere and also on the impact of the ULEZ on health outcomes across the life course, and whether these differ by socio-economic or demographic factors. The findings are expected to be written up in a PhD Thesis, presented at conferences/meetings and published in academic papers. Long term exposure to air-pollution and COVID-19 mortality: The role of pre-existing conditions: The results are expected to provide information about COVID-19 populations with worse prognosis and highlight the importance of the existing air pollution regulations. Spatio-temporal patterns in excess mortality and morbidity in England during Covid-19 pandemic: The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there may be adverse consequences on non-COVID-19 morbidity and mortality. Understanding effect modifiers of the relationship between health and exposure to urban green and blue space: This project aim is to develop new exposure metrics to assess health effects of green/blue space. Research findings hope to advance SAHSU's understanding of which factors are driving or influencing the relationship between green/blue space and health. Knowledge gained from the results on the drivers that potentially change the magnitude and direction of any health effects are essential to guide efficient policies both at the local level (e.g., tree planting scheme in city) and national level (e.g., recommendations on available green/blue space per person). Evaluating the burden of climate-related respiratory disease using high resolution spatiotemporal models: This work hopes to provide an integrated framework to quantify the health effects and costs of temperature changes in the UK on a nationwide level at a small-area scale. SAHSU hopes to communicate the results among public health experts and the public via a website. This methodology aims to be transferable to other drivers of disease affected by climate change such as infectious diseases in more vulnerable areas such as developing countries. A natural experiment of the Western Extension to the London Congestion Zone (WEZ): The WEZ is one example of road user charging, or systems of making motorists pay directly to drive within a certain area. These schemes are being considered in a range of areas in England, including Bath, Bristol and Sheffield. This project hopes to provide information on the health impacts of such schemes and give clues as to how they can best improve health. This research findings are expected to provide information on the air pollution and hospital admissions before, during, and after use of the WEZ. Asthma admissions and grass pollen counts, levels and potency in London and its surroundings: Airborne outdoor pollen is a major cause of asthma hospital admissions. Using unique pollen data available in London, this project aims to test the hypotheses that asthma hospitalizations increase with increasing airborne allergen levels, and that this association is underestimated by current exposure assessment methods based only on pollen counts. The results of this research may be useful for clinicians, patients and researchers (understanding risks and how to reduce them) as well as government and public health policymakers (i.e., may suggest the need for improved monitoring of allergens in the air). Given that future urbanization and climate change is expected to lead to important changes in how and which plants grow in our cities (and potentially how they interact with air pollutants), it is important to understand these relationships so the people in the UK may get the right information to protect themselves from asthma attacks. Health risks in the area exposed to the plume from the October 2000 chemical fire at CSG in Sandhurst, Gloucestershire – A small-area study update: Beyond improving SAHSU's understanding of the potential long-term health impact of this incident, it is likely that this work may contribute to provide updated evidence and hopefully reassurance to the local communities. Research findings are expected to be shared with stakeholders and the local community. Geographic inequalities in Acute Myocardial Infarction (AMI) case-fatality in hospitalised patients in England: the role of multi-morbidity: The findings hope to directly inform planning decisions about the common profiles of AMI patients that visit England’s hospitals, and their relative chances of survival versus death. Pathways to equitable health cities: Research findings are expected to provide the evidence underpinning actions and policies at the city level that aim to create liveable, sustainable and healthy environments, and effective public services for all. This study being inherently solution-oriented hope to directly inform actions that influence people’s health. In London, SAHSU hopes to work with the UK Health Security Agency and the Greater London Authority to address and inform contemporary policy choices. PhD: Time series analysis of air pollution: Results aim to be summarised in a publication and the results from daily spatio-temporal model are expected to be shared with the academic community, stakeholders and the public. The outcome of this study may further provide evidence of the acute adverse effects of air pollution, using refined air pollution estimates that can better represent exposure levels. The study also aims to produce air pollution surface maps of Great Britain, to help identify the ‘hotspots’ of polluted areas, and provide evidence and assistance in policy-making. Results aim to be summarised in a publication and the results from daily spatio-temporal model are expected to be shared with the academic community, stakeholders and the public. Impact of environmental inequities on health in England: Results are expected to provide a comprehensive picture of the effect of deprivation and environmental exposures on disease burden in Great Britain and how this has changed over time. This may also provide an important baseline to which future trends can be compared to and further highlighting areas of specific need for policy intervention and to better tailor policies aimed at tracking heath inequities. Small area variation in Coronary Heart Disease (CHD) event rates, mortality and survival in England: Results are expected to be a cross-sectional estimates of small area CHD event rates and survival. The final part of the project aims to examine the socioeconomic and health service correlates of the variations seen and hope to suggest possible interventions to reduce the overall burden of CHD as well as its inequalities. Health Inequality: Result findings are expected to demonstrate how the combination of social determinants and public health and health service policies are affecting health inequalities and where the largest needs for interventions are in order to help protect the health of the worst-off ensuring that no one is left behind in SAHSU's efforts to improve the public’s health. Childhood type 1 diabetes(T1D): re-admissions and co-morbidities: The results of these additional analyses hope to improve SAHSU's understanding of clinical presentation of Type 1 diabetes (T1D), the management of the disease, and associated co-morbidities, and how the wider environment might influence these, for example, by providing insight into the environmental and care factors which associate with T1D re-admission and/or co-morbidity. Air Pollution Mixtures -Tools for characterising multi-pollutant patterns of exposure for use in environmental health studies: Results are expected to provide further evidence on health effects of air pollution, including on metals exposures, which have been relatively little studied to date. The methodological component of the work aims to investigate whether looking at combinations of pollutants in this way gives better predictions of health risks than standard epidemiological techniques. Results may be relevant to air pollution regulation to protect public health and also provide information about environmental justice. Climate and climate change: In order to quantify the health impacts of climate change and the benefit of specific adaptation measures risk assessment models are required to consider how the effects of temperature on human health vary geographically and as a function of socio-demographic, environmental, and healthcare factors. These models can be used to assess how individuals and communities may adapt to climate change through modifying such environmental and healthcare determinants. Peer reviewed publications of the methods and results are expected to be the main outputs, the timeline depending on further funding being obtained. Analysis of HES inpatient data for Carbon Monoxide (CO) hospital admissions in England: Integration of information on population exposure and health effects aim to support an overall estimate of disease burden from CO in the national population, and support work on Environmental Public Health Tracking led by the UK Health Security Agency to help prevent CO poisoning cases. The outputs of the project are expected to be published in peer-reviewed journals during the course of the study and after completion. All SAHSU’s projects are aligned with the Terms of Reference of the SAHSU programme, which includes addressing environmental and health issues. All projects have been approved by the UKHSA Programme Board, which includes membership from the Department of Health and Social Care. In order to assist with standardising approaches across application processes, SAHSU have offered membership of the approving group to the Data Access Request Service at NHS England.

