Introduction

"Clinicians should be a consistent and reliable source of information, and take a primary role in educating families about the risks of lead-exposure. If appropriately educated, all families will be better equipped to make sound housing decisions based on an understanding of the risks associated with lead hazards" [ACCLPP 2012].

The primary instruction to patients and parents of children exposed to lead should be to eliminate or control sources of all lead exposure. These recommendations will depend on lead exposure source type and setting (e.g., home or workplace).

Guidance for parents should cover a number of lead risk topics, including

• In-home exposures,
• Potential lead-exposures associated with parental occupations and hobbies, and
• Unsafe renovation practices.

This section focuses on instructions the health care provider can give to parents and patients regarding steps they can take to prevent, reduce, or mitigate lead exposure from the home, workplace, and environment.

Also discussed are risk communication and education strategies that health care providers can use to best explain lab results, deliver instructions on clinical follow-up, and impart preventive messages to their lead exposed or potentially exposed patients.

Communications with Parents and At Risk Populations

Parents should be provided with information on identifying lead hazards and safe/reliable methods to minimize exposures, as well as contact information for additional local lead-related resources. This information should be provided in appropriate cultural formats and reading level for the target audience.

In addition, the clinician has a role in recognizing risks for potential lead exposures specific to

• Immigrant communities,
• Refugees, and
• Children adopted from foreign countries,

whose previous and/or ongoing lead exposure may include

• Ceramic ware,
• Cosmetics
• Folk/home remedies,
• Food,
• Medications,
• Toys, and
• Other less common items (like automobile batteries).

The health care provider should ensure there is time available to carefully listen to expressed concerns and questions and provide empathetic responses with voiced understanding by the parent or patient. Information may need to be repeated. This is especially important during high risk/emotionally charged situations when the ability to receive and process information may be decreased.

Blood Lead Level Risk Communication and Education Strategies

Effective screening policies and practices should ensure that the children of high-risk families (e.g., families on Medicaid) are screened, and that lead-exposed children or children with elevated BLLs receive key environmental interventions and case management services [ACCLPP 2012].

• Interactions with affected families must be performed in a culturally-sensitive, same-language, and streamlined manner (see Lead Health Literacy Initiative at:https://www.cdc.gov/nceh/lead/tools/leadliteracy.htm.
• The medical home, laboratory, and other providers should offer simple information about the meaning of elevated BLL test results, and relevant, culturally-sensitive messages about their impact should be conveyed.
• Specialized terms such as "detectable level" or "elevated BLL" should be defined.
• Pediatricians and other providers shall integrate BLL test results into the "basic" report of indicators like weight, height, and developmental percentiles.
• Pediatricians commonly present data in the form of percentiles, and a similar convention could help physicians explain elevated BLLs to parents (see [CDC 2011b] for patient handouts).
• Test results should not be difficult to obtain; parents should have continuous access to BLL test results via internet and telephone retrieval systems until the child reaches the age of twelve.
• Physicians should explain the uncertainty of all quantitative medical tests and BLL testing.

Communicating Instructions to Prevent, Lower, or Mitigate Domestic Lead Exposure

For children (and adults) with domestic exposures, there may be multiple sources. Therefore, it is important to identify and encourage patients and parents to address all potential sources of lead and to continue blood lead monitoring to help confirm that the source(s) has(have) been effectively eliminated.

It would be important to explain to parents and patients that domestic exposure to lead can come from a variety of sources, including

• Deteriorated paint,
• Contaminated soil,
• Water (i.e., lead solder in pipes), or
• Other products.

Patients or parents should be advised to

• Eliminate source(s) of lead exposure,
• Flush standing water from the lines and faucet for several minutes before use, and use cold water for drinking (if they have older homes with galvanized lead or lead soldered pipes and/or lead service lines),
• Maintain a low-fat diet high in calcium, zinc, vitamin C and iron, and
• Continue to monitor BLLs (if applicable).

