Health of the Public Capstone Project The Wyandotte County Lead Program

1. Health of the Public Capstone ProjectThe Wyandotte County Lead Program October 21, 1998 Presented by Tom Moss with special thanks to Mr. Sam Upscheid of the WYCO Health Department

2. Population and focus of program Adults with high lead levels in Wyandotte County - G.M., referred to OSHA Children with high lead levels in Wyandotte County

3. Hazard Characteristics of Lead Ubiquitous in nature - everywhere! Can be invisible, dust Sticky - adheres to most surfaces Sweet - taste is a factor with children Heavy - settles on surfaces No nutritional value

4. Why are children at high risk? Bodies need more calcium during their growing years - if lead is present, children will absorb lead instead Frequent hand-to-mouth activity Children who ingest lead will absorb from 5-50 times as much as adults

5. Uses of lead/sources of intoxication Lead based paints - very durable, banned in 1978 by CPSC for residencies, furniture and toys. Dust, chips, soil contamination - see fig. 1 in H/O for locations, pre-1950’s housing Gasoline - anti-knock agent,EPA reduced amount of lead in 1978; Soil in areas of underground tanks Household pipes - 1986,1988, SWDA restricted use in residential, public plumbing

6. Uses of lead/sources of intoxication Food cans - solder, banned in U.S. in 1995, still found in cans imported from other countries Cosmetics, imported candy wrappers, bread wrappers TODAY, fishing sinkers, lead smelters, etc. Also found in painted toys, imported non-glossy mini blinds, furniture (pre-1978), cribs and playpens, lead - glazed pottery, leaded crystal, folk remedies such as "Greta" and "Azarcon" used for GI upset in some Asian and Hispanic communities, Pay loo-ah, red powder used to treat rash or fever

7. Lead intoxication - effects Almost all organ systems affected In children, permanent damage at low lead levels: Nervous system and kidney damage, heme syn ADD, learning disabilities, decreased intelligence, and other behavior problems speech, language impairment poor muscle coordination, decreased muscle and bone growth, hearing damage

8. Lead intoxication - effects In adults, high lead levels can cause: increased chance of illness during pregnancy fetal damage/demise fertility problems HTN GI problems neurological disorders muscle, joint, coordination problems memory/concentration problems

9. Laws restricting the use of lead 1978 - CPSC banned sale of lead pigmented paints used in residencies, toys, furniture 1978 - EPA reduced amount of lead allowed in leaded gasoline 1986,1988 - SWDA changed to restrict use of lead pipes, solder and other components used in public, residential and non-residential plumbing

10. Laws restricting the use of lead 1988 - Lead Contamination Control Act- authorized CDC to make grants to state and local agencies for screening, medical/environmental referral, and education about lead poisoning 1995 - use of lead solder in cans banned in US, not other countries

11. Lead poisoning-at what level? Childhood lead poisoning was re-defined in 1991 by the Centers for Disease Control and Prevention as a blood lead level of 10 micrograms per deciliter (ug/dL) or above

12. Lead poisoning? At what level? Previously 25ug/dL, changed in part to to 1990 work by Needleman et al. The long-term effects of exposure to low doses of lead in childhood: An 11-year follow-up report. N Engl J Med 1990;322:83-8. This particular study followed children exposed to "low" levels of lead through high school and found that lead exposure was associated with lower levels of vocabulary, class standing, and with increased frequency of dropping out of school. The work done in this and related papers served in part to alter the CDC's recommendation to lower the acceptable blood lead level in children from 25 ug/dL to 10 ug/dL.

13. Lead intoxication screening CDC - 1991 recommends screening if the answer is YES to any of the following 5 questions: 1. Does the child live in or visit a home or other location built before 1978 with chipping or peeling paint? 2. Does the child live in or visit home or other location built before 1978 which has been recently renovated? 3. Does the child live with or visit an adult whose job or hobby involves the use of lead? 4. Does the child have brothers, sisters or playmates with confirmed lead poisoning? 5. Does the child live near a lead smelter, battery recycling plant or industry likely to release lead?