Benefits reported

Examples of how outputs from SAHSU’s studies are being used to inform health policy include: The results of SAHSU studies are placed in the public domain via conference presentations, reports and peer reviewed publications and are intended (and have been used) to inform decision making by public health and healthcare providers and to national public health policy-makers. Results of studies also are directly shared with relevant Policy Leads within UKHSA and other government departments. > The carbon monoxide project: This integration of information on population exposure and health effects provides an overall estimate of the disease burden from carbon monoxide in England. It supports work on Environmental Public Health Tracking led by Public Health England to prevent carbon monoxide poisoning cases. SAHSU have had 20 peer-reviewed publications in the last 2 years. Details of the research programme and outputs are published on the SAHSU website: (https://www.imperial.ac.uk/school-public-health/epidemiology-and-biostatistics/small-area-health-statistics-unit/our-research/). > Health Impact Assessment of air pollution on asthma in London: Commissioned by the Greater London Authority, this study estimated the impact of air pollution in London on asthma-related hospital admissions at current levels and if particulate matter levels were reduced to the WHO guidelines level. Their results have been widely used by the Mayor of London to support the introduction of the Ultra Low Emissions Zone (ULEZ) in London and provides the baseline for further assessments to evaluate the impact of the ULEZ. Results have the potential to further influence air pollution policy and regulatory practices in London and the UK. Example of the benefit of a completed study: In 2013, SAHSU launched a detailed web atlas with environment and health maps at the ward level across England and Wales. The open-access atlas allows researchers, policymakers and members of the public to study the geographical pattern of 14 diseases and conditions such as lung cancer, breast cancer, heart disease, leukaemia and low birth weight. Alongside this, it provides maps of geographical variations of selected environmental factors, such as air pollution, sunshine and pesticides. (http://www.envhealthatlas.co.uk/homepage/). > Health effects of large airports – the London Heathrow example (Heathrow): The results of this study allow for better understanding of the health problems caused by noise from aircraft in London. The findings had a high media-profile and were directly relevant to the Davies commission and decisions on whether to build a third run-way at Heathrow. Results of this study have been reported widely in local, national and international media and been raised as questions at Prime minister question. The Environment and Health Atlas for England and Wales application informs policy-makers and the public on the geographic patterns of disease and potential exposure to various pollutants and assist in developing hypotheses and research into the reasons for variability in disease risk that may relate to environmental exposures. It is essential reading for public health professionals and academics from within the field of public health, epidemiology, health geography and statistics. The results of SAHSU studies are placed in the public domain via peer-reviewed publications and presenting results at scientific meetings and conferences and are used to inform the behaviour of health care providers and to inform national public health policy. To reach relevant stakeholders, SAHSU puts out a press releases in collaboration with the Imperial College Press Office and holds press conference, where relevant (e.g. as part of the re launch of the SAHSU Environment and Health Atlas for England and Wales). All studies equally feedback their results into the relevant policy leads within PHE and PHE is informed of any outputs ahead of publication. In 2021, SAHSU collaborated with DISCOVER-NOW Health Data Research UK (HDR-UK) Hub for Real-world evidence synthesis to link modelled long-term air pollution exposure to participants in North West London Whole Systems Integrated Care record at the individual level based on residential postcode. This data will be used to study the impact of air pollution on health outcomes. SAHSU puts details of its research on its website (www.sahsu.org), including publications and outputs. Some examples of how outputs from SAHSU’s studies are being used to inform health policies: Examples of peer reviewed outputs produced in the last 2 years include: SAHSU’s report on the health impacts related to air pollution in London focusing on asthma and chronic obstructive pulmonary disease (http://erg.ic.ac.uk/Research/home/Health%20Impact%20Assessment%20Of%20Air%20Pollution%20On%20Asthma%20In%20London.pdf) was commissioned by the Greater London Authority and formed the baseline for the introduction of the Ultra-Low Emission Zone (ULEZ) in London in April 2019. A follow-up report, highlighting the impact of the ULEZ on health improvements was published in support of the expansion of the ULEZ in 2021 (https://www.imperial.ac.uk/media/imperial-college/medicine/sph/environmental-research-group/HIA-Asthma-Air-Pollution-in-London-with-new-cover[34].pdf). Roca-Barceló A, Helen Crabbe , Rebecca Ghosh R, Freni-Sterrantino A ,Fletcher T, Leonardi G, Hoge C , Hansell AL, Piel FB. Temporal trends and demographic risk factors for hospital admissions due to carbon monoxide poisoning in England. Preventative Medicine; Volume 136, July 2020, 106104. Result findings have been widely used by the Mayor of London to support the introduction of the Ultra-Low Emissions Zone (ULEZ) in London and provides the baseline for further assessments to evaluate the impact of the ULEZ. Results have the potential to further influence air pollution policy and regulatory practices in London. Implementation of clean air zones, similar to the Ultra-Low Emission Zone in London is currently being actively considered by several UK cities. However, the current evidence regarding the health impacts of such zones is still unclear. The outcomes of this study, with respect to clinically meaningful health benefits, are expected to evidence the effectiveness of large-scale, city-wide traffic emission control interventions. Sheehan A, Freni-Sterrantino A, Fecht D, Elliott P, Hodgson S. (2019). Childhood Type 1 Diabetes: an Environment Wide Association Study across England. Diabetologia. 2020 May;63(5):964-976. doi: 10.1007/s00125-020-05087-7. Epub 2020 Jan 24. Health Impact Assessment of air pollution on asthma in London (2) commissioned by the Greater London Authority: Roca-Barcelo A, Douglas P, Fecht D, Freni-Sterrantino A , Williams B , Blangiardo M , Gulliver J, Hayes ET, Hansell AL (2019). Risk of respiratory hospital admission associated with modelled concentrations of Aspergillus fumigatus from composting facilities in England. Environ Res. 2020 Apr;183:108949. doi: 10.1016/j.envres.2019.108949. Epub 2020 Jan 3. The report commissioned by the Greater London Authority (GLA) commissioned was also published: (https://www.imperial.ac.uk/school-public-health/environmental-research-group/research/air-pollution-epidemiology/air-pollution-and-asthma-in-london-2016-2019/) which resulted in the following:(https://www.imperial.ac.uk/news/234356/air-pollution-london-contributes-over-1700/) from Imperial College. Smith R, Beevers S, Gulliver J, Dajnak D, Fecht D, Blangiardo M, Douglass M, Hansell A, Anderson H, Kelly F, Toledano M (2020). Impact of air pollution and noise on risk or preterm birth and stillbirth in London: a retrospective population-based cohort study. Environ Int. 2020 Jan;134:105290. doi: 10.1016/j.envint.2019.105290. Epub 2019 Nov 26. The meta-analysis has informed the WHO EMAPEC project (https://www.who.int/activities/estimating-the-morbidity-from-air-pollution-and-its-economic-costs). Freni-Sterrantino A, Afoakwah P, Ghosh R, Smith RB, Hansell AL (2019). Birthweight centiles and small for gestational age (SGA) by sex and ethnicity for England and Wales. Archives of Childhood Diseases Published Online First: 13 June 2019. doi: 10.1136/archdischild-2018-316518 Health effects of aircraft noise: The results of the original study relating to Heathrow airport, (published in the BMJ in 2013), allow for a better understanding of the health problems caused by noise from aircraft in London. The findings had a high media-profile and were directly relevant to the Davies commission and decisions on whether to build a third runway at Heathrow. Results of this study were reported widely in local, national and international media and raised in parliamentary questions. Wang Y, Pirani M, Hansell AL, Richardson S, Blangiardo M, Using ecological propensity score to adjust for missing confounders in small area studies. Biostatistics. 2019 Jan 1;20(1):1-16. doi: 10.1093/biostatistics/kxx058. The long-term health effects linked to aircraft noise from Heathrow airport identified a link between noise from aircraft and cardiovascular disease and deaths. SAHSU result findings have informed policies and public health guidance on how to reduce health risk from noise exposure in the UK and beyond, including the 2018 WHO Environmental Noise Guidelines for the European Region and the debate around expansion plans at Heathrow Airport. Paper: https://www.bmj.com/content/347/bmj.f5432. Two follow-up studies on the transferability of results to other airports around the UK (ANCO) and short-term health effects from aircraft noise (RISTANCO) are currently under way. SAHSU also widely shares research outputs with members of the public via a wide range of public facing events. Events over the last 2 years include: Incinerators study: The study was commissioned to extend the evidence base and to provide further information to the public about any potential reproductive and infant health risks from municipal waste incinerators and to extend the evidence base with respect to exposures and any potential reproductive and infant health risks from municipal waste incinerators. Study information has been provided on the SAHSU website for the public. The outputs of the project have been published in peer-reviewed journals. >October 2019: Launch of air pollution in parks website - To coincide with the launch of their interactive website which lets people explore the air pollution levels in their local parks, SAHSU hosted a British Lung Foundation-funded public panel discussion on air pollution, which was attended by ~40 members of the public. SAHSU incinerator papers have been cited in the debate pack for the parliamentary debate on 11 Feb 2020: https://researchbriefings.files.parliament.uk/documents/CDP-2020-0029/CDP-2020-0029.pdf. > October 2019: New Scientist Live - The New Scientist Live attracts more than 40,000 people and SAHSU was represented as part of the HPRU in Health Impact of Environmental Hazards (https://live.newscientist.com/exhibitors/public-health-england/#/), alongside colleagues from PHE. We offered various activities around the theme of environmental epidemiology to identify the main environmental concerns of the public through a voting system and short online survey; and showcasing the interactive Environment and Health Atlas. SAHSU estimated that over 4 days they had 3,626 interactions with members of the public from a wide range of age groups. Parliamentary debate on Incinerators: > January 2019 – Anna Hansell, the former Assistant Director of SAHSU was interviewed about their findings on aircraft noise and health from the Heathrow study for a Japanese network. There were questions around general aspects of noise as well as how SAHSU accessed health data. This was aired on NHK which is a TV network in Japan. https://hansard.parliament.uk/commons/2020-02-11/debates/D1799344-3D26-4DF0-94C1-3AEB397AF375/WasteIncinerationFacilities. Public Involvement (PPI) SAHSU further involves members of the public throughout the research cycle. Examples of public engagement and involvement over the last 2 years include: > January 2021: SAHSU researchers run a focus group with members of the public to feed into the study design of a project looking at the health impacts of government strategies to meet its climate change target. > 2020: The MRC Centre in Environment and Health and the NIHR HPRUs in Health Impact of Environmental Hazards and Chemical and Radiation Threats and Hazards have established a Public and Community Oversight Group (PCOG) to provide public and stakeholder input into the research programme and activities of the Centre. SAHSU has had a key role in establishing this function (e.g. strategy development, role descriptions, recruitment, and terms of reference). In future meetings of the PCOG, SAHSU members with attend to present research projects for review and development. > November 2019: SAHSU hosted a table at a Public and Patient Involvement Café entitled “Using routinely collected data to investigate the impact of the environment on health” at the Imperial NIHR Biomedical Research Centre Open Day at Hammersmith Hospital. The focus was on SAHSU holding a set of Patient Identifiable Data (NHS Number, Date of Birth, Date of Death, Postcode and Address) without explicit consent from data subjects. After the researchers explained the necessity to why those patient identifiable data (PID) are essential for SASHU research programme, the public participants widely supported the work and SAHSU holding these data. > November 2019: At the same PPI Café, discussions on the perception of strategies proposed by the government to meet its net-zero carbon emissions target in 2050 to feed into the study design of a project identifying co-benefits of climate change policies. > July 2019: Public survey using VOICE platform (https://www.voice-global.org/opportunities/archived/which-environmental-hazards-most-concern-you/) - In response to the first PHE Challenge highlighted for the HPRU, SAHSU surveyed members of the public on the following and asked which environmental hazard they are most interested in hearing about. Outcomes for this consultation will inform SAHSU’s future research direction.

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Datasets: + COVID-19 General Practice Extraction Service (GPES) Data for Pandemic Planning and Research (GDPPR) · − HES-ID to MPS-ID HES Accident and Emergency

