Child and School Health Archives - Page 6 of 16

Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism

North Carolina’s Comprehensive Approach to Preventing and Reversing Drug Overdoses

Early in 2000, state public health surveillance identified a surge of deaths in North Carolina. The Centers for Disease Control and Prevention conducted an investigation into the increase, finding the main driver was unintentional drug overdoses from prescription drugs.

In 2003, the Governor created the Task Force to Prevent Deaths from Unintentional Drug Overdoses, which helped establish the North Carolina Controlled Substances Reporting System (CSRS), which was the state’s prescription drug monitoring program (PDMP).

Since then, North Carolina has implemented a variety of measures to prevent deaths from drug overdoses. With increased access to data from the PDMP and a brighter light shined on the issue, public health continued to collect data, finding, in 2007, that Wilkes County, in the northwest part of the state, had the third highest drug overdose death rate in the country.

Child Fatality Task Force

North Carolina’s Child Fatality Task Force (CFTF)—a standing committee of the general assembly that is composed of 10 legislators and numerous technical advisors—is essentially the policy component of the state’s child death review system.

CFTF provides a unique opportunity for the public health community to present data and bring in outside experts, including law enforcement and subject matter and harm reduction experts. Everyone sits in a room, discusses policies and gets on the same page. Most bills addressing the overdose epidemic since 2010 have come from CFTF, including revisions to CSRS and increasing/improving naloxone access laws.

Project Lazarus

Established in 2007, Project Lazarus— a public health model based on the twin premises that overdose deaths are preventable and that all communities are responsible for their own health—was one of the first initiatives designed to respond to the extremely high overdose mortality rates in Wilkes County.

“Project Lazarus Offers Communities & Individuals Access To:

Coalition formation, capacity building, & sustainability.
Chronic pain management.
Safe prescribing practices for providers.
Opioid overdose education, awareness, & safe medication usage materials.
Naloxone, the opioid overdose rescue medication.
Project Pill Drop, a community based medication disposal program.
Lazarus Recovery Services, a peer guided recovery support program.
Local & state data on overdose and poisoning rates.
Local & state funding sources for overdose prevention work.”

The University of North Carolina Injury Prevention Research Center (UNC IPRC) evaluated Project Lazarus and found an initial drop in the overdose death rate of 40 percent, which grew to a 69 percent decline in 2011. The program has since be brought statewide.

University of North Carolina Injury Prevention Research Center

The University of North Carolina Injury Prevention Research Center (UNC IPRC) is a key partner in addressing the overdose epidemic. UNC IPRC provides evaluation, research, training, and technical assistance to partners and programs working to combat the opioid epidemic.

Drug Takebacks

In 2009, Safe Kids North Carolina, located in the Office of the Chief Fire Marshall worked with the State Bureau of Investigation and a diverse group of partners to develop Operation Medicine Drop. Since its establishment, Operation Medicine Drop has collected and safely disposed of 89.2 million pills at more than 2,000 events and established a network of permanent drop boxes that serve most counties in the state.

NC DHHS noted that drug takeback programs are a great way to get the community involved and raise public awareness of the issue—it gives everyone a little skin in the game when they realize that items in their medicine cabinet could be fueling the drug epidemic. This process helped move the conversation upstream to ensuring people knew of the problems and the steps they could take to prevent people from developing a substance use disorder.

PDMP

North Carolina has worked to improve CSRS to be a valuable tool to prescribers and dispensers to better manage pain and appropriate prescribing. In 2012, the Child Fatality Task Force convened a study group that resulted in the Revision to the CSRS Law in 2013. They added delegate accounts, shortened the time dispensers have to report data, and enabled proactive reporting from CSRS to licensing boards and prescribers.

In 2014, the Program Evaluation Division of the General Assembly conducted an extensive evaluation of CSRS, concluding that further funding and improvements of CSRS should be included in the state budget bill of 2015.

In 2017, the STOP Act— the most comprehensive bill in the state to address the opioid epidemic—became law. The Act includes mandated use of CSRS, limits on prescribing opioids in line with CDC’s Prescribing Guidelines, expansion of naloxone distribution, and numerous other provisions to address the opioid epidemic.

To develop the Act and identify evidenced-based strategies, NC DHHS worked with UNC IPRC, CDC’s Prevention for States Program, and national experts, including Corey Davis at the Network for Public Health Law.