14. Lead intoxication screening What does the AAP say? AAP - In a revision to its 1993 policy statement, the AAP now recommends targeted blood screening for lead. However, in some high-risk areas and population groups, it may be necessary to screen all children, according to the AAP. Previously, the AAP recommended universal screening for all children at 1 year of age and again, if possible, at 2 years of age.

15. Lead intoxication - action at what level? CDC guidelines - generally accepted Blood Lead Level (ug/dL) Action Taken 0-9 Not considered poisoning, continue routine testing 10-14 Moderate concern. Environmental and nutritional education and a home lead check is done. Retest in 3-4 months 15-19 High concern. Child should have a venous blood test to confirm the blood level result. Environmental and nutritional education and a home lead check is done.Retest in 3 months 20-44 Severely high concern, confirm with venous blood test. Refer to doctor for possible chelation therapy. Environmental and nutritional education and a home lead check is done. 45-69 Institute above environmental interventions and chelation therapy >69 Medical emergency, chelation, support

16. Lead intoxication - action at what level? Most screening protocols utilize a capillary stick, and if elevated LBL, confirmation with venous blood sample prior to possible chelation. Unfortunately, adherence to these guidelines and practices are in part a function of the medical professional's education and awareness of this problem, and sometimes are not followed completely. At present very few pediatricians ask the five screening questions above, and more must become educated to do so. This alone represents a potential problem in the process of preventing, detecting and treating, lead poisoning.

17. Lead intoxication - treatments and strategies Chelation Therapy edetate calcium disodium (CaNa2EDTA) dimercaprol(BAL) D-penicillamine succimer

18. Lead intoxication - treatments and strategies, continued Dietary adjustments Foods high in calcium Foods high in vitamin C Foods high in Iron decrease lead absorption Limit fats and oils promote lead absorption

19. Lead intoxication - treatments and strategies, continued Allow tap water to run 2 min. before collecting water for infant formula Never heat foods in cans Never store food in open cans Wash your hands Beware of suspect ceramic/glazed containers

20. Lead intoxication - treatments and strategies, continued Abatement methods replacement encapsulation enclosure removal via scraping and stripping

21. Epidemiology of lead intoxication - U.S. CDC Data-1996 Although the number of U.S. children ages 1 to 5 with elevated blood lead levels of >10 ug/dL decreased from 88.2 percent between 1976 and 1980 to 4.4 percent between 1991 and 1994, nearly 900,000 children still had elevated levels of lead in their blood.

22. Epidemiology of lead intoxication - Kansas KDHE Data Child lead blood levels > 10 ug/dL 15.1% in 1993 15.4% in 1994 13.9% in 1996

23. Epidemiology of lead intoxication - Wyandotte County Why is lead a problem in Wyandotte County? See H/O - fig’s 2,3,4 The northeast area of Wyandotte County, Kansas (primarily in Kansas City, Kansas within zip codes 66102, 66102, 66103, 66104 and 66105) have children under 6 years of age with elevated blood levels. The time frame this data was collected includes May 1997 to May 1998. 10 children with blood lead levels between 10 -15 ug/dL 10 children with blood lead levels between 15 - 20 ug/dL 33 children with blood lead levels > 20 ug/dL

24. Current programs for dealing with lead intoxication in Wyandotte County Screening/Testing per CDC guidelines On-site inspections, referrals, testing Education - presentations to all levels Data collection Grant from EPA - Denver Developmental Testing research EPA to adopt Wyandotte County protocol for monitoring/testing of daycare centers nationwide, high risk areas, etc.

