1 Childhood Lead Poisoning in Ohio
2 Objectives • Overview of childhood lead poisoning in Ohio • Provide an overview of the Public Health Lead Investigation Process • Bring awareness to funding resources for lead hazard control
3 State Data Ohio is one of the top states in number of homes built pre-1980, and also in percent of total homes built pre-1980 Ohio has the third-highest percentage (5.0%) of tested children under age 6 with elevated blood lead levels (CDC 2016)
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7 Prevalence of Confirmed Elevated Blood Lead Levels ≥10 µg/dL Among Ohio Children, Less than Six Years of Age, 1999 - 2018 10 8.7 9 7.6 8 7 6.3 Prevalence (%) 6 5.1 5 4.3 3.6 4 2.7 3 2.2 1.8 1.6 2 1.5 1.3 1.1 1 0.8 0.8 0.8 0.8 0.8 0.7 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Year
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9 Blood Lead Testing Statistics for Ohio Children, 2018 Confirmed BLLs Only Unconfirmed % % Total Total 5-9 ≥10 0-4 5- 9 10 -44 ≥45 Total ≥5 Tested Tested Children ≥10 µg/dL µg/dL µg/dL µg/dL µg/dL ≥5 ≥10 µg/dL µg/dL Tested µg/dL µg/dL µg/dL 168,352 163,153 2,737 1,100 19 3,856 2.29% 1,119 0.66% 1,135 208 1. The table above contains data for children less than 72 months (6 years) of age at the time of test. 2. To be confirmed, a test must use a venous blood sample and not be analyzed on a point-of- care device. Capillary samples cannot be confirmed, regardless of how the blood is analyzed. 3. Blood lead levels above reflect the highest confirmed test if a confirmed test exists for the child, or the highest test for the year, otherwise.
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3 Lead Paint Hazards Peeling, chipping, chalking, or cracking Windows, windowsills, doors • Porches, stairs, railings • Antique furniture • Fences • Dust Created when lead-based paint is scraped or • bumped US EPA clearance level for floors: 40 µg/sq ft •
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7 Other Sources of Lead • Older plumbing • Traditional cosmetics and remedies (e.g. Azarcon, Greta, and Kohl) • Pottery and ceramics • Toys
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7 High-Risk Zip Codes
8 Blood Lead Testing Requirements
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5 Reduce Absorption: Nutrition • Eating a proper diet can help increase iron intake and possibly decrease lead absorption. • Iron • Fiber • Protein • Zinc • Vitamin C • Calcium
6 Public Health Lead Investigations • ODH covers 83 of 88 counties • 11 delegated boards of health • Total of 40 investigators statewide • When the Director becomes aware that a child under 6 has a BLL of 10 micrograms/dL or higher, a lead investigation is performed
Delegated Boards of Health Cincinnati City Lorain County Cleveland City Montgomery County Columbus City Muskingum County Cuyahoga County Summit County Franklin County Toledo City/Lucas County Hamilton County
Elevated Blood Lead Levels 5- 9 μg/dL Children with confirmed tests of between 5 • μ g/dL and less than 10 μ g/dL Telephone questionnaire • Send Public Health Lead Investigation Report • Provide educational materials by mail • Case closed in HHLPSS • Reimbursement for Medicaid enrolled children •
Referral of case > 10 μg/dL • Child is tested (physician’s office, WIC clinic) • Lab submits required data to ODH • Elevated level above ten(10) μ g/dL • Surveillance system (HHLPSS) • Referred to ODH investigator or local board of health • Referral contains child’s Medicaid number
Investigation Contact parent/guardian to administer • questionnaire If unable to contact, collaborate with case • manager, health care provider, Healthchek coordinator, or others to obtain current contact information
Investigation (Cont’d) Contact successful No Contact (at least 6 attempts) Investigator • reviews the Send certified letter • questionnaire Receive no response • Schedule the on- Close case in surveillance • • site investigation system after 30 days Sends educational • material
Source from property? Property is possible Source is not related to the source property Conduct lead risk Ceramic ware • • assessment Folk remedies • Issue lead hazard Painted furniture • • control order Toys • Compliance •
Are there other sources? Investigate supplemental addresses: • Grandma’s house • Daycare facility • School • Neighbor’s property