Objective for processing

This is an amendment to request more frequent HES APC, Critical Care and Emergency Care dataset to enable COVID-19 related studies. The purpose of this renewal is to extend Small Area Health Statistics Unit (SAHSU) at Imperial College Programme Level Agreement for a further 3 years and to request additional annual refresh of Hospital Episode Statistics (HES) data. The more regular data feed will support SHASU in their response to the Covid-19 pandemic. The Small Area Health Statistics Unit (SAHSU) is based within the Department of Epidemiology and Biostatistics at Imperial College London (ICL). SAHSU now form a core part of the MRC Centre for Environment and Health at ICL. As of 23rd March 2020 the UK public health response to the Covid-19 pandemic include school closures and social distancing measures, strongly recommended for people over 70 year, those with an underlying health condition or who are pregnant. In addition, the NHS is expanding critical care capacity to the maximum, freeing up at least 30,000 of the 100,000 general and acute beds and acquiring a further 8,000 beds from within the private sector. SAHSU was established in 1987 as a recommendation of the Black Inquiry into the incidence of leukemia and lymphoma in children and young adults near the Windscale/Sellafield nuclear power plant. SAHSU have a particular role nationally in carrying out environmental health surveillance of the population in relation to environmental contaminants and point sources of industrial pollution, based on routinely collected health data. This is a highly specialised area of work requiring excellence in computing, database management, Geographical Information Systems (GIS), statistics, environmental exposure assessment and epidemiology. The set of skills and expertise that has been established and built up in SAHSU being a unique resource both nationally and worldwide. SAHSU hold comprehensive sets of health, demographic, and a range of environmental data at high spatial resolution. The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there will be adverse consequences on non-COVID-19 morbidity and mortality. SAHSU aim to inform the UK public health and NHS response to this emergency by determining the spatio-temporal patterns in excess mortality and morbidity during the COVID-19 pandemic. SAHSU has a no-cost funding in place by the UK Health Security Agency (UKHSA)to contribute to public health in the UK. The Small Area Health Statistics Unit (SAHSU) is a long-standing and internationally-recognised centre of excellence assessing the risk of exposure to environmental pollutants to the health of the population, with an emphasis on the use and interpretation of routine health statistics at small-area level. SAHSU was established in 1987 as a recommendation of the Black enquiry into the incidence of leukaemia and lymphoma in children and young adults near the Windscale/Sellafield nuclear power plant. SAHSU has a particular role nationally in carrying out environmental health surveillance of the population in relation to environmental contaminants and point sources of industrial pollution, based on routinely collected health data. This is a highly specialised area of work requiring excellence in computing, database management, geographical information systems (GIS), statistics, environmental exposure assessment and epidemiology. The set of skills and expertise that has been established and built up in SAHSU is a unique resource both nationally and worldwide. Since its inception, SAHSU has been funded by the Government, initially by the Department of Health and since 2009 in collaboration with the Medical Research Council (MRC) as part of the MRC and Health Protection Agency (HPA) and latterly MRC-Public Health England (PHE) Centre for Environment and Health. This funding arrangement has been extended until 30 November 2022 to allow work to continue during the transition from PHE to UK Health Security Agency. SAHSU and UKHSA are currently developing a governance framework to replace the no-cost extension to the MRC-PHE programme grant. Most SAHSU studies are funded through peer-reviewed grants from research councils such as National Institute for Health Research (NIHR) Health Protection Research Units, the Medical Research Council, Health Data Research UK, Wellcome Trust and charities e.g., the Cystic Fibrosis Trust. SAHSU also has a no-cost funding extension in place with the UK Health Security Agency (UKHSA). SAHSU holds comprehensive computerised sets of health and demographic data and a range of environmental datasets at high spatial resolution. ICL is the sole Data Controller who also process the data under this Data Sharing Agreement (DSA) as they are solely responsible for determining the means and purpose of processing the data. Data processing and storage are limited to ICL only. UK Health Security Agency (UKHSA) continue to support SAHSU in managing the governance aspects of SAHSU’s programme of work. UKHSA do not have any decision-making responsibilities over the project initiations within SAHSU or have access to the data and are therefore not considered a Data Controller. SAHSU is funded by Public Health England (PHE) to contribute to public health in the UK. SAHSU has a programme of work established which is defined by the following terms of reference: - SAHSUs programme of studies are covered by the National Research Ethics (NRES) approval from the London-South East Research Ethics Committee - reference 22/LO/0256 and the Health Research Authority - Confidentiality Advisory Group (HRA-CAG) under section 251 of the National Health Service Act 2006 and the Health Service (Control of Patient Information) Regulations 2002 - HRA CAG reference: 20/CAG/0028. • Developing and maintaining databases of health data, environmental exposures as required to meet specific need, also of social confounding factors at a small-area level SAHSU undertake a programme of research, surveillance and cluster investigation that includes both methods development and investigation of priority questions in environment and health (including social, economic and demographic factors). SAHSU have a unique role to support the UK Health Security Agency (UKHSA) in their mission to protect the health and wellbeing of the population with respect to environment and health concerns. • Carrying out substantive research studies on environment and health issues SAHSU currently hold HES data in the form of Admitted Patient Care (APC), Critical Care (CC), Accident & Emergency (A&E), Emergency Care Data Set (ECDS), HES-linked mortality data and GPES data for pandemic planning and research (GDPPR). • Working in collaboration with other scientific groups, to build up reliable background information on the distribution of environmental exposure, socio-economic data and disease amongst small areas The additional data required are HES Admitted Patient Care (APC), HES Critical Care (CC), HES Emergency Care Data Set (ECDS) and HES-linked mortality (annual refreshes of 2021/22, 2022/23 and 2023/24) to allow SAHSU to continue their on-going programme of work. • Acting as a centre of expertise, disseminating information on developments in spatial epidemiological methods to regional, national and international groups Justification for requesting the data: • Responding rapidly, with expert advice, to ad hoc queries from the core funding bodies (Department of Health and Public Health England) about unusual clusters of disease, particularly in the neighbourhood of industrial installations SAHSU have a programme of work agreed with the UK Health Security Agency (UKHSA), which is defined by the following terms of reference: To deliver against the Terms of Reference, SAHSU utilises the research database to meet the following purposes: 1) To develop and maintain databases of health data, environmental exposures as required to meet a specific need, and social confounding factors at the small area level Purpose 1 - Maintenance of the SAHSU health research database 2) To carry out substantive research studies on environment and health issues including studies of the relationship between socio-economic factors and health, in collaboration with other scientific groups as necessary At the core of the overall programme of work is the maintenance of the SAHSU research database, which combines multiple datasets and has both ethics and s251 approvals in place. A particular strength is the maintenance of historic data, which allows SAHSU to examine long term trends and use of data at high spatial resolution (address and postcode), which are crucial for studies of environmental exposures determined by spatial location e.g. electromagnetic field exposure arising from proximity to an overhead power line. 3) In collaboration with other scientific groups, to build up reliable background information on the distribution of environmental exposure, socio-economic data and disease amongst small areas Purpose 2 - To carry out a programme of research projects and studies 4) To develop methodologies for analysing and interpreting health outcomes related to small areas The research programme includes both methods development and investigation of priority questions in environment and health. A key aim is to improve the science base underlying translation of knowledge on the effects of the environment on health into policy. SAHSU conducts national research studies on environmental factors that may affect health ranging from exposures to e.g. electromagnetic fields (such as from mobile phone base stations), traffic-related air pollution, road and aircraft noise, water contaminants, waste disposal, using nationally collected patient data including mortality, hospital admissions, cancer registrations and births data. Additional small-area analyses are conducted that help support the general remit of the unit e.g. investigating differential hospital admission rates in ethnically diverse neighbourhoods. SAHSU provides national expertise in cluster detection and small-area statistical methods and has close links with Public Health England including input into their environmental public health tracking programme and surveillance activities. 5) To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups Purpose 3 - To build up reliable background information on the distribution of environmental exposures, socioeconomic data and disease amongst small areas 6) To respond rapidly, with expert advice, to ad hoc queries from the core funding bodies about unusual clusters of disease, particularly in the neighbourhood of industrial installations SAHSU have developed an extensive collection of environmental exposure data e.g. air pollution, magnetic fields, environmental noise, that SAHSU hold at high spatial resolution, together with geographically-referenced health data as needed in approved studies - all SAHSU studies are controlled via the PHE-SAHSU Liaison Committee. An example of this work is the Environment and Health Atlas for England and Wales, which included 14 conditions (nine cancers) at small area level (website http://www.envhealthatlas.co.uk/homepage/ and OUP book: Hansell AL, Beale LA, Ghosh RE, Fortunato L, Fecht D, Järup L, Elliott P. The Environment and Health Atlas for England and Wales. Oxford University Press, April 2014, Oxford, UK.). To deliver against these Terms of Reference, SAHSU utilise the research database to meet the following purposes: Purpose 4 - To develop methodology for analysing and interpreting health outcomes related to small areas Purpose 1 - Maintenance of the SAHSU health research database: Some of SAHSU's studies are methodological, relating to for example, statistical uncertainty in observed health risks in areas relating to choice of spatial boundaries or uncertainties in the population estimates; development of methods to detect clusters of disease in time and space (surveillance); development of methods to better adjust for lifestyle factors in health risk analyses by using risk scores constructed at area-level from cohort datasets and surveys in analyses of hospital admissions and mortality. At the core of the overall programme of work is the maintenance of the SAHSU research database. A particular strength is the maintenance of historic data, which allows us to examine long term trends and use of data at high spatial resolution (postcode and address), which are crucial for studies of environmental exposures determined by spatial location e.g., electromagnetic field exposure arising from proximity to an overhead power line. Purpose 5 - To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups Purpose 2 - To carry out a programme of research projects and studies: SAHSU participate in national and international scientific meetings and provide training to PHE and internationally including to the US Centers for Disease Control (CDC) in use of small area analysis for public health purposes. SAHSU use aggregate non-disclosive data in outputs, presentations and training. The research programme includes both methods, development and investigation of priority questions in environment and health. A key aim is to improve the science base underlying translation of knowledge on the effects of the environment on health into policy. SAHSU conduct national research studies on environmental factors that may affect health ranging from exposures to electromagnetic fields to traffic-related air pollution and road and aircraft noise, using nationally collected patient data including mortality, hospital admissions, cancer registrations and births data. Additional small area analyses are conducted that help support the general remit of the unit e.g., investigating differential hospital admission rates in ethnically diverse neighbourhoods. SAHSU provide national expertise in clusters and small area statistical methods and has close links with the UK Health Security Agency including input into their environmental public health tracking programme and surveillance activities. Purpose 6 - To provide rapid ad hoc support to PHE and DH about unusual clusters of disease, particularly in the neighbourhood of industrial installations Purpose 3 - To build up reliable background information on the distribution of environmental exposure, socio-economic data and disease amongst small areas: Such work is carried out on the instruction of Department of Health or Public Health England, and is approved by the Director of SAHSU. By its nature, such requirements cannot be detailed in advance, but the only outputs would be aggregate with small numbers suppressed, and provided to DH and PHE. In all cases data are either extracted using the Rapid Enquiry Facility (RIF) - see below - or by the database team, and all extracts are supervised by the database manager. SAHSU have developed an extensive collection of environmental exposure data including