Elimination of Childhood Lead Poisoning in Detroit : A 10 Year Trend Analysis
Harolyn Tarr, MPH Lead Epidemiologist Detroit Department of Health and Wellness Promotion Office of Health Information, Planning, Policy, Evaluation, and Research (HIPPER)
Objectives
• Provide an overview of lead and the various risk factors associated with lead exposure • Describe the role of Detroit Childhood Lead Poisoning Prevention and Control Program (DCLLP&CP) and the various components of the program • Assess trends of key indicators describing the problem of Childhood Lead Poisoning • Highlight policies and partnerships working towards Childhood Lead Poisoning Elimination
Overview: Lead Poisoning
Lead
• Lead is a toxicant with no health benefits • High levels of exposure may lead to damage of the brain and nervous system, behavioral and learning disabilities, slower growth, hearing problems, headaches, and death • There is no safe threshold of lead exposure • Women with high lead level in their system prior to pregnancy would expose a fetus to lead through the placenta during fetal development
Key Risk Factors Associated With Lead Poison
Age of house
Socioeconomic status
Age
Lead Poisoning
Environmental (interactive effects)
Overview: Detroit Childhood Lead Poisoning Prevention Program
The Detroit Health Department
• Monitored childhood lead poisoning for nearly 3 decades through service and regulatory capacities • Begin tracking elevated blood lead levels (EBLs) since 1984 • In 2000 received funding from CDC to build program components to include testing, case management, and primary prevention activities • In 2003 developed the Jurisdiction-Wide Strategic Plan to Eliminate Lead Poisoning by 2010
Detroit Lead Program Components
• Case Management – Medical Case Management – Environmental Case Management • Testing – Clinic laboratory – Community Health Assistants
• Laboratory
• Primary Prevention
• Epidemiology and Data Management • Strategic Partnerships
Mission of DCLPP&CP
• The prevention of childhood lead poisoning, identification and treatment of lead burden children, and the facilitation of reducing environmental hazards in the home
Childhood Lead Epidemiology
• Collect and monitors data pertaining to the lead testing, the occurrence of elevated blood lead levels, and environmental and case management • Measure progress over time
• Identify and target high-risk areas
• Determine policy implications and promote lead policies (screening, housing, environmental, etc)
• Communicate of results to decision makers and other key stakeholders
Assessing Trends: Elevated Blood Lead Levels
Burden to the State and the Nation
• Over the years childhood lead poisoning in Detroit has consistently accounted for more than 50% of the State level total lead burden • In 2006,58% (1,338) of the Statewide burden were from Detroit; there were 2,307 children with EBL statewide • In 2007, 56.4% (2,031) of the Statewide total were from Detroit; there were 2,031 children reported with EBL statewide • Nationally, Detroit ranks fourth among large cities for lead poisoning (CDC 2004)
City of Detroit Number and Percentage of Elevated Blood Lead Levels (10ug/dL & above) Among Children Less Than Six Years
6000 30.0% Number of EBL
27.1%
5000
23.9%
4846
Percent EBL
25.0%
4000
20.0%
16.6%
2974 3000 3637 2520
3210 2853
15.0% 2014 1975 2006 1391 1164
10.7%
2000
10.5% 8.8%
10.0%
6.4%
1000
6.0%
6.1%
4.2%
3.7%
5.0%
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database,Datafiles, January 2008 Note: Children Less Than Six Years are categorized as children up to 2189 days old or less Elevated Blood Levels by Confirmed Venous Test Only
0.0%
• The city of Detroit has experienced a 86.3% decrease in the proportion of children with elevated blood lead levels • Surveillance data shows a 10.8% decrease in the prevalence of confirmed elevated blood lead levels since last year alone
