Preventing Lead Poisoning in Young Children: Chapter 9

• Table of Contents
• Chapter 1. Introduction
• Chapter 2. Background
• Chapter 3. Sources and Pathways of Lead Exposure
• Chapter 4. The Role of the Pediatric Health-Care Provider
• Chapter 5. The Role of State and Local Public Agencies
• Chapter 6. Screening
• Chapter 7. Diagnostic Evaluation and Medical Management of Children with Blood Lead Levels > or = to 20 µg/dL
• Chapter 8. Management of Lead Hazards in the Environment of the Individual Child
• Chapter 9. Management of Lead Hazards in the Community
  • Surveillance
  • Risk Assessment and Integrated Prevention Planning
  • Outreach and Education
  • Infrastructure Development
  • Hazard Abatement
• Appendix I. Capillary Sampling Protocol
• Appendix II. Summary for the Pediatric Health-Care Provider
• Tables
• Figures

Chapter 9. Management of Lead Hazards in the Community

In theory, primary prevention has always been the goal of childhood lead poisoning prevention programs. In practice, however, most programs focus exclusively on secondary prevention, dealing with children who have already been poisoned. As programs shift the emphasis to primary prevention, their efforts must be designed to systematically identify and remediate environmental sources of lead, including, most importantly, dwellings containing old lead paint.

The shift from case management to community level intervention will require a fundamental shift in perspective. The focus must shift from the individual child to the population of children at risk and the environment in which they live. The purpose of community-level intervention is to identify and respond to sources, not cases, of lead poisoning. The responsibility for addressing lead poisoning will have to be expanded beyond health agencies to include a variety of housing, environmental, and social service agencies at the local, county, state, and national level.

To be successful, community level intervention will involve at least five type of activities:

1. Screening and surveillance: Determining populations at risk and the locations of the worst exposures.
2. Risk assessment and integrated prevention planning: Analyzing all available data to assess sources of lead, exposure patterns, and high-risk populations and developing primary prevention plans.
3. Outreach and education: Informing health-care providers, parents, property owners, and other key people about lead poisoning prevention.
4. Infrastructure development: Finding the resources needed for a successful program of risk reduction.
5. Hazard reduction: Reducing the hazards of lead-based paint and lead in dust and soil, particularly in high-risk buildings and neighborhoods.

Surveillance

For the most effective allocation of resources, data on the extent of the lead poisoning problems and the location of the worst lead hazards must be available for study. By combining data on blood lead levels, environmental sources of lead, and community demographics, public health agencies can identify and quantify the risk of lead poisoning in the community.

Data on Blood Lead Levels

Results of regular blood lead screening for pre-school children (as recommended in Chapter 6 of this report) will eventually provide an important source of information on the distribution of lead hazards in a community. Current data, which are based on limited public screening or the experience of practitioners or clinics, cannot provide the true prevalence of elevated blood lead levels in the children of a community. Communities may need to undertake additional, focused screening surveys to obtain data on the prevalence of elevated blood lead levels. Even after near-universal screening is in place, such targeted screening efforts will continue to be necessary in areas and populations in which substantial numbers of children do not have regular pediatric health-care providers. To be accurate, such surveys should use door-to-door (rather than fixed-site) sampling and blood lead (rather than EP) analysis.

Health officials can evaluate risks better if they have the results of all blood lead tests, not just the elevated blood lead levels. A convenient mechanism for gathering such information is for laboratories to report all blood lead testing results to an appropriate local or state health agency. Where mandatory reporting is not in place, health agencies should work with laboratories and pediatric health- care providers to obtain as much data as possible on blood lead test results.

Environmental Surveys

Environmental surveys that are designed to identify the common sources of childhood lead exposure can be undertaken in conjunction with or as a complement to community-based surveys of blood lead levels. Environmental surveys do not, however, replace measurement of children's blood lead levels. The environmental sources and pathways of lead that can be assessed in environmental surveys include lead-based paint, lead in dust and soil, lead in drinking water, lead from industrial sources and wastes, and lead from unusual sources such as folk medicines or ceramicware.

