Preventing Elevated Blood Lead Levels High Level of Lead in Sindoor - - PDF document

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Preventing Elevated Blood Lead Levels in Children

Funded by the New Jersey Department of Health

Lead in the News

Tests find more lead in products Physician’s 2-year old son poisoned by lead in their home High Level of Lead in Sindoor

Learning Objectives

Summarize public health’s role in preventing and managing elevated blood lead levels in children Identify sources, its route(s) of exposure and prevention measure(s) Summarize the role of the pediatric health care provider in preventing, identifying, and managing elevated blood lead levels in young children List three effects of lead exposure in the pediatric population

Prevention is # 1

Through family education, screening, care coordination and communication within the medical home neighborhood, the pediatric provider can educate families

• n prevention, while at the same time screen for lead

poisoning prevalence in the community

Childhood lead poisoning is one of the most common – AND PREVENTABLE – pediatric environmental health problems in the United States today

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Lead 101

 A naturally

• ccurring metal

 Found in air, soil,

water, and in our homes

 May still be found

in paint, ceramics, pipes and plumbing materials, batteries, ammunition, and cosmetics

 It can travel via air

before settling to the ground and

 Sticks to soil

particles

 May move from

soil to groundwater

 May also move

because of flooding or damage to homes

What exactly is lead? What happens when it enters the environment?

No Safe Level of Lead

 When the body is

exposed to lead, it can act as a poison

 At very high levels,

lead poisoning can be fatal

Sources of Lead

Lead dust resulting from:

 Old lead paint

flaking off

 Home repair

activities

 Tracking lead

contaminated soil into home

 Clothing worn

at a job site

Contamination due to water intrusion & sediment flow Lead-based paint:

 Most

common for children

 Found on

impact & friction surfaces

 Often found

under layers

• f new paint

Sources of Lead

Hobbies & Occupations Cultural Remedies & Practices Soil Consumer Goods

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3,797 6,112 2,792 2,750 4,117 14,189 24,530 11,091 2,908

Most Affected Counties in NJ Number of Housing Units Damaged

New Jersey Housing

Percentage of pre-1980 housing in NJ by municipality

National Housing Stock Who is at Risk?

Children under 6 years of age Children living at

• r below

poverty line Children of some racial and ethnic groups Children living in older housing Pregnant women

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• Lead exposure in utero can

lead to premature birth, smaller babies, decreased mental ability in infants, learning disabilities, & reduced growth in young children

• High level exposure in adult

males can damage sperm production

• In pregnant women, high levels
• f exposure may lead to

miscarriage

Health Implications Health Implications

• Elevated blood lead levels are

not easy to detect without a blood test

• Many times there are no

symptoms, or the symptoms are the same as those of more common illnesses like an upset stomach or the flu

Health Implications

Signs of an elevated blood lead level may include:

• Persistent tiredness or

hyperactivity

• Irritability
• Loss of appetite
• Weight loss
• Reduced attention span
• Difficulty sleeping
• Constipation/abdominal pain
• Anemia

If not detected early, children with high levels of lead can suffer from:

• Damage to the brain & nervous system
• Behavior & learning problems;

hyperactivity

• Slowed growth
• Hearing problems
• Headaches
• In rare cases elevated blood lead levels

can result in seizures, coma and even death

Health Implications

Source: http://www.cdc.gov/lead/

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Health Implications

Source: http://www.nchh.org/Portals/0/Contents/Childhood_Lead_Exposure.pdf

The rate of IQ loss per 1 μg/dL is greatest at lead levels below 10 μg/dL BLL increase from 1 – 10 μg/dL  3.9 – 7.4 IQ points BLL increase from 10 – 30 μg/dL  2.5 – 3.0 IQ points Lower blood lead levels may have an even greater effect on IQ than high BLLs

Lead Poisoning: A Civil Rights Issue

Child’s IQ = Aggression Impulsivity Crime Removing disparities in access to healthy, safe, and affordable homes is essential to improving the quality of life for minority and low-income populations.

