Variation in allowable or recommended maximum concentration levels of lead in drinking water 0 ppb <1 ppb 5 ppb 10 ppb 15 ppb 20 ppb Other EPA-LCR EPA – AL for 3T’s 5 water FDA for system 4 “No bottled water 2 safe 1 state WHO 3 level AAP 1 (4%) for 13 lead” 8 states states (32%) (52%) 3 states (12%) Findings from Early Adopters study Other standards for lead in drinking water (sources below) 1 American Academy of Pediatrics (AAP) COUNCIL ON ENVIRONMENTAL HEALTH. Prevention of Childhood Lead Toxicity. Pediatrics. 2016;138(1):e20161493. AAP available at http://pediatrics.aappublications.org/content/pediatrics/138/1/e20161493.full.pdf 2 Food and Drug Administration (FDA) 21 CFR § 165.110. Subpart B- Requirements for Specific Standardized Beverages (CFR 2016) Title 21- volume2-section 165.110 available at https://www.govinfo.gov/content/pkg/CFR-2016-title21-vol2/pdf/CFR-2016-title21-vol2- sec165-110.pdf [accessed September 19, 2018]. 3 Guidelines for drinking-water quality: fourth edition incorporating the first addendum. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Available at http://apps.who.int/iris/bitstream/handle/10665/254637/9789241549950- eng.pdf;jsessionid=3881FE535AD164B693E889262390B0A1?sequence=1%20Guidelines%20for%20-%20apps.who.int. [Accessed September 19, 2018] 4 EPA (Environmental Protection Agency). Title 40 Chapter I Subchapter D § 141.80 General requirements. United States Environmental Protection Agency; 2018. Available at https://www.ecfr.gov/cgi-bin/text- idx?SID=531617f923c3de2cbf5d12ae4663f56d&mc=true&node=sp40.23.141.i&rgn=div6#se40.25.141_180. [Access date September 19, 2018]. 5 EPA (Environmental Protection Agency). 3Ts for Reducing Lead in Drinking Water in Schools: Revised Technical Guidance. United States Environmental Protection Agency; 2006.
Key findings There is no uniformity in states’ protocols to test school drinking water for lead and to share their findings There is no uniformity in states’ recommendations for school responses to testing
Variation in state school drinking water lead testing program data collection strategies as of February 2018 Types of taps Frequency of Sampling protocol sampled sampling/testing
Treatment & remediation strategies and stakeholder communication Treatment measures specified Notification of results & treatment efforts 30 20 25 18 16 9 (36%) 20 6 (24%) 14 15 12 5 (20%) 7 (28%) 10 19 (76%) 19 (76%) 10 17 (68%) 8 16 (64%) 4 (16%) 1 (4%) 12 (48%) 5 10 (40%) 6 6 (24%) 10 (40%) 5 (20%) 4 0 2 0 Routine Short-term Long-term Treatment measures specified Results Treatment efforts
School water quality results Schools in these 24 states (and DC) educate 54% of all public school students in the U.S. in grades PK-12
Key findings There is no uniformity in the formats used to organize and maintain data on water quality
Key findings from twelve state school drinking water testing programs FIRST DRAW Testing was completed in 485,152 44% first draw tests were completed 57,152 of schools tested had one (12%) 10,888 or more water samples with a lead concentration of all tests were above at or above the state’s schools 1 the state specified action level action level 1. In 12 states; these 12 were those with available data on the lead content found in drinking water in schools
Key findings Schools that collected and tested water from a greater number of taps were also more likely to identify a sample with elevated lead concentrations The use of lower action levels by a state program would increase the proportion of schools needing to take steps to address the lead content in the drinking water
Implications Specified, standardized practices for tap water sampling for lead testing of school tap water together with financial and technical assistance for both testing and remediation could support more states in adopting programs and recommended practices to limit lead exposure in school drinking water
Implications Up-to-date electronic data management guidance bolstered by improved federal financial and technical support, could standardize practices for data collection, database development and reporting to improve timely identification of elevated lead levels in school tap water and limit lead exposure from school water outlets
Policy relevance Federal agencies State programs Policymakers
Limitations o Study recommendations limited to available information and data o Data are not representative of all states or schools in states with programs o Reporting of precise lead content level not always required by states o Uncertainties in sampling process o Lack of a health-based standard for lead in drinking water
Ensuring that all children have easy and appealing access to lead-safe school drinking water should be a health promotion policy priority for relevant federal and state agencies and will support the promotion of drinking water as a healthy beverage of choice.
