R E N E E O ’ B R I E N , B S N , R N
P U B L I C H E A L T H N U R S E
S A N T A C L A R A C O U N T Y P U B L I C H E A L T H D E P T .
C H I L D H O O D L E A D P O I S O N I N G P R E V E N T I O N P R O G R A M
Childhood Lead Poisoning Working Together
Toward Prevention and Healthy Outcomes
Acknowledgements
Iman Abouazra, MPH
Environmental Epidemiology, Loma Linda University
Somayeh Bolourchi, MPH
Research Epidemiology, Loma Linda University
William F. O’Brien, MBA, CPA
Accounting Professor / Lecturer
San Jose State University
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Which One?
Can YOU identify the child
in this slide show
who is lead poisoned?
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How Can We Know For Sure?
Can we as medical providers, Head Start family advocates, parents, and public health professionals know for sure which children we can safely ignore and which children we must more closely assess when it comes to determining
lead risk?
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Learning Objectives
At the end of this presentation, participants will be able to:
Understand why lead poisoning and prevention awareness is important for providers, the Head Start community, and families alike.
Understand how each of us play specific roles in facilitating healthy outcomes for children.
Describe four ways in which children can be kept
lead-safe.
Be able to confidently answer the questions posed in the previous slides.
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Lead Poisoning Today
A Little Bit About Lead
Data/Statistics
Why Lead Poisoning and Prevention
Awareness are Important
Sources of Lead
Populations at Risk
A Day in the Life… Through the Lens of the “Lead” Nurse
Working Together Towards the Goal of Health
Things to Remember
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A Little Bit About Lead
A Few Key Points About Lead
Lead poisoning continues to remain a serious environmental health hazard, especially for low-income families.
Lead poisoning is the most common and preventable environmental disease among California children.1
Early diagnosis is best achieved through screening.
o The best way to detect elevated lead levels is through a blood test.
o Children often do not display obvious symptoms of elevated lead levels.
1. MMWR May 27, 2005/54(20); 513-516
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Scope of the Problem
There are NO known safe levels.1,2
Even low levels of lead in the blood have been shown to affect IQ, the ability to pay attention, and academic achievement.
The effects of lead exposure cannot be reversed or erased…..prevention is the key!
1. Koller et al. EHP, Jun 2004 2. Bellinger, Current Opinions in Pediatrics, 2008, 20: 172-177
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Data / Statistics
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National Statistics
Estimated 500,000 American children between 1 and 5 yrs old have blood lead levels ≥5µg/dL1
1Centers for Disease Control (CDC), 2012; www.cdc.gov/nceh/lead
Santa Clara County No. of Children Screened for Lead - 20101
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1http://www.cdph.ca.gov/programs/CLPPB/Documents/BLL%20Counts%202010%20by%20LHD%20final.pdf
Age Group (yrs.)
BLL <4.5µg/dL _______
n % (row)
BLL >4.5 to <9.5µg/dL _______
n % (row)
BLL > 9.5µg/dL
_______ n % (row)
Total Children Tested
Age <6 26,052 98.70% 285 1.08% 59 0.22% 26,396
Age 6 -<21 1,919 96.68% 54 2.72% 12 0.60% 1,985
Local Total Age <21
27,971 98.56% 339 1.19% 71 0.25% 28,381
Head Start Statistics – Lead
Children in Head Start Programs in Santa Clara County:
Head Start: 2268
Early Head Start: 88
Numbers tested for lead:
Head Start: 2189 (96.5%)
Early Head Start: 88 up to date (100%)
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Courtesy of Pam DeJesus, Health Services Coordinator/Children Services/ Head Start Program- Santa Clara County
Office of Education, 12/2013
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1 . L E A D P O I S O N I N G I S P R E V E N T A B L E … . B U T T H E D A M A G E I S I R R E V E R S I B L E !
2 . L E A D E X P O S U R E C A N H A R M D E V E L O P I N G B R A I N S .
3 . E V E N L O W L E V E L S O F L E A D C A N C A U S E P R O B L E M S W I T H C O G N I T I O N A N D B E H A V I O R A L D E V E L O P M E N T .
4 . L E A D P O I S O N I N G C A N B E P R E S E N T W I T H O U T S I G N S O F I L L N E S S .