air pollution, electromagnetic fields, traffic noise and industrial installations that we hold at high spatial resolution (e.g., less than 100m resolution). This is linked to pseudonymised health data extracts as needed in approved studies - all SAHSU studies are controlled via the UKSHA-SAHSU Liaison Committee [a]. The Rapid Enquiry Facility (RIF) is an automated software tool that uses both database and Geographic Information System (GIS) technologies to rapidly address epidemiological and public health questions using routinely collected health and population data. This allows SAHSU to respond rapidly, with expert advice to ad hoc queries from the funding departments about unusual clusters of disease, particularly in the neighbourhood of industrial installations. The RIF can perform risk analysis around putative hazardous sources and can be used for disease mapping. It generates standardised rates and relative risks for any given health outcome, for specified age and year ranges, for any given geographical area. This facility was initially designed as a tool for SAHSU staff to analyse routinely collected health data in relation to environmental exposures. The software has general public health utility and was further developed as part of the European Health and Environment Information System (EUROHEIS) project and as part of the US Centers for Disease Control (CDC) environmental public health tracking programme. Purpose 4 - To develop methodologies for analysing and interpreting health outcomes related to small areas: A newer version of the Rapid Enquiry Facility (RIF) software is currently being re-developed. This version will allow SAHSU to test on various scenarios to help detect clusters or increased rates of disease near industrial installations. As a result of the RIF software being re-developed, SAHSU have been doing less on this function (due to less capacity/resources available) but SAHSU are expecting to be doing more in the near future. For SAHSU's use, the RIF software will sit on the air-gapped 'Private Network'. Some of SAHSU’s studies are methodological, relating to - for example, statistical uncertainty in observed health risks in areas relating to choice of spatial boundaries or uncertainties in the population estimates; development of methods to detect clusters of disease in time and space (surveillance); development of methods to better adjust for lifestyle factors in health risk analyses by using risk scores constructed at area-level from cohort datasets and surveys in our analyses of hospital admissions and mortality. As an example of the most recent request SAHSU have just responded to a request from the Committee on the Medical Aspects of Radiation in the Environment (COMARE) to use the RIF to provide ongoing surveillance of cancer around nuclear power stations using cancer registrations. Purpose 5 - To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups: SAHSU’s Welcome Trust seed award on “Public health surveillance of chronic diseases: suitability of spatio-temporal methods” will be testing capacity of HES data to look at clusters and appropriate statistical methods to use which may vary by disease type. SAHSU participate in national and international scientific meetings and provide training to the UK Health Security Agency (UKHSA) and internationally including to the US Centers for Disease Control (CDC) in the use of small area analysis for public health purposes. SAHSU use aggregate non-disclosive data i.e., small numbers supressed in outputs, presentations and training. Approval of individual projects Purpose 6 - To provide rapid ad-hoc support to the UK Health Security Agency (UKHSA) and the Department of Health and Social Care (DHSC) about unusual clusters of disease, particularly in the neighbourhood of industrial installations: Such work is carried out on the instruction of the DHSC or UKHSA and approved by the Director of SAHSU. By its nature, such requirements cannot be detailed in advance, but the only outputs provided to DHSC and UKSHA would be aggregated with small numbers suppressed. PHE’s representation on the PHE-SAHSU Liaison Committee is to provide oversight of the use of the PHE funding ensuring that it is being used within the remit of the funding agreement. Most SAHSU studies are funded through peer-reviewed grants from research councils such as UKRI, NIHR and the Wellcome Trust and other charities e.g. the Cystic Fibrosis Trust. Even though, PHE provides the core infrastructure funding for SAHSU, they do not have any decision making responsibilities over the project initiations within the SAHSU unit. SAHSU have developed the Rapid Inquiry Facility (RIF) which is an automated software tool that uses both a database and Geographic Information System (GIS) technologies to rapidly address epidemiological and public health questions using routinely collected health and population data. This allows SAHSU to respond rapidly, with expert advice to ad hoc queries from the funding departments about unusual clusters of disease, particularly in the neighbourhood of industrial installations. The RIF can perform risk analysis around putative hazardous sources and can be used for disease mapping. It generates standardised rates and relative risks for any given health outcome, for specified age and year ranges, for any given geographical area. This facility was initially designed as a tool for SAHSU staff to analyse routinely collected health data in relation to environmental exposures. The software has public health utility and was further developed as part of the European Health and Environment Information System project and as part of the US Centers for Disease Control environmental public health tracking programme. For use within SAHSU, the RIF software will sit within the SAHSU Secure Research System facility. Project/study initiations are done by researchers within SAHSU. All new studies using SAHSU data must be approved as a ‘SAHSU-study’. To do so, researchers have to provide a project outline detailing the project rational, its relevance to patients and the public (i.e. health and/or social care) and which data will be required. The study can then be approved by either the Director or Assistant Director of SAHSU under consideration of SAHSU’s overall programme terms of reference and whether the study is adequately covered by SAHSU’s existing ethical approval and if not, separate ethical approval must be sought. SASHU currently hold a limited set of confidential/sensitive patient information: date of birth, date of death, address, postcode, NHS number. Confidential/sensitive patient information is only accessible to the database team. Researchers only have access to minimised and de-identified data. Dates of birth and death are required for temporal analysis. They are only used by the database team to link to temporal exposure data and researchers receive age in month/years. Postcodes are used for geospatial data linkage across environmental, administrative geographies and socio-economic datasets. NHS numbers are used for linkage; either within datasets or between datasets. For linkage between datasets further approvals are required from NRES, HRA CAG and data providers. Once approved internally, the project will be introduced to PHE via the PHE-SAHSU Liaison Committee which will provide confirmation that the project falls within the PHE-SAHSU funding remit and will then be forwarded to get formal minuted approval from the appropriate PHE programme board attended by a member of the Department of Health (e.g. Environmental Hazard Board). SAHSU request national data to provide any ad-hoc rapid response required by UKHSA. Given that UKHSA coverage is across England, and the requirements cannot be predicted in advance, national data is required given that response times do not permit time to request, receive and process individual extracts of data. SAHSU have a single s251 support in place to cover the above. Any project which may have additional requirements (for example to require the linkage of an additional dataset beyond that previously agreed) must seek an amendment to the existing s251 and ethics approvals. It would also be outside the scope of this application, and therefore an amendment would be put before NHS Digital for consideration. Historical data is also essential to enable SAHSU to obtain longitudinal data on prior admissions for patients for example to identify a patient’s first admission for a particular diagnosis. Access to historic data has enabled SAHSU to examine long term trends and use of data at high spatial resolution (postcode), which are crucial for studies of environmental exposures determined by spatial location e.g., electromagnetic field exposure arising from proximity to an overhead power line. Risk modelling also requires access to data items on prior patients’ admissions including previously recorded co-morbidities. This data request justification for a national dataset is based on the following core (PHE funded) infrastructure work, the Rapid Inquiry Facility (RIF) and for Surveillance Methodology based projects. [a] UKHSA's representation on the UKHSA-SAHSU Liaison Committee is to provide oversight in managing the governance aspects of the SAHSU database and the research infrastructure ensuring studies falls within the remit of the agreed terms of references. The UKHSA-SAHSU Liaison Committee that has a Terms of Reference document describing the purpose, scope, membership and authority of the committee. Specifically, proposed SAHSU projects are approved by the SAHSU Director or Deputy Director, presented to the UKHSA-SAHSU Liaison Committee for minuted approval and subsequently ratified by the UKHSA Environmental Public Health Programme Board, attended by a member of the DHSC, via minuted approval. Approval is subject to the research or surveillance being needed to support the public health function of UKHSA or the devolved administrations and falling within SAHSU’s agreed remit. Approved studies are then adopted onto the SAHSU portfolio. The UKHSA-SAHSU Liaison Committee meeting is held twice a year and chaired by UKHSA. These meetings inform UKHSA, DHSC, stakeholders from public health bodies in the devolved administrations (Public Heath Wales, Welsh Government, Welsh Cancer Intelligence and Surveillance unit, Health Protection Scotland, Scottish Government, Northern Ireland Government) and data providers (including NHS Digital, Office for National Statistics) of SAHSU’s work programme and support SAHSU’s governance requirements. The RIF study facilitates spatial epidemiological analyses, relating spatial and non-spatial data. Two types of analysis can be carried out with the RIF: risk analysis around putative hazardous sources and disease mapping. The RIF calculates and can map rates and relative risks either by distance around one or more selected point, line or area sources, or groups of areas defined by exposure levels. Previous versions of the RIF have been widely disseminated, and used by public health departments in the USA, Canada and Europe. The RIF is currently being redeveloped and v4.0 will be freely available for application in any public health setting and with particular usefulness in initial epidemiological investigations of potential clusters of disease, in relation to environmental contamination such as around industrial sites, and disease surveillance. SAHSU are working with Public Health England and CDC re testing, refining the software and implementation. The lawful basis for processing data under GDPR has been reviewed and been assessed as acceptable. Imperial College London process data under Article 6(1)(e): "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller" as they are a public Authority. The Data Protection Act 2018 s7(1) (a) defines 'public bodies' for the purpose of the GDPR as "a public authority as defined by the Freedom of Information Act 2000". The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means anybody which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists "Maintained schools and further and higher education institutions" as public authorities. SAHSU surveillance methodology work includes the development of space-time clusters methods suitable for surveillance of all cancers at small area-level. As part of this development SAHSU would look at space-time clusters at small-area level of not only single cancers, but cancers that might be plausibly linked to specific environmental exposures, such as smoking-related cancers and endocrine disruptor-related cancers. For example, SAHSU are just piloting a study to evaluate the potential of machine learning methods for application to high-dimensional administrative health data and to apply this to the SAHSU datasets. SAHSU have a Non-Communicable Disease Surveillance study funded by the Wellcome Trust to investigate use of hospital data for non-communicable disease surveillance SAHSU has a particular role nationally in carrying out environmental health surveillance of the population in relation to environmental contaminants and point sources of industrial pollution, based on routinely collected health data. Having national data will enable SAHSU to provide the ad-hoc rapid response to Public Health England. Given that PHE coverage is across England, and the requirements cannot be predicted in advance, national data is required given that response times do not permit time to request, receive and process individual extracts of data. Historical data is also essential for all projects to enable SAHSU to obtain longitudinal data on prior admissions for patients. The lawful basis for processing data under GDPR has been reviewed and been assessed as acceptable. Imperial College London process data under Article 6(1)(e): "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller" as they are a public Authority. The Data Protection Act 2018 s7(1)(a) defines ‘public bodies’ for the purpose of the GDPR as “a public authority as defined by the Freedom of Information Act 2000”. The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means any body which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists “Maintained schools and further and higher education institutions” as public authorities. Imperial College London is an independent corporation whose legal status derives from a Royal Charter granted under Letters Patent in 1907. In 2007 a Supplemental Charter and Statutes was granted by HM Queen Elizabeth II. This Supplemental Charter, which came into force on the date of the College's Centenary, 8th July 2007, established the College as a University with the name and style of "The Imperial College of Science, Technology and Medicine". Statistical research is stated as a reserved area of business in the Imperial College of Science, Technology and Medicine CHARTER AND STATUTES 2007. [1 paragraph unchanged]

