Lead Screening in North Dakota To do or

Lead Screening in North Dakota “To do or not to do that is the question. . . ” North Dakota Health Department 1

Lead Screening - General l Changes in Pb intoxication definition levels – 1985 - 25 ug /d. L – 1991 - 10 ug /d. L l ND has no official statewide Pb screening plan l Should we have one? CDC says “Yes” North Dakota Health Department 2

Lead Screening - General l US Screening in children 12 -72 mo in the since 1991 (CDC recommendation for universal screening) – 25% (generally) – 33% (poor children) North Dakota Health Department 3

Lead Screening - Clinical l l 900, 000 (1997) US children have lead levels high enough to cause adverse effects on learning 1991 -94 – – – l 1 -2 yo - 5. 9% (Note this!!) 3 -5 yo - 3. 5% 6 -11 yo - 2% Greater risk - inner city, living in older houses – – 0% Alaskan poor children had levels > 11 ug / d. L 10% with levels > 25 ug / d. L 21. 9% black children living in houses built before 1946 66% with levels > 15 ug / d. L North Dakota Health Department 4

Lead Screening - Clinical North Dakota Health Department 5

Lead Screening - Clinical North Dakota Health Department 6

Lead Screening - Clinical l Internationally adopted children (MMWR 49: 5; 97 -100, Feb 11, 2000) – China - 38% > 10 ug / d. L – Russia - 58% > 10 ug / d. L North Dakota Health Department 7

Lead Screening - Clinical l Calcium and iron deficiency increase the amount of Pb absorbed l Neurologic consequences of chronic exposure are irreversible l Screening - serum lead levels (capillary or venous) not FEP or ZPP North Dakota Health Department 8

Lead Levels - Children North Dakota Health Department 9

Lead Screening - IQ Effects North Dakota Health Department 10

Lead Levels - Adults North Dakota Health Department 11

Lead Screening - Clinical l Association with ADHD / ADD - all should be screened l Aggressive / delinquent behavior / violent crime associated with bone lead levels - Nevin R. Environ-Res. 2000 may; 83(1): 1 -22. North Dakota Health Department 12

Lead Screening - Sources l Pb paint (housing built before 1978, particularly built before 1950) - greatest risk, residual is a problem (dust, soil) l Gasoline (outside the US) North Dakota Health Department 13

Lead Screening - Sources l Industries , work sites, occupations, etc – – – – Smelting / refining of nonferrous metals Brass / copper foundries Firing ranges Automotive repair shops Bridge / tunnel / elevated highway construction Motor vehicle parts / accessories Storage batteries (lead batteries) / primary batteries (wet / dry) Valve and pipe fittings Plumbing fixures / fittings / trim Pottery Chemical / chemical preparations Industrial machinery / equipment Inorganic pigments North Dakota Health Department 14

Lead Screening - Sources l Hobbies / Home activities – – – – Recreational use of firing ranges Home repairs / repainting / remodeling Furniture refinishing Stained glass making Making fishing weights / sinkers / toy soldiers Using lead solder (electronics) Using lead-containing artists’ paints / ceramic glazes – Burning lead painted wood – Car / boat repair North Dakota Health Department 15

Lead Screening - Sources l Others – Calcium supplements - brand name oyster shell derivatives (Ross EA et al: JAMA, Sep 20 2000; 284: 1425 -1429) - impact likely negligible – Public playground equipment (Consumer Product Safety Review, vol. 1, No. 2, Fall, 1996. North Dakota Health Department 16

Lead Screening - Playground Equipment l 1978 CPSC banned sale of paint with > 0. 06% lead by weight l 1992 - Residential Lead-Based Paint Hazard Reduction Act (Title X) - 0. 5% lead by weight - target for lead hazard control measures. North Dakota Health Department 17

