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Lead Poisoning in Milwaukee –Effects of Home Lead Abatement
Kevin Smith, MPH
Joseph J. Zilber School of Public Health &
City of Milwaukee Health Department
Acknowledgements• Amy Kalkbrenner – Joseph J. Zilber School of Public Health
• Elise Papke – Joseph J. Zilber School of Public Health
• Joyce Whitebsky – School of Architecture and Urban Design
• Lisa Lien – City of Milwaukee Health Department: Lead Poisoning Prevention Program
• Robert Colla – City of Milwaukee Health Department: Lead Poisoning Prevention Program
• Sanjib Bhattacharyya – City of Milwaukee Health Department: Public Health Laboratories
• Steve Gradus - City of Milwaukee Health Department: Public Health Laboratories
• Kristen Grimes – Children’s Health Alliance of Wisconsin
• Chuck Warzecha – Bureau of Environmental and Occupational Health
• Margie Coons – Wisconsin Childhood Lead Poisoning Prevention Program
Introduction to Lead Based Paint• 24 million homes in USA have lead
paint (CDC, 2014)
• ~3 million metric tons of lead paint in US homes (CDC, 1991)
• Nearly 4 million homes with children living in them have lead based paint (CDC, 2014)
• *Leaded Gasoline Emissions*
5.5–6.7 million metric tons in soil (CDC, 1991)
75% remains
Introduction to Lead Based Paint
• 14.1% of pre-1940 housing >1200 ppm
• 1% of post-1960 housing >1200 ppm
http://www.usgs.gov/blogs/features/usgs_top_story/getting-the-dirt-on-soil/
Introduction to Lead Based Paint• Homes built before 1978 most likely to have lead based paint (HUD, 2011)
Introduction to Lead Based Paint• 1940s: Manufacturers began to remove lead from paint voluntarily
• 1971: Lead Based Paint Poisoning Prevention Act
Prohibited paint ≥ 1% lead by weight
Allowable levels
0.5% until 12/31/1974
0.06% (600 ppm) after 12/31/1974
• 1978: Consumer Product Safety Commission
Banned use of leaded paint in homes
Childhood Lead Poisoning• Approximately 535,000 children currently have elevated blood lead
levels ≥ 5μg/dL (CDC, 2014)
2012: Standard for lead poisoning was lowered
Previously ≥ 10μg/dL
Now ≥ 5μg/dL
• Children ages 1 – 6 years old are at highest risk for lead poisoning (CDC, 2014)
• Children living in Renter occupied units are at greater risk for significant exposure to lead based paint (HUD, 2011) Renter: 30% of homes
Owner: 23% of homes
Childhood Lead Poisoning• Learning Impairments
4th grade standardized tests (Amato, 2012)
Reading
Mathematics
Language Arts
IQ Reductions (Nevin, 2012)
Childhood Lead Poisoning• Learning Impairments
4th grade standardized tests (Amato, 2012)
Reading
Mathematics
Language Arts
IQ Reductions (Nevin, 2012)
• Behavioral Impairments 4th grade suspension rates (Amato, 2013)
2.66 times more likely
23% of the racial discipline gap
Crime (Nevin, 2012)
Violent Crime – 23 year lag time
Childhood Lead Poisoning• Learning Impairments
4th grade standardized tests (Amato, 2012)
Reading
Mathematics
Language Arts
IQ Reductions (Nevin, 2012)
• Behavioral Impairments 4th grade suspension rates (Amato, 2013)
2.66 times more likely
23% of the racial discipline gap
Crime (Nevin, 2012)
Violent Crime – 23 year lag time
Homicides – 21 year lag time
Childhood Lead Poisoning
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
% O
F C
HIL
DR
EN
TE
ST
ED
YEAR
Percent Children Tested with Elevated BLLs (≥10 µg/dL )
U.S. Totals Wisconsin Milwaukee, WI