The 911 Good Samaritan Law/Naloxone Access Act

Expanding access to naloxone has been an important part of North Carolina’s strategy to address the overdose epidemic and was a founding principle of Project Lazarus. The North Carolina Harm Reduction Coalition (NC HRC) has worked with the Law Enforcement community to gain their support for enactment of a series of naloxone laws since 2013.

Since the successful passage of naloxone-related legislation, NC HRC distributed more than 41,000 overdose rescue kits and confirmed 7,408 overdose reversals in North Carolina. Working with law enforcement agencies to develop naloxone programs has resulted in 164 law enforcement agencies with officers carrying naloxone and 403 reported law enforcement reversals by naloxone.

In 2016, the Naloxone Standing Order Law—enables any pharmacy in the state to offer naloxone without a prescription under the state health director’s standing order—Became law. The Standing Order Law was developed in response to requests from the retail pharmacy industry, which wanted to easily offer naloxone in their pharmacy outlets across the state.

After passage, DHHS developed a resource web site with UNC IPRC that contains technical resources on how to use the standing order. Nearly 1,400 pharmacies in the state offer naloxone under the standing order law.

The 911 Good Samaritan Law waived prosecution for individuals experiencing or witnessing an overdose who seek help by calling 911. The law also removed civil liabilities for doctors who prescribe naloxone and bystanders who use naloxone to attempt to save someone’s life and allowed community organizations to dispense naloxone with medical provider oversight.

Syringe Exchange

In 2016, North Carolina became the first state in the south to legalize syringe exchanges with passage of House Bill 972.

The years of work on harm reduction and everyone working together broke down the historical resistance of syringe exchanges and they were able to decriminalize needles. Advocates performed demonstration projects and worked with law enforcement early to identify legislation that the law enforcement community would find acceptable and help them in their daily work.

In addition, the argument was made that needle exchanges could save the state money—DHHS noted that Medicaid charges for Hepaticas C treatment went from $3.8 million in 2011 to $85 million in 2016

Following the legalization of the syringe exchanges, DHHS developed the Safer Syringe Initiative and registered 22 syringe programs in the first year of the law—reaching 19 counties.

Initially, to pass the Bill, language was included that prohibited the use of public funds to support exchanges. When the STOP Act passed, it included provisions that only prohibited the use of “State Funds,” enabling local health departments and other governmental units to use local funds to do needle exchange.

The DHHS sees needle exchanges and drug take programs as a way for communities to take direct action in the overdose epidemic.

The District of Columbia’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

The District of Columbia is at the national forefront of efforts to reduce childhood lead poisoning, enacting several prevention-focused laws. Reflecting a long legacy of lead usage – an estimated 75 percent of housing predates the 1978 ban on residential use of lead-based paint – the District also mandates universal screening, requiring two lead tests for all children by age two.

The law at the center of the city’s efforts to combat lead poisoning is the District’s Lead Hazard Prevention and Elimination Act of 2008, amended in 2011 (D.C. Official Code § 8-231.01 et seq.). This law prohibits the presence of a lead-based paint hazard in dwelling units, common areas of multifamily properties, and day care and prekindergarten facilities constructed before 1978. Under the law, any paint in or on a pre-1978 dwelling unit or “child-occupied facility” that is not intact is automatically considered hazardous.

Clearance Examination

A key preventive provision in the District’s lead law (see implementing regulations) is the required clearance examination whenever a pre-1978 residential rental property is about to be occupied by a pregnant woman or a child under age six. Specifically, the property owner must furnish a passing clearance report, issued within the previous 12 months, providing documented proof that the individual rental unit contained no lead-based paint hazards, including deteriorated lead-based paint or lead-contaminated dust or soil. This information must be disclosed before a buyer or renter is obligated under contract to purchase or lease the unit.

A related provision extends this requirement to units occupied or visited by a child or pregnant woman. Additionally, if owners discover lead-based paint in their properties, they must disclose it to their tenant within 10 days.

Lead-Based Paint Presumption

The District’s lead law also expands the definition of “lead-based paint hazard” to presume that any paint in or on a pre-1978 residential or child-occupied facility is lead-based. Any paint that is peeling, chipping, cracking, flaking, or otherwise not intact is automatically considered to be a lead-based paint hazard, unless proven otherwise.

This broader definition facilitates the District’s proactive approach to lead-based paint hazards. Any time there is a “reasonable belief” that a lead-based paint hazard may be present, the Government of the District of Columbia is empowered to inspect residential housing or child-occupied facilities (DC Official Code § 8-231.05(a)). Under this authority, inspections can take place for a variety of reasons, including a tenant complaint or knowledge that a particular neighborhood has a higher prevalence of lead hazards.