Lead Screening - Playground Equipment l l l Cities sampled - 13 Playgrounds inspected - 26 Age of equipment – 14 -15 yo average, 4 cities (25 -45 yo) Lead containing paint – > 0. 06% - 20 playgrounds / 11 cities – > 0. 50% - 16 / 20 playgrounds Median Pb found – > 0. 06% - 0. 87% (range 0. 07 -8. 76) – > 0. 05% - 1. 47% (range 0. 62 -8. 76) Child ingesting 1/10 sq inch /day ( tip of a pencil eraser) / 15 -20 days would have lead level > 10 ug / d. L. Assumes 1. 47% Pb in paint and 30% absorption. North Dakota Health Department 18

North Dakota Housing 1990 Census North Dakota Health Department 19

Oregon - December, 1997 North Dakota Health Department 20

Oregon l l l 1991 CDC recommendations widely ignored 26. 5% of homes built < 1950 < 5 % of children 12 -72 mo have been screened Estimated 6000 intoxicated children in the state. Only 1042 have been identified. Targeted strategy to identify most at risk children – Young age (1 -2 yo) – Living in pre-1950 housing North Dakota Health Department 21

Oregon - Participation Plan l Developed a coalition to identify target communities for childhood lead screening – local health departments – private practices – managed care organizations – Medicaid – private insurance organizations – general community (any interested) North Dakota Health Department 22

Oregon - Revised Screening Recommendations l BLL’s should be determined at 1 -2 yo (or if not previously screened, at least once between the ages of 3 -6 yo), if they meet any of the following criteria: – Live in a high risk zip code area (where > 27% of housing was built < 1950. – Live in poverty (receive public assistance - WIC or Medicaid) – Have a parent or guiardian who answers yes to any of the three magic questions: – Have a parent or guardian with a job or hobby where lead is used. North Dakota Health Department 23

Oregon Magic Questions l l l Does your child live in or regularly visit (e. g. a home day-care) a house built before 1950? Does your child live in or regularly visit a house built before 1978 with recent (within the last 6 months) or ongoing renovations or remodeling? Does your child have a sibling or playmate who has had lead poisoning? North Dakota Health Department 24

Missouri - 2000 l l l Missouri is the #1 lead producing state in the US. 29% of Missouri housing was built < 1950. 80% of housing was built < 1978 Estimated 12% of children < 6 yo have BLL > 10 ug / d. L 9% of children < 6 yo were screened in 1995. Goal was to increase to 11% in 1999. North Dakota Health Department 25

Missouri - 2000 l l l Universal BLL testing of all children at least twice during the 1 st 24 months of life (e. g. 12 and 24 mo). Risk assessment may indicate the need for BLL testing at an earlier age (e. g. 6 mo) and more frequently. – BLL may be done by venipuncture or capillary methods – Confirm capillary results with a venous sample if the results are: > 10 ug / d. L or questionable. Immediate BLL testing of any child 12 -72 mo who has not had a documented BLL test. Re-evaluation of all children < 6 yo for risk of lead poisoning at health care visits (at least annually). Use the lead risk assessment tool. BLL tests should be done for all those found at risk. North Dakota Health Department 26

Missouri - 2000 l A statewide advisory committee developed the testing plan. l Guidelines used to develop the plan: CDC and AAP l Missouri Dept of Health and Social Services endorsed the plan. North Dakota Health Department 27

North Dakota - Pb Screening l CDC (Screening of Young Children for Lead Poisoning, Nov 1997) “Exercise caution in using BLL data to assess risk for lead exposure, because these data may not reflect the risk of the entire population. If BLL data are not thought to be reliable, other data should be used until improved BLL data are available”. North Dakota Health Department 28

North Dakota - Fargo l l October - December, 1991 Average of housing 67. 8 yo Children from Head Start and kindergarten in older neighborhoods Samples – 202 capillary samples (9 duplicates) – 193 children and adults tested (24 unaatisfactory specimens, 169 successfully screened) – 12 were over 6 yo with 157 from 1 -6 yo. North Dakota Health Department 29