Conducting the Onsite Lead Investigation Centralized scheduling 4.5 lead investigators on staff Onsite investigation components • Visual assessment • Comprehensive Questionnaire • XRF analysis • Environmental Sampling
Challenges Locating parents to schedule No shows Travel distance Environment Social worker mentality Distrust of government
Issuing the Lead Hazard Control Order • Issued to the property owner • Must control identified lead hazards • Must hire licensed lead abatement contractor • Given 90 days to comply • Extensions offered • Lead poisoned child protected • Forward progress towards compliance
Compliance Achieved • Clearance examination performed • Licensed lead risk assessor or inspector • All hazards controlled • Ongoing monitoring for interim controls • Annual Clearance examination required • Compliance letter sent – order lifted
Noncompliance • Failure to comply by deadline • Issue order of noncompliance • 14 days to vacate property • Property placarded • Failure to vacate – civil or criminal action
4 **WARNING** ORDER TO VACATE This property contains lead hazards and has been declared unsafe for human occupation especially for children under six years of age and pregnant women as ordered by the Director of the [Name of health department] Date _______ Issued by: ______________________ ORC 3742.40 OAC 3701 - 30 - 11 Ohio Revised Code Section 3742.99 - Removal of this sign is punishable by a fine and/or imprisonment. Each day of violation is a separate offense. Please call [Telephone #] with questions or concerns.
Funding Available • Three rounds of HUD funding for a total of $7.7 million • Ohio Department of Medicaid SCHIP funding • $9 million total • Various local HUD grants across Ohio • Community Housing and Impact Preservation (CHIP) funding
7 Partnership For over 16 years ODH has partnered with the Ohio Department of Medicaid (ODM) to address the needs of enrolled children with elevated blood lead levels
Partnership • ODM has provided funding for public health lead investigations to ODH and its local health department partners • Rate has increased over the years from $475/investigation in FY ‘03 to $1,289/investigation in FY ’17 • Highest reimbursement rate in the nation • Actual cost methodology now implemented
Partnership Expansion • ODM and partnered to seek Centers for Medicare and Medicaid (CMS) approval for lead hazard control funding • State Children’s Health Insurance Plan (SCHIP) funds used • Established a Health Services Initiative to protect children’s health • State Plan Amendment (SPA) revision submitted to CMS—expansion of services
Medicaid Funded Lead Abatement What is a health services initiative? States have the option to develop a state- designed Health Services Initiatives (HSI) to improve the health of low-income children. Both direct services and public health initiatives are permitted.
Health Services Initiatives CMS has approved 26 HSI state plan amendments (comprised • of 49 programs/projects) in 19 states At least 3 states have current HSI’s for lead abatement • Missouri – 2011 – $2.9 million to increase lead awareness • and importance of blood lead screening Michigan - 2016- $24 million/year for 5 years for lead • abatement including water service line replacement Maryland- 2017- $7.1 million- Lead abatement and asthma • education and intervention
SCHIP Project • Request $10 million over 2 years for two specific projects • Project 1 – Lead Abatement Activities • Project 2 – Lead-Safe Rental Registry • Required legislation approval for match funding and language for rental registry • Approved in the state budget bill
Project 1 – Phase 1 • Conduct lead hazard control • A statewide project – all 88 counties included • Target properties with lead hazard control orders
Eligibility Specific requirements are under development. • Initial discussions include the following but have not yet • been approved by CMS: The property owner shall demonstrate proof the • occupants’ income is at or below 206% of the federal poverty level (FPL) Consideration will be given to occupants whose income • exceeds this threshold up to 250% FPL if no other financial resources are available to the family. Owner contribution is required in these cases.
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