Small Area Health Statistics Unit (SAHSU) (ODR1516_371/A4)

The Small Area Health Statistics Unit (SAHSU) currently holds National Cancer Registration Service Data (NDRS) for Cancer Registrations, National Radiotherapy (RTDS) and Systemic Anti Cancer (SACT). This agreement has a sister application under (DARS-NIC-204903-P1J7Q) where SAHSU holds identifiable HES data for 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 (spatial, socio-economic and environmental exposure data which is vital for SAHSUs research studies), minimised per project, to enable specific project datasets that answer particular research questions in line with the objectives listed. NDRS data disseminated under this agreement is not linked to data disseminated under agreement DARS-NIC-204903-P1J7Q

The purpose of this renewal is to extend the current agreement for a further 3 years, the continued retention of NDRS data (1995-2017), ONS cancer data (1974-1994) and to request the annual refresh of Cancer Registration, SACT and RTDS data and updated years for 2018/2019 & 2020. During the term of this agreement SAHSU seek to apply for annual refreshes in 2024 and 2025.

SAHSU is based within the Department of Epidemiology and Biostatistics at Imperial College London (ICL). SAHSU 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 leukaemia and lymphoma in children and young adults near the Windscale/Sellafield nuclear power plant. SAHSU has a particularly significant role 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, Geographic Information Systems (GIS), statistics, environmental exposure assessment and epidemiology. SAHSU's skills and expertise are an invaluable resource both nationally and worldwide. SAHSU holds comprehensive sets of health, demographic, and environmental data at high spatial resolution.

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 Health Protection Research Unit (HPRUs) SAHSU does not receive funding from UKHSA. Funders do not determine the means and purpose of data processing and will have no ability to suppress or otherwise limit the publication of findings.

ICL is the sole Data Controller who also processes 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) continues to support SAHSU in providing governance oversight to the SAHSU research/surveillance programme. UKHSA do not have any decision-making responsibilities over project initiations within SAHSU or have access to the data and are therefore not considered a Data Controller. The liaison Committee Terms of Reference will be updated in the next committee meeting to accurately reflect this arrangement.

Microsoft Limited supply Microsoft Defender for cloud, an anti-malware service for Imperial College London and are therefore listed as a data processor. They support the system, but do not access data.

SAHSU’s 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 Regulation 3 for the processing of identifiable confidential patient information in relation to communicable diseases and other threats to public health UKHSA Caldicott Ref: CAP-2017-14.

SAHSU undertakes 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.

Data Required:

SAHSU currently holds NDRS Cancer Registration data (1995-2017), ONS cancer data (1974-1994), NDRS National Radiotherapy Dataset and NDRS Systemic Anti Cancer Dataset and is requesting annual refresh of the following datasets from 2018- latest available.

NDRS Cancer Registration data - Latest available

NDRS Systemic Anti Cancer Dataset (SACT)- Latest available

NDRS National Radio Therapy Dataset (RTDS)- Latest available

Justification for requesting data:

SAHSU have a programme of work agreed with the UK Health Security Agency (UKHSA), which is defined by the following terms of reference:

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

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

3) In collaboration with other scientific groups, to build up reliable background information on the distribution of environmental exposure, socio-economic data and disease in small areas.

4) To develop methodologies for analysing and interpreting health outcomes related to small areas

5) To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups

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

To deliver against the Terms of Reference, SAHSU utilises the research database to meet the following purposes:

Purpose 1 - Maintenance of the SAHSU health research database

At the core of the overall programme of work is the maintenance of the SAHSU research database, which combines multiple datasets and has ethics and the Health Service (Control of Patient Information) Regulations 2002: regulation 5 (for DARS-NIC-204903-P1J7Q) and regulation 3 approvals (for DARS-NIC-656768-C1Z1M) in place. A particular strength is the maintenance of historic data, which allows SAHSU to examine long term trends and the 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; noise pollution arising from residential proximity to aircraft flight paths.