Processing activities

SAHSU currently holds - and continues to obtain - HES data in the form of Admitted Patient Care (APC), Critical Care (CC), Accident & Emergency (A&E), Emergency Care Data Set (ECDS) as well as Civil Registration mortality data which includes identifiable data (NHS Number, Home address and Date of Birth) under this agreement. This ******This is an amendment to request more frequent HES APC, Critical Care the addition of GPES data for pandemic planning and Emergency Care Data Set (ECDS) linked research (GDPPR) data set to Civil Registrations (Deaths) data the agreement to enable SAHSU to undertake COVID-19 related studies. **** SAHSU is currently planning to move its processing and storage location from St Mary's campus to the Imperial college ICSNPD environment which is based at Virtus datacentres. The new location has been added. In the previous iterations of this agreement, the data recipient needed to be physically present in their office on Imperial College London (ICL) St Mary’s Campus to download/ upload the NHS Digital data extract files from the NHS Digital’s Secure Electronic File Transfer (SEFT) system to the server (located in the same building on St Mary’s Campus) within the Private network i.e. Secure Research Systems environment (SSRS). Data extracts are downloaded from the NHS Digital’s SEFT System and copied to an encrypted USB drive and immediately transferred to Secure Research Systems environment (SSRS). SAHSU has extensive mechanisms in place to secure the health data including a robust information governance framework, privacy-enhancing technologies and physical security measures. The move of ICL’s SSRS to the Virtus Data centre happened during the lockdown restriction period in May 2020. However, the ICL Security Manager looked at the NHS Digital requirements and considered that an improvement in the transfer process could be made. Instead of the data recipient coming in and using an ICL secure PC onto a hardware encrypted drive (USB) with a hardware PIN , they could connect remotely and securely to a server specifically designed for secure data transfers via a secure ICL remote device. Data are loaded to an Oracle Database with Advanced Security implemented. This allows us to protect data at the source using Transparent Data Encryption (TDE) by enforcing data-at-rest encryption in the database layer which prevent unauthorised access from bypassing the database and reading sensitive information directly from storage. After the data are encrypted, data are transparently decrypted for authorised users when they access the data. ORACLE Transparent Data Encryption (TDE) helps protect data stored on media (also called data at rest) in the event that the storage media or data file is stolen. To prevent unauthorised decryption, TDE stores the encryption keys in a security module external to the database, called a keystore - a built-in encryption key management that eliminates the complex task of managing and securing encryption keys. NEW DATA DOWNLOAD METHODOLOGY Only 3 members of the database team have access to the Oracle database which holds patient-identifiable and sensitive data. Data loading, cleaning, validations, derivations, and any authorised data linkage are performed by the database team. The data recipient logs into a secure transfer server within ICL via pulse secure VPN from their ICL owned secure workstation which they use solely to connect to the Secure Enclave and the SSRS. This secure transfer server has all outgoing connections blocked apart from approved data providers transfer service. The data recipient then downloads the NHS Digital data extract files from SEFT direct to the enclave file transfer gateway to be collected from the SAHSU database server. The data recipient then connects to the SAHSU database server and moves the NHS Digital data extract files into the SAHSU Identifiable Enclave which holds the SSRS Database Server (Oracle Database[a]). No copies of files are kept during the transfer process and ICL uses a “shred” program to securely delete data in line with NHS Digital requirements. A USB drive (or any other removable storage device) is no longer used for data transfers. All data extracts performed by the database team are all logged and cross checked by the database manager prior to extraction. No record-level identifiable or pseudonymised data is downloaded from the SSRS. Data manipulation of patient identifiable data is conducted within the SAHSU Identifiable enclave (as in Data flow) Database server only. Extractions of data from the SAHSU database are taken based on specifications provided by the researchers according to their study protocols. An extract is taken from the NHS Digital data in the database which may require linkage to geographic or environmental exposure data as per the study specification. The study extract is then pseudonymised - in case future linkage to more environmental exposure data may be required at a later stage or anonymised depending on the requirement of the study once the linkage has been performed by the database team. The database team copies the pseudonymised/anonymised data extract to the File Server - study folder which sits within the SSRS Minimised de-identified enclave to which the researcher is given access to via their VM Statistical server. Researchers do not have access to the ORACLE database server which is located within the SSRS “Identifiable Enclave” (refer to Data flow diagram). The researchers access and analyse the data from the File server project folder within the SSRS Minimised enclave. Individual level data are not allowed to be taken from the SSRS. Research Findings/aggregate data with small number suppression can be taken out of the SSRS for publications. This new and improved data transfer methodology is now in use and the current lockdown data download process is that the data recipient logs into a secure transfer server within Imperial College London via pulse secure VPN (that checks on the status of the client’s workstation patches and anti-virus software) from a secure dedicated ICL owned remote device. This secure transfer server has all outgoing connections blocked apart from approved data providers' transfer service. The data recipient then downloads the NHS Digital files from SEFT direct to the enclave [b] file transfer gateway to be collected from the SAHSU database server. No copies of files are kept during the transfer process and they use the “shred” program to securely delete data in line with NHS Digital requirements. The method for downloading data from SEFT using a remote device will cease once the lockdown restrictions are over and authorisation for home working is no longer allowed. [b] The Secure Enclaves are trusted research environments within ICL which are isolated from the “internet” and most ICL services (such as email, network drives). All communication into and out of the SSRS network is via gateways. These gateways control and monitor access to servers and file transfers. It is for this reason that the data recipient cannot connect directly to the SEFT server from a SSRS server. The gateways are not public facing, they can only be accessed by approved workstations within the college or remote clients with pulse VPN running. It was built and is controlled by the ICL Security Manager and is a Linux windows server running samba shares. It is dedicated to the Secure Enclaves. As well as recording the data transfers, it keeps copies of all files transferred (except raw data downloaded from data providers) so they can be audited for IG compliance with data sharing agreements and GDPR requirements. The study team data recipient will revert to only allowing approved workstations within Imperial College to access the transfer gateway. [a] Data are loaded to an Oracle Database with Advanced Security implemented. This allows us to protect data at the source using Transparent Data Encryption (TDE) by enforcing data-at-rest encryption in the database layer which prevent unauthorised access from bypassing the database and reading sensitive information directly from storage. After the data are encrypted, data are transparently decrypted for authorised users when they access the data. ORACLE Transparent Data Encryption (TDE) helps protect data stored on media (also called data at rest) in the event that the storage media or data file (i.e. the SAHSU Database and disk arrays) is stolen. To prevent unauthorised decryption, TDE stores the encryption keys in a security module external to the database, called a keystore - a built-in encryption key management that eliminates the complex task of managing and securing encryption keys. Only members of the database team have access to the Oracle database which holds patient-identifiable and sensitive data. Data loading, cleaning, validations, derivations, and any authorised data linkage are performed by the database team. All extractions of data from the SAHSU database performed by the database team are all logged and cross checked by the database manager prior to extraction. *** [2 paragraphs unchanged] 2. User is under contract with Imperial College; College London; [1 paragraph unchanged] to be strongly justified; to be necessary for the purpose required; 4. SAHSU confidentiality form Acceptable Use Policy and Agreement has been signed; and the user has undertaken mandatory [2 paragraphs unchanged] Researchers/statisticians/PHD students do not have access to patient identifiable data and can only request pseudonymised extracts. No record level will be transferred outside of England and Wales under this agreement, and is only processed and stored at the addresses given within this application and data provided under this agreement will not be shared with any third party. No record level will be transferred outside of the EEA under this agreement, and is only processed and stored at the addresses given within this application and data provided under this agreement will not be shared with any third party. [4 paragraphs unchanged] • British Isles Network of Congenital Anomaly Registers • Previously NHS Numbers for Babies (NN4B) which is now Births Registration data • Scottish births, mortality and congenital anomalies • National Pupil Database • NN4B now Civil Registration - Birth data [2 paragraphs unchanged] • Approval via a substantial amendment from HRA CAG Health Regulation Authority Confidentiality Advisory Board (HRA CAG) [1 paragraph unchanged] To date, amendments to the s251 support have been sought and granted for the following three projects requiring specific data linkage: *** GDPPR data - No linkage will be undertaken with the other health datasets SAHSU currently hold in their database (listed above). *** To date, amendments to the section 251 support have been sought and granted for the following three projects requiring specific data linkage: [3 paragraphs unchanged] Any projects requiring linkage beyond that covered by this application would also [13 words unchanged] support from ethics, and be covered by an amendment to the current s251 section 251 approval [2 paragraphs unchanged] Staff accessing the record level data are substantive employees of Imperial College London or PHd registered students (including PhD and Masters students) who have signed a legally binding data access contract (in place of a substantive contracts in place. employment contract) which has been approved for use by NHS Digital. Any other individual on a honorary contract will only be accessing data which has been aggregated with small numbers suppressed. suppressed as per the HES analysis guide. All PhD students have substantive contracts in place with Imperial College London. All registered students (including PhD and Masters students) are additionally required to sign the Imperial College London (ICL) Terms and Conditions as part of their registration and enrolment process at the start of their course, the Facility of Medicine Code of Practice for Handling of health and social care research data, and the Secure Research Systems (SSRS) Acceptable Use Policy and Agreement. In addition, all students and substantive staff members undertake regular Data Protection training. [7 paragraphs unchanged] ****GDPPR Disclosure Controls / Suppression Rules Whilst there are no specific GDPPR disclosure controls, outputs for public consumption should follow the Government (ONS) Statistical Service disclosure controls.  NHS Digital recommend that users review and follow the disclosure control guidelines as set out within the HES Analysis Guide. Some, but not all requirements are outlined below: Disclosure control only needs to be applied to values relating to individuals. No rounding or suppression is required for values not relating to individuals, such as a count of providers. No small number suppression is required for national totals. For any sub national geographies e.g. NHS Commissioning Region / Government Office Region or smaller, then the following apply: • Zeroes can be shown. • Values between 1-7 to be displayed as “*”. • Any other numbers rounded to nearest 5. • Percentages calculated from rounded values ****