Thank you! Angie Cradock acradock@hsph.harvard.edu Christina Hecht ceahecht@ucanr.edu Learn more about this project, read the full report and the supplemental state reports by visiting: https://www.hsph.harvard.edu/prc/projects/school-research/early- adopters
Questions
Investigating Drinking Water Quality in California Public Schools C H I L D H O OD O BESI T Y CON F E RE N C E J ULY 1 7 , 2 0 1 9 Anisha Patel, MD, MSPH Stanford University Christina Hecht, PhD Nutrition Policy Institute
Study Objectives – Examine schools’ reported practices related to drinking water testing – Investigate language regarding drinking water testing or remediation in school district wellness policies – Assess the prevalence of key contaminants in school drinking water
Study Design
Study Design
Characteristics of Study Schools Characteristic California Survey Study State schools schools testing testing (n=240) (n=64) (n=126) Student enrollment Elementary 525 494 439 538* Middle 758 622 755 739* High 1326 1269 1365 1561* Academic performance 790 786 761* 798* index Free/reduced price 58 63 68* 60 eligible, % English learners, % 21 20 20 18 Latino students, % 53 52 55 49 Respondent type, % Principal n/a 47 42 44 Vice principal 15 16 17 Facilities 7 11 6 Other 31 31 33
Results: Administrator Surveys
Schools’ Report of Water Testing Practices (%) Practice Yes No Don’t Know Periodic inspections that 47 16 37 test drinking water outlets for lead Periodic inspections that 27 22 51 test drinking water outlets for contaminants other than lead Drinking water safe to 95 1 4 drink at each outlet
Results: School District Wellness Policies
Schools with Wellness Policy Language about Water Testing and Remediation 100% 90% 80% 70% 64% 60% % of schools 50% 40% 30% 20% 10% 1% 0% Testing drinking water for lead Treatment/remediation of unsafe water
Results: VA Tech Water Testing Study
Schools that Violate Standards for Lead in Drinking Water 100 n=64 schools, 192 taps 92 90 81 1st draw 2nd draw 80 73 70 % of schools 60 50 40 33 30 19 20 10 6 3 2 0 EPA FDA bottled AAP PHG water 15ppb 5ppb 1ppb 0.2ppb
Violations for Other Key Drinking Water Contaminants 100 n=64 schools, 192 taps EPA PHG 90 78 80 70 64 60 % of schools 50 41 40 30 20 10 5 0 0 0 0 0 Copper Arsenic Nitrate Hexavalent Chromium EPA 100ppb EPA 1.3mg/L; EPA 10ppb; EPA/PHG CA 50ppb PHG 0.3mg/L PHG 0.004ppb 10mg/L PHG 0.02ppb
Schools with Violations for One or More Contaminant* 100 100 n=64 schools, 192 taps 90 80 73 % of schools 70 60 50 40 30 20 8 10 0 EPA AAP PHG *Contaminants include lead, copper, arsenic, nitrate, or hexavalent chromium
Results: California State Lead Testing
Schools in CA State Testing Program that Violate Lead Drinking Water Standards 100 n=126 of 240 study sample schools 90 80 70 % of schools CA state program does not test below 5ppb; 60 unable to examine AAP and PHG violations 50 40 30 20 12 10 4 0 EPA (15 ppb) FDA bottled water (5 ppb)
Location of Taps Tested through State Program Food service area Unknown 17% 19% n=126 schools, 617 taps Physical activity space 14% Classroom 8% Hallway/common area 42%
67 Gaps in Testing through State Program – 40% of schools did not test a tap in the food service area – 21% of schools tested a tap that wasn’t accessible to students • 78% staff/admin area • 16% nurse’s office • 6% maintenance area
Conclusion – Administrators have a low awareness of water testing practices – Wellness policies do not address remediation – Variation in violations depending on standard applied – CA state testing of busiest taps showed: • Less than half of schools tested water in food service areas • Taps not used by students for consumption used to meet testing requirements
69 Acknowledgments – Study schools – Co-investigators • Marc Edwards and Jeff Parks at Virginia Tech – Research associates and students • Emily Altman, Gala Moreno, Jeff Ezennia, Caitlin Joseph, Isi Umunna – Funding • RWJF Healthy Eating Research Program
Assessed for eligibility (n=10,481 public schools) Randomized sample (n=240) Study testing State testing Schools tested Schools Schools Schools not yet Schools Schools Schools through state submitted enrolled responded haven't tested declined (n=49) ineligible (n=7) program exemption (n=102) (n=82) yet (n=101) (n=126) forms (n=13) Schools with Schools that testing results haven't yet (n=64) tested (n=38)
Participating Study Schools that Violate Lead Drinking Water Standards in California State Testing Program 100 n=33 of 240 study 88 90 sample schools 80 73 70 % of schools 60 50 40 30 18 18 20 10 6 3 n/a n/a 0 EPA FDA bottled water AAP PHG (15 ppb) (5 ppb) (1 ppb) (0.2 ppb) state program 240 study
Location of Taps Tested through State Program among schools that also tested through 240 study Unknown/other 5% Food service area 20% n=33 schools, 172 taps Physical activity space 15% Hallway/common area 52% Classroom 8%
Types of Taps Tested through State Program Sink 16% Unknown/other 24% n=126 schools, 617 taps Water filling station 5% Fountain 55%