The law allows the Government of the District of Columbia to enter a property and conduct a lead risk assessment to determine if lead-based paint hazards may exist. If a lead hazard is found, the property owner may be issued an Administrative Order to Eliminate Lead-Based Paint Hazards. The order specifies the type and location of the hazard and how and when it must be eliminated. Additionally, the property owner is charged for recovery of costs associated with conducting the risk assessment.

Eliminating the lead-based paint hazard must follow specific safe practices. Once the work is complete – to ensure that no lead-based paint hazards remain – the owner must hire a District-certified risk assessor to perform a clearance examination.

The law also states that contractors that disturb paint during work in a pre-1978 property must use lead-safe practices, which includes containing the immediate work area to protect the occupants. A Cease and Desist Order, a Notice of Violation, and/or a Notice of Infraction can be issued to any contractor who fails to do so.

The District may require landlords to arrange and pay for temporary relocation of tenants whose homes contain lead-based paint hazards. In addition, the landlords must make all reasonable efforts to relocate tenants in the same school district or ward and near public transportation.

The law also includes tough disclosure requirements. Owners are required to disclose any “pending actions” ordered by the District and any reasonably known information about the presence of lead-based paint or lead-based paint hazards.

Renovation, Repair and Painting Permitting Requirement

Another preventive measure applies to contractors seeking renovation permits. They must provide proof of training as required under EPA’s Renovation, Repair, and Painting Rule to the permitting office at the District’s Department of Energy and Environment (DOEE). DOEE provides a list of individuals and business entities certified by DOEE to conduct lead-based paint activities in the District.

Universal Lead Screening and Reporting

The District also passed the Childhood Lead Screening Amendment Act of 2006 (D.C. Official Code § 7-871.01 et seq.), mandating that all District children be tested twice by the time they are two-years-old, once, between 6 and 14 months, and the second time between 22 and 26 months. Additional screening is required up to age six if the child has received no prior screening and whenever there are other risk factors. Laboratories must report all test results to DOEE’s Childhood Lead Poisoning Prevention Program. Similarly, health care providers must notify the DOEE about lead-poisoned children within 72 hours.

To increase compliance with the District’s lead screening and reporting law, DOEE provides education to health care providers and builds community awareness, especially among at-risk populations. DOEE has also created formal data-sharing agreements with several District agencies to identify and reach out to families who need to update their children’s screenings.

DOEE provides case management to families whose child has an elevated blood lead level, including help with follow-up testing, education, and referrals. In addition, a DOEE lead inspector conducts an environmental investigation and provides a risk assessment report detailing where lead-based paint hazards were found, with instructions for the property owner about necessary steps to eliminate the hazards. The law also allows DOEE to be reimbursed by the District’s Medicaid agency for lead risk assessments it conducts in the homes of Medicaid-enrolled, lead-exposed children.

Lead-Safe and Healthy Homes

In 2011, DOEE published a Strategic Plan for Lead-Safe and Healthy Homes, the first-ever District-wide agenda for maintaining homes free of lead hazards, asthma triggers, and other environmental health threats. The plan was developed with extensive input and feedback from community groups, providers, environmental experts, and sister agencies.

In 2012, DOEE launched the District’s first full-fledged Healthy Homes program. Local health providers and social service agencies identify families with children or pregnant women in distress due to lead exposure, poorly controlled asthma, or hazardous conditions, and refer those families to DOEE. Participants receive a comprehensive home environmental assessment, family education, an asthma management diagnostic, and case management coordination. Once health and safety threats are identified and systematically documented, DOEE issues a technical assistance report to the property owner to help them correct the identified hazards. The agency also provides a customized care plan to help clients avoid additional exposure while waiting for hazards to be addressed. DOEE’s case managers monitor progress as the identified hazards are eliminated.

DOEE also designed the District’s Lead-Safe and Healthy Homes Hub to help teach residents about possible health risks at home. This interactive site features a variety of healthy homes topics, including lead, mold, secondhand smoke, pest infestations, and radon, and describes how residents can help prevent exposure to these hazards.