It may be difficult for low-income patients and their families to permanently address all lead hazards in their homes, due in part to costs and/or landlord accountability (if they rent).

Patients or parents should be informed of the following:

• There are federal disclosure laws for potential renters/buyers that require landlords and sellers to disclose any known lead hazard.
• State and/or local ordinances require property owners to address higher lead content paint hazards, and in many communities, grants are available to help with lead hazard control.
• Additionally, there are many low-cost ways to temporarily reduce lead hazards in homes. The "Sources of Additional Information" section provides several helpful resources.

Since lead poisoning from old or peeling paint continues to be a serious health risk to American children, the U.S. Environmental Protection Agency (EPA) wants to remind parents and contractors and increase the awareness of health care workers of the importance of lead-safe practices during renovation of homes built before 1978. See: https://www3.epa.gov/region9/lead/index.html

Covering bare soil contaminated with lead in the yard with grass or other type of covering may reduce exposures. Guidelines are available from governmental and nongovernmental organizations to help health care providers instruct their patients in reducing home lead hazards [ACCLPP 2012]. It is also important that residents mop the floors and use a wet rag for cleaning the window sills regularly, as children's BLLs have been found to be directly correlated with levels of lead in dust in their homes [Lanphear et al. 1998].

OSHA's Lead and Hazard Communication Standards

Health care providers need to be aware of OSHA regulations for workplace lead exposure prevention and surveillance. They should also be aware of the OSHA Hazardous Communication standard.

Inform workers that they have a right to a safe workplace. The Occupational Safety and Health Act of 1970 (OSH Act) was passed to prevent workers from being killed or seriously harmed at work. The Act created the Occupational Safety and Health Administration (OSHA), which sets and enforces protective workplace safety and health standards. The law requires employers to provide their employees with working conditions that are free of known dangers [OSHA 2014]. It is important that workers understand what these regulations and controls mean and the proper use of personal protective equipment to avoid exposures.

OSHA requires employers to establish hazard communication programs to transmit information on the hazards of chemicals to their employees by means of labels on containers, material safety data sheets, and training programs. Implementation of these hazard communication programs will ensure all employees have the "right-to-know" about the hazards and identities of the chemicals they work with, and will reduce the incidence of chemically - related occupational illnesses and injuries [OSHA 2014b].

Communicate with workers that as part of OSHA's lead standard, BLLs are monitored. If workers have elevated BLLs, they need to understand and comply with work site controls to lower these levels and their responsibilities to prevent future exposures.

Inform workers in environments with lead that they can take lead home on their skin, hair, shoes, tools, and clothing. That is why it is important to change clothing and shower after work before going home to avoid taking lead home. Clothing contaminated with lead can be placed in a plastic bag and washed separately from other clothing to avoid contamination. Some workplaces provide work clothing and/or laundering service for their employees.

Advise workers that it is a violation of the Act for an employer to fire, demote, transfer or discriminate in any way against a worker for filing a complaint or using other OSHA rights.

OSHA can help answer questions or concerns from employers and workers. To reach a regional or area OSHA office, go to OSHA's Regional & Area Offices https://www.osha.gov/html/RAmap.html or call 1-800-321-OSHA (6742).

Employee rights under OSHA [OSHA 2014b]:https://www.osha.gov/Publications/osha3021.pdf.

Clinical Follow Up Instructions to Patients

Patients need to understand when and why they should call their physician for further medical attention. This will depend on several factors including their blood lead level results, signs and symptoms, exposure risk and exposure status, comorbid health conditions, and past and current health status. In particular, they should know that they may need their blood lead monitored on an ongoing basis to confirm removal from the source of exposure and/or response to clinical modalities including chelation therapy.

ATSDR's Lead Toxicity Patient Education Sheet https://www.atsdr.cdc.gov/csem/csem.asp?csem=7&po=19 provides a job aid to facilitate patient education and clinical care follow-up instructions.

Progress Check