In 1988, the Agency for Toxic substances and Disease Registry released a report on lead poisoning giving health partners and stakeholders an overview of the adverse health effects of lead poisoning in children 6 months to 5 years of age. They found that about 2.4 million children nationwide (excluding other racial categories) living in metropolitan areas were at risk of lead exposure health effects using a blood-lead level of a maximum 15ug/dl acceptable standard. Higher blood-lead threshold levels were found in black children living in inner-cities as well as children from low income families. Another report in 1990 released by the Environmental Defense Fund (EDF) saw varying differences in lead exposure in children ranging from racial, economic (Perkins, 1992) and residential location. Based on this study, lead exposures were found to be higher in states of the Midwest (Wisconsin) and Northeast where most of the housing were very old. This doesn’t mean states with larger amounts of relatively new housing don’t suffer from lead exposure as found in Las Vegas where despite increase in new buildings, over 12,000 children making up 28% of the entire population has blood-lead levels exceeding 10ug/dl. Among the states of the Mid West of the USA, Wisconsin stands out as one that has over the years being at high risk of lead exposure. In a study carried out in 2006 by the Wisconsin Childhood Lead Poisoning Prevention Program (WCLPPP), lead exposure prevalence within the state stood at 2.6% in children tested under the age of 2 years. This was twice the national prevalence which stands at 1.4%. Lead exposure in children has been a major public health concern for over a century now. According to the CDC Surveillance Data of 1997-2006, the number of children being poisoned by lead in Wisconsin was greater than in other states, leading to serious health hazards with high financial burden to families’ especially low income families. In 2010, over 735 new cases of children with blood lead levels â‰¥10ug/dl were identified. In that same year the prevalence of lead poisoning in children tested in Milwaukee with blood lead levels â‰¥10µg/dL stood at 3.4% which is 2.4 times the national average of 1.4%.
Source: Wisconsin Department of Health and Family Services, Division of Public Health, Bureau of Environmental and Occupational Health; April 201
In the state of Wisconsin the précised number of children at risk of lead poisoning still remains unknown but in compliance with the Chapter 151 of Wisconsin statutes which requires that every physician reports any conformed or suspected cases of blood-lead poisoning, over 3265 children with blood lead concentrations of over 20ug/dl were reported to the Wisconsin Department of health between the periods of July 1992 to June 1993 (Schirmer, 1993). Based on the national estimate of 17% of blood lead poisoning, the Wisconsin Division of Health estimated that over 36000 children within the state were at high risk of lead poisoning (Schirmer, 1993). According to the Title XIX program also known as the HealthCheck program which makes blood-lead screening mandatory for all children between the ages of 2-6years (Hoffman, 1993), in 1992, , over 12,435 children were screened for blood lead poisoning based on the HealthCheck under the Wisconsin Medicaid program and of this number 2644 of them had blood-lead levels â‰¥ 10ug/dl (Department of Health and Social Services, 1992).
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In 2006, 5% of enrolled children in Wisconsin public schools had at least a blood lead concentration above the normal value. In two separate studies carried out in 2000 and 2007, their resulting data showed that childhood lead poisoning accounted for about 88% of violent crime rates in the USA over several decades as could be seen in the rate of school disciplinary problems resulting to an increase in school dropouts, juvenile delinquency and even adult criminality. In the fall of 2006, it was estimated that one in every 20 children between the ages of one and two years who entered the Wisconsin school system had lead poisoning and below a third of these children who are at high risk of lead exposure have been screened for lead in their blood (WI DHS; 2008). Most of the children identified in Wisconsin to be at risk of lead poison accounting for over 90% lived in very old homes that were built before the 1950s. Lead poisoning is not just a serious problem here in the Milwaukee County but it’s a major problem in all the 72 counties statewide affecting children primarily. In a study carried out in 2006, it was estimated that over 75% of children known to be poisoned with lead lived in 266 out of all 1330 high risk census tracts in Wisconsin with over 200,000 homes built before 1950. Blood lead levels equal to or greater than 10micrograms per deciliter (mcg/dl) is regarded as a call for concern as set by the center for Disease Control (CDC) in 1991 (CDC, 1991) and in 2007, the CDC reaffirmed this level (CDC, 2007). These findings made law makers to look deeper into the issue of lead poisoning as a major cause of unusual societal behaviors (Nevin 2000; 2007). Based on this blood lead level, Wisconsin children with these levels are considered to be lead poisoned and this blood lead concentration has been used for surveillance purposes to help identify, treat and manage new cases (Wis. Stats 245.11 CDC Blood Lead Surveillance Data, 1997 – 2006).