Results

For Fiscal Year 2015, the District reported that it had 196 new confirmed cases of children below age six with a blood lead level at or above CDC’s reference value of 5 µg/dl. Overall, District data suggest a downward trend in children’s lead exposure, with approximately 98 percent of children under six testing below the 5 µg/dL action level. DOEE’s Healthy Homes documented improvements in 80 percent of the 137 homes it managed in 2012, the program’s first year. Over time demand for the Healthy Homes program has grown, with 202 households served in Fiscal Year 2016.

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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.

The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Washington State’s Efforts to Prevent and Respond to Childhood Lead Exposure

“While no imminent public emergency has been discovered, recent detections of lead in some water systems are highlighting the important roles our water utilities, schools, public health departments and the state play in ensuring we all have access to safe, clean drinking water. This directive will better ensure we’re working in coordination and leveraging resources effectively to tackle lead at all its primary sources, whether it’s water, paint, or soil.” – Governor Jay Inslee

Background

In May 2016, in the wake of recent detections of lead in drinking water systems in the state, Governor Jay Inslee issued a directive to the state Department of Health and partner agencies to reduce lead exposure in Washington State. The directive instructs the Department of Health to take a series of actions to reduce lead exposure and help those with lead poisoning. It calls for additional investments in and funding for foundational public health services and infrastructure to help prevent, reduce, and remediate lead from water as well as other sources, such as paint.

The governor’s instructions focus on reducing environmental exposures to lead and making sure that children with lead poisoning receive all necessary case management and public health services. It directs the state Department of Health to take the actions and report back to the governor on budget and policy recommendations relating to these actions.

Partner with Other Sectors to Prevent and Reduce Lead Exposure

Governor Inslee’s directive instructs the Department of Health to work with schools, child care facilities, residential landlords, and public water system operators to prevent and reduce exposure to lead.

Key Partner: Schools

The directive instructs the Department of Health, the Washington State Board of Health, and the Office of Financial Management to review and update school health and safety regulations as needed (also known as the “School Rule”). They also should compile a budget decision package to put the regulations in place, beginning with those that pertain to lead exposure.

The Department of Health must continue providing technical assistance and guidance related to voluntary water quality testing schools can perform. This will help ensure that testing meets water sample collection protocol standards. In addition, the Department is asked to conduct workshops for schools that will heighten awareness about water quality and how to correctly test and repair any problems they find.

Key Partner: Child Care Settings

The directive instructs the Departments of Early Learning and Health, in collaboration with the Office of Financial Management, to determine the need for and feasibility of requiring child care providers located in buildings constructed before 1978 to complete an evaluation for potential sources of lead exposure. This includes drinking water testing.

Key Partner: Residential Landlords

The directive instructs the Department of Health to assess the feasibility of possible policy changes associated with developing a Lead Rental Inspection and Registry program. This step would require residential rental properties built prior to 1978 to register and complete a lead inspection and show proof of safety every time new tenants move in.

Key Partner: Public Water System Operators

The directive instructs the Washington State Department of Health to work with large public water system operators (those with more than 15 home/business connections or that serve 25 or more people per day for more than 60 days annually) to identify within two years all lead service lines and lead components in water distribution systems.

The directive also instructs the health department to make the removal of lead service lines and other lead components a top priority when it provides low-interest loans to eligible public water systems to address public health concerns. The department is also directed to work with stakeholders to develop policy and budget proposals, with the aim of removing all lead service lines and lead components in large public water systems within 15 years. This would make Washington State the first state to set such a goal.

Improve Lead Screening Rates and Provide Case Management and Remediation Services

To help those who already have lead poisoning, the governor has asked the Department of Health to work with the Healthcare Authority and the Office of the Insurance Commissioner to increase lead screening rates for the children on Medicaid at highest risk, provide case management services to children with lead poisoning and their families, and determine whether private payers provide coverage for lead screening and case management services or if further coverage policy change is called for.

Governor Inslee also asked the Department of Health to work with stakeholders and other partners to make the blood level monitoring system more efficient. This step entails transitioning the Child Blood Lead Registry to a fully electronic reporting system–and developing an adequate funding mechanism so that local health departments can fully implement home visits and other investigative work necessary to identify and remediate lead exposure.

Federal Funds to Expedite Lead Removal in Drinking Systems

Finally, the governor has asked the Department of Health to partner with the Department of Ecology and the Environmental Protection Agency to seek federal funds to expedite lead removal in drinking systems, require lead testing in childcare settings, and support revisions to the federal Lead and Copper Rule. The rule requires water utilities to monitor drinking water, control corrosion, and inform the public when lead or copper concentrations exceed a designated threshold.