National & State Lead Poisoning Prevention Goals

Healthy People 2020 Healthy New Jersey 2020 To eliminate childhood lead poisoning as a public health problem

Healthy People 2020 Objective

Identification and control of lead paint hazards Identification and care for children with elevated blood lead levels Surveillance of elevated blood lead levels in children to monitor progress Research to further improve childhood lead poisoning prevention methods CDC shifting focus  primary prevention

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NJ DOH Leads the Way

• Create a collective voice on health policy
• Combine resources across all State departments
• Pool data
• Coordinate efforts
• Prioritize and direct implementation
• Catalog what each State department is already doing
• Identify “hot spots” for targeted action

NJ DOH Leads the Way Earlier Intervention Old Rule: 10 μg/dL New Rule: 5 μg/dL Healthy New Jersey 2020 Objectives

To reduce mean blood lead levels in children

NJ Baseline: 3.8 μg/dL Federal Baseline: 1.8 μg/dL NJ Target: 3.4 μg/dL Federal Target: 1.6 μg/dL Target-Setting Method: 10% Improvement NJ State FY 2016: 1.7 μg/dL

Healthy New Jersey 2020 Objectives To reduce blood lead levels in children

NJ Baseline: 8.0 μg/dL Federal Baseline: 5.8 μg/dL NJ Target: 7.2 μg/dL Federal Target: 5.2 μg/dL Target-Setting Method: 10% Improvement NJ State FY 2016: 5.0 μg/dL

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Role of the Provider: From Prevention to Care Management

Provide screening for lead poisoning following established screening schedules Conduct appropriate diagnostic blood lead testing in children with symptoms or signs consistent with lead poisoning Interpret blood lead results Educate parents about reducing blood lead levels Coordinate with local public health officials Ensure that poisoned children receive appropriate medical, environmental and social service follow-up Provide anticipatory guidance about childhood lead poisoning and its prevention

Role of the Provider

New Jersey State Law (N.J.A.C. 8:51A-2.2) Lead screening must be performed:

• 1 year & 2 years of age
• Older than 26 months, but < 6 years
• f age if never previously screened
• Children found to be at risk

Role of the Provider

New Jersey State Law (N.J.A.C. 8:51A-2.2)

• Requires physicians, nurses, health care facilities to

perform blood lead screening on children up to 27 months.

• Parents must be given results, and its meaning, for all

blood lead level results 5 μg/dL or greater.

www.nj.gov/health/childhoodlead

Role of the Provider

Screening for Lead Levels

BLL 5+ BLL 0 - 4 Coordination with Health Officials Retesting Appropriate Follow-up Care Management Education Education

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Role of the Provider

*For BLLs > 5 μg/dL, provider has responsibility to intervene PCP identifies EBLL > 5 μg/dL PCP arranges for venous confirmation (if EBLL is based on capillary specimen) Local health department notified by NJ DOH via LeadTrax of EBLL; contacts PCP Local health department begins case management and inspects home; informs PCP of outcomes PCP arranges for follow-up testing; local health department & PCP monitor BLL until discharge

PCP: Re-Testing Protocol

Source: https://www.cdc.gov/nceh/lead/publications /screening.htm If result of capillary screening test (μg/dL) is: Perform diagnostic test on venous blood within: 5-9 3 months 10-19 3 months 20-44 1 week – 1 month 45-59 48 hours 60-69 24 hours 70 or higher Immediately as emergency lab test

Role of the Provider

Risk Assessment Questionnaire

• Has there been a recent renovation of the child’s residence if

built before 1978, or if lead-based paint is known to be present?

• Is there deterioration of the paint in the child’s residence?
• Has the child moved into a house built prior to 1978 that has

peeling, chipping, or deteriorated paint?

• Did an adult living in the home undertake a new job or

hobby that involves exposure to lead?

Role of the Provider

Recommended actions for parents to reduce lead exposure:

• Do not let child play in bare soil
• Wash child’s hands after playing outside, before eating and

sleeping

• Frequently clean floors and windowsills with damp cloth or

mop

• Put washable doormats at all entries to home
• Remove/wipe shoes before entering home
• Wash toys with soap and water
• Offer a diet high in calcium and iron, low in fat

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Role of the Provider

Recommended actions for parents to reduce lead exposure:

• Store foods and liquids in lead-free containers
• Know if your home has lead-based paint before doing

renovations or remodeling

• Use lead-safe work practices or hire a Certified Renovator if

your home was built before 1978

• Use only cold tap water to prepare formula, for drinking and

cooking

• Run water for 15 to 30 seconds before using
• Wash work clothes separately if a job uses lead