Purpose 2 - To carry out a programme of research projects and studies

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 the translation of knowledge on environment effects 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, green and blue space, 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 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 exposures, socioeconomic data and disease among small areas

SAHSU has developed an extensive collection of environmental exposure data e.g., air pollution, magnetic fields, environmental noise, that SAHSU holds 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 ideas for some studies are formulated by the funder however it is SAHSU that determines the means and purpose of processing data for those studies. An example of this work is the Environment and Health Atlas for England and Wales, which includes 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 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 to study air pollution's impact on health outcomes.

Purpose 4 - To develop methodology for analysing and interpreting health outcomes related to small areas

Some of SAHSU's studies are methodological, relating to for example statistical uncertainty in observed health risks in areas relating to the 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.

Purpose 5 - To act as a centre of expertise, disseminating information on developments in spatial epidemiological methods to national and regional groups.

SAHSU participates in national and international scientific meetings and provides training to UKHSA and internationally including to the US Centres for Disease Control (CDC) in the use of small area analysis for public health purposes. SAHSU uses aggregate non-disclosive data in outputs, presentations and training.

Purpose 6 - To provide rapid ad hoc support to 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 UKHSA or DHSC and approved by the Director of SAHSU. By its nature, such requirements cannot be detailed in advance. However, the only outputs would be aggregated 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.

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 analyses 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 developed which will allow SAHSU to test on various scenarios to 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 expects to do more in the near future.

As an example of the most recent request, SAHSU 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 SAHSU’s work remit. 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 project initiations within the SAHSU unit and are therefore not considered a Data Controller. UKHSA's role within the Liaison Committee is to provide governance oversight to the SAHSU research/surveillance programme only.

Researchers at SAHSU initiate projects or studies. All proposed studies using SAHSU data must be approved as a 'SAHSU study'. To do so, researchers must provide a project outline detailing the project rationale, 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 has support under Regulation 3 of the Health Service (Control of Patient Information) Regulations 2002 for NDRS data for the processing of confidential patient information in relation to communicable diseases and other threats to public health to cover the above. Any project with additional requirements (for example, requires the linkage of an additional dataset beyond that previously agreed) must seek an amendment to the existing Regulation 3 and ethics approvals. It would also be outside the scope of this agreement, 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 maps 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 use in any public health setting. It will be particularly useful in initial epidemiological investigations of potential clusters of disease, in relation to environmental contamination such as around industrial sites, and disease surveillance. SAHSU aims to work with UKHSA and CDC on retesting, refining and implementing the software.

SAHSU surveillance methodology work includes the development of space-time clustering 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 is planning a study to evaluate the potential of machine learning methods for application to high-dimensional administrative health data and apply this to the SAHSU datasets. SAHSU has a Non-Communicable Disease Surveillance study funded by the Wellcome Trust to investigate the use of hospital data for non-communicable disease surveillance.

SAHSU has a particular national responsibility for 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 respond quickly 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 of patients.

The lawful basis for processing data under GDPR has been reviewed and assessed as acceptable. Imperial College London processes 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 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 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.

The application relies on Regulation 3 of the Health Service (Control of Patient Information) Regulations 2002 to process patient identifiable information without consent and national opt outs are not upheld. Where individuals have opted out of disease registration by the National Disease Registration Service (NDRS), their data has been permanently removed from the registry and therefore will not be disseminated under this Data Sharing Agreement (DSA). https://digital.nhs.uk/ndrs/patients/opting-out

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 isolated from the "internet" and ICL services (email, network drives, one drive etc). The Secure Enclave is an isolated environment within the Imperial College network, operated by Virtus SDC Ltd. The servers located at Virtus SDC are owned and managed by ICL in a dedicated area of the Virtus SDC data centre. ICL does not share racks with other organisations and operates their own switches. Access into the ICL area is via swipe card. CCTV covers the area and is monitored by ICL and Virtus staff (24 hours). Servers can only be accessed by approved users appropriately trained at ICL. To access the ICL servers swipe card access is required, and live logging and alerts of that access are available.