“Lead is all around us, and the governor’s directive is a positive step in the right direction of reducing lead exposure.”

– Secretary of Health John Wiesman

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Rhode Island’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In June 2016, the Rhode Island General Assembly passed the Lead and Copper Drinking Water Protection Act, requiring schools, day care facilities, public playgrounds, shelters and foster homes with children under six, and other state facilities to certify that drinking water conduits are lead-safe. It also directs state inspectors to conduct an annual lead and copper test at these facilities. In conjunction with the law, which will be implemented once regulations are promulgated, the state created a commission to study lead in the water system.

Documentation of Lead-Safe Remodeler/Renovator License Required to Receive a Building Permit to Complete Housing Renovations

In 2011, the City of Providence began requiring applicants for building permits at pre-1978 homes to provide proof of training and licensing in lead-safe work practices. The state of Rhode Island requires all construction contractors working in homes and child care facilities built before 1978 to hold a Lead-Safe Remodeler/Renovator License or a higher level of lead hazard control certification. The lead-safe remodeler/renovator program has been overseen by the state since 2001. It is authorized by the U.S. Environmental Protection Agency to administer the federal Renovation, Repair, and Painting rule in Rhode Island. To increase compliance with the state remodeler/renovator law, the City of Providence will issue permits for construction work at properties covered by the law only if proof of licensure is provided. In January 2015, the City of Pawtucket put in place a similar requirement: contractors must document their training and licensure to receive a building permit for renovations.

Use of Local Housing Officials to Enforce Lead Hazard Mitigation Law

The state of Rhode Island passed the Lead Hazard Mitigation Act in 2002 and implemented regulations in 2004. Under the law, rental property owners are required to attend a training on unsafe lead conditions, inspect/repair any lead hazards at their properties, make residents aware of their findings and actions, address residents’ lead-hazard concerns, use lead-safe work practices during maintenance, and verify each unit’s compliance through a lead inspector. Typically, the owner must have the property inspected every two years and prove its safety for children by showing a Certificate of Conformance (COC) or a Lead-Safe or Lead-Free Certificate. Owners of two- and three-dwelling properties who live onsite are exempt from the law.

Since the law’s enactment the state has been challenged by compliance. In 2014, when the Providence Plan completed an evaluation of the Lead Hazard Mitigation Law, it found that only 20 percent of the covered properties had complied with the regulations within the first five years of implementation. Several cities have taken steps to improve enforcement. Providence, for example, created a separate division of Housing Court to address lead violations.

The Inspection and Standards division reported that of 537 lead violation cases filed over the first four years, 484 resulted in corrective action. An analysis conducted by the Rhode Island Department of Health discovered that between 2012 and 2013, there was a significant decline in children with elevated blood lead levels in Providence. Notably, the declines coincided with the implementation of the building permitting requirements and the lead docket.

Medicaid Reimbursement for Lead Follow-Up Services and Lead Centers and Reimbursement

Rhode Island Medicaid, which covers nearly 40 percent of children in the state and roughly half of children below six with elevated blood lead levels, provides reimbursement for lead follow-up services under its 1115 demonstration waiver (known as the Rhode Island Comprehensive Demonstration). The waiver gives Rhode Island the flexibility to “redesign the state’s Medicaid program to provide cost-effective services that will ensure beneficiaries receive the appropriate services in the least restrictive and most appropriate setting.”

Lead follow-up services eligible for reimbursement in Rhode Island are provided through four “lead centers” certified through the state health department. Because the services are offered under specifications of the contract with Rhode Island Medicaid, the centers have the flexibility to hire a range of personnel to deliver in-home lead services. These include community health workers, nurses, and certified lead inspectors.

Medicaid reimbursement is currently available to the lead centers for follow-up services provided to Medicaid-enrolled children up to age six who are identified to have elevated blood lead levels. The lead centers bill by the “Current Procedural Terminology” billing code for each service provided to Medicaid recipients. Medicaid reimburses them for an initial visit, a follow-up visit, or to close the case. The lead centers are reimbursed by the state for services provided to non-Medicaid-enrolled children.

Follow-Up Services: Education, Case Management, Assessment, and Inspection

Written Rhode Island Medicaid standards require the lead centers to contact associated healthcare providers when providing lead follow-up services. For each child or family, the lead center identifies a specific case manager who handles all communication and coordination with the child’s primary care provider or treating physician, all treatment providers and community support agencies, and the child’s health plan, when appropriate. When necessary, the lead center case manager also works with the Rhode Island Department of Human Services and Department of Health, serving as the point of contact for the child, family, and all providers and agencies.