An environmental survey of the sources of lead around children's homes (paint, dust, and soil) can be undertaken in conjunction with a door-to-door blood lead screening program. A team would consist of a nurse or phlebotomist who would obtain the blood samples and an inspector who could use the most cost-effective combination of measurements of lead in dust, soil, and paint (for example, XRF analyzers, chemical spot tests, or removal of paint chips for laboratory analysis). When screening for lead-based paint in housing, inspectors should obtain representative data on the prevalence of hazards and need not undertake the type of comprehensive inspections described in Chapter 8. Protocols for environmental sampling must be developed, and inspectors must be trained in sampling techniques before the survey program begins.

In addition to looking for lead hazards in housing, a comprehensive environmental lead testing program could look for other lead sources, including drinking water in schools and residential buildings, soil in playgrounds and schoolyards, street dusts, and lead-based paint in nonresidential buildings such as day-care centers and schools. In some cases, environmental data obtained for other purposes may be useful. For example, the federal Safe Drinking Water Act and Lead Contamination Control Act requires some testing for lead in drinking water, so health officials could, therefore, contact water suppliers and school officials to obtain test results. Agricultural extension services may have data on lead levels in soil.

Demographic Data

Health surveys, such as the National Health and Nutrition Examination Survey (NHANES), have correlated children's blood lead levels with demographic factors such as family income and place of residence (for example, center city vs. suburbs). Demographic data now becoming available from the 1990 census can be used to broadly identify high-risk areas. Variables to consider include the age of housing (pre-1960 housing has the most lead), income levels, socioeconomic status, ethnicity, and the number or density of preschool children in the area. For best results, communities would use this demographic information to predict where the greatest lead hazards might be located and then to conduct appropriate blood lead or environmental surveys to see if the predictions are true. Once the most predictive demographic variables have been identified, algorithms or survey instruments could be designed to accurately predict which areas pose the greatest risk on the basis of demographic data alone.

Risk Assessment and Integrated Prevention Planning

Public health officials should use all of the information at their disposal—blood lead screening results, environmental survey data, and demographic information—to create the most accurate picture of community lead hazards, including sources of lead, exposure patterns, and high-risk populations. Whenever possible, officials should focus on specific sources and the smallest pertinent geographic area of concern. In some new suburban communities, for example, the risks may not justify a communitywide program to abate lead-based paint in housing. Nevertheless, there may be a need to address specific sources (for example, drinking water in new houses with lead solder) or specific neighborhoods (for example, an old part of town where Victorian homes are being rehabilitated).

Because lead poisoning is completely preventable, public health officials should assess the success of current prevention efforts. Local communities should focus on how well the hazards of lead are being addressed in that community, rather than on whether the community has a bigger or smaller lead problem than other communities.

Once a decision is made to address at least some aspects of the lead problem in a community, public health officials should develop an integrated primary prevention plan. The plan should be assembled with input from other agencies (including housing and environmental agencies), pediatric health-care providers, parents, teachers, community groups, and other interested persons. The plan should identify which sources, geographic areas, or high-risk populations are to be addressed. Each element of the plan should include a description of who will have the primary responsibility for implementation, where financial and other resources will be obtained, and a time schedule for implementation. Plans should be as specific as possible in order to allow public officials and community groups to periodically assess whether and how the plan is being carried out.

The remaining sections of this Chapter address in more detail three types of activities that should be addressed in any comprehensive primary prevention plan: outreach and education, infrastructure development, and hazard abatement.

Outreach and Education

Outreach and education must take place during every phase of the community activity, beginning before health and environmental screening and ending when risk abatement is complete. Among the most important targets for outreach and educational programs are local officials, health-care providers, parents, property owners, day-care providers, and early childhood educators. The outreach programs can be carried out through pamphlets and other written materials, local news media, public meetings, school programs, and social service agencies.

Local health officials who have traditionally carried out all or most lead poisoning prevention activities in a community must begin by reaching out to other agencies that will have a role in communitywide primary prevention efforts. When possible, lead poisoning prevention should be part of an integrated program for creating safe and affordable housing or for providing poor people in the community with the full range of needed social services. Local, state, and federal agencies dealing with health, housing, environmental, and children's issues should be contacted.

