Public Health Approach to the Elimination of Childhood Lead Poisoning
Albany-Tula Alliance Lead Symposium April 10, 2006
Rachel de Long, M.D., M.P.H. Michael Cambridge, R.S. NYS Department of Health
Elimination of Childhood Lead Poisoning by 2010
Goal: Eliminate lead poisoning (BLL > 10 mcg/dL) among children under six years of age by 2010 NYS Lead Elimination Plan
Released June 2004 Complements NYC Elimination Plan
Plan provides a framework for lead elimination work of NYSDOH and partners
Living document informed by ongoing input from multiple stakeholders and success of elimination activities
Public Health Approach to Elimination of Childhood Lead Poisoning
Surveillance Screening Follow-up/management of EBLLs: education, nursing, environmental Primary Prevention Targeting High-Risk Populations Strategic Partnerships
Incidence of childhood lead poisoning
Incidence: newly identified children with elevated blood lead levels 2,805 incident Cases, 10+ ug/dL in NYS (excluding NYC)
Incidence Rate = 1.6 per 100 children screened
92 incident cases 10+ ug/dL in Albany County
Incidence rate = 2.64 per 100 children screened
Figure 3: Number and Rates of Children Newly Identified with Blood Lead Levels > 10ug/dL New York State excluding New York City Supplemental Report
6000 3.5
5,491
5000
2.9 4,547 2.5
3
2.5
Number Newly Identified
4000
3,682 2.0 3,175 1.8 2,805 1.7 1.6
1.5 2
3000
2000 1
1000
0.5
0 1998 1999 2000 Year of Test Number of Children Newly Identified Incidence Rate > 10ug/dL 2001 2002 2003
0
Incidence Rate
3,348
Lead Poisoning is not evenly distributed across the state
36 high-incidence upstate zip codes account for over 40% of the new cases of EBLL outside NYC (2000-2001 data)
Zip codes with >5% incidence rate EBLLs 2% of all upstate zip codes Urban neighborhoods characterized by higher rates of poverty and pre-1950 housing
Lead Poisoning distribution in NYS, by county, 1999-2001
High Incidence rate Zip Codes, 2001
Other Measures of Risk
Target communities defined in multiple ways
Lead poisoning incidence rates Total number of children with lead poisoning Lead screening rates Pre-1950 housing High proportion of new immigrant families Families with young children in poverty
Albany County: A Targeted Upstate Community
Top quartile for total number and rate of incident cases of children with EBLLs 42% of housing units built prior to 1950 6.5% of population is foreign-born; 40% of immigrant families arrived in the last decade Five high-incidence zip codes (12202, 12206, 12208, 12209, 12210)
7% of children tested within these zip codes have EBLLs 36.1% families with children <5 years old in these zip codes live below the poverty level
Strategic Partnerships: Key to advancing elimination efforts
NYS Lead Advisory Council Other DOH programs and state agencies Local Health Departments Community and statewide coalitions State medical academies, insurers, and health care providers Regional Lead Resource Centers CDC, EPA, HUD and other federal partners
Surveillance and Screening
Routine lead screening is the foundation of NYS surveillance system Surveillance essential for:
Identification and follow-up of individual children with lead poisoning State and local planning and monitoring
Current surveillance priorities
Complete deployment of new statewide data system Improve timeliness, quality, and accuracy of lead laboratory reporting Expand data analysis Apply data to program planning, education, and evaluation Improve screening rates!
NYS Lead Screening Requirements
Universal blood lead screening of all children at or around age one and age two years Annual risk assessment, with blood lead test as indicated, ages six months to six years Assessment of lead screening status on enrollment in child care/preschool, with information and referral for those without documented screening Risk assessment, with blood lead test as indicated, for all pregnant women at initial prenatal visit
Lead Screening Rates in NYS
Initial Test Data
67.6% children outside of NYC received at least one blood lead test by 24 months of age (2001 birth
cohort)
74% of NYS children enrolled in Medicaid Managed Care tested at least once by age 24 months 63.3% children in Albany County received at least one lead test by 24 months of age (2001 birth cohort)
NYS Data: Lead Screening Rates
Second Test Data
Of those upstate children with non-elevated initial screening test, 32% received a second lead test
(1996-2000 data)
31% of children in Albany County received a second lead test
Figure 1: Number* and Percent of Children First Screened for Elevated Blood Lead Levels Before Age 24 months, by Birth Year Cohort: New York State excluding New York City Supplemental Report
92,500 91,582 100
88,124
88,146
88,759 80
Number of Children First Screened
87,500 85,864 85,210 67.6 82,500 62.6 62.2 61.7 64.8 66.6
Percent of Children Screened
60
77,500
40
72,500 1996 1997 1998 Birth Cohort Number of Children First Tested for Blood Lead Level Screening Rate per 100 Children 1999 2000 2001
20
What are challenges to accomplishing universal screening?
Lack of single, unified message from public health and medical academies. Confusion among providers over terms: screening vs. testing vs. risk assessment. Insufficient consequences for not screening Provider skepticism about need for or benefits of screening Availability and reimbursement for on-site testing. Test characteristics – negative patient experiences with initial test.