Along with case management, other Medicaid-reimbursable follow-up services provided to children under age six with elevated blood lead levels by Rhode Island lead center staff include:

Visual assessment of the primary residence
Nutrition counseling
Lead education
Interim controls to limit exposure to lead hazards
Information on safe cleaning techniques
In-home education

For children with blood lead levels elevated above the designated threshold (as set by the U.S. Centers for Disease Control and Prevention), Medicaid also reimburses for a Comprehensive Environmental Lead Inspection of the home by a Rhode Island Department of Health lead inspector. After the inspection, lead center staff review the results with the family to help them understand sources of lead in their home.

The lead centers provide some education and other services to children with blood lead levels that are high but do not exceed the designated threshold. However, these services are funded by a Rhode Island Department of Health contract, not by Medicaid. The services include an educational home visit to discuss lead poisoning, nutrition, and cleaning practices that can protect children from additional lead risks; a Visual Environmental Lead Assessment by a trained community health worker, which provides education and preventative next steps; and the provision of soil and dust wipes for the home. The Rhode Island Department of Health is also piloting a limited environmental investigation (soil testing only) in partnership with the lead centers for children with lower blood lead elevations that do not meet the designated threshold.

Additional Services: Structural Remediation

While Rhode Island Medicaid can provide some reimbursement for window replacement and spot repair of conditions found to pose a lead-related threat to children with elevated blood lead levels, this structural remediation benefit has been used rarely. The primary reasons include: (1) the current reimbursement rate for window replacements is less than the typical replacement cost and (2) the mechanisms by which lead centers receive this reimbursement are cumbersome. In an effort to increase use, the Rhode Island Department of Health is exploring ways to improve the window replacement program. One possibility may be a revolving loan fund since lead centers must pay for replacement first and seek Medicaid reimbursement later.

In addition, when a lead violation is found and a notice of violation issued, property owners and families are automatically referred to local Housing and Urban Development-funded lead hazard control grant programs that may pay for structural remediation. Access to these grant programs depend on income, the property’s age (pre-1978), and the presence of a child under age six living in or frequently visiting the home or unit. The Rhode Island Department of Health is currently assessing how often cited owners use these grant programs and whether or not there are enrollment barriers.

Use of Medicaid Reimbursement for Lead Follow-Up Services

This table from the Rhode Island Executive Office of Health and Human Services shows the total number of Medicaid-enrolled children who received lead follow-up services from the Rhode Island lead centers and the corresponding amount of total Medicaid reimbursement for selected years between 2006 and 2014.

Rhode Island’s current Medicaid 1115 demonstration waiver is in place through 2018, and there has been consistent support for the continuation of the lead follow-up service reimbursement program in the state. Stakeholders attribute this enthusiasm to the relatively low total cost of the lead program within Rhode Island’s overall Medicaid budget, along with the well-known dangers of lead poisoning.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Massachusetts’ Efforts to Prevent and Respond to Childhood Lead Exposure

Background

The Massachusetts lead law, enacted in 1971, is one of the oldest in the country and contains some provisions not found in many other states. The law requires that any property built before 1978 and occupied by a child under age six be “deleaded.” The statute applies to both rental and owner-occupied dwellings and embodies the principle of primary prevention. This means that the requirement to delead is triggered by the occupancy of a child not by whether a child is experiencing an elevated blood lead level. Massachusetts also has laws making it illegal for property owners to discriminate against families with children when renting or selling.

The Massachusetts lead law, which has been amended multiple times since originally enacted, requires owners to hire a lead inspector to identify all surfaces with lead-based paint and develop a plan to address lead hazards. In some cases, the owner or agent can be trained to address certain conditions, while in others, a contractor with a Massachusetts deleaders’ license must be hired to conduct the work. Owners can opt to receive a Letter of Interim Control, which means that they will address “urgent lead hazards” immediately but defer action on intact surfaces. They must then fully cover or remove all lead hazards within two years of the issuance of the Letter of Interim Control. If an inspection does not identify lead hazards, or if owners fully address lead hazards, the inspector issues a Letter of Full Compliance. Although a Letter of Full Compliance does not expire, it does not certify a dwelling is lead-free, and therefore it is the owner’s responsibility to check the dwelling routinely for new hazards.