Sources of childhood lead poisoning
Most of the routes of lead poisoning in children include inhalation, ingestion of soil (Harrison et al., 1981) or household dust and drinking water (Harrison et al., 1991) that has been contaminated with lead from old paintings flakes which occurs during when old houses are being renovated or through lead paint coated surfaces found in the kitchen, bathroom walls and windows of homes that were built before 1950. Most of these lead particles are extremely small and cannot be seen with the naked eye. Since its ban in 1978 in the USA, it has still been used to coat walls, frames of windows, doors, floors and ceilings of old homes and toddlers and other children are at risk of ingesting these surface fall offs reason why the CDC recommended lead testing and required by the federal Medicaid policy in children under 6 years (CDC, 2000). Lead poisoning within the state is a complex combination of the poverty, and low socio economic status of most families coupled with the old housing putting children at risk. However, other sources of lead exposure have been found in some consumer products which may pose a health risk to children and adults alike. They include toys, lunch boxes, and jewelries for kids, ceramics, candies as well as products made in China and Mexico. The state recommends that people stop buying these products, dispose of them or return them for a refund if bought. The Center for Disease Control and Prevention through the U.S Consumer Product Safety Commission has recalled a list of these items with unsafe levels of lead some of which include toys, candies such as ‘SINDOOR’ a coloring food product was recalled by the Food and Drug administration (FDA) 2007 after a series of test were conducted by the Illinois Department of Public Health found this product to have over 87% of lead.
Lead poisoning and its Adverse Health effects
Lead, is a naturally occurring element on earth whose chemical properties allow for its use in building construction. Its use dates back to about 3500BC (Needleman, 1990) when Romans started using it to make lead pipes and storage containers. It has been extensively used in many products such as paint, gasoline, and ceramic. Even though adults can suffer from lead poisoning it is much more severe in children. Despite the fact that it’s preventable its health impact is severe ranging from behavioral defects, delay in speech, hearing problems, poor performance at school, increased juvenile delinquency and in severe cases death. There is really no safe level of lead in our bodies as even very smaller amounts below the Wisconsin blood lead concentration could cause serious long term health effects such as a brain damage (Mendelson et al, 1998). Other strange behaviors exhibited by lead poisoned children include aggression and the tendency to become over active (Nevin 2000). Other studies have shown that lead exposure in children may cause kidney disease when they reach adulthood, diabetes and even memory loss as seen in Alzheimer’s disease and severe cases stroke and heart attack (Needleman 1990). It affects especially their brains and the central nervous system since both systems are still forming and low exposure could result in reduced IQ learning disabilities, stunted growth (Brubaker et al., 2009). Studies have shown that blood lead concentrations as low as 70ug/dl and as high as 100ug/dl can lead to encephalopathy in children which is linked to anorexia, decreased in activity, poor coordination, vomiting and aggressiveness and rapidly progresses to death (CDC 1991)
Structure of Wisconsin’s Lead Poisoning Prevention Programs
The Wisconsin Department of Health services (DHS) is in charge of all health programs and services that are geared towards promoting the protecting and promoting the health and safety of the people of Wisconsin. They carry out functions like assessment, policy development and advocacy. Of these programs is the WIC program which is a federally funded program under the child and youth services of the DHS. This program provides special supplemental nutrition to women, Infants and Children (WIC) in other to promote and maintain the health and wellbeing of pregnant women, breastfeeding and postpartum women, infants and children. Children eligible for this program must be infants of up to a year or a child up to age 5 and whose parents are Wisconsin residents, be income eligible and have a health or nutrition needs. In the state of Wisconsin, children are required to be tested twice for lead in blood with the first testing taking place between 6-16 months of age and the second testing between 17-28 months.