Access to the servers is controlled by Imperial ICT staff and heavily restricted. Virtus staff cannot enter the Imperial Cages without ICL permission. 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 ICL.

The SSRS facility is split into two different enclaves/zones: (1) holding identifiable data and (2) holding processed minimised (to a small geographical area under specification of the study) and pseudonymised data. All processing, storage and analysis of patient level data are done within these 2 enclaves. By default, remote users have only "screen view" access to the data. Users within the office can only access the SAHSU servers using the organisation managed devices.

The data recipient will access the NHS England's Secure Electronic File Transfer service (SEFT), from a specified ICL office using a secured ICL managed device/workstation, download and copy the Cancer Registration 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 research database resides within the identifiable enclave/zone of the SSRS. This zone is restricted to the database team for loading, processing, and data linkages with spatial, socioeconomic and environmental exposure data using the requested identifiers. Once the purpose for requesting identifiers has been fulfilled, 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 that require linkage to exposure data demand 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.

NHS England 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 geographical 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 geographical 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.

Researchers must follow the SAHSU governance process for requesting data extracts for their studies. The following checks are performed prior to data extraction::

• Their studies have been approved by the UKHSA-SAHSU Liaison Committee.

• They are under contract with Imperial College London.

• They have signed the SAHSU Acceptable Use Policy and have completed 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, registered students (including PhD and Masters students) or individuals from other institutions under a honorary contract with ICL. The researcher under ICL honorary contract will have access to minimised and de-identified data for the study they are collaborating with a SAHSU. Occasions when a researcher leaves ICL and they have not yet completed their study, they will be issued an honorary contract by ICL to complete the study they have already started. 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.

Researchers can request minimised (to a small geographical area defined by the study) or pseudonymised data extracts. The database team will generate extracts for the research team based on the specifications provided for 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.

Users requesting access to SAHSU’s data must complete data protection training and have a good understanding of the sensitivities around using health administrative data. They must also know 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.

Only aggregated data with small number suppression can removed from 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.

SAHSU understands that data linkage between health datasets is only permitted with explicit written permission from data providers and substantial amendments to SAHSU’s NRES ethics and HRA/CAG approvals.

In addition to NHS England data, SAHSU also holds and receives the following record level identifiable datasets:

• ONS death registrations

• ONS birth and still birth 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 provide support for 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 access to the database[s] containing the data. ICL uses offsite data centre services provided by VIRTUS data centre. VIRTUS does not have access to the data.

Data will not be made available to third parties other than those specified except in aggregated outputs with small numbers suppressed in line with the HES Analysis Guide.

SAHSU has a long record of publishing research findings in high-quality peer-reviewed journals and presenting results at scientific meetings and conferences to inform policy and 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 issues a press release and, if necessary, hold a press conference.

SAHSU research findings are placed in the public domain via conference presentations, reports and peer-reviewed publications and are intended (and have been used) to inform public health decision making and national public health policy-makers. Results of studies are also shared directly with relevant Policy Leads within UKHSA and other government departments

SAHSU has a publication policy that includes sharing all publications with colleagues at UKHSA and the devolved administrations. 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.

SAHSU research is presented to scientific advisory committees where it is of national interest e.g., our work childhood cancer surveillance was considered by the Committee on the Medical Aspects of Radiation in the Environment (COMARE).

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 Community Involvement Engagement and Participation (PCIE) is also undertaken by researchers in 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.

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/).

SAHSU's research programme aims to provide evidence underpinning actions and policies that hope to create liveable, sustainable and healthy environments and effective public services for all which may 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/).

Benefits are achieved on an on-going basis, and it is difficult to outline specific target dates which depend on a range of factors both within and outside of SAHSU.