SFY 2015: Number of Children (<6 years of age) by BLL and County of Residence

County Total Children in County % Tested BLL < 5 (μg/dL) % BLL < 5 (μg/dL) Atlantic 19,909 24.5% 4,662 95.4% Bergen 61,192 20.4% 12,272 98.2% Burlington 31,546 11.3% 3,506 98.1% Camden 40,195 13.8% 5,413 97.4% Cape May 5,423 12.8% 672 97.0% Cumberland 12,963 23.6% 2,886 94.4% Essex 64,591 40.4% 24,746 94.8% Gloucester 21,059 7.2% 1,480 97.2% Hudson 49,759 37.4% 18,085 97.1% Hunterdon 7,484 13.4% 982 98.2% Mercer 26,052 23.7% 5,919 96.0% Middlesex 60,249 20.4% 11,978 97.4% Monmouth 42,404 17.4% 7,201 97.3% Morris 33,493 11.5% 3,765 98.0% Ocean 46,657 23.9% 11,048 99.0% Passaic 41,179 35.9% 14,230 96.2% Salem 4,625 17.4% 723 89.7% Somerset 23,622 12.4% 2,886 98.2% Sussex 9,701 10.8% 1,032 98.2% Union 43,085 33.0% 13,779 97.0% Warren 7,434 14.0% 1,000 96.0% Not Specified N/A 19,306 98.2% Total 652,622 26.5% 167,571 97.0%

% low/moderate income by municipality % pre-1980 housing by municipality

In-Office Screening Methods

 Taking blood from a vein (venous)  Taking blood from a finger (capillary)

• Filter Paper
• Lead Care II Analyzer

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Public Law 2016, Chapter 86

 P.L. 2016, c.86 requires promulgate rules

and regulations regarding point-of-care testing

 N.J.A.C. 8:44 requires laboratories to

report BLL results to NJ DOH within two days of analysis

Medicaid Procedure Codes

36406.59

• Venipuncture < 3 years

36415.59

• Venipuncture age 3 and above

36416.59

• Capillary (includes filter paper)

Other Screening Options

 Federally Qualified Health Centers (FQHC)

www.njpca.org/page/LocateCenter

 Local Health Departments

www.nj.gov/health/lh/community/index.shtml#1

Health Insurance Plans & Screening

New Jersey State Law (N.J.S.A. 17B:27-46.1l) Group health insurance plans require coverage for the screening and treatment of elevated blood lead levels.

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Public Health’s Role

 Educate patients about the effects and

prevention of elevated blood lead levels

 Educate patients and parents about nutrition,

handwashing, housekeeping, and other ways to reduce exposure

 Assist in testing of siblings, other children and

pregnant women living in the same household

 Arrange home visit by a nurse case manager and

lead inspector/risk assessor

Public Health’s Role

 Assess a family’s needs for community resources  Collect information about the home  Test painted surfaces  Determine sources of lead exposure in the

neighborhood

 Test other possible sources of lead such as water,

soil, play structures and consumer products, such as toys

Public Health’s Role

 Development of policies  Enforcement of administrative codes  Provision of grant funding for education,

prevention and intervention

 Use of geographic information systems and

databases to monitor progress of key indicators

Education and Outreach Resources

Northern Regional Coalition

Coordinated by: Partnership for Maternal & Child Health of Northern New Jersey Serving: Bergen, Passaic, Union, Essex, Hudson, Sussex, Warren & Morris

Central Regional Coalition

Coordinated by: Monmouth County Health Department Serving: Monmouth, Ocean, Hunterdon, Somerset, Mercer & Middlesex

Southern Regional Coalition

Coordinated by: Southern NJ Perinatal Cooperative Serving: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester & Salem

New Jersey Poison Information & Education System

1-800-222-1222 http://www.njpies.org/

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Medical Home Neighborhood

The identification and management of lead poisoning requires a medical home neighborhood

Takeaway Questions for Providers

Who are the key populations at risk for lead exposure, and what are the health implications? Can I identify the many sources of lead? What questions should I ask my patients to help identify lead exposure? What are the various screening methods? What do I do, and who do I contact, if I identify an elevated blood lead level? What intervention is required – and when? What recommendations do I share with parents to help reduce lead exposure?

Awareness Campaign

• Increase awareness of

all lead hazards for children

• Educate parents and

healthcare providers about the risks of lead exposure in children

• Encourage parents to

get their children tested at ages 1 and 2 years

www.nj.gov/health/childhoodlead

Insert screen shot of web page

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www.njaap.org Acknowledgements

New Jersey Chapter, American Academy of Pediatrics Fran Gallagher, MEd Harriet Lazarus, MBA Elizabeth Griffin, MPH New Jersey Department of Health Crystal Owensby, M.S., MCHES Trenton Division of Health James Brownlee, MPH New Jersey Poison Information & Education System Diane Calello, MD, FAAP Bellevue Pediatrics Puthenmadam Radhakrishnan, MD, FAAP

Acknowledgements

Art in Motion Robert Stoller Child Voiceover Griffin Faith

Funding for this initiative was provided by the New Jersey Department of Health