However within the DHS is the Wisconsin Division of Public health (DPH) which addresses three major lead hazard control programs namely the Adult Blood Lead Epidemiology and Surveillance (ABLES) program, Asbestos and Lead Certification Unit and Wisconsin Healthy Homes and Childhood Lead Poisoning Prevention Program. The ABLES program focus on monitoring laboratory based lead levels in blood of adults most due to occupational exposure while the Asbestos and Lead Unit program provides accreditation and certification programs for the Wisconsin DHS under the Chapter 254 Wisconsin statue provision as well as standard guidelines required for abatement activities within the state. There is also the Wisconsin Healthy Homes and Childhood Lead Poisoning Prevention Program (WHHCLPPP) which makes possible resources such as technical, financial and consultations to help stakeholders completely eliminate and treat childhood lead poisoning
Funding for Lead poisoning control programs
Increased pressure from the Wisconsin public lead to the creation of a federal law called the “Title X Residential Lead-based Paint Hazard Reduction Act” of 1992 with focus on the federal government taking a major role in lead poisoning prevention. This law requires that all housing programs have lead safety addressed in them. It also calls for the Environmental Protection Agency (EPA) to set up guidelines for lead safety to be executed by a well trained workforce and lastly it calls for all owners of private property to provide basic information with any possibilities of lead exposure hazards to home buyers or new tenants. It was not until 1991 when the CDC started funding lead poisoning preventions programs within the state of Wisconsin such as blood lead testing, managing serious cases as well as raising programs aimed at educating the public on the issue. This led to increase testing of Wisconsin children for lead poisoning with many new cases being identified an indication that many local health department within the state lacked sufficient resources to facilitate follow-ups of lead poisoned cases or identify potential lead hazards in homes. These concerns and pressure from parents and other NGOs such as the March of Dimes and the Council of Developmental Disabilities pushed the Wisconsin State Legislature to implement state laws by providing more resources to help facilitate the work of the Department of Health and Family Services (DHFS) and other local health departments to effectively response to lead poisoning prevention programs and develop a good reporting system for blood lead test results in children. This saw an increase in funding for local health departments from zero dollars to $1.2 million each year which subsequently decreased to $879,100 because of certain cuts in the state budget. Wisconsin was amongst the 12 grantees in 1994 to receive a housing grant of $6 million to help fund projects aimed at fixing lead hazards such as eliminating dust containing lead in old homes and screening children living in these homes. The project was a huge success as lead dust levels greatly reduced in homes and since then many cities within the state namely Milwaukee, Kenosha and Sheboygan have submitted grant proposals and received competitive grant funds aimed at control lead hazards programs in high risk homes.
In February of 2011, the city of Milwaukee received a $4.5 million grants from the U.S department of Housing and Urban Development to help fund a program aimed at controlling lead hazards in two areas namely the city’s North and South sides known to have a very high rate of childhood poisoning within the city covering over 900 city homes. The prevalence of lead poisoning in these areas peaked 7.1% causing a serious alarm to public health officials. In a press release on January 2011, the U.S Department of Housing and Urban Development (HUD) awarded over $127 million to some 48 projects nationally which focused on improving quality of lead paint based low income homes that served as a health hazard to its occupants. This grant would help clean up lead paint based hazards in over 11000 homes, increase public awareness on the issue as well as train more personnel in lead safety practices. The following is a breakdown of the grants
Lead-Based Paint Hazard Control Grant Program
“Healthy Homes Initiative” funding
Lead Hazard Reduction Demonstration Grant Program
Healthy Homes Production Grant Program
City of Milwaukee Health Dept
City of Sheboygan
Wisconsin Dept. of Health Services
HHP – Healthy Homes Production, LBPHC – Lead Based Paint Hazard Control Grant Program (includes Healthy Homes Initiative supplemental funding, as applicable), LHRD – Lead Based Paint Hazard Reduction Demonstration Grant Program (Source: HUD, 2011 HUD No. 11-004)
Ongoing Lead-based paint control programs
In June 2004 the Phase 1 of the Wisconsin Childhood elimination strategic Plan was completed and this plan was developed by a diverse group of experts from the health field, the housing departments, government agencies and other community groups with the aim of eliminating childhood lead poisoning by 2010. This strategic work plan focus on achieving four main goals through the creation of these subcommittees namely;
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Education through which the general public will be aware of the problem within their community and how to protect children from lead exposure. Also parents and childcare providers would be educated about lead hazards through home visit. Policy makers and state legislators were to be educated on how much impact lead poisoning has in the community while addressing issues of neglect of the problem and what needs to be done to overcome some of this negligence which could be potentially costly. Property owners and construction contractors would be educated and provided with opportunities to maintain old homes while ensuring a safe work environment
Lead hazard correction in homes with emphasis on identifying and analyzing some of the risk factors associated with lead poisoning while focusing resources on homes that were built before the 1950s as they pose a high risk of lead exposure. This goal focused on enforcing home owners so they can repair possible lead hazards in their buildings and to ensure a strong community engagement on the problem, incentives were to be provided to home owners who comply with all these regulations.