Examples detailing potential benefits from SAHSU's new and on-going studies relating to the use of NDRS data, including examples of research, surveillance, commissions and methodology development:

Kidney Cancer spatio-temporal patterns in England

Incidence rates of kidney cancer in the UK have doubled since the 1990s and it is currently the 7th most commonly diagnosed cancer (n=12,900 cases per year). This temporal trend cannot be fully explained by secular changes in smoking or obesity prevalence. To generate hypotheses on the aetiology of kidney cancer risk, SAHSU will apply spatio-temporal epidemiological methods to analyse in kidney cancer incidence in England. The aim of this study is to generate hypotheses for advancing understanding of the aetiology of the condition which is essential for appropriate and effective public health interventions.

Report on childhood cancer incidence around nuclear installations in England, Wales and Scotland for the Committee on the Medical Aspects of Radiation in the Environment (COMARE).

This project examines rates of childhood cancers in neighbourhoods around nuclear installations in England, Scotland, and Wales. The work has been requested by the Committee on the Medical Aspects of Radiation in the Environment (COMARE) as part of ongoing surveillance of these facilities.

NIH Spatial uncertainty in small area analysis from survey and administrative data:

This collaborative project with Emory and Harvard researchers aims to:

• to describe spatial uncertainty, with a particular focus on census data and sampling-based risk denominators and covariates (e.g., from the US American Community Survey (ACS) or UK Population Coverage Survey (PCS));

• to model spatial uncertainty through a flexible, model-based framework that accounts for uncertain elements within small area estimation and disease mapping accurately, reliably, and reproducibly; and

• to develop improved ways of communicating and visualising spatial uncertainty.

Through an international collaboration between three leading research groups in spatial analyses, this project aims to carefully document, model, and communicate the impacts of spatial uncertainty in local populations and covariates on small area estimates of health risk, yielding more accurate inferences on spatial patterning of social and environmental determinants of health. The freely developed software tools and visualization guides will be able to be translated to a large number of research settings, potentially changing standard practice for disease mapping based on survey-based data.

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 the 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 Inequality:

This study aims at quantifying the patterns of major causes of mortality and morbidity in relation to socio-economic factors, such as income, employment and education. All-cause mortality as well as mortality from specific causes and the incidence of specific cancers will be considered. 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.

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.

The work of SAHSU has helped to progress UKHSA’s remit in respect of (i) protection of the public’s health from public health hazards, particularly in relation to environmental exposures and (ii) surveillance of non-communicable diseases. Examples include a public-facing web application with interactive searchable maps and explanatory text - the SAHSU Environment and Health Atlas for England and Wales; publications in leading scientific journals and substantive studies on health effects of environmental air pollution and noise, and future impacts of climate change on mortality.

Example of the benefit of a completed study: In 2013, the SAHSU Environment and Health Atlas for England and Wales was launched in the form of 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. (https://www.envhealthatlas.co.uk/homepage/)

The Environment and Health Atlas for England and Wales application informs policy-makers and the public on the geographical patterns of disease and potential exposure to various pollutants and assists 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.

SAHSU has also supported scientific advisory committee work e.g. SAHSU was asked by the Committee on Medical Aspects of Radiation Effects (COMARE) to undertake an epidemiological analysis of clusters of childhood cancers around UK nuclear installations, as part of COMARE’s periodic monitoring and surveillance activities. This project examined rates of childhood cancer 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 as part of ongoing surveillance of these facilities. This work provides critical information to support public health protection regarding the safety of nuclear installations in Britain.

SAHSU’s work includes investigation of inequalities in health and inequalities of environmental exposure, which inform policy to reduce inequalities in health. Data analyses may also indirectly support service development, for example, our recent work, working with directors of public health working in rural areas, to adapt national deprivation indices to better define inequalities in rural areas.

SAHSU has a long record of publishing research findings in leading peer-reviewed journals and presenting results at scientific meetings and conferences to empower public debate 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 are also shared directly with relevant Policy Leads within UKHSA and other government departments.

SAHSU has 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/).