1. Primary Prevention of Lead Poisoning: Shifting the Paradigm A Community-Based Initiative Michael A. Noll, M.D. Walden University School of Health Sciences November 12, 2009

2. Welcome! Prenatal Services: You are literally on the Front Lines of Medicine You can Affect Meaningful Positive Changes Preventive Measures are Key to Healthy Families and Children

3. Our Focus Today: Preventing Exposure to Lead in Children What We Know What We Know Toxic Effects of Lead Exposure Toxic Effects of Lead Exposure Special Focus of Neurodevelopmental Issues Special Focus of Neurodevelopmental Issues Sources of Exposure Sources of Exposure Current Preventive Measures Current Preventive Measures Changing the Status Quo Changing the Status Quo

4. Lead Poisoning in Children 250,000 U.S. children under age 5 have blood lead levels greater than 10 micrograms of lead per deciliter (mcg/dl). 250,000 U.S. children under age 5 have blood lead levels greater than 10 micrograms of lead per deciliter (mcg/dl). 10 mcg/dl of lead is the level at which CDC recommends public health actions be initiated (CDC, 2009). 10 mcg/dl of lead is the level at which CDC recommends public health actions be initiated (CDC, 2009). Lead interferes with a variety of body processes (CDC, 2009) including, most notably in children: The Nervous System Lead interferes with a variety of body processes (CDC, 2009) including, most notably in children: The Nervous System Reference: Center for Disease Control (2009). Lead. Retrieved October 10, 2009, from: http://www.cdc.gov/lead/http://www.cdc.gov/lead/ Credit: Image of Neuron used with permission from Quasar Jarosz (2009). Retrieved October 25, 2009, from: http://en.wikipedia.org/wiki/File:Neuron The Neuron

5. Neurotoxic Effects High levels of exposure can lead to: High levels of exposure can lead to: Seizures, coma and death (Cecil, 2008). Seizures, coma and death (Cecil, 2008). Exposure has been linked to: Exposure has been linked to: Learning Disabilities (Meyer & McGeehim, 2003) Learning Disabilities (Meyer & McGeehim, 2003) Aggression and Delinquency (Needleman, 2004) Aggression and Delinquency (Needleman, 2004) ADHD & antisocial behavior (Bellinger, 2008). ADHD & antisocial behavior (Bellinger, 2008). References Bellinger, C (2008). Very low lead exposures and children's neurodevelopment. Current Opinions in Pediatrics, 20 (2): 172–177 Cecil, M, et al. (2008). Decreased brain volume in adults with childhood lead exposure. PLoS Medicine, 5 (5): 112. Meyer PA; Mcgeehin F (2003). A global approach to childhood lead poisoning prevention. International Journal of Hygiene and Environmental Health, 206 (4-5): 363–9 Needleman, H. (2004). Lead poisoning. Annual Review of Medicine, 55; 209–222.

6. Cerebrums of adults that were exposed to lead as children show decreased volume, especially in the prefrontal cortex. Areas of volume loss are shown as red/orange/ yellow over a normal brain. Persistent Neurological Effects Reference and Image Source Cecil M, et al. (2008). Decreased brain volume in adults with childhood lead exposure. PLoS Medicine, 5 (5): 112.

7. Exposure to Lead Lead-based paint and lead-contaminated dust in older homes are the most common sources of lead poisoning in children (CDC, 2009) Lead-based paint and lead-contaminated dust in older homes are the most common sources of lead poisoning in children (CDC, 2009) Although lead was banned for use in paints in 1978, 98% of homes built before 1940 still contain lead (HUD, 2009) Although lead was banned for use in paints in 1978, 98% of homes built before 1940 still contain lead (HUD, 2009) More than 30 million homes, roughly 1/3 of the homes in the US are at least 50 years old (Solomon, 2009). More than 30 million homes, roughly 1/3 of the homes in the US are at least 50 years old (Solomon, 2009). References: Center for Disease Control (2009). Lead. Retrieved October 12, 2009, from www..cdc.gov/nceh/lead Solomon C (2009). This old (dangerous?) house. Microsoft Network Real Estate. Retrieved October 25, 2009, from http://realestate.msn.com/article.aspx?cp-documentid=21917660 US Dept. of Housing and Urban Development (HUD) (2009). Retrieved October 20, 2009 from: www.hud.gov/offices/lead/enforcement/lshr.cfm

8. Lead Paint Image Source: US EPA. Retrieved October 19, 2009, from: http://www.epa.gov/opp00001/factsheets/child-ten-tips.htm

9. Paint Flakes Image Source: County of Marin, California (2009). Retrieved October 20, 2009, from: www.co.marin.ca.us/depts/hh/main/hs/clinicalsvcs/

10. Primary Prevention: The Status Quo. Current Recommendations: Current Recommendations: “Screen 12-month-old infants for lead poisoning if they live in communities in which the prevalence of lead levels requiring intervention is high or undefined” (AAP, 2005) “Screen 12-month-old infants for lead poisoning if they live in communities in which the prevalence of lead levels requiring intervention is high or undefined” (AAP, 2005) Reference: American Academy of Pediatrics (2005). Lead exposure in children: prevention, detection, and management. Pediatrics 2005; 116:1036-46. Reference: American Academy of Pediatrics (2005). Lead exposure in children: prevention, detection, and management. Pediatrics 2005; 116:1036-46. “All children should receive a screening blood lead test at 12 months and 24 months of age; children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning” (CDC, 2005) “All children should receive a screening blood lead test at 12 months and 24 months of age; children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning” (CDC, 2005) Reference: Centers for Disease Control and Prevention. Blood Lead Levels - United States, 1999-2002. MMWR 2005;54(20):513-6. Reference: Centers for Disease Control and Prevention. Blood Lead Levels - United States, 1999-2002. MMWR 2005;54(20):513-6.