Screening for lead poising in high risk groups through the provision of enough funds to help identify and evaluate children with risk of lead exposure as well as evaluate existing practices being performed by physicians and the barriers they may pose to families and healthcare providers in terms of providing blood lead screening to children. This goal also emphasized on the need for better data sharing and quality reporting like the STELLAR or the Wisconsin Immunization Registry among partners within the community so that children who are at risk of lead exposure are identified and tested
Funding through the allocation of and resources and making available increased funding for lead hazard control in Wisconsin was a major priority. This funding would help local communities with high risk housing by investing in homes so that the financial burden of having to treat or manage children with lead poisoning will be less on the state.
Phase 2 of the Wisconsin Elimination Plan is ongoing but in 2009 the sub committees in charge of Funding and Resources and Correcting Hazards in housing combined their efforts and all 3 existing committees now meet independently of the Implementation and Oversight Committee (IOC) and provide a progress report at each IOC meeting which usually meets 3 times a years (January, May and September). These meetings are aimed at evaluating progress made so far and identifying some of the challenges faced in the execution of some of the existing programs as well as make recommendations to the IOC for effective and efficient implementation. The IOC is made up of partners from the Wisconsin Division of public health, local councils, State departments of Hygiene and administration, community health centers as well as insurance companies. Within the city of Milwaukee, over 40 employees are involved in lead based prevention programs which provide resources and services to identified children at risk if lead poisoning and those with lead poisoning as well as programs geared towards prevention of lead poisoning before it even happens
Huge Financial burden of lead poisoning in its impact on the state of Wisconsin
The negative burden of lead poisoning to the community is the huge medical expenses in treatment and management of the health problem, increased health care premiums and increase in Medicaid expenses. Since childhood Lead Poisoning (CLP) often results to attention disorders and developmental delays (Canfield et al, 2003) in lead poisoned children, there is need for increased special education expenses for programs to help accommodate children with disabilities as well as programs to cope with juvenile delinquent lead poisoned children who are at high risk of dropping out from school and early teen pregnancies (Needleman, et al, 1990). It has been shown that most children who are poisoned by lead are thrice more likely to fail standardize test as well as being arrested for a criminal case as they transition into a young adult. Also, lead poisoned children at fourth grade where three times more likely to fail their reading tests compared to those with very minute amounts of lead exposure (Miranda et al. 2007). The state spends an estimated $5 billion in school aids to children including a $375 million to assist children with special needs and a $1 billion for children who need corrects with most of these cost is attributed to lead poisoning. The number if children living in Wisconsin between the ages 0-6 is approximately 540,000 and if the state embarks on lead hazard control programs that aim at eliminating lead exposure in homes build pre 1950, it would save the state about $7 billion in direct cost with an increase in earnings of over $21 billion based on an analysis that was conducted in New Jersey that analyzed cost savings such as direct medical cost, special education, crime and juvenile delinquency, low rates of high school graduation and cost to state government (Muennin et al., 2009). The recommendation from the Wisconsin Childhood Elimination Plan and the Implementation and Oversight Committee (IOC) suggested an annual investment of $20 million would go a long way to provide resources to help control lead pain hazards in over 2,000 pre-1950 homes annually. The state would safe over $28 billion in savings if all children between the ages of 0-6 years were protected from lead hazards which will further help lead to an increase in the graduation rate of the state as well as crime reduction (Muennin et al., 2009)
