A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations November 2015 DOH 334-383 November 2015 Contents Executive Summary....................................................................................................................................... 4 Introduction .................................................................................................................................................. 5 Effects of Lead on Child Health ..................................................................................................................... 5 Risk Factors for Lead Exposure ..................................................................................................................... 8 Environmental Risk Factors ....................................................................................................................... 8 Host Risk Factors ..................................................................................................................................... 11 Lead Testing Data from Washington State ................................................................................................. 13 Risk of Lead Exposure in Washington State and the United States ............................................................ 16 Recommendations for Lead Screening in Children, Washington State ...................................................... 17 Screening Recommendations for Children 12 and 24 Months of Age .................................................... 18 Implementation of Screening Recommendations ................................................................................... 20 Risk Geographically – Lead Exposure Risk Index Model.......................................................................... 21 Screening Recommendations for Children 3 – 17 Years Old ................................................................... 22 Diagnostic Blood Lead Testing ................................................................................................................ 22 Testing Methods ..................................................................................................................................... 22 Reporting Requirements ......................................................................................................................... 23 Clinical Management of Children with Elevated Blood Lead Levels ........................................................... 23 Medical Management of Children with Lead Exposure and Poisoning .................................................. 23 Interpreting and Managing Low Blood Leads Levels .............................................................................. 23 Public Health Management of Children with Elevated Blood Lead Levels ................................................. 24 Public Health System Response............................................................................................................... 24 Education Materials and Forms .............................................................................................................. 25 Targeted Approach to Lead Screening Page 2 Appendix A: Clinical Algorithm for Recommended Blood Lead Testing of Children in Washington State ............................................................................................................................................................ 28 Appendix B: Lead Exposure Risk Index Methods ........................................................................................ 30 Appendix C: Pediatric Environmental Specialty Units Recommendation on Medical Management of Childhood Lead Exposure and Poisoning .................................................................................................... 32 Appendix D: Interpreting and Managing Low Blood Lead Levels ............................................................... 34 Appendix E. Letter to Parents of Child with Elevated Blood Lead Level ..................................................... 38 Appendix F. Lead Exposure Investigation Form .......................................................................................... 39 Acknowledgements..................................................................................................................................... 41 References .................................................................................................................................................. 42 Targeted Approach to Lead Screening Page 3 Executive Summary A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations Prepared by Washington State Department of Health, Division of Environmental Public Health, Office of Environmental Public Health Sciences, Environmental Epidemiology Section; Childhood Lead Poisoning Prevention Program. The Centers for Disease Control and Prevention encourages each state to develop their own screening guidelines based on state-specific data. This document summarizes the justifications, clinical recommendations, and tools for a more targeted approach to childhood blood lead screening in children in Washington State. An Expert Panel consisting of public health and clinical practitioners, academia, health plans, state agencies, and lead poisoning prevention advocates was convened and chaired by the Washington State Health Officer. The Expert Panel reviewed current practice, state specific data, current research on risk factors, and national best practices to identify strategies for targeting screening of children at increased risk of exposure to lead. The Expert Panel acknowledges that primary prevention (i.e., reducing environmental lead exposures from soil, dust, paint and other sources before children become exposed to these hazards) is the only practical approach to preventing elevated blood lead levels. The recommendations put forth in this document are clinical guidelines to assist health care providers in targeting their blood lead testing for children at increased risk for lead exposure. This document includes supporting evidence, a one-page clinical algorithm, a list of risk factors to consider, and a link to an interactive mapping tool for identifying communities by census tract that are at higher risk of lead exposure. Additionally, this document includes reporting requirements, clinical guidance on the medical management of children with elevated blood lead levels, and recommendations and resources for public health management and response to children with elevated blood lead levels. For more information, please contact: Elisabeth Long, MPH Childhood Lead Poisoning Surveillance Epidemiologist Washington State Department of Health Elisabeth.Long@doh.wa.gov (360) 236-3336 November 2015 Targeted Approach to Lead Screening Page 4 Introduction In 1997, the Centers for Disease Control and Prevention (CDC) withdrew their former recommendation of universal childhood lead screening and encouraged each state to develop their own screening guidelines based on state-specific data. In response to this recommendation, the Department of Health (DOH) convened an Expert Panel in 1999 which concluded “healthcare providers should use clinical judgment to identify children who should be tested.” The panel did not recommend universal screening or the use of a risk factor questionnaire. A second Expert Panel was convened in 2008 to review and revise the department’s existing guidelines related to lead exposure in children. This panel recommended that the department “adopt and modify a risk factor questionnaire and make it available to physicians and other healthcare providers.” In March 2015, the Department of Health convened a third Expert Panel to develop targeted childhood lead screening recommendations for clinicians in Washington State. The Expert Panel was comprised of representatives from DOH, Department of Ecology, Health Care Authority, Department of Commerce, University of Washington-Pediatric Environmental Health Specialty Unit, health care providers, and local public health jurisdictions. The methods used to develop these targeted lead screening recommendations included reviewing the national literature to identify risk factors for lead poisoning, analyzing and interpreting lead testing data from the DOH Childhood Lead Program, reviewing strategies used in other states, and exploring the use of various tools including a Lead Exposure Risk Index model and risk factor questionnaires. The Expert Panel also developed public health recommendations for follow-up of children with elevated blood lead levels. Effects of Lead on Child Health Lead is a heavy metal that occurs naturally in the earth’s crust and is also found throughout the manmade world. All people can be affected by lead, but young children and pregnant women are the most vulnerable. Lead has negative impacts on nearly every system of the human body, particularly the nervous (brain), renal (kidney), and hematologic (blood) systems. Targeted Approach to Lead Screening Page 5 Neurodevelopmental effects occur at low levels. At levels below 10 μg/dL, there is a strong inverse relationship between blood lead level and IQ. Other observed effects include decreased learning ability and attention span, lower school test scores, and reduced fine motor skills. Increased dropout rates, aggressiveness, and delinquency have been associated with lead toxicity in some studies. At high levels, lead can cause problems like anemia, high blood pressure, seizures, and death. There is no known safe level of lead exposure for children. 1 Lead’s toxicity primarily stems from its ability to mimic calcium and zinc thus interfering in virtually every organ system in the body. 2 Our understanding of adverse effects of lead continues to evolve and is best reflected in the incremental lowering of CDC’s reference value, the level requiring intervention. As of today, a safe blood lead level has not been identified. The latest CDC reference level of 5 μg/dL is based on the 97.5th percentile of the National Health and Nutrition Examination Survey’s (NHANES) blood lead distribution in children. It represents a level based on the U.S. population of children 1-5 years of age who are in the highest 2.5% of children when tested for lead in their blood. 