Expected output

[1 paragraph unchanged] Below are some of SAHSU’s studies which require HES and Civil Registration/Mortality Data: SAHSU research findings are fed back to relevant policy leads within PHE and other government departments and used to consider population health risks and to inform national public health policy. The study finding using the GDPPR data will be in the public interest and will benefit the health and social care as it will provide information about COVID-19 populations with worse prognosis and will highlight the importance of the existing air pollution regulations. Disease clustering: Below are some examples of SAHSU’s studies which require HES and Civil Registration/Mortality Data: **** NEW for Version 4 > Public Health Impacts of Clean Air Zones In 2021, SAHSU have commenced a programme of work, funded by a five-year MRC programme grant, to determine the impact of the London Ultra Low Emission Zone (ULEZ) on air quality, the composition of pollutants, health, health inequalities and multi-morbidities across the life-course. The ULEZ is a large-scale public health intervention targeting urban air pollution, principally from primary traffic emissions. It operates in the London Congestion Charge area and vehicles must either meet emission standards or pay a daily charge to drive within the area. Globally, air pollution is the leading environmental risk factor for mortality. A previous SAHSU collaboration on a health impact assessment estimated the 2010 mortality burden from PM2.5 and nitrogen dioxide (NO2) in London was approximately 141,000 life-years lost. The ULEZ is a large scale public health intervention and it is essential to evaluate its effectiveness in delivering the expected impacts on air quality and health. SAHSU are planning (with appropriate approvals) to use HES and civil registration data during the period of this DSA, to study the health outcomes in people within and outside the ULEZ (and pre/post implementation) to provide evidence to Public Health England, the Greater London authority, Local Authorities and other public health organisations to inform air pollution strategy including clean air zones. > COVID-19 research SAHSU is undertaking a programme of studies that apply spatio-temporal methodologies [a] to understand the role of the environment in vulnerability and resilience to the health impacts of the COVID-19 pandemic. SAHSU has published an analysis of the community factors associated with excess mortality during the first wave of the pandemic in England, and is currently working on a cross-country comparison of excess mortality that will generate hypotheses about the different national responses to the pandemic and will be of importance and relevance to public health policy in England. The GDPPR data and mortality data from NHS Digital will be used in a forthcoming study of the role of co-morbidities in the observed associations between COVID-19 mortality and air pollution. The findings of this work hope to be significant to the formation of air pollution policy. [a] Data has both a spatial and a temporal context, i.e. everything happens someplace and occurs at some point in time and this analysis can define neighbour relationships by analysing both spatial and temporal aspects of data. This provides a richer context. > Vulnerability to Climate Change: Inequalities in exposure, susceptibility and adaptation capacity in two metropolises The overall aim of this PHD study is to characterize the vulnerability to temperature changes of the citizens of Sao Paulo (Brazil), London and Greater Manchester (United Kingdom), from the perspective of their exposure, sensitivity and adaptation capacity, and to quantify the impact of these vulnerabilities on the temperature-related mortality and morbidity (i.e. hospital admission and A&E data) association, for all-cause and specific outcomes using data between 1990 and 2020 (when available). > Understanding effect modifiers of the relationship between health and exposure to urban green and blue space Despite a body of evidence linking green and blue space exposure to physical health benefits, specific effect modifiers of this association are currently understudied or unknown. The aim of this PhD project is to identify and assess important factors that might act as modifiers of the relationship between urban green/blue space and health. > A natural experiment of the Western Extension to the London Congestion Zone This project will use data on air pollution concentrations and hospital admissions between 2003 and 2014. Air pollution data (nitrogen dioxide and particulate matter) will be linked to residential addresses. This will allow SAHSU to examine exposure to air pollution before, during and after the implementation of the Western Extension Zone. SAHSU will assess all hospital admissions, and admissions for all respiratory and all cardiovascular diseases separately. These will be combined with population data to examine hospitalisation rates. SASHU hope to have one intervention group of the residents compared with two other groups: one from just outside the area and another similar in terms of deprivation. > Asthma admissions and grass pollen counts, levels and potency in London and its surroundings Airborne outdoor pollen is a major cause of asthma hospital admissions. Current exposure assessment methods rely primarily on daily changes in the number of airborne pollen counts and thus do not capture changes in the true biological allergenic potential of the air (i.e. allergen levels). Using unique pollen data available in London, this project will test the hypotheses that asthma hospitalizations increase with increasing airborne allergen levels, and that this association is underestimated by current exposure assessment methods based only on pollen counts. > Geographic inequalities in AMI case-fatality in hospitalised patients in England: the role of multi-morbidity The overall aim is to understand patterns of multi-morbidity in hospitalised AMI patients and their role in AMI mortality, nationally and sub-nationally. > Pathways to equitable health cities This project aims to understand the impacts of planning and policy actions on population health and on health inequalities, focusing on cities in five countries (Bangladesh, Canada, China, Ghana and the UK). SASHU hope to capture spatial inequalities in health focusing on mortality, hospitalisation, cancer incidence and birth outcomes (prematurity and birth weight) using methods from spatial and spatio-temporal statistics. SASHU hope to also use environmental epidemiological models to simulate how specific actions related to housing, neighbourhood design, transportation, sanitation, water and safety and health services impact population health, which will help inform planning and policy decisions. Their work is in close collaboration with the PHE. **** > Disease clustering [1 paragraph unchanged] Cardiovascular >Cardiovascular health effects of aircraft noise exposure: exposure [1 paragraph unchanged] > Small area variation in Ischemic heart disease incidence, mortality and survival and their risk factors and determinants in England: England [1 paragraph unchanged] HES data and Civil Registration/Mortality data have the advantage of providing almost complete national coverage of England - allowing for robust conclusions about regional variation which are not limited [91 words unchanged] strategy can potentially be applied to any cause of morbidity and mortality. [2 paragraphs unchanged] > Cystic fibrosis project: This project is funded jointly by the UK Cystic Fibrosis (CF) Trust and the MRC Doctoral Training Programme at Imperial College London. It includes two PhD registered degree-level studentships for a duration of 3.5 years. The research projects will focus [121 words unchanged] reports, while HES will provide a more precise encounter-based source of information. > Carbon monoxide project: [1 paragraph unchanged] Non-communicable disease surveillance project: This project is funded by a Wellcome Trust Seed Award for 2 years to look at spatio-tempotal methods for non communicable disease surveillance. The primary aim of the project is to investigate the neglected area of non communicable disease (NCDs) surveillance. The primary focus is to complement the work already done on integrated surveillance of infectious disease, including by Public Health England (PHE), to develop improved methods to quickly and reliably identify spatio-temporal signals in NCD data (e.g., ‘clusters’ peaks or unusual trends). Surveillance of NCDs usually focuses on use of a specific method for a given condition rather than on the development of a generic approach that would detect signals due to underlying risk factors as well as shifts in epidemiology, demography or treatment, for a wide range of NCDs. HES represents an information-rich real-world dataset to assess the impact of completeness (e.g. opt outs), quality (e.g. case assignment bias) and consistency (e.g. change from ICD 10 to ICD 11 due in 2018), as well as methodological choices for spatio-temporal surveillance systems of NCDs. SAHSU holds postcoded high-resolution HES data updated monthly/annually forming a comprehensive research database of hospitalisations across England. Linking HES with Civil Registration/Mortality data will allow SAHSU to assess whether the signals detected in HES are linked to excess mortality in Civil Registration data, which will be a very important public health aspect of this project. [5 paragraphs unchanged] Examples of outputs produced to date Future outputs from the study hope to be disseminated via peer reviewed publication and academic conferences presentations. -Traffic pollution and health in London study All outputs from individual projects will aggregated with small numbers suppressed in line with the HES Analysis Guide. To confirm, no record level data is provided to any third party organisation and no commercial use is permitted. Recent papers published include: •Halonen, JI et al. Road traffic noise is associated with increased cardiovascular morbidity and mortality and all-cause mortality in London. European Heart Journal 2015. •Gulliver, J et al. Development of an open-source road traffic noise model for exposure assessment. Environmental Modelling & Software. 2015. •Halonen JI et al. Is long -term exposure to traffic pollution associated with mortality? A spatial analysis in London. Environmental Pollution. 2015. Future outputs from the study will be disseminated via peer reviewed publication and academic conferences presentations. The outputs of the project will be published in peer-reviewed journals during the course of the study and after completion, which was expected by 2017 but will now be in 2018. -Possible reproductive and other health effects associated with Municipal Waste Incinerators (MWIs) in England, Wales and Scotland (incinerators) There have been three papers published to date arising from work on this study: •Font A et al. Using Metal Ratios to Detect Emissions from Municipal Waste Incinerators in Ambient Air Pollution Data. Atmospheric Environment. 2015 •Ashworth DC, et al. Comparative assessment of particulate air pollution exposure from municipal solid waste incinerator emissions. Journal of Environmental and Public Health. 2013 •Ghosh R, et al. Ghosh RE, Ashworth DC, Hansell AL, Garwood K, Elliott P, Toledano MB. Routinely collected English birth data sets: comparisons and recommendations for reproductive epidemiology. Arch Dis Child Fetal Neonatal Ed. 2016 Further papers are expected in 2018. Study information is provided on the SAHSU website for the public. -Health effects of large airports – the London Heathrow example (Heathrow) The results of this study have been published in the peer-reviewed BMJ (http://www.bmj.com/content/347/bmj.f5432 ). All outputs from individual projects will be anonymised (data will only be shared where aggregated with small numbers suppressed in line with the HES Analysis Guide). To confirm, no record level data is provided to any third party organisation and no commercial use is permitted.

Expected measurable benefits

The Small Area Health Statistics unit forms a major part of the national MRC-PHE Centre for Environment and Health – it is the only such specialist unit in the UK and its studies span surveillance and research. SAHSU is core- funded by Public Health England and has a programme of work agreed with Public Health England, with terms of reference in the contract between PHE and the Centre being: SAHSU has a unique role to support Public Health England’s mission to protect the health and wellbeing of the population with respect to environment and health concerns. SAHSU delivers authoritative analyses of routine health statistics in support of public health policy, environment and health surveillance and environmental public health tracking. • To develop and maintain databases of health data, environmental exposures as required to meet specific need, and social confounding factors at the small-area level The key points in demonstrating the benefit to health and social care are: • To carry out substantive research studies on environment and health issues including studies of the relationship between socio-economic factors and health, in collaboration with other scientific groups as necessary SAHSU undertakes a programme of research, surveillance and cluster investigation, subject to funding from external sources, that includes both methods development and investigation of priority questions in environment and health (including social, economic and demographic factors) as approved through PHE governance. The governance is overseen by the PHE-SAHSU Liaison Committee. • In collaboration with other scientific groups, to build up reliable background information on the distribution of environmental exposure, socio-economic data and disease amongst small areas The work of SAHSU helps progress PHE’s remit to protect the public’s health from public health hazards, particularly in relation to environmental hazards, and also in surveillance of non-communicable disease. For example SAHSU have published neighbourhood and postcode searchable maps in the SAHSU Environment and Health Atlas for England and Wales (www.envhealthatlas.co.uk) and published in recent years substantive studies on health effects of environmental air pollution and noise and future impacts of climate change on mortality. • To develop methodology for analysing and interpreting health outcomes related to small areas In June 2021, SAHSU published a study exploring the community factors associated with vulnerability and resilience to excess mortality in the first wave of the COVID-19 pandemic in England (pre-printed in November 2020). SAHSU are currently progressing a similar study looking at environmental factors and health outcomes using hospital admissions as the outcome event. • To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups A fundamental part of SAHSU’s work is the investigation of inequalities in environmental exposure and health. Findings from our studies are shared widely with stakeholders including PHE and feed into policy to reduce inequalities in health such as the Mayor of London’s Health Inequalities Strategy. Data analyses also indirectly support service development, for example, adapting national deprivation indices to better define inequalities in rural areas in collaboration with Directors of Public Health. • To respond rapidly, with expert advice, to ad hoc queries from the core funding bodies (DH and PHE) about unusual clusters of disease, particularly in the neighbourhood of industrial installations The key points in demonstrating the benefit to health and social care are: - The core SAHSU programme of work is funded by Public Health England, and this includes the service to Public Health England to assist PHE in fulfilling their duties The work of SAHSU helps progress PHE’s remit to protect the public’s health from public health hazards, particularly in relation to environmental hazards, and also in surveillance of non-communicable disease. For example SAHSU have published neighbourhood and postcode searchable maps in the SAHSU Environment and Health Atlas for England and Wales(www.envhealthatlas.co.uk) and published in recent years substantive studies on health effects of environmental air pollution and noise and future impacts of climate change on mortality. Covid-19 pandemic As of 23rd March 2020 the UK public health response to the Covid-19 pandemic include school closures and social distancing measures, strongly recommended for people over 70 year, those with an underlying health condition or who are pregnant. In addition, the NHS is expanding critical care capacity to the maximum, freeing up at least 30,000 of the 100,000 general and acute beds and acquiring a further 8,000 beds from within the private sector. The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there will be adverse consequences on non-COVID-19 morbidity and mortality. SAHSU aim to inform the UK public health and NHS response to this emergency by determining the spatio-temporal patterns in excess mortality and morbidity during the COVID-19 pandemic. SAHSU’s work includes investigation of inequalities in health and inequalities of environmental exposure, which help inform policy to reduce inequalities in health. Data analyses may also indirectly support service development, for example, adapting national deprivation indices to better define inequalities in rural areas. [1 paragraph unchanged] All SAHSU’s projects are aligned with the Terms of Reference of the [10 words unchanged] projects are approved by the PHE Programme Board, which includes membership from DH. the Department of Health (DH). In order to assist with standardising approaches across application processes, SAHSU have offered membership of the approving group to the Data Access Request Service. Service at NHS Digital.