North Dakota - Fargo l Results – 6. 3% (10) with BLL > 10 – 20% (2/10) with abnormal BLL (capillary) had BLL (venipuncture) > 10 - both < 14 – 1. 3% (2/157) had BLL > 10 – No correlation of BLL with housing – Average of children 1 -6 yo - 5. 2 yo – Average of housing - 67. 8 yo North Dakota Health Department 30

Grand Forks l May, 1994 l Children from large day care centers and included children living in housing built prior to 1970 North Dakota Health Department 31

Grand Forks - Results l 198 samples (161 adequate to test) l 2. 4% (4/161) with levels 10 -15 ug / d. L North Dakota Health Department 32

EPSDT - 1995 l 510 tests completed l 3. 5% (18/510) were > 10 North Dakota Health Department 33

EPSDT - 1996 l l 572 tests done 3. 8% (22/572) had BLL > 10 with 0. 5% (3/572) > 20 45% (10/22) would have been picked up via risk CDC questionnaire. Elevated lead levels due to: – – – lead based paint mini-blinds pool cue chalk North Dakota Health Department 34

Crude Summary l 3. 3% (46/1400) children screened had BLLs > 10 ug / d. L l Confidence intervals for each ND study (CDC charts, 1997) – Fargo (157 children) <1% - 4% – Grand Forks (161 children) 1% - 5% – EPSDT 1995 (510 children) 2% - 6% – EPSDT 1996 (572 children) 2% - 6% North Dakota Health Department 35

CDC Recommendations l Develop a statewide plan (targeted or universal) for lead screening – May need to divide the state into different areas with different recommendations – Develop specific screening recommendations for each area – Dissemination of screening recommendations – Evaluation l l “Screening policy should be based on data representative of the entire population”. “In the absence of a statewide plan or other formal guidance from health officials, universal screening for virtually all young children should be carried out”. North Dakota Health Department 36

Costs and benefits of a universal screening program for elevated blood lead levels in 1 year-old-children - Briss PA, Matte TD, et. al. l “When more than 14% (range 11 -17%) of children had elevated blood lead levels, the economic benefits of universal screening exceeded the costs” l Targeted screening will likely be the most cost effective program in North Dakota Health Department 37

Basic Targeted Screening - CDC l Use only as an interim measure l Screen children at 1 -2 years and children 36 -72 mo who have not previously been screened, if they meet one of the following criteria. North Dakota Health Department 38

Basic Targeted Screening - CDC l l l Resides in zip code area where > 27% of the housing was built < 1950 Receives public health assistance (e. g. WIC or Medicaid) Child’s parents or guardian answers “yes” or “don’t know” to any of the following questions – Does your child live in or regularly visit a house that was built before 1950? – Does you child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within the last 6 months)? – Does your child have a sibling or playmate who has or did have lead poisoning? North Dakota Health Department 39

Efficacy of Targeted Screening Rhode Island l 1995 analysis l RI has universal screening l 92% efficacy - screen all children with zip codes with a > 27% pre-1950 housing. l 93% efficacy - screen all in census tracts with > pre-1950 housing North Dakota Health Department 40

North Dakota Considerations l Form an advisory committee – Composition l l l Child health providers Local health departments Managed care organizations Private insurance organizations Community – Mission l l l Assess lead exposure and screening capacity Determine boundaries of recommendation areas Decide on the appropriate screening – Universal? – Targeted? North Dakota Health Department 41

North Dakota Considerations l Initial Screening Plan – Basic Targeted Screening (e. g. based on zip code or census data for homes built < 1950) - should pick up 92 -93% of those > 10 – Use the basic 3 CDC questionnaire plus l l l Does the child live with an adult whose job or hobby involves lead? Does the child live near industry likely to release lead? – Screen all with significant foreign country exposure Well designed population based research - John’s Hopkin’s consultation North Dakota Health Department 42

North Dakota Considerations l Adjust Screening recommendations based on ND BLL research and targeted screening data l Recurrent re-evaluation and screening adjustments North Dakota Health Department 43