3 This level is not considered a safe threshold; instead it is meant to be a reference level to trigger public health action. Health effects of lead range from sub-clinical effects at the lowest exposure levels to fatal lead encephalopathy after extreme exposure. Acute high dose exposure can lead to symptomatic poisoning often characterized by constipation, fatigue, anemia and neurological disorders. Even though acute high dose exposures still occur in the U.S., these exposures are now rare. For the low-level lead exposures now observed in the U.S., the most important sub-clinical effect is on the central nervous system and is widely studied using IQ tests. It is estimated that for preschoolers with blood lead levels between 10–20 μg/dL, each 1 μg/dL rise in blood lead level is associated with a lower IQ of up to 1 point. Recent evidence suggests that this relationship is steeper at blood lead levels below 10 μg/dL. 4,5 In an international pooled data analysis on 1,333 children from seven population based cohort studies, authors found that lead associated IQ decline was significantly greater in populations with a maximum blood level of 7.5 μg/dL than that of children whose lead level was above 7.5 μg/dL. These neurological deficits are irreversible and persist in young adulthood, independent of later changes in blood lead Targeted Approach to Lead Screening Page 6 levels. An 11-year follow-up study of children with elevated blood lead levels in childhood found that their impaired neurobehavioral function persisted in young adulthood, which manifested in the form of higher risk of dropping out of school, lower test scores, and increased absenteeism.6 Additionally, a study following children with elevated blood lead levels into adulthood showed that blood lead levels were associated with higher rates of total arrests and/ or arrests for offences involving violence. 7 The primary target organ of non-neurodevelopmental effects of lead in children is the kidney. Lead interferes with activation of vitamin D and increases the risk of children developing hypertension in adulthood. 8 In addition, lead also interferes with the heme biosynthetic pathway at blood lead levels higher than 18 mcg/dL. 9 Lead exposure in pregnancy Maternal lead exposure is also a substantial source of in utero lead exposure for children. Evidence from several prospective cohort studies indicates that even at maternal blood lead levels below 10 μg/dL, prenatal exposure is inversely related to fetal growth and neurodevelopment.10 These adverse effects are most pronounced in the first trimester. Continuous monitoring of maternal and fetal blood lead levels in 146 pregnant women with blood lead levels lower than 10 μg/dL, revealed that an increase in maternal blood lead level by one standard deviation in the first trimester was associated with a 3.5 point reduction in the child’s mental development index score at 24 months of age.11 In addition to environmental exposures during pregnancy, children are also susceptible to lead stored in the mother’s body. Adults with chronic exposure to lead store 95% of their total lead body burden in the skeleton. After chronic exposure, elimination of lead from the body is very slow with a half-life of 25-30 years. 12 This skeletal reserve serves as an endogenous source of lead and is mobilized in events of physiological stress like pregnancy and lactation resulting in pre-and post-natal exposure for the infant even in the absence of environmental lead sources.13 Targeted Approach to Lead Screening Page 7 Risk Factors for Lead Exposure Phasing out of leaded gasoline and lead-based paint in the 1970s has led to a dramatic decline in blood lead levels. Figure 1.Decline in average blood lead levels in US children and in total lead used in gasoline for years 1974-1992. Image: Michigan Network for Children’s Environmental Health. Legacy lead paint and dust remain primary sources of lead exposure in the U.S. 14 However; more than 30% of elevated blood lead levels do not have a lead paint source. These non-paint sources remain insufficiently characterized including but not limited to ethnic remedies and goods, consumer products (imported children’s toys and jewelry), and imported ceramics. This section presents environmental and host risk factors for elevated childhood blood lead levels. Environmental Risk Factors Age of Housing Even though lead-based paint was banned in 1978, as of 2000, 38 million households in the U.S. still had lead-based paint and 24 million households had significant lead-based paint hazards.15 Targeted Approach to Lead Screening Page 8 Children living in houses with lead-based paint can attain blood lead levels as high as 20 μg/dL even without frequently engaging in pica. 16 A 2002 study of 34,798 children found a doseresponse relationship between the age of housing (by decade built) and elevated blood lead levels. 17 Notably, for a given housing age, lesser-valued houses were associated with higher blood lead levels suggesting that lesser valued houses had more likelihood of deteriorating paint. Lead dust from chipping paint and home renovations that settles into household soil presents additional risk of childhood exposure. In fact, renovation of older houses is significantly associated with increased childhood blood lead levels in the household.18 According to a DOH analysis performed in 2009, the proportion of children with blood lead levels at or above 5 µg/dL declined steadily as age of housing decreased. At the present time, housing age, as an indication of potential residential lead hazards, is the most established risk factor for lead poisoning. Washington State ranks 17th in the nation in number of homes built prior to 1950 and in number of pre-1978 homes. 19 Residential lead hazards include chipping, peeling, and cracking paint, interior settled dust, contaminated soils, and the activities of remodeling and repainting buildings built prior to 1978. Table 1. Estimated number of housing units with lead hazards by housing age. Source: Washington State Department of Ecology Lead Chemical Action Plan, 2009. Age of Housing Lead-Based Paint Lead Hazards 20 Housing Units in Washington State All Housing 40% 25% 2,451,075 # Housing Units in Washington State with Lead Hazards 472,035 Pre-1940 87% 68% 307,078 208,813 1940-1959 69% 43% 414,555 178,259 1960-1977 24% 8% 661,598 52,928 Targeted Approach to Lead Screening Page 9 Parental Occupation Children of workers in lead-related industries have a higher risk of lead absorption, primarily due to inadequate use of protective equipment and taking work clothes home resulting in elevated lead dust levels at the household that could be potentially inhaled and ingested by children. 21,22 According to the Occupational Safety and Health Administration (OSHA) approximately 1,642,000 workers in the U.S. are exposed to lead in several industries including construction, manufacturing, transportation and remediation. 23 Jobs or hobbies that may involve working with lead or being exposed to dust or fumes from lead include: construction (particularly remodeling or renovating); painting, indoor target practice or bullet making; mining, smelting or battery recycling; soldering and welding work; stained glass work; and making fishing weights. Use of Imported Goods Containing Lead Some other sources of lead exposure include imported goods like ceramic pottery with lead glazing used for food consumption, foreign cosmetics and foods contaminated with lead and traditional folk medical remedies. For example, laboratory analysis of kajal, a traditional eyecosmetic from Afghanistan, revealed a lead content of 54% and was association with elevated blood lead levels in refugee children residing in New Mexico.24 Similarly, many traditional remedies can have high lead content. Greta and Azarcon (also known as alarcon, coral, luiga, maria luisa, or rueda) are Hispanic traditional medicines taken for an upset stomach (empacho), constipation, diarrhea, and vomiting. They are also used on teething babies. Greta and Azarcon are both fine orange powders with lead content as high as 90%. Ghasard, an Indian folk medicine, has also been found to contain lead. It is a brown powder used as a tonic. Ba-baw-san is a Chinese herbal remedy that can also contains lead. It is used to treat colic pain or to pacify young children. Some cosmetics such as Kohl, Kajal, Surma and Sindoor may also contain lead. Lead has been found in some consumer candies imported from Mexico. Certain candy ingredients such as chili powder and tamarind may be a source of lead exposure. Lead sometimes gets into the candy when processes such as drying, storing, and grinding the ingredients are done improperly. Also, lead has been found in the wrappers of some imported Targeted Approach to Lead Screening Page 10 candies. The ink of these plastic or paper wrappers may contain lead that leaches into the candy. Host Risk Factors In addition to the environmental risk factors presented above, several host risk factors have been shown to be associated with elevated blood lead levels. Since 1976, blood lead data from the National Health and Nutrition Examination Surveys (NHANES) have been used to characterize children’s blood lead levels. The most recent analysis performed by CDC concluded that despite progress in reducing overall blood lead levels in the 1-5 year age groups, difference between the geometric mean blood lead levels of different racial/ethnic and income groups still persist. The analysis concluded that children at highest risk are non-Hispanic Black, live in housing built before 1950, and are from poor families. 