% of Children with EBL
# of Children With EBL
City of Detroit Prevalence of EBL Among Children One and Two Years
30.0%
25.0%
24.0%
1&2 All Children
19.2% 16.1%
20.0%
% of Children
15.0%
11.4%
10.0%
11.8% 10.0% 7.9% 7.2% 7.4% 4.9% 4.3%
5.0%
0.0% 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data Source: DCLLP STELLAR Database, January 2008 Note: Children 1 & 2 years old are categorized as children betw een 365 to 1094 days old Elevated Blood Lead Levels of Confirmed Venous Tested Only
•
Children ages 1&2 years old and children enrolled in Medicaid programs are the city’s highest risk populations for lead poisoning
•
•
Longitudinal data shows that prevalence of poisonings among children age 1&2 years old has remained consistently higher than other age groups since the year 2000
Data also shows that lead poisoning prevalence has decreased by 82% since 1997
City of Detroit Prevalence of Elevated Blood Lead Levels Among Infants
7.0%
6.0%
6.1% 5.3%
5.0%
4.0%
3.0%
2.9% 2.0% 2.0%
2.0%
1.8% 1.6%
1.7%
1.5% 1.0% 0.7%
1.0%
0.0% 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Data Source: DCLPP STELLAR Database, Datafiles, January 2008 Note: Infants are categorized ase up to 354 days old
• •
•
Infants are also most vulnerable to becoming lead poisoned due to crawling The first year is a critical period for many developmental milestones
Lead poisoning among this age group dropped significantly between 1998 and 2000 and has been on a steady decline since
Elevated Blood Lead Level Categories
• In 1997 the Centers for Disease Control and Prevention (CDC) defined Blood Lead Levels of 10ug/dL as elevated • At this point other categories of BLL were defined to describe the severity of poisoning, which prompts actions for medical and environmental case management activities
• These blood lead categories are defined as having EBLs 1014ug/dL, 15-19ug/dL, 20-44ug/dL, and 45-70 ug/dL, and 70 and above
City of Detroit Proportion of Children Tested with EBL by Blood Lead Level Category Children Less Than Six Years
16.0% 14.8% 14.0% 14.2%
% EBL 10 to 14 % EBL 15 to 19 % EBL 20 to 44 % EBL 45+
12.0%
10.0%
10.3%
% of Children
8.0% 7.1% 6.0% 5.6% 5.7% 4.0% 4.0% 3.2% 2.0% 0.3% 0.0% 1997 1998 1999 2000 2001 2002 Ye ar Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, November 2007 Note : Children Less Than Six Years equals Children up to 2189 days old or less 0.1% 2.1% 1.3% 0.0% 0.0% 1.1% 0.0% 2.5% 2.4% 2.0% 1.7% 1.3% 0.7% 0.0% 2004 1.5% 1.0% 0.7% 0.0% 2003 0.6% 0.0% 2005 0.4% 0.0% 2006 4.0% 6.9% 6.9% 5.8%
4.0%
4.1% 2.8% 2.3% 0.7% 0.5% 0.0% 2007
1.0% 0.0%
• Data shows significant decreases in all levels of EBL since 1997
3,500 3,000 2,500
# of Children
City of Detroit Number and Proportion of Children with Elevated Blood Lead Levels Between 10 to 14 ug/dL Children Less Than Six Years
10 to 14 14.2% 3011 14.8% % EBL 10 to 14
16.0% 14.0% 12.0% 10.0% 8.0%
% of Children
2273 10.3% 2,000 1,555 1,500 1,000 500 0 1997 1998 1999 2000 1629
2117 1878 6.9%
6.9%
1259 5.8%
1329
1328 6.0% 931
4.0%
4.0%
4.1% 2.8%
751
4.0%
2.3%2.0% 0.0%
2001
2002 Year
2003
2004
2005
2006
2007
Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, December 2008 Note : Children Less Than Six Years equals Children up to 2189 days old or less EBL (Confirmed Venous Test Only)
1400
City of Detroit Number and Proportion of Children with EBL 15 to 19 ug/dL by Year Children Less than Six Years
15 to 19 % EBL 15 to 19
7.0%
1200 1166 1000
# of Children
5.7% 5.6%
886
6.0% 5.0%
% of Children
800 612 600
4.0%
583
739 637 520 486 416 338
4.0%
3.0%
2.5%
400 200
2.4% 2.0%
2.0% 225 1.0%
1.7% 1.3%
1.5%
1.0%
0.7%
0.0%
0 1997 1998 1999 2000 2001 2002 Year
Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, December 2008 Note : Children Less Than Six Years equals Children up to 2189 days old or less EBL (Confirmed Venous Test Only)
2003
2004
2005
2006
2007