In the spring of 2010, a Joint Resolution 65 was passed and approved by the Wisconsin State Legislature which called on the Implementation and Oversight Committee of the Wisconsin Childhood Lead Poisoning Elimination plan, a program within the Wisconsin Department of Health Services to provide report on the financial burden result from childhood lead poisoning been experienced through the state’s education and criminal justice systems resulting from juvenile delinquent risk behaviors that most children with lead poisoning are at high risk at encountering at some stage in their lives which will help policy makers and state officials make financial resources and other logistics available to address lead paint hazards as well as create a widespread community awareness campaign program which makes loans available to home owners of house build pre 1950 thus reducing lead hazard risk. This report was delivered to the State legislature on December 30th of that year. This joint resolution gained several approval from state agencies such as Departments of Public Instruction, Children and Families, Corrections Division of Juvenile Correction, the Wisconsin Court System and State Prosecutor’s Office with the creation of a committee that helps gather relevant data which will help stakeholders within the state to better evaluate the cost due to lead poisoning and ways to completely eliminate lead hazards in homes. In a 2006 study, over 80,000 young children are estimated to be living in lead paint hazards in Wisconsin and if the state focuses more on protecting families from exposure, we would be saving over $40,000-50,000 for each under the age of six giving us a estimated savings of over $3.6 billion (Jacobs and Nevin, 2006).
Lead Testing and Reporting
To increase blood lead testing coverage within the state of Wisconsin, four main Medicaid managed Care organizations teamed up with state and local WIC agencies in 2010 and together donated a quick three minute LeadCare II testing instrument approved by the CDC with the overall aim to improve on the blood lead testing levels in children at risk. These organizations also gave WIC staff access to the electronic reporting system that exists within the state as well as resources to follow up children who showed high levels of lead in blood. Within the city of Milwaukee, the WIC program is the only program that has got direct access to the STELLAR (State Blood-Lead Reporting System) and the WIR (Wisconsin Immunization Registry) and this enables them to enter data correctly which is required for state and federal reporting compliance. This system also helps WIC staff to easily identify children who have not been tested for blood lead and follow-up with them to get tested as well as follow up with cases that show elevated levels of lead in their blood. With the donation of 10 LeadCare II analyzers as well as 20 test kids in 2010 in all 10 WIC clinics within the state of Wisconsin, the program has witnessed over 41% increase in the number of WIC children tested for lead in blood in the city of Milwaukee. Children enrolled in the WIC program receive two rapid tests namely an Iron and blood lead test using a finger stick. Over 139 children in 2009 tested positive for high levels of lead in their blood samples giving a 300% increase in lead poisoning cases when compared to the previous 2 years due to the fact that most of the children living in high risk urban areas who were now being tested had previously been missed.
Since 2006, Medicaid health care providers have received an annual Blood Lead Testing developed through collaboration with the Wisconsin Medicaid Program and the Wisconsin Childhood Lead Poisoning Prevention Program. The individualized reports summarize the blood lead testing data for children under age 6 within each provider’s practice. In addition providers received a list of untested children in their practice to facilitate follow-up to ensure these children get tested. It is normally required that children be tested for lead poisoning at ages 1 and 2 and since most of them are not tested at those early ages because of lack of follow-up, it is mandatory that they get at least a test between the ages of 3 to 5 years. For example in 2007, over 2,049 children with blood lead levels of greater than or equal to 10mcg/dL were identified within the state and almost two thirds of children eligible for the Medicaid program entering the Wisconsin school system that fall have not properly tested even though 88% of children eligible for Medicaid which covers blood lead poisoning were enrolled that year. (Data is from Individual Medicaid Providers for period of July 1, 2006 through June 30 2007 (SFY07)
There are some NGOs within the state that are focused on raising awareness through community leadership on lead poisoning and one of them is the Milwaukee’s Hmong American Friendship Association (HAFA) through its Parents Against Lead (PAL) alliance. It’s made up of neighbors, parents and other passionate individuals who have come together to collectively eliminate childhood lead poisoning. Being a great partner with city of Milwaukee Health Department, they have promoted lead abatement activities in families living in pre 1950 homes as well as amongst home owners on how to eliminate possible lead hazard within the city. Another community based group working within the community is the Sherman Park Community Association (SPCA), a group of over 167 residents who come together during a cold Winter day and have breakfast with Santa Claus as a way to bring communities together and educate them on the work they do including a window repair/replacement program with emphasis on lead based pain hazard.