25, 26 Age Young children 6 – 36 months of age are especially susceptible to lead exposure because of their higher metabolism relative to body weight, ongoing neurological development, poor hygiene status, and lack of control over their environment.27 Blood lead levels are known to peak around two years (24 months) of age. Children under 3 years (36 months) of age expose themselves to lead more readily by spending time on the floor and exhibiting hand to mouth behavior which increases dust and soil intake. Race and Ethnicity Within the 1-5 years age group, blood lead levels are associated with race and ethnicity.28 Even though the gap is narrowing with time, Black non-Hispanic children have disproportionately higher blood lead levels. Among children aged 1‒2 years participating in the National Health and Nutrition Examination Study (NHANES)29 in 2007‒2010, 7.7% (CI 4.0‒12.4) non-Hispanic Black children had blood lead levels 5 µg/dL or higher compared to 1.6% (CI 0.7‒3.0) Mexican American and 3.2% (CI 1.2‒6.0) non-Hispanic, White children. Targeted Approach to Lead Screening Page 11 Poverty Low income children are at particular risk for lead exposure. 30 According to the analysis of recent NHANES data among children aged 1-2 years, differences in the prevalence of blood lead levels ≥5 µg/dL were observed by poverty levels; 6.0% of children living in a household with a poverty-to-income ratio of <1.3 had blood lead levels ≥5 µg/dL, compared to 0.5% of children living in a household with a poverty-to-income ratio of ≥1.3. 31 Table 2. Number and percentage of children 1-2 years with blood lead levels ≥5 µg/dL, by poverty. Source: National Health and Nutrition Examination Survey, US 1999-2010. Income-to-poverty ratio* <1.3 Number % (95% CI) 430 6.0 (3.7-8.9) ≥1.3 309 0.5 (0.1-1.2) *Income-to-poverty ratios represent the ratio of family or unrelated individual income to their appropriate poverty threshold. Source: US Census Bureau. Current population survey [CPS] – definitions. Washington, DC: US Census Bureau 2014. http://www.census.gov/cps/about/cpsdef.html Immigrant and Refugee Status In addition to the mentioned environmental factors, foreign birth is also a known risk factor for elevated blood lead levels in children. 32 A matched case-control study of 203 pairs of New York City children revealed that the blood lead levels were strongly associated both with foreign birthplace and recent immigration. Many migrant children are exposed to lead in their native countries and their blood lead levels may rise after coming to the U.S. due to lead contamination in their new environment or use of imported goods. Refugee children originating in all regions of the world, especially those from resource-poor countries are at risk of having elevated blood lead levels upon arrival to the United States.33 In areas of the world where many refugees originate, potential lead exposures include leadcontaining gasoline combustion, industrial emissions, ammunition manufacturing and use, burning of fossil fuels and waste, and lead-containing traditional remedies, foods, ceramics, and Targeted Approach to Lead Screening Page 12 utensils. Malnourished children may be at increased risk for lead poisoning, likely through increased intestinal lead absorption mediated by micronutrient deficiencies. Poor nutritional status of children can also lead to higher lead uptake through increased absorption from the gastrointestinal tract. 34 The best-studied micronutrient deficiency related to lead levels is iron deficiency. Iron-deficient children are at increased risk for developing lead poisoning. Deficiencies in calcium and zinc may also increase a child’s risk. 35 Lead Testing Data from Washington State The Department of Health has been conducting lead surveillance since 1993 and continues to receive, record, and analyze blood lead results reported as a requirement of the Washington State notifiable condition rule (WAC 246-101). While the number of blood lead tests has increased in Washington State over the past decade, the proportion of children screened in Washington State remained well below the national average (Table 3). Table 3 compares Washington State data to U.S. data using the CDC definition of a confirmed case; defined as a venous test or two elevated capillary tests performed within 12 weeks of each other that are ≥5 µg/dL. Table 3: Estimated proportion of children under 6 years old screened for lead and proportion of confirmed blood lead results > 5µg /dL in Washington State and the United States. Source: CDC National Lead Poisoning Surveillance Data (1997-2013). Year Estimated % of WA children screened Estimated % of US children screened Proportion of WA tests ≥10 µg/dL Proportion of US tests ≥10 µg/dL Proportion of WA tests ≥5 µg/dL Proportion of US tests ≥5 µg/dL 2007 1.3% 15.9% 0.48% 0.94% * * 2008 2.4% 17.1% 0.31% 0.72% * * 2009 3.0% 17.2% 0.28% 0.61% * * 2010 3.5% 16.7% 0.23% 0.60% 3.02% 6.64% 2011 3.1% 15.2% 0.15% 0.56% 2.40% 5.81% 2012 3.4% 10.5% 0.10% 0.62% 2.60% 5.42% *Prior to 2010 tests ≤10.0 µg/dL were not considered elevated Targeted Approach to Lead Screening Page 13 Screening rates vary by county from 0% in Garfield to 25% in Adams County. Figure 2 shows that the variability in screening rates does not seem to correlate with risk from an older housing stock and greater likelihood of lead risks in homes. Figure 2. Proportion of pre-1950 housing and 2012 screening rates by county, Washington State vs. U.S. average. Sources: U.S. Census Bureau, American Community Survey (ACS), 2014 and DOH Lead Registry. 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 0.0% United States Adams Grant Whitman Ferry Cowlitz Okanogan Walla Walla Yakima Kittitas Chelan Grays Harbor King Franklin Benton Pierce Stevens Skagit Clark Spokane Jefferson Lewis Kitsap Snohomish Whatcom Clallam Pacific Pend Oreille Thurston Klickitat Wahkiakum Douglas San Juan Island Asotin Mason Garfield Columbia Lincoln Skamania 10.0% Proportion of Pre-1950 Housing Screening Rates Washington State’s Childhood Blood Lead Prevention Program has been under resource constraints that limit the ability to enter non-elevated tests into the database in a timely matter. Figure 3 shows that the total test numbers are not available after 2012. Targeted Approach to Lead Screening Page 14 Figure 3. Childhood lead screening tests and elevated results in children <6 years old in Washington State, 2008-2014. Source: DOH Lead Registry. Childhood blood lead surveillance data collected by the Department of Health (DOH) have several limitations. First, healthcare providers in Washington State often do not either perform confirmatory testing or report confirmatory test results after identifying a child with an elevated capillary result. Therefore, DOH includes all elevated results in data summaries which would include probable and false positive tests. The type of blood draw is important for interpreting a blood lead test result; however draw type data is missing for approximately 45% of tests. In addition, data collected by DOH represent a non-random sample of 3‒4% of children in the state. Having the child’s address is important for understanding likely exposure; however addresses are only available for approximately 60% of the children screened. Other demographics such as insurance status and race/ethnicity are also rarely reported. Approximately 2000-3000 new refugees arrive in Washington State annually. Starting July 1 2013, DOH implemented universal screening among refugees entering Washington State. Many of the refugees that resettle to Washington State come from countries such as Targeted Approach to Lead Screening Page 15 Afghanistan, Iraq, and Burma; all countries that still use leaded gasoline and may pose a risk to exposure. When comparing the crude rates of elevated blood lead levels (≥5 µg/dL) between refugees and non-refugees aged 0-16 years, for the time period July 1, 2012 – December 31, 2012, refugees had a rate of 16.7% compared to 3.4% for non-refugee children (DOH Lead Registry). Figure 4. Proportion of elevated blood lead tests by country of origin for refugee children aged 6 months – 16 years, screened July 1, 2013 – December 31, 2014 in Washington State. Sources: DOH Lead Registry and DOH Refugee Health Program. Risk of Elevated Blood Lead Levels in Washington State and the United States The prevalence of elevated blood lead levels has decreased dramatically in the United States and Washington State since the 1970’s. Some data suggest the risk of childhood lead exposure in Washington State may be lower than the risk of lead exposure in other states. In 1999, DOH conducted a statewide survey that estimated 0.9% (95% CI 0.3‒2.7) of 1- to 2- year old children in Washington State had blood lead levels of 10 μg/dL or higher. During the same time period, the national prevalence estimate among 1- to 5- year olds participating in the National Health and Nutrition Examination Survey was 2.2%. Since 1999, the proportion of elevated blood lead levels in Washington State has remained lower than the proportion elevated in the U.S. as a Targeted Approach to Lead Screening Page 16 whole. From 1999 to 2012, the proportion of blood lead levels >10 μg/dL decreased from 0.9% to 0.1% in Washington State compared to 5.0% to 0.6% in the US.36 In addition, a study performed by the Department of Housing and Urban Development between 1998 and 2000 showed that the prevalence of lead hazards in housing in the Northeast and Midwest was approximately double the prevalence of lead hazards in homes in the South and West. 37 In contrast, a study performed in Multnomah County, Oregon in 2001 showed that 71% of homes built prior to 1930 had lead dust levels above the federal standard which was similar to the results found in Rochester, NY in 1996.38 Recommendations for Lead Screening in Children, Washington State The Centers for Disease Control and Prevention (CDC) and the Department of Health concur with the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) that primary prevention (i.e., ensuring that all homes are lead-safe and do not contribute to childhood lead exposure) is the only practical approach to preventing elevated blood lead levels in children. Prevention requires reducing environmental exposures from soil, dust, paint, and water before children are exposed to these hazards. Efforts to increase awareness of lead hazards and nutritional interventions to increase iron and calcium, which can reduce lead absorption, are other key components of a successful prevention policy. 