City of Detroit Number and Proportion of Children with EBL 20 to 44 ug/dL by Year Children Less than Six Years
900 800 700 600
# of Children
8.0% 7.1% 777 656 20 to 44 % EBL 20 to 44 6.0% 5.0% 473 4.0% 348 301 2.1%
% of Children
7.0%
500 400 300 200 3.2%
332 3.0% 229 225 189 119 1.0% 0.7% 0.7% 2004 0.6% 2005 0.4% 2006 1.0% 0.5% 0.0% 2007 179 2.0%
1.3% 100 0 1997 1998 1999 2000
1.1%
2001
2002 Year
2003
Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, January 2008 Note : Children Less Than Six Years equals Children up to 2189 days old or less *EBL Confirmed Venous Test Only
City of Detroit Number and Proportion of Children with EBL 45 and above ug/dL by Year Children Less Than Six Years
35 30 0.3% 30 25 20 0.2% 15 10 0.1% 5 0.0% 0 1997 1998 1999 2000 2001 2002 Year
Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, January 2008 Note : Children Less Than Six Years equals Children up to 2189 days old or less EBL (Confirmed Venous Test Only)
0.3% 45+ % EBL 45+ 0.3%
13 0.1% 7 5 0.0% 6 6 6 5 3 0.0% 0.0% 0.0% 2003 0.0% 2004 0.0% 2005 3 0.0% 2006 3 0.0% 2007
0.1%
0.0%
• In 1997, there were 30 children reported to have very high EBL of 45ug/dL or greater. This was 0.3% of all confirmed EBL cases. In 2007, there were 3 children with EBL in this category.
% of Children
0.2%
# of Children
City of Detroit Number & Proportion of Children with BLL 5-9 ug/dL Children Less than Six Years Old 7000 6000 20.0% 5000 4000 3000 2000 5.0% 1000 0 2004 2005 2006 2007 0.0% 18.5% 16.4% 16.2% 15.0% 6587 6046 5471
BLL 5-9 Proportion
25.0%
5302
20.0%
10.0%
Data Source: Detroit Childhood Lead Poisoning Prevention and Control Program, STELLAR Database, February 2008 Note: Children Less Than Six Years equals Children up to 2189 days old or less
•
•
Studies have shown that there is no safe level of lead poisoning
In fact, low levels of lead exposure has more detrimental effects on IQ than higher levels (Canfield, 2003)
•
Surveillance data shows a slow but steady decline in BLLs of 5-9ug/dL
City of Detroit Incidence of Childhood Lead Poisoning Among Children Six Years
4000 18.9% 3458 17.0% 16.0% 3000 14.0% 2500 20.0% 18.0%
3500
# of Children
2228 2071 2000 10.1%
2110 1735 1545 1310 6.0% 5.4% 3.9% 3.7% 4.0% 2.5% 832 808 4.0% 2.5% 2.0% 0.0% 10.0% 8.0% 6.9% 1236 1218
1500 6.5% 1000
500
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data Source: DCLPP STELLAR Database, Dataf iles, March 2008 Note : Incidence is def ined as having a Blood Lead Level of 10ug/dL or above f or the f irst regardless of the number of times tested
• • • •
In the city, new cases accounts for approximately 60% to 70% of the total cases each year In 2007, new cases accounted for 69% of the total 1164 cases compared to 59% in the previous year Surveillance data shows significant drops in new cases between 1997 and 2000 Incidence has been on a steady decline since 2001
% of Children
12.0%
Childhood Lead Poisoning in 2007
Data Source: DCLLP STELLAR Database, January 2008 48217 259 1515 7 23 2.7% 1.5%
ZIP 48201
48202 48203 48204 48205
# Tested 398
582 788 1288 2491
# of EBL 7
39 48 81 86
% of EBL
48219
1.8% 48221
6.7% 48223 6.1% 48224 6.3% 3.5% 1764 37 2.1% 962 11 1.1%
978
26
2.7%
48225
48226
25
46
0
0
0.0%
0.0%
48206
48207
1020
657
73
29
7.2%
4.4%
48227
48228 48230
1904
2357 5
39
30 0
2.0%
1.3% 0.0%
48208
48209 48210
363
2495 2633
18
63 77
5.0%
2.5% 2.9%
48234
48235
1512
1260
30
18
2.0%
1.4%
48211
48212
350
827
30
49
8.6%
5.9%
48236
48238
32
1382
0
55
0.0%
4.0%
48213
48214 48215
1568
959 646
103
104 43
6.6%
10.8% 6.7%
Unknown Zip Codes
Citywide excl HP & HMTMK
1515
31273
33
1131 3.6%
48216
207
5
2.4%
Childhood Lead Poisoning in Detroit Elevated Blood Lead Levels (EBLL) among Children less than Six Years of Age
3500
No. of Children w/confirmed EBLL
3230 10.5% 2833 8.7% 2063
12.0%
Projected
(based on pr ojected 10% annual incr ease in testing)
3000 2500 2000 1500 1000 500 0
10.0% 8.0%
1964 6.0%
