Health of the Public Capstone Project The Wyandotte County Lead Program

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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

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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

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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

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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

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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-1950s 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

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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

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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

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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

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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

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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

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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

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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
  199032283-8.
• 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.

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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?

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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.

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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

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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.

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Lead intoxication - treatments and strategies

• Chelation Therapy
• edetate calcium disodium (CaNa2EDTA)
• dimercaprol(BAL)
• D-penicillamine
• succimer

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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

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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

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Lead intoxication - treatments and strategies,
continued

• Abatement methods
• replacement
• encapsulation
• enclosure
• removal via scraping and stripping

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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.

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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

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Epidemiology of lead intoxication - Wyandotte
County

• Why is lead a problem in Wyandotte County?
• See H/O - figs 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

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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.

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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)

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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

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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

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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.

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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

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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

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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

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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

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Are these methods implemented in clinical
practice?

• Sporadically at best
• Depends on pediatrician
• education
• awareness
• experience
• health department rotation a must

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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

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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
  199032283-8.
• 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

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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

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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

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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

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THE END

• Thanks for your attention!