Why Lead Poisoning Prevention and Awareness
Are So Important
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Pregnant Women and the Developing Fetus
Transplacental transfer of lead during pregnancy, even at levels <10µg/dL1
Lead has been measured in the fetal brain as early as the first trimester of pregnancy2
1 American Family Physician, Figure 1, February, 1998 2 U.S. Department of Health and Human Services. (2010)
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Studies Correlate Lead Exposure in Children with…
Poor academic achievement1
Juvenile delinquency2
Elevated school drop-out rate3
Direct effect on behavior4
ADHD5
1Bellinger DC, et al. Pediatrics 1992; 90(6):855-61 2 Dietrich KN, et al. Neurotoxicol Teratol 2001; 23(6): 511-8 3 Needleman, et al. NEJM 1990; 322(2):83-8 4 Chen, et al. Pediatrics 2007; 119:e650-8 5 Braun, et al. Environ Health Perspect 2006; 114:1904-9
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Prolonged IQ Effects
Low levels of exposure can
cause hearing, behavior,
and learning problems1,2
IQ can drop 5-8 points as a
result of early childhood
exposure3
1Pocock & Smith, 1994, Review 2Needleman, 2004, Lead Poisoning 3Bellinger, 1992, decrease of 5.8 IQ points
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Correlation of Symptoms to BLL
Death
IQ
Children Lead μg/dL (μmol/L) Adults
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Sources of Lead Poisoning
• Deteriorating lead paint
in pre-1978 housing • Lead-glazed ceramic pots • Home remedies, ayurvedic medicines, and cosmetics
• Spices and imported foods
• Candy, toys, and jewelry • Take-home exposure
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Deteriorating Lead-Based Paint
Major source of high dose lead poisoning in the U.S. 1
1 U.S. Housing and Urban Development Department
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Lead-Glazed Ceramic Cooking Pots
Food prepared in lead-glazed pots or dried on clay plates allows lead to leach into the food.
Acidic foods enhance this leaching process.
Examples:
Chapulines (Grasshoppers)
Semillas (Pumpkin seeds)
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Home Remedies, Cosmetics, & Ayurvedic Medicines
Vietnamese Ayurvedic
medicine used for asthma
Spices and Imported Foods
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Chile powder
and turmeric
have been
found to have
lead
Recently, some
imported rice
had lead
Some imported cans have
seams soldered with lead
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Candy, Toys, and Jewelry
Please check current websites for most recently recalled candies and toys—these change monthly!
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Take-Home Exposure of Lead
• High-risk lead occupations include: o painting, construction, radiator/battery recycling and repair, landscaping, and metal/glass working
Populations at Risk
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Children of Crawling Age
Children ages 1-6 are at highest risk
• Hand-mouth
behavior
• Crawling
• Greater absorption rate
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Children Residing in Pre-1978 Housing
Higher prevalence of lead-based paint and paint dust from deteriorating paint
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Housing in Santa Clara County - 2011 Update
Approximately 67% (426,418) of all housing units were built
before 1980 and presumed to contain lead-based paint1
12011 U.S. Census data
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Child Immigrants
Dietary, cultural, religious, or ceremonial habits may cause unknowing ingestion of lead.
Gastrointestinal Absorption
40% in children compared to 15% in adults1.
Deficiencies in iron, calcium, protein, and zinc are related to increased blood lead levels and an increased vulnerability to the adverse effects of lead2.
1Ziegler et al, 1978
2Mahaffey, 1981; Mahaey and Michaelson, 1980
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A Day in the Life… Through the Lens of the “Lead” Nurse
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Case Study #1 New Lead Source Identified – Ceremonial Powder
9 mo. old East Indian male
Born in Chennai, Southern India
Initial BLL: 24.4µg/dL
Initial HV/ assessment: potential exposure from India; use of sindor
No significant drop in BLL over 2 yrs.