Advocacy and Public Policies
The presence of GIS Maps within each Wisconsin legislative district identifying areas with Lead poisoning is now available and from this data no place within the state is free from lead poisoning with more cases in communities with old housing. As part of the Healthier People 2020 Public Health plan, the state of Wisconsin through the U.S Department of Health Services, EPA, HUD, Energy and the CDC came together during the 2011 National Healthy Homes Conference which brings partners, leaders and experts from the public and private sector to discuss on how to improving on housing conditions and making them safe from lead paint based hazard and environmentally sustainable. However, certain rules and number of statutes that regulate activities geared towards lead hazard control have been approved within the State and these rules protect residential areas, tenant/landlord agreements, drinking water facilities, lead hazard reduction and the manner in which blood lead results are reported. They include the Wisconsin statute Chapter 254 which lays emphasis on detection, treatment and response to lead hazards. In Wisconsin, a number of statutes and rules have been enacted to regulate activities having to do with hazards due to lead-based paint and include residential facilities, worker protection, landlord and tenant agreements, housing sales, lead hazard reduction, drinking water, reporting of blood lead test results and public health response to lead poisoning. There is the Wisconsin Statute Chapter 704 which outlines conditions in which tenants could move without having to face any liabilities from health hazards such as lead. We have the Statue Chapter 709 which requires that owners of residential real estate make certain disclosures about their property. Amongst the administrative rules is the DHS 163 which requires people such as contractors to get certification for identification, removal and reduction of Lead-based paint which was amended in 2009 and the DHS 181 which allows for quality reporting of blood lead test results.
Assessment Performance of Childhood Poisoning in Wisconsin
The State department of Health and Services is charged with the collection, evaluation and sharing information concerning the incidence of lead poisoning in risk populations and communities while the local health departments within the state would maintain a local surveillance system that gives the population an idea of the prevalence and trends of testing and making this information available to the state Department of Public health and other stakeholders. A tracking system to effectively monitor children at risk and those with very high blood levels would be maintained and made available to the department of Health and Family Services (DHFS) through the WCLPPP. The local health departments trough the support of state agencies of Public health would develop protocols and procedures to better monitor the screening of children at risk of lead poisoning and well as provide clinical and educational resources for better programming and reporting
Lead Prevention and Control
Lead poisoning is preventable if the necessary precautions are well respected one of which is the lead abatement of homes. The primary way to protect Wisconsin children from lead exposure is by stabilizing all cracked, deteriorating, peeled or flaking paint in old homes, replacing very old windows, fixing roofs with and other leaks, while making sure that the window sills and floors remain smooth hence eliminating major sources of lead exposure. Other precautionary measures include re-painting on interior surfaces with no friction such as ceiling, walls but surfaces that are susceptible to friction or bad weather should not be repainted. All the above precautions are carried out through a process called Lead abatement which refers to any action by and individual (a certified lead abatement contractor), the state or a company to effective minimize lead exposure by permanently eliminating or removing lead-based paint or dust lead hazards or any possible lead containing object or surface in response to orders from the state or the local council. The Milwaukee Health Department is charged with giving orders so that homes identified within the community to be at risk of lead exposure are lead abated and this requires either voluntary consent from the owner of the property or through a Court order in case the home owner doesn’t comply with orders from the Health department to allow his property to be abated.
Despite the huge progress in reducing childhood lead poisoning rate within the city of Milwaukee, the number of children been identified with lead poisoning is still on the rise within the state and it has surpass the national average. In 2009, the state prevalence of lead poisoning was 1.5 and in Milwaukee alone, of all the children tested for lead poisoning 4.4% of them had blood lead levels greater than 10ug/dl. More work is needed in this fight despite the progress mad
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