39 Additionally, healthcare providers should annually educate parents of children 6 months to 6 years of age by providing lead anticipatory guidance during routine check-ups, as detailed in Figure 5 below. Bright Futures and the American Academy of Pediatrics recommend healthcare providers assess a child’s risk for lead exposure and provide anticipatory guidance around lead hazard identification when children are 6 months, 9 months, 12 months, 18 months, 24 months, 3 years, 4 years, 5 years and 6 years of age. 40 Targeted Approach to Lead Screening Page 17 Figure 5. Lead anticipatory guidance for parents of young children. Lead Anticipatory Guidance for Parents of Young Children 1. Keep your child away from peeling paint and home repairs that disturb lead paint. 2. Report peeling paint to your landlord. If your landlord does not make repairs, contact your local tenant’s rights organization. 3. Frequently wash hands, toys, pacifiers, bottles, and other items your child places in his or her mouth. 4. Clean floors, windowsills, and dusty places often with wet mops and wet cloths. 5. Avoid using health remedies (such as azarcon, greta, paylooah) and eye cosmetics (such as kohl, kajal, surma) from other countries. Some of these products have been found to contain high levels of lead. 6. Use caution when using candies, spices, snack foods, and children’s toys and jewelry made in other countries. These items may contain lead. 7. Use only cold water for making baby formula, drinking, and cooking. Let the water run for at least 60 seconds before use. 8. Keep your child away from work clothes and tools of household members who do construction work or other work and hobbies that may expose them to lead. 9. Wash work clothes separately from other laundry. Remove shoes and work clothes before entering your home. 10. Use safe work methods when doing home repair that disturbs paint. For information on lead-safe work methods, see EPA’s lead webpage at www.epa.gov/lead . Screening Recommendations for Children 12 and 24 Months of Age Healthcare providers should assess all children for risk of lead poisoning at 12 and 24 months of age. The Department of Health recommends performing a blood lead test based on the following guidance. If the parent or caregiver does not know if the child has one of the following risk factors, a blood lead test should be performed. See Appendix A for one-page clinical algorithm for targeted screening recommendations. Targeted Approach to Lead Screening Page 18 The Department of Health recommends testing children with any of the following risk factors:  Lives in or regularly visits any house build before 1950.* • The risk of lead exposure is highest to children living in low income housing built prior to 1950.  Lives in or regularly visits any house built before 1978 with recent or ongoing renovations or remodeling (i.e., within the past six months).  From a low income family (defined as incomes <130% of the poverty level).**  Known to have a sibling or frequent playmate with an elevated blood lead level.  Is a recent immigrant, refugee, foreign adoptee, or child in foster care.  Has a parent or principal caregiver who works professionally or recreationally with lead. • Examples: remodeling & demolition; painting; works in or visits gun ranges; mining; battery recycling; makes lead fishing weights or shotgun pellets; hobbies involving stained glass, pottery, soldering, or welding.  Uses traditional, folk, or ethnic remedies or cosmetics. • Examples include Greta, Azarcon, Ghasard, Ba-baw-san, Sindoor and Kohl *Screening may not be indicated if the home has previously undergone lead abatement or tested negative for lead after remodeling. **Apple Health in Washington State Medicaid covers children with family incomes up to 300% of the federal poverty level. If family income is unknown, testing should be offered. Note: Healthcare providers are encouraged to use the Department of Health Lead Exposure Risk Index found at https://fortress.wa.gov/doh/wtn/WTNIBL/ to better understand which areas in their community are at higher risk for lead exposure. See Appendix B for further information. Targeted Approach to Lead Screening Page 19 Healthcare providers should consider testing additional children per clinical judgment, including:  Children whose parents have concerns or request testing (including older children that have risk of exposure).  Children living within a kilometer of an airport or lead emitting industry, or on former orchard land. • Information about lead emitting industries in WA can be found on EPA’s web site. • Information about former orchards is available on the Washington State Department of Ecology’s website.  Children with pica behavior.  Children with neurodevelopmental disabilities or conditions such as autism, ADHD, and learning delays. Note: Other consumer products that have been found to have lead risk are informally imported foods and spices. Some candies imported from Mexico have been found to contain lead. Certain ingredients used in the candies, such as chili powder and tamarindo, are found to be the most common source of exposure. Lead has also been found in the ink of some imported candy wrappers as well as in nonregulated imported spices such as turmeric. Implementation of Screening Recommendations This guidance is primarily based on published national research studies and may be challenging to implement as stated in a clinical setting. Since every clinic serves a different community, healthcare providers are encouraged to develop implementation plans which work best for their patient population. These plans will likely vary from clinic to clinic. For example, clinics that serve very low income children may decide to perform universal testing, rather than attempting to determine if children have any of the risk factors stated above. Targeted Approach to Lead Screening Page 20 As mentioned above, children living in low income or deteriorating housing built prior to 1950 are among the highest risk groups. While it is ideal to try to determine the age of the patient’s home, some healthcare providers may feel the only reasonable way to assess risk is to understand the lead risk in their community (see below) and ask the patient in which part of community they live. Risk Geographically – Lead Exposure Risk Index Model To assist providers with understanding lead risk in the communities they serve, the Department of Health created a Lead Exposure Risk Index model which can be accessed at: https://fortress.wa.gov/doh/wtn/WTNIBL/. The model combines lead risk from housing and poverty and displays it on a map in deciles from 10 where there is the greatest risk from these two factors to 1 where there is the lowest risk. (See Appendix B for Methods. There are many other factors that influence lead exposure that are not included in the map, such as take home occupational exposure and risk from lead emitting industries. If high quality data becomes available they may be added to the map in the future. Providers and clinics should use the risk map in addition to other information when deciding on their screening protocol. Figure 6. Example of Lead Exposure Index Model information (for illustration purposes only) Targeted Approach to Lead Screening Page 21 Screening Recommendations for Children 3 – 17 Years Old Healthcare providers should also consider performing blood lead testing on older children at increased risk for lead poisoning, including those who have hobbies that potentially expose them to lead (e.g., shooting guns) and those who use traditional, folk or ethnic remedies or cosmetics imported from abroad. The Centers for Disease Control and Prevention recommends performing blood lead level testing of all refugee children 6 months–16 years of age upon their arrival in the United States. Within 3–6 months post-resettlement, a follow-up blood lead test should be conducted on all refugee children aged 6 months–6 years of age, regardless of the initial screening blood lead level. 41 Diagnostic Blood Lead Testing Blood lead testing should also be considered as part of a diagnostic work-up of any child regardless of age with the following symptoms: • Behavioral problems: aggression, hyperactivity, attention deficit, school problems, learning disabilities, excessive mouthing or pica behavior, and other behavior disorders. • Developmental problems: growth, speech and language delays and/or hearing loss. • Symptoms or signs consistent with lead poisoning: irritability, headaches, vomiting, seizures or other neurological symptoms, anemia, loss of appetite, abdominal pain or cramping or constipation. • Ingestion of foreign body. Testing Types Blood lead testing is the only acceptable laboratory test for screening and confirming lead poisoning. Venipuncture is preferred for specimen collection, but finger stick (capillary) collection is acceptable if care is taken to properly clean and prepare the finger. Capillary samples are easier to contaminate because of the possibility of lead containing dust and dirt on Targeted Approach to Lead Screening Page 22 the hand or under the fingernails. Children with capillary specimens testing 5 μg/dL or higher on a point of care test should undergo confirmatory testing, ideally with a venous specimen. Reporting Requirements WAC 246-101-201 requires laboratories performing blood lead testing to report all blood lead test results to the Washington State Department of Health. Healthcare providers using a capillary point of care machine (LeadCare®II) are also required to report all results. All elevated blood lead levels (5 µg/dL or higher in youths under age 15, and 10 µg/dL or higher in adults) must be reported to the Department of Health within two business days. All other test results must be reported within one month. Information reported must include: specimen type; name and telephone number of laboratory; date specimen collected; date specimen received; health care provider’s name and telephone number or address; test result; name of patient; sex; date of birth of patient; and patient’s address. Additional information on reporting is available on the DOH web site. Clinical Management of Children with Elevated Blood Lead Levels Medical Management of Children with Lead Exposure and Poisoning Healthcare providers should manage children with blood lead levels >5 μg/dL per the recommendations from the Pediatric Environmental Health Specialty Unit (PEHSU): Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (See Appendix C.) Interpreting and Managing Low Blood Leads Levels Healthcare providers should also review supplemental information on interpreting and managing low blood lead levels produced by the NW PEHSU: Interpreting and Managing Low Blood Lead Levels: Supplemental Information for Clinicians. See Appendix D. Targeted Approach to Lead Screening Page 23 Public Health Management of Children with Elevated Blood Lead Levels Responding to growing evidence that there is no safe level of lead exposure in young children, CDC has revised its case management recommendations. 