Missouri Childhood Lead Poisoning Prevention Program Annual Report for Fiscal Year 2018 July 1, 2017 – June 30, 2018 Missouri Department of Health and Senior Services http://health.mo.gov/living/environment/lead/index.php 573-751-6102 or 866-628-9891 Missouri Childhood Lead Poisoning Prevention Program (CLPPP) Annual Report for Fiscal Year 2018 July 1, 2017 – June 30, 2018 Table of Contents About Our Program 1 Lead Poisoning in Missouri 2 Statewide Screening Plan 3 Reporting of Blood Lead Testing 4 Housing Risks 5 Testing and Prevalence 6 Lead Poisoning Prevention Education 12 Collaborations 12 This report meets the statutory mandate for an annual report per §701.343, RSMo. About Our Program PROGRAM MISSION The Missouri Department of Health and Senior Services (DHSS) Childhood Lead Poisoning Prevention Program’s (CLPPP) mission is to assure the children of Missouri a safe and healthy environment through primary prevention and the identification of lead exposures that may cause illness or death. The DHSS CLPPP was established in 1993 and continues to assure that health care providers have current information and tools available to screen patients less than six years of age for lead and provide primary prevention education. The DHSS CLPPP is staffed by the following positions: a Program Manager, a Senior Office Support Assistant, a Research Analyst, a Health Program Representative, two Data Entry Personnel, seven Environmental Specialists, and a Public Health Consultant Nurse. State guidelines describe appropriate follow-up of children with elevated blood lead levels (EBL) of at least 10 micrograms per deciliter (10 µg/dL). Based on the 97.5th percentile of the blood lead level distribution among children one to five years old in the United States, the current Centers for Disease Control and Prevention (CDC) reference level is set at > 5 µg/dL. CLPPP has been working to identify ways to provide services based on CDC’s reference level. DHSS staff currently notifies all Local Public Health Agencies (LPHAs) and Managed Care health plans when a blood lead level is received regardless of the level. This ensures LPHAs and health plans are aware of all the children’s blood lead level results and can discuss what actions will follow if any. Follow-up activities and case management are generally provided for children six years and younger with an EBL > 10 µg/dL. These activities help the family understand the causes and health effects of childhood lead poisoning. Environmental risk assessments are required per statute to be performed to identify potential sources of lead exposure for children with an EBL > 15 µg/dL. While not required by statute, CLPPP also offers environmental risk assessments for children with an EBL > 5 µg/dL. These risk assessments provide the family with information about where lead hazards exist in and around their home. A work plan is developed to reduce these hazards and the risks associated with them. By reducing or eliminating exposures to the environmental sources of lead, the child’s blood lead level should decrease and repeated elevations should be prevented. Parents with elevated blood lead children less than three years of age are also provided with “First Steps” pamphlet. A DHSS produced Lead Fact Sheet and CDC’s “Protect Your Family from Lead” booklet are mailed to families of children who have been identified with having a lead level of 5 µg/dL to 9.9 µg/dL to provide information on lead poisoning and prevention. These pamphlets and booklets are also given to the parents during risk assessments for blood lead levels equal to or greater than 5 µg/dL. Lead poisoning prevention educational materials are provided to Missouri citizens at various community venues. DHSS works with LPHAs, the medical community, other state agencies, businesses, schools, and community organizations to prevent childhood lead poisoning. The DHSS CLPPP created a mascot to promote lead poisoning prevention messages called Leady. The costume may be loaned to any organization in Missouri wanting to increase lead poisoning prevention education and blood lead testing. The program currently uses the Missouri Health Strategic Architectures and Information 1 Cooperative (MOHSAIC) database to collect lead-specific data from medical and lead program activities. This database is part of an electronic health records system to provide documentation of medical testing, case management, and environmental risk assessments statewide. The data is used to provide comprehensive lead case management services and for statistical information. All child and adult lead test information is tracked in MOHSAIC. Lead Poisoning in Missouri Lead poisoning is one of the most common and preventable environmental health problems today. Almost a quarter million children in the United States are estimated to have an EBL level of at least a 10 μg/dL. According to Missouri blood lead testing data for July 1, 2017, through June 30, 2018, there were 517 children under the age of six identified with EBL levels of at least 10 μg/dL (0.62 percent of the 83,681 children tested that year). There were 2,553 children with a level of at least 5 μg/dL equating to 3.05 percent. The primary lead hazard to children in Missouri is deteriorated lead-based paint. Lead-based paint was banned for residential use nationwide in 1978. Any home built before 1978 may contain lead-based paint. The highest risk of lead exposure for children is found in homes built before 1950, when most paint contained a high percentage of lead. More than 21 percent of the housing stock in Missouri was built before 1950 (see page 5). Lead mining and smelting are an important part of Missouri’s history. Lead in Missouri was first discovered along the Meramec River by French explorers in the 1700’s while searching for gold and silver. Missouri became the dominant lead-producing state in the nation in 1907. It has remained so ever since. Most early lead production came from the Old Lead Belt district of southeast Missouri in the Park Hills-Bonne Terre area, and in the Tri-State Zinc-Lead district in southwest Missouri around Joplin. Today, all of the state’s lead production comes from the New Lead Belt, also known as the Viburnum Trend district. This district is a very narrow, 35-mile- long ore area extending southward from the town of Viburnum, Iron County, in southeast Missouri. Mining waste products in these areas have been found in driveways, yards, and even children’s play areas. Dust, air, and soil around mining activity have consistently shown elevated levels of lead contamination. Lead is a shiny, silver-colored metal found naturally in the earth’s crust. Lead has historically been used in a variety of ways including in paints, gasoline, batteries, bullets, keys, and some vinyl products such as mini-blinds. Fine particles of processed or recycled lead and/or lead dust become a health hazard when they are taken into the body through inhalation (breathing) and/or ingestion (swallowing). Lead affects almost every organ and system in the body. The effects of lead are the same whether it is inhaled or ingested and can damage the brain, central nervous system, kidneys, and immune system. Lead in the human body is most harmful to young children under six years of age, and is especially detrimental to children less than three years of age because their systems are developing rapidly. 2 A blood test is used to determine lead levels in the body. Lead can be measured in blood drawn from a vein or capillary (finger stick). Blood lead levels are measured and reported as micrograms of lead per deciliter of whole blood (µg/dL). Statewide Screening Plan Legislation passed in 2001 required DHSS to promulgate rules and regulations to establish a statewide screening plan. The rules and regulations define criteria for establishing geographic areas in the state considered to be at higher risk for lead poisoning, outline blood lead testing requirements and protocols, and define lead testing follow-up. In developing these regulations, CLPPP applied Missouri surveillance and census data to establish criteria for High-Risk Testing and General-Risk Testing areas in Missouri. Based upon those criteria, and as required by state statute, the following activities shall occur in these two areas. In High-Risk Testing Areas: • Any child under the age of six living in or visiting for more than 10 hours per week in the