1. Guide to Preventing Childhood Lead Exposure Childhood Lead Poisoning Prevention Program Serving Fillmore, Gage, Jefferson, Saline, and Thayer counties 995 East Highway 33, Suite 1  Crete, NE 68333 phone 402-826-3880  toll free 888-310-0565  fax-826-4101 www.phsneb.org District Health Department This Guide is organized into three sections, each designed to inform primary health care providers, home health visitors, and individual residents of the appropriate lead poisoning screening, case management, and lead hazard control measures for children who have been or are at risk for being exposed to lead. By providing this information the Department seeks to increase screening of children who are at-risk for lead exposure, improve follow-up care of children diagnosed with unhealthy lead exposure, and generate a pro-active stance against lead exposure in our district among health care providers and parents. The guide provides information organized into separate sections, for: Primary Health Care Providers Home Health Visitors Parents of young children The Department is committed to the elimination of childhood lead exposure and poisoning. This guide incorporates recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics. It was developed by the PHS District Health Department.

2. Lead Overview Lead in our health district Recommendations on testing Recommendations for managing children with blood lead levels less than 10 micrograms per deciliter (μg/dL) Recommended follow-up care for children diagnosed with lead poisoning Guide to Preventing Childhood Lead Exposure Contents

3. Lead Overview Toxic heavy metal Once used widely in paint, gasoline, other products Causes damage to the blood, brain, kidneys, heart, and sensory organs Damage to a child’s brain is not reversible Still the most common and the most preventable environmental hazard for children

4. Not getting tested Not getting tested, at-risk* Fillmore 466233 Gage 1481740.5 Jefferson 510255 Saline 981490.5 Thayer 409204.5 TOTAL 38311923.5 Lead Overview These kids are at risk of poor academic performance, behavioral problems, etc. Even from low-level lead exposure! * Based on average housing age, not including other risk factors

5. Clinical overview Screening/Testing Guidelines Screening/Testing Methods Follow up Section 1: Primary Health Care Providers

6. Clinical overview – lead poisoning Case definition: Childhood lead poisoning is a reportable disease. A confirmed case of lead poisoning is defined as a child with a blood lead level ≥10 ug/dL from a venous blood draw, or two capillary blood draws within three months of one another that are ≥10 ug/dL. Health effects: Lead interferes with the production of hemoglobin and use of calcium. It crosses the blood-brain barrier to affect the nervous system, causing developmental delays and learning impairment. It also damages the kidneys, sensory organs (especially auditory), reproductive system, and heart. At-Risk Populations: Children, particularly those 6 years old and younger, who are exposed to lead. Lead exposure usually comes from the dust of homes built before 1979. It can also come from ‘carried-in’ sources like parents working in a lead- related industry, or contaminated toys. Section 1: Primary Health Care Providers

7. Clinical overview – lead exposure Case definition: child with a blood lead level from 5 – 9 ug/dL Health effects: unknown, but suspected to impair learning and academic performance, trigger or worsen ADHD, increase aggressive tendencies. Section 1: Primary Health Care Providers

8. Clinical overview - Biological Fate and Transport Lead winds up in the mineralizing tissue (95%), soft tissues, and blood. During pregnancy and lactation, the body can mobilize lead stores from bone and fat to the bloodstream. The body accumulates lead over a lifetime and normally releases it very slowly. Both past and current elevated exposures to lead increase patient risks for lead effects. Section 1: Primary Health Care Providers HHS’s Agency for Toxic Substances and Disease Registry

9. Clinical overview – locally relevant risk factors Housing: pre-1950 structures pose the highest risk, but any property built before 1979 has the potential to provide a lead source. Testing Rates: low testing rates in high risk areas indicate that many children with undetected lead exposure go without intervention. EBLL Rates among those tested: Particularly if testing rates are low, a high percentage of those tested with EBLL supports the hypothesis that a significant risk for lead exposure exists in that population. Borderline lead levels: As more research is published, there is more and more support for once again lowering the “action level” from 10 to enable more early intervention. Section 1: Primary Health Care Providers

10. Symptoms and Indicators, <10 ug/dL: Delayed motor skill development Delayed speech development Short stature, underweight Very mild hearing impairment (“my child just won’t listen) Low iron Attention deficit, hyperactivity * Long-term damage can be done even if no symptoms or indicators are immediately apparent Section 1: Primary Health Care Providers

11. Symptoms and Indicators, 10+ ug/dL: More severe presentation of previous symptoms/indicators Fussiness Abdominal pain Loss of appetite, nausea, vomiting Constipation Section 1: Primary Health Care Providers

12. Minimum Screening Technique Regardless of whether symptoms or indicators are present At 12 and 24 months old, or Annually from 1-6 years if high- risk conditions exist Section 1: Primary Health Care Providers

13. Minimum Screening Questions  Does the child reside in or regularly visit a residence that was built before 1950 (alt. 1979)? including day care, babysitter, relative’s home  Does the child reside in or regularly visit a residence built before 1978, that is undergoing a renovation or has recently (past 6 months) been renovated?  Does the child have a sibling or playmate who has been diagnosed with lead poisoning?  Is the child enrolled in Medicaid? Section 1: Primary Health Care Providers

14. Testing Guidelines Blood lead collection must be done properly to ensure an appropriate sample:  Venous Blood Lead Test  Capillary Blood Lead Test using a capillary tube  Capillary Blood Lead Test using an onsite blood lead analyzer  Capillary Blood Lead Test using filter paper kit Section 1: Primary Health Care Providers

15. Follow-up Blood test results Educational materials Reminder to retest (w/ date) Referral to PHSDHD’s Environmental health office* Section 1: Primary Health Care Providers * For results that are 5ug/dL or higher

16. 5-6 ug/dL7-9 ug/dL Letter with results, informative insert Reminder to retest annually Provide contact info in case of questions Follow-up when retesting is due Offer free retest if cost/schedule barriers exist Letter with results, informative insert Reminder to retest annually (or more often) Offer consultation to help locate lead hazards (automatic lead hazard screen for certain cases) Offer free retest if barriers exist PH Nurse follow up if necessary PHSDHD ** On-going relationship building efforts with physicians to encourage testing, retesting, and case referral to PHS 16

17. ≥ 10 ug/dL  Provide Lead Hazard Assessment with: Environmental sampling Customized report Recommendations on interim and permanent hazard controls Consultation on seeking financial assistance for hazard control  Follow-up on interim controls, retesting PHSDHD 17

18. PHSDHD Current case load: As of: 20-Apr-09 Blood lead level# children 5 to 6 ug/dL50 7 to 9 ug/dL29 10 + ug/dL11 TOTAL90 Year in review: at least 10 children brought to lead levels below 5 ug/dL due to our efforts 18

19. PHSDHD – Cultural Competence Staff support for Spanish translation/interpreting Relationship with local employer to access Asian language translators as needed Specialized lead risk questionnaire to capture culturally appropriate potential exposure sources 19