42 Even the terminology has changed "level of concern" has been replaced by a "reference value" that is used to identify children with a blood lead level that warrants case management. That value is set as the top 2.5% of 1 – 5 year-olds that have been tested in the National Health and Nutrition Examination Survey. Currently the blood lead reference value is 5.0 µg/dL. The new CDC guidance also emphasizes the importance of prevention as a primary approach to deal with the threat of lead exposure. Public Health System Response The clinical management of the child is the responsibility of the health care provider and parent/guardian of the child. The following steps describe the ideal process the public health system could undertake when a child receives a blood lead result of ≥5 μg/dL. Local health jurisdictions with inadequate resources may not be able to perform all recommended follow up. 1. Laboratory or health care provider report elevated blood lead level result directly to DOH within two business days (48 hours). 2. DOH staff contacts the laboratory or health care provider to collect complete case information. 3. DOH enters the case into the Childhood Lead Registry and also enters case information into the Public Health Issue Management System (PHIMS). PHIMS is a web-based reporting system for notifiable conditions that facilitates communication between DOH and local health jurisdictions. 4. The local health jurisdiction responds to elevated blood lead cases based upon capacity. Ideally, the following steps should be taken. In all cases, the health care provider of record is notified. Health care providers unclear about the public health actions being taken for their patients are encouraged to consult with their local public health Targeted Approach to Lead Screening Page 24 department about specifics. Links to contact information for local health departments can be found on the DOH website.  When children’s blood lead test results are in the 5 – 7.5 µg/dL range, a letter (see Appendix E) and educational brochures are sent to the family.  If blood lead test results are in the 7.5 – 10 µg/dL range, the family is contacted by phone, interviewed to identify sources of the lead exposure (see Appendix F) and educated to minimize exposure to lead and its health impacts. An action plan letter and educational brochures are sent to the family and health care provider.  When blood lead results are above 10 µg/dL, depending on local health resources, the family may be contacted to schedule an in-home investigation. During the investigation analytical sampling with X-ray fluorescence (XRF) is used to identify the source of the lead exposure. The investigator works with the family to develop an action plan to eliminate the exposure. Interpreters may be provided if needed. Education Materials and Forms Lead education and outreach materials have been developed and fine-tuned over a number of years. Below is a listing of frequently used materials, some of which have been translated into additional languages, related to increasing awareness of lead and its health impacts; clinical reporting; investigations; and understanding the blood lead testing results from the Department of Health and the U.S. Environmental Protection Agency. To increase parent awareness of the new targeted policy for lead screening, the Health Care Authority will partner with the Washington State Department of Early Learning (DEL) to develop communication and educational tools for parents of children enrolled in preschool programs under DEL’s leadership, including Early Childhood Education and Assistance Program and Head Start. This listing is not topically comprehensive (i.e., working lead safe, Ayurveda, environmental sampling) nor does it reflect local variations. Targeted Approach to Lead Screening Page 25 Type Agency DOH Title/Languages LEAD WARNING! Lead Can Poison Your Child Chinese English Doc ID Photo DOH 334-141 DOWNLOAD Korean Russian Somali Spanish Tagalog Vietnamese EPA General Protect Your Family For Lead In Your Home Arabic English EPA747-K-99-001 DOWNLOAD Somali Spanish Vietnamese EPA Fight Lead Poisoning With A Healthy Diet English Spanish WA DOH Reporting English WA DOH Investigation Blood Lead Level Reporting Childhood Lead Investigation Form English Targeted Approach to Lead Screening EPA-747-F-01-004 DOWNLOAD DOH 334-153 DOWNLOAD DOH-334-169 DOWNLOAD Page 26 Type Agency Title/Languages WA DOH What Does Your Child’s Lead Test Result Mean? English Arabic Doc ID Photo DOH 334-339 DOWNLOAD Burmese Results Farsi Nepali Russian Somali Spanish Swahili Tigrinya Targeted Approach to Lead Screening Page 27 Appendix A: Clinical Algorithm for Recommended Blood Lead Testing of Children in Washington State See next page Targeted Approach to Lead Screening Page 28 Targeted Approach to Lead Screening Page 29 RECOMMENDATIONS FOR BLOOD LEAD TESTING OF CHILDREN IN WASHINGTON STATE The Depamnent of Health recommends screening children using the below algorithm at 12 and 24 months ofage. Does the child have an?;r of the following risk factors: Lives in or regularly visits any house built before 1950.* Lives in or regularly visits any house built before 19?3 that has recent or ongoing renovations or remodeling. From a low income famin [defined as incomes (130% of the poverty Known to have a sibling or frequent playmate with elevated blood lead level. Is a recent immigrant, refugee, foreign adoptee, or child in foster care. Has a parent or principal caregiver who works professionally or recreationally with lead. [See sidebar for examples.) Uses traditional, folk, or ethnic remedies or cosmetics {such as lGreta, Azarcon, Ghasard, Ba?baw-san, Sindoor or Kohl.) Screening may not be indicated if the home has previously undergone lead abatement or tested negative for lead after remodeling. Apple Health in Washington Medicaid covers children with family incomes up to 300% of the federal poverty level. lffamily income is unknown, testing should be offered. YES UN N0 Perform lead testing Healthcare providers should consider testing child per clinical judgment, if: Pa rents have concern or request testing [including older children that have risk of exposure.) Child lives within a kilometer ofan airport or lead emitting industry or on former orchard land. - Child with pica behavior. Child with neurodevelopmental disabilities or conditions such as autism, ADHD, and learning delays. Healthcare providers are encouraged to use the Department of Health?s Lead Risk Index Map to better understand which areas in their community are at higher risk for lead exposure. See Interpretation and Medical Management of Blood Lead Levels: If blood lead level is 25 See FEHSU Recommendations on Medical Management of Childhood Lead Poisoning LEAD RISK EXPOSURE EMMFLES: Occupations and Hobbies: Remodeling and demolition Pointing - Work or visit gun range - Mining, smelting, bo rt?eri.r recycling Making lead fishing weigh ts or omrn unirion - Stained glass - Soldering and welding Consumer Products: Po ttery or porcelain with lead glaze lnformaliy imported foods, candies and spices - Antique furniture and inexpensive jewelry ?6 DOH 334-382 November 2015 Appendix B: Lead Exposure Risk Index Methods Methods The Washington Tracking Network (WTN) is a public website where users can find data and information about environmental health hazards, population characteristics, and health outcomes. Relative lead exposure risk is provided on the WTN’s Information by Location (IBL) feature. IBL allows users to view a map of multiple indicators, with rankings, at the community level. After reviewing a large number of possible geospatial risk factors for estimating geographic lead exposure risk only two were appropriate for use in Washington State: Lead risk from age of housing and poverty. These two risk factors were identified by the Washington State Department of Health and were reviewed by a multi-stakeholder expert panel. Although there are other risk factors for lead exposure such as having a sibling or playmate with an elevated blood lead level or parents who work in an industry where lead is used, we did not have sufficiently high quality data to account for these variables in the tool. Data and sources: Age of housing – data on housing age comes from the U.S. Census’s American Community Survey’s 5-year rollup. This dataset provides the total number of houses and proportion of houses by year of construction. We used this data in conjunction with national estimates of the proportion of housing from each era with lead risks. 