Contaminant Arsenic Nitrate Hexavalent Chromium Source Pesticide, Fertilizers, Industrial processes groundwater human waste Health Skin warts/ Limited ability of Nose and breathing Impacts Discoloration blood to problems – nose transport oxygen ulcers, runny nose, Cancers – - Blue baby asthma, cough, skin/bladder/ syndrome shortness of breath, ↓ BP liver/lung - or wheezing ↓ HR - IQ/growth/ - HA Cancers – lung/ development - Abdominal stomach cramps/ vomiting https://www.atsdr.cdc.gov/substances/index.asp
Policy Implications Two Big “P” Questions › Closing the gap between allowable Maximum Contaminant Level (MCL) and a public health goal › Who should regulate More concrete implications › Mandatory vs. voluntary testing › Improving implementation of testing programs
Questions
78 Working Collaboratively against Sugary Drinks & for Water Equity • Shape Up and SFHIP • July 2019 • Vanessa Bohm, MPH; Monique LeSarre, PhD; Eric Mar, JD; • Christina Nip; Anisha Patel, MD, Christina Goette, MPH; • Marianne Szeto, MPH; Roberto Vargas, MPH
Collective Impact for Water Equity Steps leading to where SF is today • Education • Sugary drinks 101 • Water promotion • Research • Leveraging existing literature • CBPR leads to need for Water Access & promotion • Policy and Environmental change • Organizational wellness policies • City policies, including Soda Tax Current activities: • Soda tax implementation • Water access, policy and promotion
SF SPECTRUM OF PREVENTION FOR SSB/ H2O EDUCATION & TECHNICAL ADVISING ON POLICY AND LEGISLATION ASSISTANCE TO POLICY MAKERS ORGANIZATIONAL WELLNESS CHANGING ORGANIZATIONAL PRACTICES POLICIES SHAPE UP SF COALITION; SFHIP; FOSTERING COALITIONS AND NETWORKS REGIONAL UTILITIES SUGAR SCIENCE and DPH EDUCATING PROVIDERS TRAINING OF TRAINERS LAY HEALTH WORKER EDUCATION; PROMOTING COMMUNITY EDUCATION SFUSD WELLNESS STRENGTHENING INDIVIDUAL TABLING AT SUNDAY STREETS, CBO EDUCATION ACTIVITIES KNOWLEDGE AND SKILLS 80
Shape Up SF Coalition 82
Multi-stakeholder efforts • SF Policymakers • UCSF • SF Department of Public Health • SF Mayor’s Office • SF Public Utilities Commission • BANPAC • SF Unified School District • Community Based Organizations and more… 83
Holding Their Stake: Public Health • Promote education in clinics • Community education Citywide • Build community capacity for peer education • Technical assistance and data for policy (org. and public) • Staffing coalitions (backbone org.) 84 84
SODA EXPENDITURES Percent of Total Expenditures, National Rank by Tract (2011) TENDER LOIN MISSI ON BAYVI EW EXCELSI OR VISITACION VALLEY
Percent of Children (Ages 2-11) and Adolescents (Ages 12- 17) Drinking At Least One Sugar-Sweetened Beverage per Day in 2005-07 and 2011-12, by Race/Ethnicity Consumption of sugary drinks for young children Consumption of sugary drinks for adolescents among all ethnic/racial groups except Whites.
87
Holding Their Stake: Impacted Communities • Co-convened focus groups – health equity coalitions • Adopted beverage policies – Y, BVHPF, Children’s Council, Boys and Girls Club, Cornerstone church, etc. • Educated community • Spa water only events • Lay health worker workshops on SSBs and H2O • Counter-marketing 88
Community-based education • Healthy Beverage Education Partnerships Community Based Coalitions/ Councils – Asian/ Pacific Islander Health Parity: NICOS – African American Health Equity: Rafiki Culturally/ Community specific – Chicano/ Latino/ education– Indigena: CARECENSF critical to changing behavior
90
91
Community Specific Outreach 92
Lay Health Worker Sessions 93
Community Events 94
Social Media and web-based campaigns against SSB • www.sugarscience.org • www.TheBiggerPicture.org (Check UCSF CHARM website) • www.OpenTruthNow.org • Shape Up SF Coalition • Dunk the Junk 95
Holding Their Stake: Universities • Leverage science for City strategy and policies • Research – CBPR and traditional, expert testimony • Evaluation – including parks study on H2O consumption • Grad/Undergrad student support • Authoritative education materials 96
Community Perspectives: What will Get Us to Drink Less Sugar What we learned from communities drinking the most sugar, and how we put those lessons into action • Policy • Structural change • Education/ Promotion
Findings: “Protect our children” • Wanted protection for kids; even those who didn’t like policy • Desire to limit marketing & access for kids Cost and affordability • Keep it cheap, even if it’s unhealthy • Don’t tax consumers or retailers; tax producers or distributors • Make healthy drinks cheaper; including water
Finding: More Water Access, Now! • Increase access to clean drinking water. Most think bottle-filling stations are more sanitary; dual is better • Education about water should be near the tap • Be safe, clean, accessible and protected • Placed in low-income communities
Holding Their Stake: Policy Makers • Convened Hearings on Water Equity, Economic Impact of SSB consumption • Proposed City investment in H2O • Served as Spokespeople 100
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