The Local Problem Natalie Colabianchi, Ph.D. Chris Kippes, M.S. Mireya Diaz-Insua, Ph.D. Alfred Rimm, Ph.D. Jessica Diggs In cooperation with: Cuyahoga County Board of Health Cleveland Department of Public Health

Background Lead poisoning may be the most significant environmental problem facing our children Lead poisoning may be the most significant environmental problem facing our children Nationally and locally, lead levels in children have been decreasing dramatically over the past 20 years Nationally and locally, lead levels in children have been decreasing dramatically over the past 20 years –Much of the decline is due to the removal of lead from gasoline Rates remain high in urban areas and in poor communities Rates remain high in urban areas and in poor communities Steep rates of decline not likely to continue Steep rates of decline not likely to continue

Ohio compared to 18 other states

Cuyahoga County relative to other counties in Ohio EBLL (10  g/dL +) Cuyahoga17% Cuyahoga17% Hamilton 7% Hamilton 7% Franklin 2% Franklin 2% Lucas11% Lucas11% Mahoning 14% Mahoning 14% Summit 1% Summit 1%

Estimated Number of Children with Elevated Blood Lead Levels (EBLL) CityEst. Children w/EBLL (10  g/dL +) 1. New York, NY41, Chicago, IL20, Los Angeles, CA15, Detroit, MI12, Philadelphia, PA11, Baltimore, MD 6, Houston, TX 6, Cleveland, OH 5, New Orleans, LA 4, Milwaukee, WI 4, Milwaukee, WI 4,600

Cleveland relative to other cities in Ohio EBLL (10  g/dL +) Cleveland20% Cleveland20% Cincinnati 7% Cincinnati 7% Columbus 2% Columbus 2% Toledo12% Toledo12% Youngstown16% Youngstown16% Akron 2% Akron 2%

Local Data Years Years ,190 tests representing 82,396 children 130,190 tests representing 82,396 children 33% of children had more than one test 33% of children had more than one test Included only children less than 6 years of age Included only children less than 6 years of age Children across the years: Children across the years: –28404 children tested in 1997 –27603 children tested in 1998 –24371 children tested in 1999 –23441 children tested in 2000

Sampling Data come from mandatory reporting; Not a random sample Data come from mandatory reporting; Not a random sample Proportions are influenced by rates of testing, who is tested and requirements for testing Proportions are influenced by rates of testing, who is tested and requirements for testing Cleveland is considered a universal screening area Cleveland is considered a universal screening area Medicaid population also mandated to be tested Medicaid population also mandated to be tested Other high risk zip codes in Cuyahoga County with universal designation Other high risk zip codes in Cuyahoga County with universal designation

High risk zip codes with universal designation

Defining a confirmed test Venous tests are confirmed tests Venous tests are confirmed tests Capillary tests under 10  g/dL are confirmed tests Capillary tests under 10  g/dL are confirmed tests Capillary tests with results of 10  g/dL or higher need a second test within the CDC guidelines to be confirmed Capillary tests with results of 10  g/dL or higher need a second test within the CDC guidelines to be confirmed Other tests were deemed unconfirmed and child was consider not elevated Other tests were deemed unconfirmed and child was consider not elevated

Analyses 1. Proportion of children with EBLL  In year 2000  Across census tracts  Trends from 1997 to 2000  Demographic correlates  Neighborhoods and municipalities with high proportions of elevated children 2. Average levels over time 3. Multiple children in a household 4. Numbers of children tested

Proportion of children with EBLL in year 2000 In Cleveland, 20.3% of children, one out of five, have blood lead levels that are elevated (e.g., 10  g/dL or higher) In Cleveland, 20.3% of children, one out of five, have blood lead levels that are elevated (e.g., 10  g/dL or higher) In Cuyahoga County, 8.5% of children have blood lead levels that are elevated (e.g., 10  g/dL or higher) In Cuyahoga County, 8.5% of children have blood lead levels that are elevated (e.g., 10  g/dL or higher)