11. Image Source: www.ushersyndrome.nih.gov/join/blood.htmlwww.ushersyndrome.nih.gov/join/blood.html The Clinical Intervention Model

12. True Prevention Screen Homes for Lead Prior to Bringing a Newborn Home Image Source: http://spokanepublishing.files.wordpress.com

13. Community and Clinic-Based Intervention Let us Truly Prevent the Problem Image Source: www.ksre.ksu

14. Methods FREE lead dust kit available to NJ residents FREE lead dust kit available to NJ residents The Lead Kit Image Source: State of NJ (2009). Lead Safe NJ Program. Retrieved October 15, 2009, from: http://www.state.nj.us/dca/dcr/leadsafe/

15. If Lead is Detected in the Home Hire a Certified Lead Abatement Contractor Hire a Certified Lead Abatement Contractor NJ Lead Abatement Hot-line at (609) 633- 6224. NJ Lead Abatement Hot-line at (609) 633- 6224. Financial assistance is available. Financial assistance is available. Reference: State of NJ (2009). Lead Safe NJ Program. Retrieved October 15, 2009, from: http://www.state.nj.us/dca/dcr/leadsafe/ Image source: http://rwss.ap.nic.in/pred/images/contractor.gif

16. Image courtesy of: http:// burningourmoney.blogspot.com

17. For Further Information EPA Website: www.epa.gov/lead EPA Website: www.epa.gov/leadwww.epa.gov/lead EPA (New Jersey regional) info: (732) 321-6671 EPA (New Jersey regional) info: (732) 321-6671 CDC Childhood Lead Poisoning Prevention Program: www.cdc.gov/nceh/lead/about/program CDC Childhood Lead Poisoning Prevention Program: www.cdc.gov/nceh/lead/about/program www.cdc.gov/nceh/lead/about/program National Lead Info Center: 800-424-LEAD National Lead Info Center: 800-424-LEAD Lead Safe NJ Program (To Obtain the Free Lead Detection Kit): 856-665-6000 ext 327 Lead Safe NJ Program (To Obtain the Free Lead Detection Kit): 856-665-6000 ext 327

18. References: American Academy of Pediatrics (2005). Lead exposure in children: prevention, detection, and management. Pediatrics, 116: American Academy of Pediatrics (2005). Lead exposure in children: prevention, detection, and management. Pediatrics, 116: 1036-46. 1036-46. Bellinger, C (2008). Very low lead exposures and children's Bellinger, C (2008). Very low lead exposures and children's neurodevelopment. Current Opinions in Pediatrics, 20 (2): neurodevelopment. Current Opinions in Pediatrics, 20 (2): 172–177 172–177 Cecil, M, et al. (2008). Decreased brain volume in adults with Cecil, M, et al. (2008). Decreased brain volume in adults with childhood lead exposure. PLoS Medicine, 5 (5): 112. Centers for Disease Control and Prevention. Blood Lead Levels - United States, Centers for Disease Control and Prevention. Blood Lead Levels - United States, 1999-2002. MMWR; 54(20):513-6. Center for Disease Control (2009). Lead. Retrieved October 10, 2009, Center for Disease Control (2009). Lead. Retrieved October 10, 2009, from: www.cdc.gov/lead/ from: www.cdc.gov/lead/ Environmental Protection Agency (EPA) 2009. Lead. Retrieved October 12, Environmental Protection Agency (EPA) 2009. Lead. Retrieved October 12, 2009, from: http://www.epa.gov/lead/pubs/rrpamph.pdf http://www.epa.gov/lead/pubs/rrpamph.pdf Meyer PA; Mcgeehin F (2003). A global approach to childhood lead poisoning Meyer PA; Mcgeehin F (2003). A global approach to childhood lead poisoning prevention. International Journal of Hygiene and Environmental Health, 206 (4-5): 363–9.

19. References (continued) Moeller, DW (2005). Environmental Health (3rd ed.). Boston: Harvard University Press. Moeller, DW (2005). Environmental Health (3rd ed.). Boston: Harvard University Press. Needleman, H. (2004). Lead poisoning. Annual Review of Medicine, 55; 209–222. Needleman, H. (2004). Lead poisoning. Annual Review of Medicine, 55; 209–222. Solomon C (2009). This old (dangerous?) house. Microsoft Network Real Solomon C (2009). This old (dangerous?) house. Microsoft Network Real Estate. Retrieved October 26, 2009, from: http://realestate.msn.com/article.aspx?cp-documentid=21917660 http://realestate.msn.com/article.aspx?cp-documentid=21917660 State of NJ (2009). Lead Safe NJ Program. Retrieved October 15, 2009, from: http://www.state.nj.us/dca/dcr/leadsafe/ State of NJ (2009). Lead Safe NJ Program. Retrieved October 15, 2009, from: http://www.state.nj.us/dca/dcr/leadsafe/ US Dept. of Housing and Urban Development (HUD) (2009). Retrieved October 20, 2009 from: www.hud.gov/offices/lead/enforcement/lshr.cfm US Dept. of Housing and Urban Development (HUD) (2009). Retrieved October 20, 2009 from: www.hud.gov/offices/lead/enforcement/lshr.cfm