National and NYS Research: Reasons Physicians Do Not Screen
Do not believe BLL 10 mcg/dL is elevated Do not believe BLL 10 mcg/dL associated with meaningful decline in IQ Do not believe benefits of screening outweigh the costs Do not believe prevalence in their community high enough to justify screening Do not believe screening is feasible
Campbell JR. Pediatrics.1996; 98:372
Improving Screening Practices: Current NYSDOH Priorities
Improve the knowledge, favorable attitudes, and practices of pediatric health care providers Strengthen and expand partnerships with other state and local agencies and programs that serve vulnerable/at-risk populations Educate and empower parents to pursue lead screening and other preventive practices for their children
Screening: Recent Activities
Screening Roundtable Fall 2004 Updated mailing to over 25,000 pediatric health care providers (Fall 2005)
Jointly signed by NYSDOH, AAP, NYSAFP, and MSSNY Links to specific educational materials Clinical Risk Assessment Tool Contact lists for referrals
Screening: Recent Activities
Changes made to WIC Medical Referral Form Developing clinical lead prevention toolkit, in collaboration with NYS AAP, NYSAFP, and Regional Lead Resource Centers December 2005 Medicaid Update Updated DOH web page:
http://www.health.state.ny.us/environmental/lead/index.htm
Screening: Recent Activities
Collaboration with other state agencies to reach high-risk families and community agencies, and to disseminate screening materials and messages Updating all educational materials Working with LHDs to expand office-based assessments and technical assistance
Follow-Up for Children with EBLLs
Confirmatory and follow-up testing Risk reduction education (> 10 ug/dL) Nutritional counseling (> 10 ug/dL) Diagnostic evaluation (> 20 ug/dL) Medical treatment (> 20 ug/dL, as necessary) Referral for environmental management (> 20 mcg/dL)
Follow-Up Services for Children with EBLLs
LHDs and health care providers must communicate and coordinate to ensure appropriate follow-up of children with EBLLs LHDs must institute measures to identify and track children with EBLLs to assure appropriate follow-up LHDs provide environmental management
21 rural counties environmental services provided by NYSDOH District Offices
Follow-Up for Children with EBLLs: Current Priorities and Activities
Education and tools for health care providers Support and technical assistance for Local Health Departments Updating state regulations Improving data systems and analysis Messages and materials related to BLLs < 10 ug/dL
CDC’s “Level of Concern”
CDC has not recommended lowering level of concern
Level of concern is not intended to serve as a toxicologic threshold – no specific threshold has been demonstrated No known clinical or public health interventions that can effectively lower BLLs already < 10 ug/dL Focusing intensive case management efforts on children with BLL < 10 ug/dL may deflect resources from children with higher levels and from primary prevention activities
What can health care providers do?
Provide culturally appropriate lead prevention education (anticipatory guidance) to all pregnant women and families with young children Screen children and pregnant women in compliance with state requirements Assure timely and appropriate follow-up for all children with EBLLs, including access to community resources Become involved with community lead prevention activities and partnerships
Primary Prevention
Increasing emphasis on strategies to identify and address lead hazards before children are exposed Longstanding concerns about old housing in NYS
Deteriorating paint Renovation and remodeling Traditional medicines, cosmetics, foods, and other products Imported commercial products
Emerging concerns about non-paint lead sources
Primary Prevention Activities
Healthy Neighborhoods Program Collaboration with HUD and EPA Training and collaboration with local code enforcement officials Home visiting/home inspection programs Explore ways to expand capacity of LHDs for primary prevention work Educate families and consumers about potential lead hazards
Environmental Activities
NYSDOH and local health departments (Albany County Department of Health) coordinate efforts to case manage children with elevated blood lead levels Presentation this afternoon on “Secondary Prevention” will focus on:
current environmental referral and assessment procedures identifying and eliminating conditions conducive to lead poisoning preventing further exposure to residential lead paint hazards and/or to non-lead paint sources.
New Environmental Model Primary Prevention
Strengthen Preventive Environmental Health Activities
identify hazards before children are exposed: housing, jewelry, food, candy, medicines build on existing comprehensive community programs use blood lead data to identify areas, properties and dwellings that are “high risk” map areas for targeting of activities
New Environmental Model Secondary Prevention
Strengthen Secondary Prevention Activities
continue to improve investigation techniques for detection of sources of lead utilize blood lead data to target areas for increased environmental health activities work with medical community for coordinated case management
Primary Prevention
Healthy Neighborhood Program (HNP)
Program Focus: carbon monoxide poisoning childhood lead poisoning fire death and burn injuries occurring in the home promote indoor air quality reduce hospitalizations due to asthma promote wellness and injury prevention. homes must be brought up to housing code standards In addition: A wide assortment of outreach items are made available from carbon monoxide detector, smoke detectors, fire extinguisher, sponges, mops and cleaner to pamphlets. Referrals for Needed Services
Housing Code referrals to correct environmental deficiencies. Identification of children at risk for lead paint poisoning. Referral for other preventive health services.
Primary Prevention
Healthy Neighborhood Program (HNP)
In 2004, 5,777 homes were assessed;
434 were found to have lead hazards, 142 had elevated carbon monoxide levels, 2,144 had inadequate smoke detection devices, 1,266 had asthmatics in residence.
Primary Prevention
Healthy Neighborhood Program (HNP)
Enhanced Local Infrastructure
HNP was recently expanded to 13 programs. HNP provides an added level of outreach and intervention activities that are consistent with the NYS Lead Elimination Goals HNP strengthening their own local strategic partnerships, such as code enforcement, and a variety of referral systems
Questions and Discussion