Cuyahoga County

 g/dL Proportion of children with EBLL >10  g/dL in Year 2000

 g/dL Proportion of children with EBLL > 10  g/dL in Year 2000 Cleveland Only

 g/dL Proportion of children with EBLL > 10  g/dL in Year 2000 Cuyahoga County Only

 g/dL Proportion of children with EBLL > 10  g/dL in Year 2000 East Cleveland Only

4 Sub-areas

Proportion of children with EBLL ( 10  g/dL) Proportion of children with EBLL (> 10  g/dL) Geographic AreaYear 2000 Cleveland20.3 Cleveland20.3 East Cleveland27.7 East Cleveland27.7 Inner Ring Suburbs4.9 Inner Ring Suburbs4.9 Outer Ring Suburbs1.8 Outer Ring Suburbs1.8

Trends over Time: Proportion of children with EBLL ( 10  g/dL ) Trends over Time: Proportion of children with EBLL ( > 10  g/dL ) mg/dL % of children with > 10 mg/dL

Proportion of children with EBLL ( 25  g/dL) Proportion of children with EBLL (> 25  g/dL) Geographic AreaYear 2000 Cleveland1.9% Cleveland1.9% East Cleveland3.2% East Cleveland3.2% Inner Ring Suburbs0.5% Inner Ring Suburbs0.5% Outer Ring Suburbs0.2% Outer Ring Suburbs0.2%

Trends over Time: Proportion of children with EBLL ( 25  g/dL ) Trends over Time: Proportion of children with EBLL ( > 25  g/dL ) mg/dL % of children with > 25 mg/dL

Proportion of children with EBLL ( 45  g/dL) Proportion of children with EBLL (> 45  g/dL) Geographic AreaYear 2000 Cleveland0.2 Cleveland0.2 East Cleveland0.3 East Cleveland0.3 Inner Ring Suburbs0.1 Inner Ring Suburbs0.1 Outer Ring Suburbs0.0 Outer Ring Suburbs0.0

Trends over Time – Proportion of children with EBLL ( 45  g/dL ) Trends over Time – Proportion of children with EBLL ( > 45  g/dL ) mg/dL % of children with > 45 mg/dL

Tracts with EBLL of 45  g/dL and 70  g/dL Tracts with EBLL of > 45  g/dL and > 70  g/dL

Areas with children that have BLL 45  g/dL Areas with children that have BLL > 45  g/dL Neighborhoods with children 45  g/dL Neighborhoods with children > 45  g/dL  Clark-Fulton  Corlett  Cudell  Detroit-Shoreway  Fairfax  Forest Hills  Glenville  Hough  Mt. Pleasant  North Collinwood  South Broadway  South Collinwood  St. Clair-Superior  Union-Miles  Woodland Hills  Cleveland Heights  East Cleveland  Garfield Heights

Areas with children that have BLL 70  g/dL Areas with children that have BLL > 70  g/dL Neighborhoods with children 70  g/dL Neighborhoods with children > 70  g/dL  Cudell  Fairfax  Glenville  North Collinwood  Union-Miles

Demographic correlates

 g/dL Proportion of children with EBLL >10  g/dL in Year 2000

Percent of Housing Built before 1950

Median Levels of Income

Cleveland

Statistical Planning Areas with over 12% of children having BLL of 10  g/dL Statistical Planning Areas with over 12% of children having BLL of > 10  g/dL Cleveland Only

Cleveland Neighborhoods

Highest and Lowest Neighborhoods in Cleveland over Time

6 Highest and 6 Lowest Neighborhoods in Cleveland Year 2000

3 Highest Neighborhoods by Tract

St. Clair-Superior Tract% with EBLL of 10  g/dL + (N) (36) (26) (103) (116) (194) (94) (80) Overall SPA37.7 (671) Note: Tract had insufficient sample and is therefore not reported

3 Highest Neighborhoods by Tract - Glenville Tract %BL 10+ (N) (97) (70) (62) (71) (219) Tract %BL 10+ (N) (185) (115) (164) (143) (96) Overall SPA = 32.0 (1222)

3 Highest Neighborhoods by Tract – Fairfax Tract % with EBLL of 10+ (N) (43) (53) (97) (69) (45) Overall SPA 31.3 (320) Note: Tracts 1131, 1132 and 1139 have insufficient sample and are therefore not reported