Repeat HV/assessment (11/09):
Ceremonial chalk (110,000 ppm)
Identification:
Used in religious ceremonies by FOB-worn 24 hours/day
Worn on 12 parts of the body
Identified by the California CLPPB as “srichoornam”
Mode of transmission:
Inhalation-child slept with father
Ingestion-hand/mouth behavior
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Case Study #2 Food Ingestion – Chapulines
2 ½ y.o. Hispanic male
U.S. born; lived with mother and maternal grandparents (of Oaxacan descent)
Initial BLL: 17.3 µg/dL
Findings at Initial HV:
Possible Take-home exposure from Grandfather ( OLPPP; BLL: 7.0ug/dL)
Possible exposure from exterior soil (EI negative findings)
BLL to 42. 4 µg/dL in < 2 months
Repeat HV:
MOB disclosed that child was eating chapulines sent by relatives living in Oaxaca, Mexico
Post-script: This child recently resurfaced with a new EBLL: 15.6ug/dL (date?); so far, PHN has been unsuccessful in contacting family…suspect…chapulines as repeat lead source???
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Case Study #3 Ingestion – Liquid – Where You Least Expect It!
2 ½ y.o. US born, Hispanic female
Initial BLL: 44 µg/dL
Initial assessment: Lead hazard believed to be occupational source from MOB
MOB OLPPP for
follow-up
worksite investigation: insignificant BLL’s
All family members tested; everyone had significant EBLL ‘s … except for child’s sibling whose level was <2 µg/dL !
Subsequent Home Visits: Several HV’s/ TC’s/Investigations
MOB disclosed that family had been consuming pineapple juice prepared and stored in a clay jug
Sibling did not drink the pineapple juice!
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Case Study #4 Old Housing – Lead in Interior and Exterior Paint
1 y.o. US born, male of Greek/Hispanic ethnicity
Initial BLL: 23.8 µg/dL
Initial assessment:
Home (circa 1886)
Environmental investigation → lead in interior and exterior paint and bare soil.
Two siblings (ages 2 and 3) tested: EBLL’s (7.9 and 8.3 µg/dL)
Follow Up:
All three children have had an
BLL ↑ since initial HV/ EI
was completed and action plan
initiated.
Interior lead abatement is complete.
Exterior lead abatement is not yet complete d/t REHS’ difficulty coordinating efforts with clean-up company and owners.
Current Status:
REHS will now send an enforcement letter to the owner.
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Working Together Towards the Goal
Many Hands Make Light Work!
EVERYONE ON THE TEAM HAS A ROLE.
THE GAME PLAN MUST BE SHARED WITH ALL THE PLAYERS.
COMMUNICATION IS KEY.
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Head Start and Lead
May 2000: Office of Head Start
Issued an information memorandum regarding the
“Childhood Lead Poisoning Prevention Collaboration:
Reiterated the importance of lead screening and clarified the requirements for lead toxicity screening for
Head Start Children
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Where Head Start Comes Into Play
Lead poisoning remains a serious environmental health hazard for those living in poverty and young children under the age of 6.
Those children living in poverty tend to live in older housing which contains lead-based paint or lead plumbing.
Estimates based on screenings show that low-income and Medicaid-eligible children are nearly 5 times more likely to have harmful blood lead levels than the general population1
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1.http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.
Screening for Lead Toxicity
2001: Journal of the American Academy of Pediatrics:
60% children with EBLL’s were Medicaid recipients
83% of children with BLL’s > 20µg/dL were on Medicaid
Centers for Medicare and Medicaid Services (CMS):
“all low-income, Medicaid-eligible children must be screened for lead poisoning using a blood test”.
Conclusion: All children who qualify for Medicaid are considered “at risk” for the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT) blood risk assessment.
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Medical Provider - Role
Know Your Responsibilities for Screening
Knowledge is Power!!!
California Health and Safety Code- Title 17
Head Start Health Requirements : Federal Regulations 1304.20 (a)(ii)and State Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Schedule, which includes:
Blood test results for lead level at 12 and 24 months or 24 to 72 months, if not tested previously
Blood lead risk assessment
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Head Start Family Advocate- Role
Assist families in insuring that child is linked to medical provider and is getting all screening completed as required.
Follow up with Head Start Director/ Lead Case Manager with unresolved problems to insure that child’s lead screening is ultimately completed in a timely fashion.
Collaboration is key!
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Family - Role
Healthy habits start with families. Make your child’s health a priority and a habit! Insure that your child is tested for lead at the appropriate times.
The only way to know for sure if a child is lead poisoned is through a blood test
Learn about lead poisoning. Find out what you can do to remove lead hazards from the environment in which your child lives.
You are the best role model for your child. The emphasis you put on good nutrition will go a long way in helping a child with lead poisoning.