Many health-care providers are unaware of the most recent developments in the field of lead poisoning prevention. Educational campaigns by local officials, licensing agencies, professional associations, clinics, and hospitals are needed to ensure that pediatric health-care providers understand current thinking about the health and environmental aspects of lead poisoning. Outreach through pamphlets, grand rounds, and continuing education programs should be targeted to pediatricians, family practitioners, pediatric and community health nurses, obstetricians, and midwives.

For parents, including pregnant women, initial education should focus on the hazards of lead and the need for blood lead testing of children at regular intervals. Parents should know about risk factors that warrant frequent screening (Chapter 6). Educational materials should help parents understand the implications of the screening results. Finally, parents (and parents-to-be) should be informed about simple steps that can be taken to reduce risks, such as proper nutrition (Chapter 4) and housekeeping measures (Chapter 4). Such outreach efforts can be targeted to individual parents and to groups of parents and prospective parents.

Property owners and managers, realtors, and other real estate professionals need to learn how to maintain property in a safe and habitable condition. Banks, mortgage companies, and insurance companies could play an important role in conveying this information at critical junctures, such as when a property owner is buying a property or seeking financing for major renovations. In addition, property owners should be given written material that explains how to remove lead safely.

Day-care providers and early childhood educators should be given information about lead poisoning and its sequelae. Those taking care of young children should also be informed about the need to identify and abate lead hazards in day-care buildings and schools. Parents of lead-poisoned children can aid in this process by informing their child's teachers about the past lead poisoning, so that the teacher can make better informed decisions about the need for remedial measures.

Infrastructure Development

Before a community can launch a broad-based program of preventive deleading and hazard reduction, many elements must be in place to support such activities.

First, regulations or other rules and standards are needed to define when and how inspections and deleading are to occur. One local agency (housing, environmental, or health) should be designated as the lead agency with respect to community intervention activities and a system should be put in place for coordinating regulatory and other activities among all involved agencies.

A second requirement is contractors who are trained 1) to identify lead hazards, including lead-based paint, and 2) to remove lead-based paint safely. Besides inspectors, abatement planners, contractors, supervisors, and workers are needed. Optimally, such persons should be licensed or certified by a federal or state agency to ensure that their work is of high quality.

A third infrastructure need is temporary housing for families during the deleading process. Because lead-based paint should not be removed while homes and apartments are occupied, communities must develop strategies to provide temporary alternative housing for families that need it. Communities should consider developing "safe houses" where families can live temporarily at little or no cost while their homes are being deleaded. If families are encouraged to "double up" with friends, measures should be in place to ensure that the home or apartment being used for temporary housing is free of lead hazards.

The final element of infrastructure involves financial resources for both the government agencies overseeing lead poisoning prevention programs and property owners or tenants seeking to delead. This may be the most difficult element, yet it is critical to a successful program. Existing federal and state housing funds (for example, Community Development Block Grants) can be used to finance lead removal if communities so choose. Starting in Fiscal Year 1992, a limited number of loans for abatement may be available from the Department of Housing and Urban Development through the HOME program.

Hazard Abatement

The final and most important step is actually abating the lead hazards. This may involve many activities, such as corrosion control to reduce the amount of lead in drinking water and covering or removing lead-contaminated soil in parks and playgrounds. In many cases, the primary risk will be lead-based paint and the primary form of risk reduction will be preventive deleading—abatement that occurs before children have been poisoned. Before the hazard abatement phase, the community must decide which lead hazards to target. Information gathered during risk assessment should be used to ensure that abatement resources are directed toward the highest risk neighborhoods and buildings.

Local officials have a variety of means at their disposal to promote preventive deleading—from education and outreach, programs designed to increase voluntary deleading, financial assistance to encourage deleading, and regulatory mechanisms to require deleading. If voluntary efforts are to be encouraged, outreach must go beyond general information to provide building owners with specific information about how to survey a building for lead hazards and how to abate those hazards.

If abatement is mandated by law, the law should require safe and effective abatements. Rental property owners should not be permitted to avoid abating their properties by evicting or refusing to rent to families with young children.

Whatever mechanisms are used, the goal of hazard abatement must be to systematically eradicate the lead hazards in the community. Such a program will protect not only lead-poisoned children but all children and thus safeguard the community's future.