Data Sources: 1 Centers for Disease Control and Prevention: Childhood Lead Poisoning Data, Statistics, and Surveillance. 2 City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports
Objectives• Identify risk of lead poisoning in:
1. Children that live in Unabated Pre-1940 Homes
Age stratification
2. Families that live in Non-owner Occupied, unabated Pre-1940 Homes
3. Children living in Previously Abated Pre-1940 Homes
Stratified by
Age
Time after abatement
Type of abatement
Methods – Incidence (1996 – 2011)
• Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
De-Identified 222,804 children
Cases: ≥ 10μg/dL
Non-Cases: < 10μg/dL
Date first confirmed
Address
Age at test
Methods – Property Information
• City of Milwaukee Master Property Records (MPROP)
Address
Taxkey
Year of Construction
Pre-1940
Post-1940
Owner Occupancy
• Parcel Base - Property Map
Methods – Home Abatement (1996 – 2011)
• Lead Safe Housing Registry (LSHR) – City of Milwaukee
Address of Abated Unit
Date of Abatement
Abatement Type
Primary Prevention
Secondary Prevention
Methods – Analysis and Mapping
• Addresses matched for each record at date first confirmed
• Geocoded with ArcGIS 10.2.2. software
Cases: N = 21,317
Non-Cases: N = 141,478
Abated Homes: N = 16,886 units
Methods – Analysis• Relative Risks calculated (1996 – 2011)
15 year aggregate risk
Year of Construction (Pre-1940 vs. Post-1940)
Stratified by Age at test
Owner vs. Non-owner occupied
Date of Abatement
Stratified by:
Age at test
Prevention Type
Time After Abatement
Annual risks
Year of Construction
Occupancy
Abatement
4 year aggregate risk
Primary/Secondary Prevention
Results – Seasonal Variation of Incidences
Data Source: Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New cases occur most frequently
during summer months every year
Overall decrease in new cases from
1996 - 2011
Results – Annual Cases and Home Abatement
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
CU
MU
LA
TIV
E #
OF
UN
ITS
AB
AT
ED
CH
ILD
RE
N W
ITH
EL
EV
AT
ED
BL
OO
D L
EA
D
YEAR
Elevated Blood Lead Levels and # of Units Abated
Pre-1940 Units Abated Total Units Abated Prevalance Incidence
Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee
Incidence and prevalence of cases
decrease each year as more pre-1940
units are abated
Results – Annual Cases and Home Abatement
• Each Year:
Prevalence decreased 13.4% (R2 = 0.98)
Incidence decreased 10.8% (R2 = 0.95)
An estimated 984 homes were abated - 821 were Pre-1940 homes
Results – Cases and Home Abatement
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
0 2000 4000 6000 8000 10000 12000 14000
NU
MB
ER
OF
CA
SE
S P
ER
YE
AR
TOTAL NUMBER OF ABATED UNITS
Case Reduction per Unit Abated (1996 - 2011)
Incidence Prevalence
Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee
Incidence decreases by 10.8% &
prevalence decreases by 13.5% for every
1,000 units abated
Results – Cases and Home Abatement
• Per 1,000 units abated:
Prevalence decreased 13.5% (R2 = 0.97)
Incidence decreased 10.8% (R2 =0.93)
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New Cases = 21,317New cases from 1996 – 2011 spatially
correlate with pre-1940 homes
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
New Cases = 21,317Abated Units = 16,886
Prevention efforts successfully
targeted homes in high-risk areas
New Cases = 5,816
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
In 1996, 5,816 new cases were reported to