43 Here is an example of how lead risk from age of housing was calculated for a fictitious census tract: Example calculation of lead risk from age of housing using a fictitious census tract: Construction Number of Percent with Lead Estimate of homes with a Year Houses Hazards lead risk After 1980 100 0 0 1960-1979 100 8% 8 1940-1959 100 43% 43 Before 1940 100 68% 68 Total 400 119 Proportion of homes with a 119/400 29.8% lead risk: Poverty – There is a significant association between poverty and elevated blood lead levels.44 Children who live below the poverty line and live in pre-1950 housing are at the greatest risk for lead exposure because the home is more likely to have aging lead paint that is in poor condition.45 Targeted Approach to Lead Screening Page 30 Weighting: IBL combines age of housing and poverty into a single geographic risk layer and classifies census tracts into deciles. A decile is a group that represents one tenth of the whole. IBL allows us to weight risk factors to best approximate the amount of risk attributable to the indicator. The weights were calculated using data from the National Health and Nutrition Examination Survey reported in CDC’s 2013 MMWR “Blood Lead Levels in Children Aged 1-5 Years – United States 1990-2010”. Weighting Risk Factors in the Lead Risk Map: Poverty <1.3 Mean BLL 4.4 µg/dL ≥1.3 Difference 1.2 µg/dL 3.2 Change in Final BLL Weight 3.2 µg/dL 42% Poverty Age of Housing 4.5 µg/dL Age of Housing Pre-1950 5.3 µg/dL 1950-1977 1.3 µg/dL Difference 4.0 µg/dL Mean Pre-1950 1978 or later Difference 4.0 4.9 4.5 58% µg/dL µg/dL µg/dL 5.3 µg/dL 0.4 µg/dL 4.9 µg/dL Targeted Approach to Lead Screening Page 31 Appendix C: Pediatric Environmental Specialty Units Recommendation on Medical Management of Childhood Lead Exposure and Poisoning Targeted Approach to Lead Screening Page 32 PEHSU He co mmendations on Medical Management of Child hood Lead posure and Poisoning h. 1.1 Heal-.n suesaln Univ. Principles of Lead Exposure in Children I A child's blood lead concentration depends on their environment, habits, and nutritional status. Each of these can influence lead absorption- Children with differing habits or nutritional status but who live in the same environment can vary on blood Ie ad concentration- Further, as children age or change residences, ha bits or environments change creating or reducing lead exposure potential- I While clinically evident effects such as anemia, abdominal pain, nephropathy, and encephalopathy are seen at levels 2340 pgi'd L, even levels below pgi'dL are associated with subclinical effects such in atte ntion and hyperactivity, and decreased cognitive function- Levels above 100 pgi'dL may result in fatal cerebral edema- 0 Lead exposure can be viewed as a lifelong exposure, even after blood lead levels decline- Bone acts as a reservoir for lead over an individual's lifetime. Childhood lead exposure has potential consequences for adult health and is linked to hypertension, renal insufficiency, and increased cardiovascular-related mortality. I Since lead shares common absorptive mechanisms with iron, mlcium, and zinc, nutritional deficiencies in these minerals promotes lead absorption. Acting synergistically with lead, deficiencies in these minelals can also worsen lead?related neurotoxicity- Principles of Lead Screening I Lead screening is typically performed with a capillary specimen obtained by a finger prick. with blood blotted onto a testing paper. Testing in this manner requires that the skin surface be clean; false positives are common. Therefore, elevated capillary blood lead levels should be followed by venipuncture testing to confirm the blood lead level- In cases where the capillary specimen demonstrates an elevated lead level but the follow-up ve nipunctu re does not, it is important to recognize that the child may live in a lead- contaminated environment that resulted in contamination of the fingertip. Efforts should be made to identify and eliminate the source of lead in these cases. Where feasible, lead screening should be performed by venipuncture. Principles of Iron Deficiency Screening I The iron deficiency state enhances absorption of ingested le ad. I Hemoglo bin is a lagging indicator of iron de?ciency and only 4091: of children with anemia are iron deficient. I Lead exp osed children {33 5 mcgi'd are at risk for iron deficiency and should be screened using CBC, Ferritin, and CRP. Alternatively, reticulocyte hemoglobin can be used, if available- I Children with iron deficiency, with or with out anemia, should be treated with iron supplementation. He sources I Pediatric Environmental Health Specialty Unit I wvvaehsunet or iPEHSU}Network I Poison Control CenterI[PCC} I or I Centers for Disease Control and Prevention I ce hflea d! or SUD-2 324535 I US. Environmental Protection Agency I or Suggested Hearings-Id Heferenca: Pediatric Emimnmentol'HeoJo?. edition. American AcademyofPediab?ies, 21:12- Woolf A. Goldman I1T Bellinger D. Pediatric Elinii: ofmnhAi-ne'ico Levin Fl. et al- Enn'ronrnentcn' Hem?s'i Perspectives zoos, Salter no. steer FFL Psalm-I'm Guidelinafor?'le Identi?cation Bid Management iflead Exposuein Pregnant and Lactlirg Won'ien. CDC. 20.10. mc?esoonse :rcrAdn'scuy Committee on cihi'dfnoo' Lead Poisoning meft'h'i Recommendathns in ?tow Les-e.I Lead Exposure Harms Children: A Renewed Coil of Pn'moanreventi'on?June T, 2012 This donnientwasslm'ted by line Associationof?ccupational and Environmental Clinics and funded in part) bythe coopemtive weement award MTSWIM from die AgencyforTonc mbslanca and Disease Registry Wetternentfl'he Envirannenial Protectim Agency supports die PEHSU by providing funds to widerlnter-Agency Agreement numb-er [Mr-3'5- 923013111-0. Neither EPA nor ATSDR endorse the purchase ofany commercial produ?s or servica memioned in PEHSU pd?icalions [April EDIE version] Appendix D: Interpreting and Managing Low Blood Lead Levels Targeted Approach to Lead Screening Page 34 - lngested lead distributes first into the red blood cells, and then re-distributes into soft tissues and bone {toss}. For children with baseline lower levels of lead exposure. after an acute exposure. the blood level will fall rapidly [weeks]- A large decrease from the Iirsl to second lead lavel may re?ect an acute exposure followed by body equilibration, or may result from laboratory or firrgerstick contamination issues- Identifying sources of lead exposure The first priorf?r is in identity sources and prevent ongoing exposure. Lead paint and contaminated dustfsoil are sources responsible for the majority of ELLs above the reference value in US. children, but there is increasing evidence of exposure through other sources- It is important to question families about the child's home environ menl as well as other potential exposure sources- Talk to parents about exposure pathways [floor to hand to mouth] and important sites of exposure [windowsills]- Some pertinent questions include: - Does the child live in a home or regularly visit 1] a building schooi. daycare] built before 1950, or 2] a building built before 19?3 with recent or ongoing painting. repair, andior remodeling? - Could the soil where the child lives or plays be contaminated with lead with cider housing. correct or historical min rhg, smelting, or agriculture)? I Could the child's drinking water be contaminated g. from indoor Consider testing water sources. such as kitchen tap water. for lead contamination. lvlost NSF certified faucet mounted waler fillers remove lead see PEH ELI factsheel on lead removal from drinking water- - Does the family have oldm or antique furniture with lead-based painl? Older children's toys? Newer imported toys? - Does the child spend time with anyone who has a job or hobby where they may work with lead in the home or bring lead dust home on shoes and clothing {re-g. parnting. remcdeh'ng. auto radiators, ship repair. soidering, making srhirers or huiiets, going to shooting ranges, weiding. mining. stained grass. pottery, iswreiry, antiques, or imported toys]? - Does the family use pottery or ceramics made in other countries {especially Mexico and lilhina], lead or pewter. or vintage dishes for cooking. storing. or serving food or drink? I: Restrictions on lead in dishes were implemented in late 1930s and strengthened in early wilds?since then US made dishes are without lead- - Are imported spices used or home spices brought from other countries? - Has the child ever used imported cosmetics or taken any traditional home remedies [e g. Asarcon, Aiancon, Greta. Rueda. Pay-ioo-ah, Kohl]? - Has the child been adopted from. lived in. or visited another country? - For children 12 months. considm mother as the source for transmission prenatally and through human milk- Are there maternal risks for lead exposure {see CD6 Guidelines for Pregnant and Lactating Mothers]? Although a specific source may not be identified. the medical provider can still provide information and counseling to the family on common sources of exposure and how to avoid 1hem use a doth and take shoes when entering the home, wash chiidren's and aduits' hands often, do not aiiow chriidren to chew on painted wooden toys or furniture or windowsr'iis}- If a lead paint hazard is identified [eg- paint prior to some practical lower cost approaches include simply keeping it in good condition. cleaning up dusl often [wel wiping and using vacuums with HEPAfilters}. painting over suspect paint. or placing a barrier over the area to keep it out of reach from children. A home inspection and risk assessment may be the best approach to identify and characterize lead hazards in the home. Such inspections typically cost will - $111100 and individual dusl wipe samples cost about $35 each- Trained lead professionals can use EPA approved test kits these test kits are not generally recommended for consumer use. Proper and safe remediation is important to avoid actually increasing the risk for a child?s exposure. lrrformation on proper remediation and repair is available from the EPA at Also. note that federal law requires that home sellers and landlords must disclose a lead hazard al the time of sale or before a rental lease lakes effect?