Municipalities

Municipalities with EBLL of >10  g/dL

Census Tracts in East Cleveland

Census Tracts in Cleveland Heights

Census Tracts in Shaker Heights

East Cleveland, Cleveland Heights and Shaker Heights

Census Tracts in Garfield Heights

Average levels of those with elevated blood levels over time

Lead Levels of those 10  g/dL over time Lead Levels of those > 10  g/dL over time

Average levels of those 10  g/dL over time Average levels of those > 10  g/dL over time mg/dL Average levels of those > 10 mg/dL

Individuals over time

Multiple Children in a Household

Households with >1 Child Tested and Measured BLL  25  g/dL HH + East Cleveland Cleveland Heights Shaker Heights Glenville All high 107 (0.8%) Mixed 803 (6.3%) All low11864 (92.9%)

Households with >1 Child Tested Households with >1 Child Tested BLL  25  g/dL CUYAHOGA All high 107 (0.8%) Mixed 803 (6.3%) All low11864 (92.9%) CLEVELAND All high 97 (1.0%) Mixed 697 (7.2%) All low 8885 (91.8%) CLEV HTS, EAST CLEV, SHAKER HTS All high 10 (1.0%) Mixed 81 (7.6%) All low 971 (91.4%) OTHERS All high 0 (0.0%) Mixed 25 (1.2%) All low 2030 (98.8%)

Households with >1 Child Tested Households with >1 Child Tested BLL  10  g/dL CUYAHOGA All high 1715 (13.5%) Mixed 3581 (28.0%) All low 7478 (58.5%) CLEVELAND All high 1511 (15.6%) Mixed 3058 (31.6%) All low 5113 (52.8%) CLEV HTS, EAST CLEV, SHAKER HTS All high 160 (15.0%) Mixed 312 (29.4%) All low 590 (55.6%) OTHERS All high 44 (2.2%) Mixed 211 (10.4%) All low 1175 (87.4%)

Numbers of Children Tested

Conclusions

Summary Point 1 Cuyahoga County and Cleveland have high proportions of children with elevated blood lead levels relative to other counties and cities in the U.S. Cuyahoga County and Cleveland have high proportions of children with elevated blood lead levels relative to other counties and cities in the U.S.

Summary Point 2 Lead levels continue to decrease although at a slower rate than previously seen Lead levels continue to decrease although at a slower rate than previously seen

Summary Point 3 Age of housing and income levels are associated with lead levels in Cleveland and in Cuyahoga County as has been seen nationally Age of housing and income levels are associated with lead levels in Cleveland and in Cuyahoga County as has been seen nationally

Summary Point 4 Many neighborhoods in Cleveland and East Cleveland show consistently high percentages of children with elevated blood lead levels across census tracts Many neighborhoods in Cleveland and East Cleveland show consistently high percentages of children with elevated blood lead levels across census tracts

Summary Point 5 Over time, the percent of children with elevated lead levels has decreased Over time, the percent of children with elevated lead levels has decreased However the average level of those that test over 10 has remained fairly constant However the average level of those that test over 10  g/dL has remained fairly constant

Summary Point 6 There are some households with multiple children under six in Cleveland and some municipalities where all the tested children have elevated blood lead levels There are some households with multiple children under six in Cleveland and some municipalities where all the tested children have elevated blood lead levels

Summary Point 7 Children that are required to be lead tested are not being tested Children that are required to be lead tested are not being tested

Conclusion We have made important progress in the past couple years but need to continue our efforts to provide our children a healthy environment in which they can thrive We have made important progress in the past couple years but need to continue our efforts to provide our children a healthy environment in which they can thrive

Acknowledgements Cuyahoga County Board of Health Cuyahoga County Board of Health –Terry Allan, M.P.H., R.S. –Chris Kippes, M.S. –John Sobolewski, R.S. –John McLeod, R.S. Cleveland Department of Public Health Cleveland Department of Public Health –Wayne Slota –Jonathan Brandt –Wendy Johnson, M.D. –Matt Carroll, J.D.

The Local Problem For further information contact: Natalie Colabianchi: Case Western Reserve University