Milwaukee Health Department prior to
Childhood Lead Poisoning Prevention efforts
New Cases = 5,816
New Cases = 381
Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)
After 15 years of Childhood Lead Poisoning Prevention
Program targeted efforts, new cases were reduced 381 in 2011
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
As targeted
abatement
efforts increase,
new cases in
that region
decrease each
year
Results –Relative Risk for Lead Poisoning based on key factors
Results – Annual Risk in Unabated Units
y = 0.2076x - 409.99
R² = 0.4299
0
1
2
3
4
5
6
7
8
9
10
11
12
13
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Rela
tive R
isk
Ra
tio
Year
Unabated Pre-1940s Homes
Annual Risk 15 yr Aggregate Risk Annual Regression
Results – Annual Risk in Rental Units
0
0.5
1
1.5
2
2.5
3
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Rela
tive R
isk
Ra
tio
Year
Renter Occupied Pre-1940 Units
Annual Risk 15 yr Aggregate Risk
Results – Annual Risk in Abated Units
y = 0.0049x - 8.6599
R² = 0.0049
0
0.5
1
1.5
2
2.5
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Rela
tive R
isk
Ra
tio
Year
Abated Pre-1940 Units
Annual Risk 15 yr Aggregate Risk Annual Regression
Summary – Risk for Lead Poisoning• Pre-1940 homes were 5.8 times higher than Post-1940 homes
Children 24 months or younger were 7.91 times higher in Pre-1940 homes
Children older than 24 months were an average of 3.99 times higher in Pre-1940 homes
• Children living in non-owner occupied homes were 2.02 times higher risk for lead poisoning than in owner occupied homes
• Lead abatement in Pre-1940 homes reduced the risk to 0.69 times that of an unabated Pre-1940 home Primary Prevention was 0.56 times lower than an unabated Pre-1940 home
Secondary Prevention was 1.15 times higher than an unabated Pre-1940 home
No difference in risk was present for 9 month cut off period
Children older than 48 months may have greater reduced risk – small sample
• Prevalence reduced by 13% per 1,000 units abated
• Incidence reduced by 11% per 1,000 units abated
Future Directions – Risk Analysis & GIS
• Few studies have investigated home paint abatement and BLLs Most studies look at Secondary Prevention
Primary Prevention are lacking
Long term integrity of prevention efforts are lacking
• This investigation has one of the most complete data sets Lead Abatement records per home
Blood Lead test results for every test taken
• Innovative data analysis and powerful risk calculations
• GIS data analysis and case surveillance
• Provides the ground work for future studies, education and policy
• Integration with soil remediation
References• Center for Disease Control and Prevention (1991, October 1). Preventing Lead
Poisoning in Young Children: Chapter 3. Retrieved from: http://www.cdc.gov/nceh/lead/Publications/books/plpyc/chapter3.htm
• Center for Disease Control and Prevention (2014, June 19). Lead – Home Page. Retrieved from: http://www.cdc.gov/nceh/lead/
• Center for Disease Control and Prevention (2014, October 30). LCDC’s national Surveillance Data (1997-2013). Retrieved from: http://www.cdc.gov/nceh/lead/data/national.htm
• Center for Disease Control and Prevention (2014, October 30). LCDC’s national Surveillance Data (1997-2013). Retrieved from: http://www.cdc.gov/nceh/lead/data/national.htm