- Targeted Approach to Lead Screening Page 35 Additional considerations I For infants with initial SLLs :v 4 mcgr?dL. recheck earlier than the standard 1-3 and include iron status testing- Their increasing mobility increases their risk of exposure- I Consider testing other members oi the house as this may aid identification of lead sources- I Chelation therapy is not recommended for BLL's 45 pgr'dL except in special circumstances. Consult the PEHSU for chelalion questions- The FDA recently released a statement warning of the dangers of off?label use of chelalion therapies: Resources for advice on identifying and reducing potential exposure sources Call the local health department for assistance in evaluating the home environment [or lead and check with your state or local housing agencies for resources to remediale lead-based pain hazards- Hogr'on .lt' State-spec'fic read programs Nationarprograms I Alaska Lead Surveillance Program: - CDC faclsheet on new reference iaval: I Idaho Depanment of Health and Welfare lead Lead Levels in Children Facl Sheet-o education :hltp Jrl'reallhandwelfare-idahc .gofoea lthr' - CDC tips for reducing lead exposure: df941rDefaull.aspx I Cregcn lead poisoning prevention: - EPA inicnnalion on childhood lead exposure and lead in general: I Washington State Childhood Lead Poisoning arid Prevention program: a. ovria ead-hlml - National Center for Healthy Housing consumer iaclsheel: Consumer ELL Fact Sheet 2-pdf For additional questions or guidance, contact the NW PEHSU- The Liniversity ct Washington based Pediatric Environmarrtal Health Specialty Unil serves medical and public health professionals in Alaska, Washington, Idaho, and Oregon. For more inform ation contact us at cr pehsu@uw-edu or visit our website Acknovr?edgmenl: A. DNP. AHMP: hi. Marlyn. MD: C. Hair. ill]. Ivicsk. hit-l. Flfii: N. Besudel. MS. CIH: S. Salhyansraysrna. HI). MPH- Last mounted .lune acts- This material vvas supported by the Association of Crocupational and Environmental Clinics and lunded under the cooperative agreement a'n'ard number the Agency for Toxic Substances and Disease Registry Acknowledgement: The LLS. Protection Agency supports the PEHSU by providing funds to under lnler? Agenoy Agreement number 301-02. Neither EPA nor ATEDH endorse the purchase of any cornmerciel products or services msrlioned in PEHSLI publications. Low- Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention- Report of" the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention- la nuary 4, 20-12 21112; to nphear BP, Dietrich ti, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations {in mgde In US children and adolucents. Public Health Report- 115521?529; Lan phear BF, Hornung It, I'll'r-Dur'v' J, et al- Lovv-level environmental lead exposure and child ren's Intellectual function: an international pooled anahrsis- Environment-of Health Perspectives. 3' fvfoodie S, lalongo H, lope: P, et al- The conjoint in?uence of home enriched environment and lead exposure on children's cognition and behaviour In a Mexican lead smelter community- Heurotoxfcofogv- 2012- Advance of print- Tk, Toscano CD, Mc-Siothan .IL, Weaver SA- Environmental enrichment reverses cognitive and molecular de?cits induced by developmental lead exposure. Annals of Neurology- 53:13: 50-56 Targeted Approach to Lead Screening Page 36 In state, WAC 246-1D1 requires labciratcirles t-d repert all bl??d lead test results ta the Washingtcin State Department at Health. All rrelewateclrr blend lead levels, currentlyI de?ned by the state as alDungL in muths ?15 Iyears aid and as 225%,de in peeple 215 Iwears cild, must he rep-drted Iwithin 1 days. All other test results must he reported I.Iii'ltl'iln 1 rncinth. [Ii ttpz?ww w?P uh I ichalthand Health ca reF'rcs-si dcrsIHcalth ca reF'ralcssiansandFaci i naIEIciad curring, Fer current regulaticin, Clinical Label-army imprarementAmen-dmenrs deEiBE. A. useful discussicin cif lab limits can be fciund in: Adulscinlr cin Childth lead Fciiscinlng Freuenti-an- Meeting ill-'iinutesr Hes-ember 16-13, 101D- Atlanta, Geergla- Pages 19-25. "1 WHO. Brief guide tci analytical fer measuring lead In bleed. 1:111. Page 3. [http:wa entfpuhlic bldadcdf. Hflg?li EPA. Residential Lead-Based Paint Fregram?ectidn 1013 cifTitle it ihtt a- cw Icaci ulas IcaleaseJitm 9:19311] Targeted Approach to Lead Screening Page 37 Appendix E. Letter to Parents of Child with Elevated Blood Lead Level [Date] Parents of [Child’s Name] [Address] [Address] RE: Blood Lead Level Consultation Dear Parents: On [Date] [Child’s Name] received a blood lead test showing a blood lead level of [Test Result] μg/dL. Blood lead levels at or above 5 μg/dl are considered elevated per the Centers for Disease Control and Prevention. Public Health would like to provide you with some information that can help you identify potential sources of lead in your home that may be contributing to your child’s lead level. There is also information on methods that can decrease your child’s lead exposure and minimize the effects on your child’s health. We provide this information because lead damages the brain and nervous systems of children at a critical time in their development. Children who are exposed to lead often have behavioral and developmental problems, and difficulty in school. If you have any questions about lead please contact me at (xxx) xxx-xxxx. Sincerely, [Name & Contact Information] Enclosures CC Targeted Approach to Lead Screening Page 38 Mail or fax coanIend form to: Appendix F. Lead Exposure Investigation Form Bookworms]: LHJ USE ID Outbreak?related Childhood Lead Poisoning El Reported to DDH Date t-IJHealth hem-mam We?: Pt] 30147316 . . LHJ Cfuster ?my-?1 9531*? Classi? cation Name: Fastest}:me El Con?m'iecl El Pinball"? boa Outbreak Child Blood Lead County REPORT SDUHEE OH to tallt to case? Yes No Don't know LH.J noti?cation date Immig??m start ate: Reporter name Reporter tcheclt all that apply} Remrter phone El Lab El Hospital El El Public health agency El lEttl'ier phone F-?rimary name INFORMATION l?lame tlast. ?rst] Birth date i_i_ Age Address El Horr'ieless Gender Other Unit Cityi'StatetEip . Ethnicity El Hispanic or Latino Not Hispanic or Latino Alt. to LII rd' 0th I con aren gua ian El spouse El er ame English Speaking? EH, Unk Zip code {school}: Rhone: Grade Schooli'child care name Native language Race {check all that apply] Amer Native El Asian Native Hli'other Pt Eilaclo'Afr Amer El White Clther CIJHICAL INFORMATION Clinical Fin dings DH HA El Any consistent ptom for elevated lead level El Abdominal pain activity El l\lausea, vom'cing. consb'pa'jon or diarrhea El Loss o? appetite El Muscle weakness -lyperac'jvit'y lrr'itability or behavior change Other. El Ever referred ?or neurological. developmental or educab'onal as sessrr'ent Specify: Reason for lead test El Routine screen El Special screening project of lead poisoning El Known exposure to lead El Anemiaiiron de?ciency El Parental request El Risl-r ?actors for lead exposure Clther reason: 1lr NH Cl El -listory o? blood lead tests. ei'J'ier before or after 'J1e elevated lead level was found Collectdate: Result: [pgi'dLi Sample type: capillary El venous El unltnown Collect date: Result: [pgidLi Sample type: capillary venous unknown Case de?ning variables are in bold. Answers are: Yes. No, to case. Not asked Not answered Targeted Approach to Lead Screening El Follow-up or oon?m'iatory lead tests scheduled l:l History of a hematocn't or hemoglobin test for iron status Collect date: Result: Laboratory Elevated lead level Collect date: Result: [ugi?dLiu Sample type: capillary venous unknown Date results received: NDTES DDH 334-159 Page 39 Washington State Department of Health I: ase arne: EIPDEURE over child's ifetime Current home type Single family Multiple unit Mobile home Home ownership Rented Public housing It not owned by family. giye owner's name and phone number. ?r'ears lived in home If less than a year list previous address: Addresses of other places the child regularly spends time. such as day care or homes of friends or relatives: ?r?ear home El Exact year. if ltnown El El 193349 1953-59 194cc: mac?ea Before 192:: Source of waterfor home Public water supply Small water system ='riya'.e well Either DKIM El El Peeling or?alting paintinside or outside home Describe: El Spends u'rne in areas 'l'l'i'J'l ?alting or peeling paint El Exposed to soil outside hemewith peeling exterior paint Seen pudi ng paint chips in results El Seen ct'rewing on painted surfaces in home Recent repairsl'renoyations done in the heme Describe: Liyes or plays in Former onehard site [orchards on propel-.y b-e?cre 1953:: Exposed to soil contaminated by Tacoma smelter plurre l-and made or imported ceramics (especially Mexican pets] used For cooking or storing ?oed Chili or tarrarind candy irr poned ?rom Mexico Played wim toys recalled due to lead content I MA Put metal or painted jewelry in mouth Household member in occupation inyolying lead te.g.. radiator repair shops. battery manufacturer or dismantler. lead or brass foundry or smelter] ElEl-s El Specie"- El 'Child or household member 1.Iyith hobbies inyolying lead te.g.. soldering. stained glass, ceramics, lead shot. casting bullets. ?shing sinlters. sheeting at a ri?e range ergun club] Specie"- El El El Received alte'natiye medications Azanem Rueda Maria Luisa Ereza Liga Coral Alarcon Pay-leach Elali Geli Ghasard Handu Estomaepil El ?ll-total [kc-hit speei?y El El El Recentty trayeled to foreign country Jates'lecations: Recentty imn?i grated or adopted from foreign country Specify mun??- Coyered by Medicaid Recei Ilres Wit: Nutrition bene?ts Attends Head Start or Early Head Start was this person lilter exposed to lead: Paint El Drinking Water Iil?tlirrerceuro'y Job l-obby Candy. toy Aitematime medication Soil Either specify Where did exposure probath occur? LE. no: W?[31ate: In 'wlc'. in L3. dnl-tneum details te.g.I expeere elateI speci?c siteI purchase or use- by slate, product narnet'description]: No rislt factors or exposures could be identi?ed El Patient could net he interviewed PATIENT DHHA El lChelated Date complete: thters in the household {provide information below for each household rnernleers and attach to case investigation term] Name Relation ?g Tested? Collection date Result {udistI DH HA Counseling on measures to avoid exposure for 3535mm Follow upl'cen?rmatory bleed lead tests recon?rnended If yes. UK to release patient 5 name and :c El Referral :0 CTED.5 Lead 4mm Mam l] l] Enwmn-EHW San-Imam mm Referral to deyebprnentalu'educational in hm Referral to master heme ens-inann'rensaiist EIAsthma trigger I:IFall hazanis l] 3-th Specie; other. specify?. HGTEE Investigator Phonetemail: Investigation complete date Local health jurisdiction Record complete date Acknowledgements Expert Panel Participants Affiliation Kathy Lofy, MD (Chair) State Health Officer, Department of Health Holly Davies, PhD Senior Scientist, Department of Ecology Charissa Fotinos, MD Deputy Chief Medical Officer, Health Care Authority Rhonda Kaetzel, PhD, DABT Toxicologist, Public Health—Seattle & King County Catherine Karr, MD, PhD Pediatric Environmental Health Specialty Unit Director and Associate Professor of Pediatrics, University of Washington Gail Kreiger, BSN Medical Benefits/Clinical Review Manager, Health Care Authority Anne Reese, MD Pediatrician, Richmond Pediatrics Cynthia Sanderson Lead-based Paint Program Manager, Department of Commerce Chris Spitters MD Health Officer, Yakima Health District , Klickitat County Health Department Nicole Thomsen, REHS Environmental Public Health Planner, Public Health – Seattle & King County Laura Wishik, JD Attorney, City of Seattle Technical Staff Rad Cunningham, MPH, MPA Environmental Health Epidemiologist, Department of Health Amanda Jones Health Promotion Specialist, Department of Health Elisabeth Long, MPH Lead Epidemiologist, Department of Health Jasmine Matheson, MPH Refugee Health Program, Department of Health Glen Patrick, MPH Environmental Epidemiology Manager, Department of Health Contributor Meenakshi Kushwaha, MPH University of Washington School of Public Health MPH student Targeted Approach to Lead Screening Page 41 References 1 Lanphear, B. P., Hornung, R., Khoury, J., Yolton, K., Baghurst, P., Bellinger, D. C., Roberts, R. (2005). Low-Level Environmental Lead Exposure and Children’s Intellectual Function: An International Pooled Analysis. Environmental Health Perspectives, 113(7), 894–899. http://doi.org/10.1289/ehp.7688 2 Godwin, H.A. (2001) The biological chemistry of lead. Current Opinion in Chemical Biology, 5.2 223-227. 