Benefits reported

SAHSU has a long record of publishing its research in high quality peer reviewed journals and presenting results at scientific meetings and conferences to inform policy and to empower public debate. SAHSU puts details of its research on its website (www.sahsu.org), including publications and outputs. Scientific publications using SAHSU health data and/or directly arising from SAHSU project work in the last two years are listed below. Examples of how outputs from SAHSU’s studies are being used to inform health policy include: •Halonen JI, Blangiardo M, Toledano MB, Fecht D, Gulliver J, Ghosh R, Anderson HR, Beevers SD, Dajnak D, Kelly FJ, Wilkinson P, Tonne C. Is long-term exposure to traffic pollution associated with mortality? A small-area study in London. 2016. Environmental Pollution. 208 (Part A); 25-32 > The carbon monoxide project: This integration of information on population exposure and health effects provides an overall estimate of the disease burden from carbon monoxide in England. It supports work on Environmental Public Health Tracking led by Public Health England to prevent carbon monoxide poisoning cases. •Ghosh RE, Close R, McCann LJ, Crabbe H, Garwood K, Hansell AL, Leonardi G. Analysis of hospital admissions due to accidental non-fire-related carbon monoxide poisoning in England, between 2001 and 2010. 2016. Journal of Public Health. 2016. 38 (1); 76-83. > Health Impact Assessment of air pollution on asthma in London: Commissioned by the Greater London Authority, this study estimated the impact of air pollution in London on asthma-related hospital admissions at current levels and if particulate matter levels were reduced to the WHO guidelines level. Their results have been widely used by the Mayor of London to support the introduction of the Ultra Low Emissions Zone (ULEZ) in London and provides the baseline for further assessments to evaluate the impact of the ULEZ. Results have the potential to further influence air pollution policy and regulatory practices in London and the UK. •Ghosh RE, Ashworth DC, Hansell AL, Garwood K, Elliott P, Toledano MB. Routinely collected English birth data sets: comparisons and recommendations for reproductive epidemiology. Archives of disease in childhood. 101 (5); 451-7 > Health effects of large airports – the London Heathrow example (Heathrow): The results of this study allow for better understanding of the health problems caused by noise from aircraft in London. The findings had a high media-profile and were directly relevant to the Davies commission and decisions on whether to build a third run-way at Heathrow. Results of this study have been reported widely in local, national and international media and been raised as questions at Prime minister question. •Fecht, D. Hansell AL, Morley D, Dajnak D, Vienneau D, Beevers S, Toledano MB, Kelly FJ, Anderson HR, Gulliver J. Spatial and temporal associations of road traffic noise and air pollution in London: Implications for epidemiological studies. 2016. Environment International. 88; 235-42 The results of SAHSU studies are placed in the public domain via peer-reviewed publications and presenting results at scientific meetings and conferences and are used to inform the behaviour of health care providers and to inform national public health policy. To reach relevant stakeholders, SAHSU puts out a press releases in collaboration with the Imperial College Press Office and holds press conference, where relevant (e.g. as part of the re launch of the SAHSU Environment and Health Atlas for England and Wales). All studies equally feedback their results into the relevant policy leads within PHE and PHE is informed of any outputs ahead of publication. •Douglas P, Bakolis I, Fecht D, Pearson C, Leal Sanchez M, Kinnersley R, de Hoogh K, Hansell AL. Respiratory hospital admission risk near large composting facilities. International Journal of Hygiene and Environmental Health. 2016. 219 (4-5); 372-9. SAHSU puts details of its research on its website (www.sahsu.org), including publications and outputs. •Bakolis I, Kelly R, Fecht D, Best N, Millett C, Garwood K, Elliott P, Hansell AL, Hodgson S. Protective Effects of Smoke-free Legislation on Birth Outcomes in England: A Regression Discontinuity Design. Epidemiology. 2016. 27 (6); 810-8 Examples of peer reviewed outputs produced in the last 2 years include: •Fecht D, Jones A, Hill T, Lindfield, T, Thomson R, Hansell AL, Shukla R. Inequalities in rural communities: adapting national deprivation indices for rural settings. Journal of Public Health (Oxf). 2017 Apr 27; 1-7 Roca-Barceló A, Helen Crabbe , Rebecca Ghosh R, Freni-Sterrantino A ,Fletcher T, Leonardi G, Hoge C , Hansell AL, Piel FB. Temporal trends and demographic risk factors for hospital admissions due to carbon monoxide poisoning in England. Preventative Medicine; Volume 136, July 2020, 106104. •Smith RB, Fecht D, Gulliver J, Beevers SD, Dajnak D, Blangiardo M, Ghosh RE, Hansell AL, Kelly FJ, Anderson HR, Toledano MB M. Impacts of London's road traffic air and noise pollution on birth weight: a retrospective population-based cohort study. BMJ 2017 Dec 5;359:j5299. doi: 10.1136/bmj.j5299. Sheehan A, Freni-Sterrantino A, Fecht D, Elliott P, Hodgson S. (2019). Childhood Type 1 Diabetes: an Environment Wide Association Study across England. Diabetologia. 2020 May;63(5):964-976. doi: 10.1007/s00125-020-05087-7. Epub 2020 Jan 24. •Wang Y, Pirani M, Hansell A, Richardson S, Blangiardo M. Using Ecological Propensity Score to Adjust for Missing Confounders in Small Area Studies. Biostatistics 2017 Nov 9. doi: 10.1093/biostatistics/kxx058. [Epub ahead of print] Roca-Barcelo A, Douglas P, Fecht D, Freni-Sterrantino A , Williams B , Blangiardo M , Gulliver J, Hayes ET, Hansell AL (2019). Risk of respiratory hospital admission associated with modelled concentrations of Aspergillus fumigatus from composting facilities in England. Environ Res. 2020 Apr;183:108949. doi: 10.1016/j.envres.2019.108949. Epub 2020 Jan 3. •Ghosh RE, Dag Berild J, Sterrantino AF, Toledano MB, Hansell AL. Are babies getting heavier? Birth weight trends England and Wales (1986-2012). Archives of Disease in Childhood Fetal Neonatal Ed. 2017 Aug 5. pii: fetalneonatal-2016-311790. doi: 10.1136/archdischild-2016-311790. [Epub ahead of print] Smith R, Beevers S, Gulliver J, Dajnak D, Fecht D, Blangiardo M, Douglass M, Hansell A, Anderson H, Kelly F, Toledano M (2020). Impact of air pollution and noise on risk or preterm birth and stillbirth in London: a retrospective population-based cohort study. Environ Int. 2020 Jan;134:105290. doi: 10.1016/j.envint.2019.105290. Epub 2019 Nov 26. •Douglas P, Sterrantino AF, Sanchez ML, Ashworth DC, Ghosh RE, Fecht D, Font A, Blangiardo M, Gulliver J, Toledano MB, Elliott P, de Hoogh K, Fuller GW, Hansell AL. Estimating particulate exposure from modern Municipal Waste Incinerators (MWIs) in Great Britain. Environmental Science and Technology 2017;51(13):7511-7519. doi: 10.1021/acs.est.6b06478 Freni-Sterrantino A, Afoakwah P, Ghosh R, Smith RB, Hansell AL (2019). Birthweight centiles and small for gestational age (SGA) by sex and ethnicity for England and Wales. Archives of Childhood Diseases Published Online First: 13 June 2019. doi: 10.1136/archdischild-2018-316518 SAHSU also present its work at scientific advisory committees where of particular national interest e.g. some of the work on the incinerators project will be considered at forthcoming meetings of the Committee on Carcinogenicity (COC) and the Committee on Toxicity of chemicals in foods, consumer products and the environment (COT). Wang Y, Pirani M, Hansell AL, Richardson S, Blangiardo M, Using ecological propensity score to adjust for missing confounders in small area studies. Biostatistics. 2019 Jan 1;20(1):1-16. doi: 10.1093/biostatistics/kxx058. SAHSU take part in a wide range of public facing events. For example, in June 2016, members of SAHSU presented work on the Environment and Health Atlas for England and Wales, bioaerosols and health effects of environmental noise at the ‘Life Bank- Interactive Science Event’ as part of MRC Festival of Medical Research which targeted young members of the public aged 18-40 years old. See video at https://www.youtube.com/watch?v=ml4XyHs720I - A look at how your environment affects your health at the MRC festival. SAHSU also widely shares research outputs with members of the public via a wide range of public facing events. Events over the last 2 years include: On 14 July 2015, SAHSU attended the launch of the Respiratory Health of the Nation project, which used respiratory hospital admission, mortality and cancer registrations data, at the House of Commons in July. This project presented SAHSU maps of hospital admissions, mortality and cancer registrations of respiratory conditions. >October 2019: Launch of air pollution in parks website - To coincide with the launch of their interactive website which lets people explore the air pollution levels in their local parks, SAHSU hosted a British Lung Foundation-funded public panel discussion on air pollution, which was attended by ~40 members of the public. In addition to meetings with the MRC-PHE Centre Community Advisory Board, SAHSU also meet with various community organisations e.g. the assistant director attends noise committee meetings of Environmental Protection UK and provides research updates. > October 2019: New Scientist Live - The New Scientist Live attracts more than 40,000 people and SAHSU was represented as part of the HPRU in Health Impact of Environmental Hazards (https://live.newscientist.com/exhibitors/public-health-england/#/), alongside colleagues from PHE. We offered various activities around the theme of environmental epidemiology to identify the main environmental concerns of the public through a voting system and short online survey; and showcasing the interactive Environment and Health Atlas. SAHSU estimated that over 4 days they had 3,626 interactions with members of the public from a wide range of age groups. The following examples below gives an overview of how outputs from SAHSU’s studies have been used to inform health policy: > January 2019 – Anna Hansell, the former Assistant Director of SAHSU was interviewed about their findings on aircraft noise and health from the Heathrow study for a Japanese network. There were questions around general aspects of noise as well as how SAHSU accessed health data. This was aired on NHK which is a TV network in Japan. Traffic pollution and health in London study Public Involvement (PPI) The results of this study allow for a better understanding of the health problems caused by air pollution and noise from traffic in London. Findings to date have received a high media-profile and have the potential to influence air pollution policy and regulatory practices in London and the UK. SAHSU further involves members of the public throughout the research cycle. Examples of public engagement and involvement over the last 2 years include: Possible reproductive and other health effects associated with Municipal Waste Incinerators (MWIs) in England, Wales and Scotland (incinerators) > January 2021: SAHSU researchers run a focus group with members of the public to feed into the study design of a project looking at the health impacts of government strategies to meet its climate change target. The study was commissioned to extend the evidence base and to provide further information to the public about any potential reproductive and infant health risks from MWIs and to extend the evidence base with respect to exposures and any potential reproductive and infant health risks from MWIs. > 2020: The MRC Centre in Environment and Health and the NIHR HPRUs in Health Impact of Environmental Hazards and Chemical and Radiation Threats and Hazards have established a Public and Community Oversight Group (PCOG) to provide public and stakeholder input into the research programme and activities of the Centre. SAHSU has had a key role in establishing this function (e.g. strategy development, role descriptions, recruitment, and terms of reference). In future meetings of the PCOG, SAHSU members with attend to present research projects for review and development. Health effects of large airports – the London Heathrow example (Heathrow) > November 2019: SAHSU hosted a table at a Public and Patient Involvement Café entitled “Using routinely collected data to investigate the impact of the environment on health” at the Imperial NIHR Biomedical Research Centre Open Day at Hammersmith Hospital. The focus was on SAHSU holding a set of Patient Identifiable Data (NHS Number, Date of Birth, Date of Death, Postcode and Address) without explicit consent from data subjects. After the researchers explained the necessity to why those patient identifiable data (PID) are essential for SASHU research programme, the public participants widely supported the work and SAHSU holding these data. The results of this study allow for better understanding of the health problems caused by noise from aircraft in London. The findings had a high media-profile and are directly relevant to the Davies commission and decisions on whether to build a third run-way at Heathrow. Results of this study have been reported widely in local, national and international media and been raised as questions at Prime-ministers question. > November 2019: At the same PPI Café, discussions on the perception of strategies proposed by the government to meet its net-zero carbon emissions target in 2050 to feed into the study design of a project identifying co-benefits of climate change policies. The results of SAHSU studies are placed in the public domain via peer-reviewed publications and are used to inform the behaviour of health care providers and to inform national public health policy. All studies equally feedback their results into the relevant policy leads within PHE. > July 2019: Public survey using VOICE platform (https://www.voice-global.org/opportunities/archived/which-environmental-hazards-most-concern-you/) - In response to the first PHE Challenge highlighted for the HPRU, SAHSU surveyed members of the public on the following and asked which environmental hazard they are most interested in hearing about. Outcomes for this consultation will inform SAHSU’s future research direction. SAHSU has a long record of publishing its research in high quality peer reviewed journals and presenting results at scientific meetings and conferences to inform policy and to empower public debate. Where results are likely to be of particular interest, SAHSU put out a press release and, if necessary, hold a press conference e.g. for the SAHSU Environment and Health Atlas for England and Wales published in 2014, SAHSU held a press conference and several media interviews, including the Assistant Director of SAHSU being interviewed on the BBC Radio 4 Today programme. SAHSU also respond to media enquiries relevant to SAHSU’s work e.g. the Assistant Director of SAHSU took part in a Newsnight report on health effects of air pollution, broadcast 17 October 2016. SAHSU puts details of its research on its website (www.sahsu.org), including publications and outputs. The website: https://www.sahsu.org/publications shows all publications to date.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Datasets: + Emergency Care Data Set (ECDS); + HES-ID to MPS-ID HES Accident and Emergency; + HES-ID to MPS-ID HES Admitted Patient Care

