Rapid Environmental Health Response to High Venous Blood Lead Concentrations in a Child Less Than 6 Years Old: A Local Health Department Perspective.

Author:Figgs, Larry W.
Position:SPECIAL REPORT - Clinical report
 
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Introduction

The Centers for Disease Control and Prevention (CDC) states that approximately half a million U.S. children ages 1-5 years have blood lead levels sufficient to impair health, 4 million U.S. homes expose children to high lead levels, and each seriously lead-poisoned child will cost the U.S. $5,600 in medical and special education services (CDC, 2013, 2015). Not all communities share the same exposure risk and evidence suggests that urban immigrant populations experience a higher lead poisoning risk than other communities (Tehranifar et al., 2008).

CDC currently recommends a childhood blood lead level reference based on the 97.5 percentile (5.0 [micro]g/dL) of children ages 1-5 in the National Health and Nutrition Examination Survey population and hospitaliza tion when venous blood lead concentrations (VBLC) are 70 [micro]g/dL or above (CDC, 2002, 2012). The Douglas County, Nebraska, Health Department's (DCHD) Lead Poisoning

Prevention Program (LPPP) actively monitors capillary and VBLC and conducts environmental hazard analysis (EHA: locating and characterizing the hazard) and lead risk assessment (LRA: exposure risk assessment).

Currently, DCHD LPPP staff members actively intervene (conduct EHA/LRA, monitor all VBLCs until child is 84 months old, and provide health education information to the child's parents/guardians) when blood lead levels reach or exceed 9.5 [micro]g/dL. This special report describes how the DCHD LPPP staff planned, organized, and executed a rapid environmental health response to pediatric lead poisoning in their community.

Context

In 1998, the U.S. Environmental Protection Agency (U.S. EPA) investigated concerns about an increase in blood lead level prevalence in Omaha, Nebraska (U.S. EPA Region VII, 2009). In 2003, the Omaha Lead Site became a U.S. EPA National Priority List Superfund site. Subsequently, DCHD now provides indoor lead dust remediation, lead exposure reduction education, lead poisoning risk education, and blood lead level monitoring for children up to 84 months.

Today Whites, Blacks, and Hispanics represent nearly 95% of Douglas County's 537,256 residents (U.S. Census Bureau, 2015). Approximately 10% of these residents are foreign born and about 14% speak a language other than English in the home. Among DCHD's 23,513 first-time laboratory reports received from January 1, 2010, to December 31, 2012, describing a previously unscreened child, the mean VBLC was 2.6 [micro]g/dL (SD = 1.43) and ranged from 0-68 [micro]g/dL among children less than 84 months.

DCHD staff members initiate an environmental investigation (EHA/LRA) in those dwelling(s) where 9.5 [micro]g/dL and higher VBLC reports arise. A VBLC report of 4.9 [micro]g/ dL or higher represented approximately 5% (n = 1,196) of all the DCHD LPPP screening results for the years 2010-2012. Therefore, a 61 [micro]g/dL VBLC report was rare for DCHD program staff.

Approach

A logic model tool (Figure 1) can be used to plan resources, outputs, and goals for a rapid response protocol. Protocol steps (Figure 2) can emerge from existing policies and practices. The child's VBLC, age, weight, and nutrition history are the primary drivers for deciding when the LPPP manager activates the protocol (see step 4). Program experiences, practices, policies, and CDC recommendations are also considered.

Rapid Response Steps 1-4: The Initial 24-48 Hours

Steps 1, 2, and 3: The response should be aggressive and rapid because 1) a high VBLC (>60 [micro]g/dL) can significantly increase encephalopathy risk in an ectomorphic child less than 5 years and 2) CDC recommends an aggressive response (CDC, 2012).

At that time, DCHD LPPP staff members also considered that a VBLC of nearly 5.0 [micro]g/dL represented the 95th percentile of its own program for the years 2010-2012, and that DCHD LPPP policy required immediate blood lead level monitoring and EHA/LRA when levels reached or exceeded 9.5 [micro]g/dL.

The network gap assessment should determine what rapid resources are available. Network stakeholders might include the victim's family members and relatives, healthcare providers and payers (clinic, pharmacy, health insurer), government organizations (DCHD, Omaha City Planning and Housing Authority, Nebraska State Department of Health and Human Services), nongovernmental organizations (Family Housing Advisory Services, Inc., Habitat for Humanity, community associations, language translation service providers), the property owner(s) where the victim currently resides and the property owner(s) at the time the blood sample was screened, a home builder and/or a repair contractor (U.S. EPA-certified renovation, repair, painting, and/or lead abatement businesses), the victim's faith community (churches, clubs), and private businesses (hardware retailers, language translation service providers).

The parent/guardian should be contacted first. The parent/guardian needs to know the child is lead poisoned, the...

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