3 Centers for Disease Control and Prevention (CDC). (2015, June) "Blood Lead Levels in Children: What Do Parents Need to Know to Protect Their Children?". Available at: http://www.cdc.gov/nceh/lead/ACCLPP/Lead_Levels_in_Children_Fact_Sheet.pdf 4 Canfield, R. L., Henderson, C. R., Cory-Slechta, D. A., Cox, C., Jusko, T. A., & Lanphear, B. P. (2003). Intellectual Impairment in Children with Blood Lead Concentrations below 10 µg per Deciliter. The New England Journal of Medicine, 348(16), 1517–1526. http://doi.org/10.1056/NEJMoa022848. 5 Lanphear, B. P., Hornung, R., Khoury, J., Yolton, K., Baghurst, P., Bellinger, D. C., Roberts, R. (2005). Low-Level Environmental Lead Exposure and Children’s Intellectual Function: An International Pooled Analysis. Environmental Health Perspectives, 113(7), 894–899. http://doi.org/10.1289/ehp.7688 6 Needleman, H.L., Schell A, Bellinger, D., Leviton, A., Alfred, EN. (1991). The Long Term Effects of Exposure to Low Doses of Lead in Childhood. An 11 Year Follow-up Report. New England Journal of Medicine, 322.2: 83-88. 7 Wright JP, Dietrich KN, Ris MD, Hornung RW, Wessel SD, et al. (2008) Association of Prenatal and Childhood Blood Lead Concentrations with Criminal Arrests in Early Adulthood. PLoS Med 5(5): e101. doi: 10.1371/journal.pmed.0050101 8 AAP Council on Environmental Health, Etzel, R.A., Balk, S.J. Pediatric Environmental Health, 3rd Edition (2011). 9 Piomelli, S., Seaman, C., Zullow, D. Curran, A. Davidow, B. (1982). Proceedings of the National Academy of Sciences of the United States of America.79:10, 3335-3339. 10 Portier, C., & Brown, M. J. (2010). Guidelines for the identification and management of lead exposure in pregnant and lactating women. A. S. Ettinger (Ed.). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry. Targeted Approach to Lead Screening Page 42 11 Hu, H. Tellez-Rojo, M.M., Bellinger, D., Smith, D., Ettinger, A.S., Lamadrid-Figueroa, H., Schwart, J., Schnaas, L., Mercado-Garcia, A., Hernandez-Avila, M. (2006). Fetal lead exposure at each stage of pregnancy as a predictor of infant mental development. Environmental Health Perspectives, 1730-1735. 12 US Department of Health and Human Services. (2007). Toxicological Profile for Lead. Agency for Toxic Substances and Disease Registry. 582. 13 Gulson, B.L., Mizon, K.J., Korsch, M.J., Palmer, J.M., Donnelly, J.B. (2003). Mobilization of lead from human bone tissue during pregnancy and lactation: A summary of long-term research. Science of the Total Environment, 303 (1-2): 79-104. 14 Levin, R., Brown, M. J., Kashtock, M. E., Jacobs, D. E., Whelan, E. A., Rodman, J.,Sinks, T. (2008). Lead exposures in US children, 2008: Implications for prevention. Environ Health Perspect, 116(10), 1285-1293. 15 Jacobs, D. E., Clickner, R. P., Zhou, J. Y., Viet, S. M., Marker, D. A., Rogers, J. W., Friedman, W. (2002). The prevalence of lead-based paint hazards in US housing. Environmental health perspectives, 110(10), A599. 16 Charney, E., Sayre, J., & Coulter, M. (1980). Increased lead absorption in inner city children: where does the lead come from? Pediatrics, 65(2), 226-231. 17 Kim, D. Y., Staley, F., Curtis, G., & Buchanan, S. (2002). Relation between housing age, housing value, and childhood blood lead levels in children in Jefferson County, Ky. American Journal of Public Health, 92(5), 769. 18 Spanier, A. J., Wilson, S., Ho, M., Hornung, R., & Lanphear, B. P. (2013). The contribution of housing renovation to children’s blood lead levels: a cohort study. Environ. Health Glob. Access Sci. Source, 12. 19 Washington State Department of Ecology. (2009) Washington State Lead Chemical Action Plan. Olympia, WA. http://wdfw.wa.gov/conservation/loons/science/doe_wa_lead_chem_action_plan.pdf 20 Jacobs, D. E., Clickner, R. P., Zhou, J. Y., Viet, S. M., Marker, D. A., Rogers, J. W., … Friedman, W. (2002). The prevalence of lead-based paint hazards in U.S. housing. Environmental Health Perspectives, 110(10), A599–A606. 21 Chan, J., Sim, M., Golec, R., & Forbes, A. (2000). Predictors of lead absorption in children of lead workers. Occupational Medicine, 50(6), 398-405. Targeted Approach to Lead Screening Page 43 22 Roscoe, R. J., Gittleman, J. L., Deddens, J. A., Petersen, M. R., & Halperin, W. E. (1999). Blood lead levels among children of lead-exposed workers: a meta-analysis. American Journal of Industrial Medicine, 36(4), 475-481. 23 U.S. Department of Labor. Occupational Health Safety and Health Administration (2015 June). Safety and Health Topics Lead. https://www.osha.gov/SLTC/lead/ 24 Centers for Disease Control and Prevention (CDC. (2013). Childhood lead exposure associated with the use of kajal, an eye cosmetic from Afghanistan-Albuquerque, New Mexico, 2013. MMWR. Morbidity and mortality weekly report, 62(46), 917. 25 Pirkle, J. L., Kaufmann, R. B., Brody, D. J., Hickman, T., Gunter, E. W., & Paschal, D. C. (1998). Exposure of the US population to lead, 1991-1994.Environmental health perspectives, 106(11), 745. 26 Centers for Disease Control and Prevention (CDC. (2013). Blood lead levels in children aged 15 years-United States, 1999-2010. MMWR. Morbidity and mortality weekly report, 62(13), 245. 27 Lanphear, B. P., Hornung, R., Ho, M., Howard, C. R., Eberly, S., & Knauf, K. (2002). Environmental lead exposure during early childhood. The Journal of pediatrics, 140(1), 40-47. 28 Centers for Disease Control and Prevention (CDC. (2013). Blood lead levels in children aged 15 years-United States, 1999-2010. MMWR. Morbidity and mortality weekly report, 62(13), 245. 29 Raymond, J., Wheeler, W., & Brown, M. J. (1999). Lead Screening and prevalence of blood lead levels in children aged 1–2 years—Child Blood Lead Surveillance System, United States, 2002–2010 and National Health and Nutrition Examination Survey, United States, 1999– 2010. Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 2011. 30 National Center for Healthy Housing. (2015 June). Issue Brief: Childhood Lead Exposure and Educational Outcomes. http://www.nchh.org/Portals/0/Contents/Childhood_Lead_Exposure.pdf 31 Raymond, J., Wheeler, W., & Brown, M. J. (1999). Lead Screening and prevalence of blood lead levels in children aged 1–2 years—Child Blood Lead Surveillance System, United States, 2002–2010 and National Health and Nutrition Examination Survey, United States, 1999– 2010. Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 2011. 32 Tehranifar, P., Leighton, J., Auchincloss, A. H., Faciano, A., Alper, H., Paykin, A., & Wu, S. (2008). Immigration and Risk of Childhood Lead Poisoning: Findings From a Case–Control Study of New York City Children. American Journal of Public Health, 98(1), 92. Targeted Approach to Lead Screening Page 44 33 Centers for Disease Control and Prevention (CDC. (2005). Elevated blood lead levels in refugee children--New Hampshire, 2003-2004. MMWR. Morbidity and mortality weekly report, 54(2), 42. 34 Mahaffey, K. R. (1995). Nutrition and lead: strategies for public health. Environmental Health Perspectives, 103 (Suppl 6), 191. 35 Wright, R. O., Shannon, M. W., Wright, R. J., & Hu, H. (1999). Association between iron deficiency and low-level lead poisoning in an urban primary care clinic. American Journal of Public Health, 89(7), 1049-1053. 36 Ossiander, E. M., Mueller, M. M., & VanEnwyk, J. (2005). Childhood lead poisoning in Washington state: A statewide survey. Archives of environmental & occupational health, 60(1), 25-30. 37 Galke, W., Clark, S., Wilson, J., Jacobs, D., Succop, P., Dixon, S., Chen, M. (2001). Evaluation of the HUD lead hazard control grant program: early overall findings. Environmental Research, 86(2), 149-156. 38 Dougherty, J. (2001, February). Prevalence of Lead Dust Hazards Study: A report for the Community. Retrieved October 2, 2015, from https://multco.us/file/30130/download 39 Betts, K. S. (2012). CDC updates guidelines for children's lead exposure. Environmental Health Perspectives, 120(7), A268. 40 American Academy of Pediatrics. Bright Futures. (2015). Recommendation s for Preventive Pediatric Care. https://www.aap.org/en-us/Documents/periodicity_schedule_oral_health.pdf 41 Centers for Disease Control and Prevention (CDC). (2015, June) CDC Lead Poisoning Prevention in Newly Arrived Refugee Children: Tool Kit. Available at: http://www.cdc.gov/nceh/lead/publications/refugeetoolkit/refugee_tool_kit.htm 42 U.S. Centers for Disease Control and Prevention. (2012). CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention. Atlanta, GA. http://www.cdc.gov/nceh/lead/acclpp/cdc_response_lead_exposure_recs.pdf 43 Jacobs, D. E., Clickner, R. P., Zhou, J. Y., Viet, S. M., Marker, D. A., Rogers, J. W., Friedman, W. (2002). The prevalence of lead-based paint hazards in US housing. Environmental Health Perspectives, 110(10), A599. 44 Centers for Disease Control and Prevention (CDC. (2013). Blood lead levels in children aged 15 years-United States, 1999-2010. MMWR. Morbidity and mortality weekly report, 62(13), 245. Targeted Approach to Lead Screening Page 45 45 Pirkle, J. L., Kaufmann, R. B., Brody, D. J., Hickman, T., Gunter, E. W., & Paschal, D. C. (1998). Exposure of the US population to lead, 1991-1994.Environmental health perspectives, 106(11), 745. Targeted Approach to Lead Screening Page 46