Objective for processing

This is an amendment to request more frequent HES APC, Critical Care and Emergency Care dataset to enable COVID-19 related studies. The more regular data feed will support SHASU in their response to the Covid-19 pandemic. As of 23rd March 2020 the UK public health response to the Covid-19 pandemic include school closures and social distancing measures, strongly recommended for people over 70 year, those with an underlying health condition or who are pregnant. In addition, the NHS is expanding critical care capacity to the maximum, freeing up at least 30,000 of the 100,000 general and acute beds and acquiring a further 8,000 beds from within the private sector. The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there will be adverse consequences on non-COVID-19 morbidity and mortality. SAHSU aim to inform the UK public health and NHS response to this emergency by determining the spatio-temporal patterns in excess mortality and morbidity during the COVID-19 pandemic. [16 paragraphs unchanged] Some of SAHSU's studies are methodological, relating to for example, statistical uncertainty [45 words unchanged] using risk scores constructed at area-level from cohort datasets and surveys in our analyses of hospital admissions and mortality. [17 paragraphs unchanged] The lawful basis for processing data under GDPR has been reviewed and been assessed as acceptable. Imperial College London process data under Article 6(1)(e): "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller" as they are a public Authority. The Data Protection Act 2018 s7(1)(a) defines ‘public bodies’ for the purpose of the GDPR as “a public authority as defined by the Freedom of Information Act 2000”. The FOI Act 2000 Part 1, section 3 (1)(a)(i) specifies that a public authority means any body which is listed in Schedule 1. Schedule 1 of the FOI Act 2000 lists “Maintained schools and further and higher education institutions” as public authorities. Imperial College London is an independent corporation whose legal status derives from a Royal Charter granted under Letters Patent in 1907. In 2007 a Supplemental Charter and Statutes was granted by HM Queen Elizabeth II. This Supplemental Charter, which came into force on the date of the College's Centenary, 8th July 2007, established the College as a University with the name and style of "The Imperial College of Science, Technology and Medicine". Statistical research is stated as a reserved area of business in the Imperial College of Science, Technology and Medicine CHARTER AND STATUTES 2007. Additionally, Imperial College London process the Special Category Health Data under Article 9(2)(j): "processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject" as the data are required for research purposes in the public interest - meeting the conditions in the DPA 2018 Schedule 1 Part 1 (4) - which GDPR Recital 52(2) determines is an appropriate derogation from the prohibition on processing special categories of personal data.

Processing activities

SAHSU currently hold holds HES data in the form of Admitted Patient Care, Care (APC), Critical Care and (CC), Accident & Emergency as well as Civil Registration mortality data which includes identifiable data (NHS Number, Homeadd Home address and Date of Birth) under reference NIC-204903-P1J7Q. This is an amendment to the application to request Civil Registration/Mortality data and also to change the data extract frequency from monthly to annually. this agreement. Data extracts are downloaded from the NHS Digital’s SEFT System and copied to an encrypted USB drive and immediately transferred to SAHSU’s secure environment – “Private Network” with no connectivity to other networks - located at a secure location. SAHSU has extensive mechanisms in place to secure the health data including a robust information governance framework, privacy enhancing technologies and physical security measures. This is an amendment to request more frequent HES APC, Critical Care and Emergency Care Data Set (ECDS) linked to Civil Registrations (Deaths) data to enable SAHSU to undertake COVID-19 related studies. Data are loaded to an Oracle Database with Advanced Security implemented. This allows us to protect data at the source using Transparent Data Encryption (TDE) by enforcing data-at-rest encryption in the database layer which prevent unauthorised access from bypassing the database and reading sensitive information directly from storage. After the data are encrypted, data are transparently decrypted for authorised users when they access the data. ORACLE Transparent Data Encryption (TDE) helps protect data stored on media (also called data at rest) in the event that the storage media or data file is stolen. To prevent unauthorised decryption, TDE stores the encryption keys in a security module external to the database, called a keystore - a built-in encryption key management which eliminates the complex task of managing and securing encryption keys. SAHSU is currently planning to move its processing and storage location from St Mary's campus to the Imperial college ICSNPD environment which is based at Virtus datacentres. The new location has been added. Only 3 members of the database team have access to the Oracle database which holds patient-identifiable and sensitive data. Data loading, cleaning, validations, derivations and any authorised data linkage are performed by the database team. Data extracts are downloaded from the NHS Digital’s SEFT System and copied to an encrypted USB drive and immediately transferred to Secure Research Systems environment (SSRS). SAHSU has extensive mechanisms in place to secure the health data including a robust information governance framework, privacy-enhancing technologies and physical security measures. Data are loaded to an Oracle Database with Advanced Security implemented. This allows us to protect data at the source using Transparent Data Encryption (TDE) by enforcing data-at-rest encryption in the database layer which prevent unauthorised access from bypassing the database and reading sensitive information directly from storage. After the data are encrypted, data are transparently decrypted for authorised users when they access the data. ORACLE Transparent Data Encryption (TDE) helps protect data stored on media (also called data at rest) in the event that the storage media or data file is stolen. To prevent unauthorised decryption, TDE stores the encryption keys in a security module external to the database, called a keystore - a built-in encryption key management that eliminates the complex task of managing and securing encryption keys. Only 3 members of the database team have access to the Oracle database which holds patient-identifiable and sensitive data. Data loading, cleaning, validations, derivations, and any authorised data linkage are performed by the database team. [17 paragraphs unchanged] • NN4B now Civil Registration - Birth data • NCCHD (National Community Child Health Database) [10 paragraphs unchanged] Data will under this agreement will be disseminated annually more frequently so that SAHSU are able to work on the most complete data historically it was released on a monthly basis. to enable SAHSU to undertake COVID-19 related studies. [2 paragraphs unchanged] The only data linkage to be undertaken will be that as outlined in the application any additional linkages would require an amendment to this agreement. HES and ECDS DISCLOSURE CONTROL / SMALL NUMBER SUPPRESSION In order to protect patient confidentiality, when presenting results calculated from HES record level data, outputs will contain only aggregate level data with small numbers suppressed in line with HES Analysis Guide. When publishing HES data, you must make sure that: · cell values from 1 to 7 are suppressed at a local level to prevent possible identification of individuals from small counts within the table. · Zeros (0) do not need to be suppressed. · All other counts will be rounded to the nearest 5. Data will not be made available to any third parties other than those specified except in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide.

Expected measurable benefits

[10 paragraphs unchanged] Covid-19 pandemic As of 23rd March 2020 the UK public health response to the Covid-19 pandemic include school closures and social distancing measures, strongly recommended for people over 70 year, those with an underlying health condition or who are pregnant. In addition, the NHS is expanding critical care capacity to the maximum, freeing up at least 30,000 of the 100,000 general and acute beds and acquiring a further 8,000 beds from within the private sector. The anticipated benefits of these actions are clear; to control the spread of infection to a rate where the adapted NHS services are able to meet demand from Covid-19 and non-Covid-19 morbidity. What is unknown is whether there will be adverse consequences on non-COVID-19 morbidity and mortality. SAHSU aim to inform the UK public health and NHS response to this emergency by determining the spatio-temporal patterns in excess mortality and morbidity during the COVID-19 pandemic. [3 paragraphs unchanged]

Unchanged: Expected output, Benefits reported.