Strict Disclosure Requirements

Massachusetts law provides strict lead disclosure requirements for prospective renters and buyers of residential units. The law is in compliance with the federal lead disclosure law and includes the notification materials mandated by the Department of Housing and Urban Development and Environmental Protection Agency. In addition, landlords must provide tenants with a Massachusetts Tenant Lead Law Notification and Certification Form, a copy of the most recent lead inspection report if the property has been inspected for lead, and a copy of any Letter of Compliance or Letter of Interim Control.ta

Before signing a purchase and sale agreement, a lease with an option to purchase, or a memorandum of agreement used in foreclosure sales, residential property sellers and real estate agents – must disclose any lead-related information on the property to the prospective purchaser. This includes a copy of any lead inspection report, risk assessment report, Letter of Compliance, or Letter of Interim Control. Real estate agents must also tell prospective purchasers that, under the Lead Law, a new owner of a home built before 1978 (in which a child under six will reside) must have it deleaded or under interim control within 90 days of taking title.

Although the Massachusetts law includes many of the provisions found in federal law, Massachusetts gives the state enforcement powers. If the landlord fails to comply with the disclosure requirements, he or she can be held liable for all damages caused by the failure to provide this information, fined up to $1,000, and may be liable for engaging in an unfair and deceptive act under the Massachusetts Consumer Protection Act. Sellers and real estate agents who do not meet these requirements can face a civil penalty of up to $1,000 under state law in addition to a civil penalty of up to $10,000 and possible criminal sanctions under federal law, as well as liability for resulting damages. If a real estate agent fails to tell a tenant or perspective buyer about known lead hazards at a property, he or she may be liable for engaging in an unfair or deceptive act in violation of the Massachusetts Consumer Protection Act.

Strict Legal Liability for Property Owners

If an owner of a pre-1978 home fails to delead the property, and a child younger than six living in the home is lead-poisoned, the property owner is strictly liable for all damages. Strict liability means that owners are liable even if they did not know lead paint or a child under six was in the home. The strict liability provision, which dates back to the original law passed in 1971, helped educate property owners about their responsibility in correcting lead hazards.

In 1993, the law was amended so that an owner is not strictly liable for lead poisoning if a Letter of Compliance or Letter of Interim Control is in effect. The 1993 amendments also require insurance carriers who provide liability coverage in the state to offer owners coverage for negligence claims (short of gross or willful negligence) that might be brought against them by their tenants.

Financing Prevention Efforts

Beginning in 1987, Massachusetts has provided a “deleading” income tax credit to help homeowners pay for the cost of abating lead hazards, including window replacement. Since 1993, an owner of a residential property can claim a tax credit up to $1,500 for addressing lead hazards, if they have a Letter of Compliance, or up to $500 if they have a Letter of Interim Control. The tax credit cannot exceed the actual amount spent by the owner. If the tax filer owes less in income taxes than the amount of the credit, the unused portion of the credit can be carried over and used within the next seven years.

The state also administers loan programs for owner occupants and rental property owners to support compliance with the lead law. Some, such as Get the Lead Out and the Home Improvement Loan, are funded by the state, while others use federal grants and loans to support lead hazard control.

In order to provide additional funds to pay for training, licensing of inspectors, and public education purposes, Massachusetts imposes surcharges of $25 to $100 on the annual fees of a variety of professional licenses, including real estate brokers, property and casualty insurance agents, mortgage brokers and lenders, small loan agencies, and individuals licensed to perform lead inspections. The collected revenue, roughly $2.5 million annually, is deposited into a retained revenue account, known as the Lead Paint Education and Training Trust Account, for use by the Department of Public Health.

Results
Massachusetts’s comprehensive approach over a number of years has successfully reduced the number of young children with elevated lead blood levels. Of the more than 175,000 children tested in 2016, just 686 under age six had blood levels of 10 µg/dL or greater, compared with 3,095 of about 194,000 children tested in 2001, the earliest date for which data is available online.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Maryland’s Efforts to Prevent and Respond to Childhood Lead Exposure

“Working with our partners, including Baltimore City and the Green & Healthy Homes Initiative, Maryland has made significant gains to protect our children, particularly those who live in older rental housing. But a significant number of lead poisoning cases in Maryland are linked to newer rental housing. The change in Maryland’s lead law will allow us to prevent more children from suffering the effects of lead poisoning. We cannot, and will not, let up in our work to eliminate childhood lead poisoning in our state.”- Robert M. Summers, Secretary, Maryland Department of the Environment

Background

The Maryland Department of the Environment’s (MDE) Lead Poisoning Prevention Program coordinates statewide efforts to reduce childhood lead poisoning including assuring compliance with Maryland’s Reduction of Lead Risk in Housing Act. The statute and associated regulations (Environmental Article 6-8) require owners of rental properties built before 1978 to annually register their properties with the Maryland Department of the Environment, comply with a lead paint risk reduction standard, and distribute tenant educational information (a Notice of Tenant’s Rights brochure, a lead education pamphlet about protecting one’s family from lead in the home, and a copy of the current lead inspection certificate for the property).