• City of Milwaukee Health Department (2014, September, 12). Lead Poisoning Prevention Data and Reports. Received from: http://city.milwaukee.gov/Lead-Poisoning-Prevention-Data#.VI88wqecteU
• Cox, D.C., Dewalt, G., O’Haver, R., and Salatino, B. American Health Homes Survey; Lead and Arsenic Findings. U.S. Department of Housing and Urban Development: Office of Healthy Homes and Lead Hazard Control, April, 2011.Mielke, 2010
Appendix 1
Appendix 2
Year of Construction, Owner Occupancy and Prior Abatement Relative Risk Calculations with 95% Confidence Intervals for Aggregate and Annual Lead Poisoning RatesRelative Risk (95% CI) 15 year Aggregate (1996 - 2011) 1996 1997 1998 1999 2000 2001 2002
Pre-1940 Unit 5.83 (5.57, 6.11) 3.64 (3.32, 3.98) 3.79 (3.42, 4.20) 5.68 (4.78, 6.75) 4.77 (4.04, 5.63) 4.55 (3.87, 5.36) 5.45 (4.51, 6.59) 5.43 (4.45, 6.64)Non-Owner Occupied 2.01 (1.96, 2.08) 1.73 (1.65, 1.84) 1.76 (1.65, 1.88) 1.89 (1.71, 2.10) 1.85 (1.67, 2.05) 1.64 (1.47, 1.82) 1.77 (1.58, 1.99) 1.77 (1.57, 2.01)
Prior Abatement 0.6908 (0.66, 0.73) 1.01 (0.45, 2.25) 0.92 (0.60, 1.41) 1.06 (0.77, 1.47)0.8792 (0.68,
1.13) 1.24 (1.04, 1.48) 1.58 (1.35, 1.85)
Case (≥ 10 μg/dL) 22769 5816 3696 1725 1657 1438 1396 1269No Case (≤ 10 μg/dL) 163398 13709 11352 9534 7373 8123 9364 9908
Relative Risk (95% CI) 2003 2004 2005 2006 2007 2008 2009 2010 2011
Pre-1940 Unit 7.06 (5.51, 9.05) 8.22 (6.32, 10.69) 5.70 (4.48, 7.25) 7.47 (5.43, 10.26) 5.86 (4.37, 7.86) 8.32 (5.81, 11.92)8.33 (5.81,
11.95) 5.98 (4.32, 8.29) 5.66 (4.01, 7.98)Non-Owner Occupied 1.70 (1.48, 1.95) 2.02 (1.75, 2.24) 1.76 (1.51, 2.05) 1.85 (1.53, 2.23) 2.25 (1.85, 2.74) 1.56 (1.28, 1.91) 1.86 (1.49, 2.31) 1.57 (1.23, 1.99) 2.05 (1.56, 2.70)Prior Abatement 1.89 (1.63, 2.19) 1.69 (1.44, 1.99) 1.59 (1.35, 1.87) 1.42 (1.15, 1.75) 1.22 (0.99, 1.51) 1.18 (0.95, 1.47) 1.08 (0.85, 1.37) 0.83 (0.63, 1.10) 1.21 (0.93, 1.55)
Case (≥ 10 μg/dL) 1046 936 838 589 600 520 461 401 381No Case (≤ 10 μg/dL) 9514 9939 9296 8968 10296 10598 11122 12680 11622
Results –Risk by Abatement Type (4-Year Range)
Year Range Abatement
Record
Relative Risk 95% CI
1996 - 1999 Total Abated 0.78 (0.61, 1.00)
Primary 0.69 (0.53, 0.91)
Secondary 3.18 (3.13, 3.23)
1999 - 2003 Total Abated 1.38 (1.27, 1.50)
Primary 1.1 (0.98, 1.23)
Secondary 2.36 (2.1, 2.66)
2004 - 2007 Total Abated 1.45 (1.32, 1.58)
Primary 1.2 (1.07, 1.34)
Secondary 2.25 (1.97, 2.58)
2008 - 2011 Total Abated 1.06 (0.94, 1.20)
Primary 0.86 (0.74, 0.99)
Secondary 1.83 (1.52, 2.20) 0
0.5
1
1.5
2
2.5
3
3.5
1996-1999 2000-2003 2004-2007 2008-2011
Rela
tive R
isk
Year Range
Abatement Type (4 Year Range)
Total Abatement Primary Prevention Secondary Prevention
Total 15 yr risk Primary 15 yr risk Secondary 15 yr risk
Appendix 3
Year Range Abatement
Record
Case
(≥ 10 μg/dL)
No Case
(< 10 μg/dL)
Total Relative Risk 95% CI
1996 - 1999 Total Abated 48 147 195 0.78 (0.61, 1.00)
Primary 41 147 188 0.69 (0.53, 0.91)
Secondary 7 0 7 3.18 (3.13, 3.23)
None 10,982 23,917 34,899
1999 - 2003 Total Abated 443 1,370 1,813 1.38 (1.27, 1.50)
Primary 274 1,135 1,409 1.1 (0.98, 1.23)
Secondary 169 235 404 2.36 (2.1, 2.66)
None 3,897 18,095 21,992
2004 - 2007 Total Abated 482 2,581 3,063 1.45 (1.32, 1.58)
Primary 305 2,036 2,341 1.2 (1.07, 1.34)
Secondary 177 545 722 2.25 (1.97, 2.58)
None 2,094 17,153 19,247
2008 - 2011 Total Abated 303 4,315 4,618 1.06 (0.94, 1.20)
Primary 192 3,441 3,633 0.86 (0.74, 0.99)
Secondary 111 874 985 1.83 (1.52, 2.20)
None 1,175 17,875 19,050