1955 6.0% 1341 4.1% 1147 3.5% 872 2.4% 479 1.2% 44 0.1%
6.3%
6.0% 4.0% 2.0% 0.0%
2001
Children Tested: 30,89 1
2002
32,54 7
2003
32,922
2004
32,87 3
2005
32,70 4
2006
33,19 0 33,01 3
2007
36,31 4
2008
39,94 5
2009
43,940
2010
Pct. of Children w/confirmed EBLL
Assessing Trends: Lead Testing
City of Detroit Number of Children Tested Among Children Less than Six Years
35,000 32,422 30,000 30,756 31,490 32,977 32,733 33,288 32,788
25,000 23,602 22,012
# of Children
20,000
20,328
15,000 10,976
10,000
5,000
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Data Source: Detroit Chidhood Lead Poisoning Prevention Program, STELLAR Database, January 2008 Note : Children Less Than Six Years equals Children up to 2189 days old or less Numbers include Venous and Capillary Tests
•
•
Lead testing among children less than six years old has increase by 200% since 1997 in the city
Points in history which marks significant increases in lead testing in the city were from 1997 to 1998 and 2000 to 2001. During the period of 1997 to 1998, there were 10,000 more children tested when compared to previous years.
City of Detroit Number of Children Tested One and Two Years
16000 14000 12720 12000 11882 10000 8000 6000 5167 4000 2000 0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
13379 12550
13470
13815
14050
9776
9568
9576
Data Source: DCLLP STELLAR Database, Datafiles, March 2008
•
• •
The city of Detroit operates under the Universal Testing Policy, testing all children living in Detroit ages 1&2 years and children ages 36 to 72 months who have never been tested Children 1&2 years accounts for 40% to 45% of all children tested each year in the city Approximately 56% of all children 1&2 years old are tested compared to 44% of all age group citywide
City of Detroit Number of Infants Tested
2500
2319 2182
2000
1903 1720 1800 1391 1107 1738 1873
1886
1500
1321
1000
500
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Data Source: DCLPP STELLAR Database, Datafiles, March 2008 Note: Infants are categorized as children 0-364 days old
•
•
Testing among infants was at it’s highest peak in 2001, this marks the period in which the city initiated a program which focused on testing infants and pregnant women Emphasis on this program declined during subsequent years however testing among this population is currently on an increasing trend
Assessing Trends: Environmental
City of Detroit Percent of Lead Paint Hazards Found per Inspections
600
567 521
# of Insp % insp w/pb hazards
120.0%
500
95.7% 89.2% 87.3% 391
100.0%
94.4%
89.1% 322
400
# of Inspection
74.0% 297 269
78.0% 36280.9% 304
76.4%
80.0%
301
300
253 208
60.0%
200
40.0%
100
20.0%
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data Source: DCLPP STELLAR Database, CDC Quaterly Management Report, March 2008
0.0%
• •
Currently, a lead inspection is conducted when a child presents a confirmed EBl of 10ug/dL or greater Surveillance data shows that lead paint remains the primary sources of childhood lead poisoning in the city, accounting for more than 80% of the exposure each year Most often no other lead hazards are found when lead paint is not the source
•
% Lead Hazards Found
84.2%
85.4%
City of Detroit
Number of Homes Abated for Lead Hazards Total 887 Homes
250 238 205 200 179
# Homes
150
128 112
100
50 1 0 2000 2001 2002 2003 Year 2004 2005 2006 2007 5 9
Data Source: Detroit Planning and Development Department, Lead Hazard Reduction Program, February 2008
• The Detroit Planning and Development Department provides resources for lead hazard abatement and remediation through the HUD Lead Hazard Reduction Grant
• Since 2001 PDD has remediated 887 homes in the city
Key Partners
• • • • • • • • • • Centers for Disease Control Michigan Department of Community Health Environmental Protection Agency Detroit Lead Partnership Planning and Development Department Wayne County Prosecutors Office (WCPO) Healthy Homes=Healthy Kids ClearCorps/Leap Detroit Buildings and Safety Engineering Children’s Hospital of Michigan