High-Risk Testing or high risk area will be tested annually for lead. • Childcare facilities located in High-Risk Testing Areas must record a “proof of lead testing” signed by the health care provider within 30 days of the child’s enrollment. The statement must verify that a blood lead test was completed in the previous 12 months. If the parent/guardian does not provide proof or a written statement explaining why they do not want the child tested, the childcare facility is to offer the parent assistance in scheduling a blood lead test. In General-Risk Testing Areas the following activities shall occur: • From six months to six years of age, every child will be screened annually using the Healthy Children and Youth (HCY) Lead Risk Assessment Guide to determine whether the child is at risk for lead poisoning. Responses given during the screening with the Guide may indicate the need for blood lead testing. *The HCY Lead Risk Assessment Guide can be viewed at: http://health.mo.gov/living/environment/lead/pdf/HCYLeadRiskAssessmentGuide.pdf. • Every child less than age six found to be at high risk will be blood tested for lead poisoning. • All MO HealthNet eligible children shall be assessed by the HCY Lead Risk Assessment Guide and/or be blood lead tested at the ages stipulated by the Federal Program Guidelines (12 months of age, 24 months of age, or 12 to 72 months of age). An updated Missouri Annual Childhood Lead Testing Area Requirements map is published every year and is available at: health.mo.gov/living/environment/lead/maps.php. 3 Reporting of Blood Lead Testing Missouri’s diseases and conditions reporting rule (19 CSR 20-20.020) requires reporting of all blood lead tests both elevated and non-elevated and clarifies demographic patient information required to be submitted with the report. All blood lead test results are required to be reported to the DHSS regardless of the age of the individual or the reported lead level. The data contributes to Missouri’s local, regional, and statewide statistics on blood lead poisoning. The following information is required: • Date test was conducted • Type of specimen (capillary or venous) • Result of the test • Name and address of the attending physician • Name of the disease or condition diagnosed or suspected • Date the test results were obtained • Patient’s complete name and home address with zip code • Patient’s date of birth • Patient’s sex and race Health care providers should assure that the laboratory they are using is reporting to DHSS. LeadCare Analyzers LeadCare Analyzers are portable and easy-to-use instruments that give results of capillary blood lead samples within minutes. These devices allow the patient to receive a result immediately from the tester. LeadCare Analyzers are very convenient for physicians’ offices and local health departments. These devices: • Prevent the patient from possibly being referred to an entirely different location to have the test done. • Save time that would be spent waiting on lab results. The use of these instruments has increased for both providers and local public health agencies. Filter Paper Blood Lead Testing Filter Paper techniques are acceptable for blood lead testing if health care providers ensure that, as with all blood lead test methods, the chosen laboratory is participating satisfactorily in Clinical Laboratory Improvement Amendments (CLIA) certified proficiency testing (PT) program. Technical assistance is available by contacting the nurse in the DHSS Childhood Lead Poisoning Prevention Program at 573-751-6102. 4 Housing Risks Nationally, the average percentage of housing built pre-1950 decreased from 22% in 2000 to 19.6% in 2010. Missouri is above the national average with 21% of housing units built before 1950. The map below lists the percentage of pre-1950 housing by zip code according to the 2000 census data. Percent of Missouri Pre-1950 Housing by Zip Code 0% -15% • 16%-26% • 27%-40% • 41%-100% ... ....... /2 ~-, ...... Kansas .