A diet high in calcium, iron, protein, and vitamin C works to fill the stomach and help assist in the removal of lead from the body.
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Public Health Professional - Role
Provides interagency collaboration and expertise regarding guidelines for lead screening.
Consults with medical providers regarding lead screening requirements for children entering Head Start programs.
Provides support and guidance to Head Start family advocates when needed with regards to lead poisoning and prevention.
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CDC Guidelines: Medical Case Management
There is no safe level of lead!
Level of Concern has been replaced by Reference Value : 5µg/dL1
Focus is on primary prevention and response to children with BLL’s 5µg/dL1
1 http://www.cdc.gov/nceh/lead/acclpp/final_document_010412.pdf
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Provider Responsibilities
California Code of Regulations, Title 17, Div.1, Ch.9: Screening for Childhood Lead Poisoning
Starting at 6 mo. and continuing to 72 mo. of age:
PUBLICLY FUNDED PROGRAMS: (MediCal, CHDP, WIC,
Healthy Families)
Screen (test) for lead
Educate parents on lead hazards/poisoning
Provide clinical evaluation for complications of lead poisoning
Refer the child to CLPPP (any BLL > 5µg/dL)
Perform follow-up blood lead analyses as determined by state guidelines or as provider/CLPPP deem appropriate
Chelate if appropriate in the judgment of the provider
1http://www.cdph.ca.gov/programs/CLPPB/Pages/CACodeofRegsfull-CLPPB.aspx
Provider Responsibilities (continued)
PRIVATELY FUNDED PROGRAMS:
Must provide oral or written anticipatory guidance:
Does your child live in or spend a lot of time in a place built before 1978 that has peeling or chipped paint or that has been recently renovated?
If parent or guardian answers yes, or don’t know to any of the questions, order child to be screened for lead poisoning
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Things to Remember
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Keeping a Child “Lead Safe”
First…Prevention is key! Be knowledgeable about lead
hazards, and avoid or get rid of them!
Secondly…Provide your child with good nutrition .
This is the best “Rx” for lead poisoning
Thirdly…Wash children’s hands before eating,
as well as the toys that so often go into their mouths.
Finally…Find safe play areas for children to play, away
from contaminated soil where lead dust has fallen.
Make sure that your child has a chance to thrive…their
future depends on your vigilance …NOW!
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In Conclusion…
1. Children living in poverty, and below the age of six are at the highest risk of lead poisoning.
2. All Medicaid-eligible children must receive a screening blood test at 12 and 24 months of age.
3. A child with lead poisoning may not necessarily act or look sick, so it is imperative that we be pro-active in appropriately screening the Head Start eligible population.
4. Medical providers, Head Start family advocates, family members, and public health officials have unique and different roles, and must work to insure that all children develop in the most optimal and healthy environment possible.
5. Lead exposure can harm developing brains, even at low levels. So….the best remedy is to stop exposure BEFORE it begins.
The Answer Revealed!
So…..what is the answer to the question posed at
the beginning of this presentation?
Which child did YOU identify as the one with
lead poisoning?
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Did you guess any of these?
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Or these?
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Did You Guess Correctly?
Any child could be the child with lead poisoning. You cannot tell by looking at a child whether or not he or she has lead poisoning.
The only way to know for sure is through a blood test.
If you are concerned that your child has been exposed to lead hazards, contact your provider and ask to have your child tested for lead.
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Web Resources
Centers for Disease Control http://www.cdc.gov/nceh/lead
California Department of Public Health CLPPP http://www.cdph.ca.gov/programs/clppb/Pages/
Santa Clara County CLPPP http://www.sccgov.org/sites/sccphd/en-us/Pages/phd.aspx
Environmental Protection Agency http://www.epa.gov/lead
Get the Lead Out Coalition of the Bay Area http://getleadout.org
Consumer Product Safety Commission: Recalled Consumer Products
http://www.cpsc.gov/en/Recalls/
California Food and Drug Administration: Recalled food
www.dhs.ca.gov/fdb
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Contact Information
Childhood Lead Poisoning Prevention Program
1993B McKee Road, SJ, CA 95116
Phone: 408-937-2263 Fax: 408-937-2249
Renee O’Brien, BSN, RN
Public Health Nurse
Thank You!
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