25. Current programs for dealing with lead intoxication in Wyandotte County Currently, no abatement projects are funded, but a grant from HUD is pending. (A bi-state not-for-profit organization called "Lead Busters" is currently in place and offers lead-poisoning education training and presentations as well, and can provide information on lead abatement contractor services)

26. Current programs for dealing with lead intoxication in Wyandotte County Additionally, a HUD grant is pending for the following activities in Wyandotte County: Implementation of lead hazard controls on 250 housing units that test positive for lead Training of 140 individuals to do risk assessments and inspections, who will be workers, cleaners and supervisors Implementation of 12 educational programs to the community and with special focus to high risk families

27. Site visits - experiences 1. KCK child/neighbor poisoned paint chips, plaster dust evident landlord given referrals, tenants signed release 2. Child poisoned teeth marks on windowsill, behavior problems Post remediation, renter took possession of house at no charge LAWSUIT

28. Legal ramifications for a landlord with children of renters with lead intoxication Wyandotte County Ordinance - Passed April, 1998 - prohibits used of lead bearing substances and creation of conditions that create a lead hazard "Every person convicted of a violation of any section of this article shall be punished by a fine of not more than $500.00 of by imprisonment for not more than 180 days, or both such fine and imprisonment." In addition, renters can be sued for civil damages resulting in permanent effects of lead poisoning.

29. Legal ramifications for a landlord with children of renters with lead intoxication EPA and HUD - Real Estate Disclosure Rule As of December 6, 1996 the owner of any house built before 1978 must inform possible buyers and renters about possible lead-based paint hazards in the home

30. Legal ramifications for a landlord with children of renters with lead intoxication If BUYING a home built before 1978 seller must tell you about any known lead hazards in the home furnish a copy of the EPA pamphlet titled Protect Your Family From Lead in Your Home provide a 10-day opportunity to test the home for lead, include warning language in a signed statement and retain it for three years Seller not required to test the home for lead, remove any lead based paint hazards discovered during buyer's inspection

31. Legal ramifications for a landlord with children of renters with lead intoxication If RENTING a home built before 1978 the landlord must do all of the above, but… not required to test the home for lead not required to remove any lead based hazards discovered not required to give the renter 10 days to test for lead

32. Local clinic lead screening policies - per CDC 5-question guidelines The Wyandotte County Health Department Pediatrics Clinic KU- Dr. Veal, 13 referrals this month Inservice/CME attendance 4 docs/20 attended 135% increased referrals Dismal education of pediatricians thus far

33. Are these methods implemented in clinical practice? Sporadically at best Depends on pediatrician education awareness experience health department rotation a must

34. What happens when a child is identified with lead intoxication in Wyandotte County, at 10-15ug/dL? Site Visit- Identify cause Testing, dust wipes, etc Recommendations to landlord/homeowner to for remediation and education, relocation If child retested at a later date, with elevated LBL, re-visit site, consider intervention by SRS

35. The role and effectiveness of lead toxicity screening - a review of the literature- Important Studies Needleman et al. The long-term effects of exposure to low doses of lead in childhood: An 11-year follow-up report. N Engl J Med 1990;322:83-8. This particular study followed children exposed to "low" levels of lead through high school and found that lead exposure was associated with lower levels of vocabulary, class standing, and with increased frequency of dropping out of school. The work done in this and related papers served in part to alter the CDC's recommendation to lower the acceptable blood lead level in children from 25 ug/dL to 10 ug/dL

36. The role and effectiveness of lead toxicity screening - a review of the literature Tejeda DM, et al., Do questions about lead exposure predict elevated lead level? Pediatrics Vol. 93 No. 2 February 1994. Concluded that the 5-question CDC risk assessment questionnaire is an effective screening method for elevated blood levels. In particular, questions about the home environment were more sensitive indicators of elevated blood levels than other standard high risk questions. Mushak, P., Defining lead as the premiere environmental health issue for children in America: Criteria and their quantitative application. Environ-Res 1992 Dec; 59(2):281-309 Helped to identify lead poisoning as a premiere environmental and public health issue for American children

37. Relevance to future clinical practice Awareness know the problem, know the population Prevention minimum standard - preceeding information Screening CDC guidelines Treatments easier to prevent than to treat

38. Conclusion Wyandotte County Lead Program Highly effective through education/prevention Setting national standards Expanding, new grants Making Wyandotte County and the US more LEAD SAFE

39. THE END Thanks for your attention!