Other Strategic Partners
• • • • • • • • American Indian Health & Family Services Arab-American & Chaldean Council BADR for Development & Relief Bagley Housing Association Child Care Coordinating Council City Connect City planning Commission Community Health & Social Services Center Community Lead Education & Reduction Corporation Department of Housing and Urban Development Detroit City Council Detroit Law Department Detroit Mayor’s Office Detroit Hispanic Development Corporation Detroit Housing Commission Detroit Immunization Program Detroit Neighborhood City Hall Detroit Public Schools • • • • • • • • • • • Greater Detroit Area Health Council Head Start Programs Health Maintenance Organization Latino Family Services Lead Elimination Action Program Detroit Legal Aid & Defenders Association Maternal and Child Health Program Michigan Association of Local Public Health Michigan Department of Community Health Michigan Department of Environment Quality Michigan State Housing Development Association National Association for the Advancement of Color people North American Indian Health Southwest Detroit Housing Corporation Wayne County Family Independent Agency Detroiters Working for Environmental Justice
• • • • • • • • • •
• • • • •
Laws and Policies
• City of Detroit Health Code/Lead Ordinance – obliges property owners to keep their properties lead safe from tenants. Enforcement and citations are performed by the Health Department.
Lead Abatement Act Part 54A MCL 333.5451 (1998) - Requires that all lead-based paint activities be performed by certified persons, except for owner of an owner-occupied residential dwelling or an owneroccupied multifamily dwelling containing 4 or fewer units, if the activity is performed only in that owneroccupied unit of the multifamily dwelling Landlord Penalty Act (eff. Jan 2004) – makes it a criminal offense for landlords to rent properties containing known lead hazards to families with children. Penalties include up to 93 days in jail and/or fine up to $5000 for a first time offense. Fines for repeat offenders are up to $10,000 Lead Safe Housing Registry, SB 756/HB 5116 (eff Dec 2004) – establishes a Lead Safe Housing Registry and recognize the fourth Sunday of October through the following Saturday as “Lead Poisoning Prevention Week”. Lead Medicaid Testing, SB 756/HB 5119 (eff. Apr 2004) – ensures that HMOs receiving Medicaid payments are in compliance with the federal standard of lead screening for 80% of enrolled children.
•
•
•
•
Limitations
• Strengths:
– Financial Support from the Centers for Disease Control and Prevention, Michigan Department of Community Health, Local General Funding, U.S. Department of Housing and Urban Development, Environmental Protection Agency – Policy for enforcement of lead violations – Strong primary prevention component
• Weakness:
– Families with children are not utilizing the resources for Lead Abatement – Need other Legislation/ Code Enforcement Strengthen – Need to improve testing strategies which covers the UTP – Detroit’s definition of Elimination: Prevalence rate not to exceed 3.2% for children under the age of six by 2010. Need to reassess and redefine through strategic planning
Next Steps
• Update the Jurisdiction-Wide Strategic Plan and reengage partners • Allocate more resources towards testing among children enrolled WIC and Medicaid • Derive strategies to address homes that poisoned multiple children • Modify and Strengthen primary prevention component; i.e testing high risk housing with newborns, include lead hazards clearance in the BSE housing code regulations
Thank You
For More Information contact me Harolyn Tarr, MPH Lead Epidemiologist Detroit Health and Wellness Promotion 1151 Taylor St, Detroit MI, 48202 Ph. 313-876-4340 Email. tarrh@health.ci.detroit.mi.us