-. ., / City - ..... -· - - St. Louis 5 Testing and Prevalence The number of Missouri’s children less than six years old who have been tested for lead poisoning has increased from 50,362 in 2000 to 83,681 in Fiscal Year 2018. Of the children tested, the percentage found to have elevated blood lead levels (10 µg/dL or greater) has declined from 11.1 percent in 2000 to 0.62 percent in 2018. This decrease mirrors a nationwide decrease in children’s blood lead levels. In 2018, of the 83,681 children in Missouri who received a blood lead test, 517 had blood lead levels of 10 µg/dL or greater. Highlights from the Fiscal Year 2018 testing data • There were 83,681 children tested for lead during Fiscal Year 2018. Of children tested in Missouri, 517 (0.62 percent) had an elevated blood lead level of at least 10 μg/dL. • The number of children found to have an EBL greater than or equal to 10 μg/dL decreased from 5,588 in 2000 to 517 in 2018. • 2,036 children tested had blood lead levels between 5 and 9.9 µg/dL (2.4 percent of the 83,681 children tested). • Total of 2,553 children greater than or equal to 5 µg/dL (3.05 percent of the 83,681 children tested. A summary of county level blood lead testing data for the period of July 1, 2017, through June 30, 2018, is presented on the following pages. 6 Fiscal 2018 CLPPP Elevated Blood Lead (EBL) Testing Summary (July 1, 2017 to June 30, 2018) Population of Children Percent of 5 to 9 ≥ 10 EBL Test EBL Jurisdiction < 72 months Population (µg/dL) (µg/dL) Total Total Rate (2017 5yr Tested ACS) ADAIR x x 5 233 2.15% 1,516 15.37% ANDREW 6 0 6 262 2.29% 1,227 21.35% ATCHISON 7 0 7 42 16.67% 330 12.73% AUDRAIN x x 18 496 3.63% 1,935 25.63% BARRY x x x 301 1.33% 2,573 11.70% BARTON x x x 143 2.80% 856 16.71% BATES 15 5 20 235 8.51% 1,157 20.31% BENTON x x x 130 3.08% 996 13.05% BOLLINGER x x 5 189 2.65% 815 23.19% BOONE x x 18 2,331 0.77% 12,531 18.60% BUCHANAN 82 23 105 1,492 7.04% 6,777 22.02% BUTLER x x x 770 0.52% 3,270 23.55% CALDWELL 5 0 5 136 3.68% 626 21.73% CALLAWAY x x 7 493 1.42% 2,996 16.46% CAMDEN x x 10 281 3.56% 2,567 10.95% CAPE GIRARDEAU 17 5 22 753 2.92% 5,441 13.84% CARROLL x x x 156 2.56% 639 24.41% CARTER x x x 91 1.10% 451 20.18% CASS x x 14 1,112 1.26% 7,621 14.59% CEDAR 6 0 6 140 4.29% 1,140 12.28% CHARITON x x 5 114 4.39% 558 20.43% CHRISTIAN x x 8 953 0.84% 6,552 14.55% CLARK x x 11 104 10.58% 473 21.99% CLAY 36 6 42 2,900 1.45% 18,943 15.31% CLINTON 6 0 6 240 2.50% 1,424 16.85% COLE 28 0 28 809 3.46% 5,571 14.52% COOPER x x x 240 1.67% 1,160 20.69% CRAWFORD x x x 321 1.25% 1,696 18.93% DADE x x x 100 3.00% 455 21.98% DALLAS x x x 196 0.51% 1,279 15.32% DAVIESS x x x 133 2.26% 641 20.75% DEKALB x x x 118 0.85% 709 16.64% DENT x x 8 238 3.36% 1,127 21.12% DOUGLAS 7 0 7 227 3.08% 891 25.48% DUNKLIN 5 0 5 528 0.95% 2,580 20.47% 7 Population of Children Percent of 5 to 9 ≥ 10 EBL Test EBL Jurisdiction < 72 months Population (µg/dL) (µg/dL) Total Total Rate (2017 5yr Tested ACS) FRANKLIN 16 5 21 849 2.47% 7,604 11.17% GASCONADE x x 8 188 4.26% 911 20.64% GENTRY x x x 122 2.46% 579 21.07% GREENE 60 15 75 3,197 2.35% 21,001 15.22% GRUNDY x x 8 147 5.44% 871 16.88% HARRISON x x x 91 3.30% 665 13.68% HENRY x x 10 247 4.05% 1,571 15.72% HICKORY x x x 84 2.38% 478 17.57% HOLT x x 7 80 8.75% 266 30.08% HOWARD 6 0 6 150 4.00% 722 20.78% HOWELL 5 0 5 360 1.39% 3,085 11.67% IRON x x 21 239 8.79% 617 38.74% JACKSON 322 105 427 12,706 3.36% 55,961 22.71% JASPER 62 17 79 2,423 3.26% 10,022 24.18% JEFFERSON x x 18 1,667 1.08% 16,142 10.33% JOHNSON x x 18 377 4.77% 4,055 9.30% KANSAS CITY 298 89 387 8,974 4.31% 40,849 21.97% KNOX x x x 48 2.08% 292 16.44% LACLEDE x x 9 495 1.82% 2,886 17.15% LAFAYETTE x x 5 491 1.02% 2,276 21.57% LAWRENCE 12 5 17 434 3.92% 3,008 14.43% LEWIS x x 9 154 5.84% 692 22.25% LINCOLN 8 0 8 547 1.46% 4,597 11.90% LINN x x x 145 2.07% 890 16.29% LIVINGSTON 8 0 8 230 3.48% 1,029 22.35% MCDONALD x x 5 262 1.91% 1,922 13.63% MACON x x 7 214 3.27% 1,075 19.91% MADISON x x 19 293 6.48% 886 33.07% MARIES x x x 79 1.27% 527 14.99% MARION 28 6 34 564 6.03% 2,193 25.72% MERCER x x x 32 3.13% 271 11.81% MILLER x x x 226 1.33% 1,876 12.05% MISSISSIPPI x x x 347 1.15% 841 41.26% MONITEAU x x 7 192 3.65% 1,285 14.94% MONROE x x x 105 2.86% 577 18.20% MONTGOMERY x x 5 222 2.25% 782 28.39% MORGAN x x 8 292 2.74% 1,530 19.08% NEW MADRID 8 0 8 399 2.01% 1,313 30.39% NEWTON x x 36 862 4.18% 4,351 19.81% NODAWAY 11 5 16 301 5.32% 1,233 24.41% 8