The law, as originally passed in 1994, was intended to make housing units safer for children and help prevent childhood lead poisoning. It was also intended to help rental property owners and managers avoid costly lead poisoning litigation by complying with registration requirements and specific lead hazard reduction and inspection certification procedures.

A legal challenge to the tort protection clauses resulted in the removal of the implementation of those liability protection provisions from the law in 2011.The law was modified in 2012 to include rental properties constructed prior to 1978 (whereas the original law was only mandatory for pre-1950 rental units and had been optional for 1950-1978 constructed units), a change motivated by a significant percentage of new childhood lead-poisoning cases in Maryland that were linked to homes built after 1949.

Registration and Risk Reduction Requirements

Owners of residential rental properties built before 1978 must register their properties annually with the Maryland Department of the Environment. They can complete registration online or via a paper form, and registration fees are $30 per unit. Registration is specific to ownership of a property and must match exactly what is on record with the Maryland Department of Assessments and Taxation. A change in ownership, including adding owners or changing to a corporation, requires a new registration and new tracking number.

Rental properties covered by the law must be free of chipping, peeling paint and lead contaminated dust. To qualify for registration, owners must hire a certified contractor to address any defective paint and have an accredited lead paint inspector verify compliance before any change in occupancy. Inspectors issue a lead paint risk reduction certificate for each dwelling unit that passes the inspection.

Whenever a tenant notifies an owner that there is defective paint or there is a child with an elevated blood lead level, the owner has 30 days to conduct modified risk reduction measures and pass lead inspection certification. The rental property owner is responsible for temporarily relocating the family to a lead-safe or lead-free dwelling while the original dwelling undergoes risk reduction measures.

Litigation Implications of the Law

The widespread and routine application of lead exclusions in general liability insurance policies covering rental units helped motivate the enactment of the lead law in 1994. The statute added provisions to the Maryland Insurance Code, which limited the circumstances under which these exclusions would be effective. The law limited tort damages when the property owner satisfied certain housing unit registration requirements and after the unit passed lead dust tests or underwent a set of risk reduction measures. It also offered the owner the option of making a “qualified offer” (a payment to provide compensation in the form of relocation and medical benefits to the child and his or her legal guardian) in lieu of litigation when a child developed an elevated blood lead level in a compliant property.

In 2011, the Court of Appeals of Maryland issued an opinion in Jackson v. Dackman Company that found the limited liability section of the law is unconstitutional. The court ruled that the possible remedies contained in the law were not adequate compensation for the potential harm to an injured child from lead poisoning. The court also found it was unreasonable for the law not to offer a child the ability to bring suit for his/her injuries after the child reaches the age of majority. The court ruled that the remaining provisions in the law could continue to be enforced.

Implementation of Strong Public and Private Enforcement

A key component in Maryland’s substantial decline in childhood lead poisoning has been its strong public enforcement of the Maryland Reduction of Lead Risk in Housing Act coupled with local enforcement coordination and private enforcement actions by non-profit agencies and pro se tenants.

MDE files 500 to 800 violation notices annually, and a team of four to five people from the state’s attorney general’s office is responsible for enforcing actions against non-compliant owners.

Another highly effective best practice has been MDE’s policy of pursuing enforcement against a rental property owner’s entire non-complaint housing portfolio once enforcement actions have been initiated against any one of the owner’s properties. Local housing code enforcement and landlord licensing officials at the city and county level also help coordinate enforcement by referring non-compliant properties in their jurisdictions to MDE for enforcement of the registration and risk reduction requirements.

To increase the law’s effectiveness, private enforcement through family advocate attorney representation from the Green & Healthy Homes Initiative and other non-profit legal services providers is utilized statewide to assist tenants in obtaining risk reduction certification of their units, temporary relocation during lead hazard remediation and the use of lead certified contractors. The passage of legislation to support the law’s implementation through private enforcement and the development of lead poisoning prevention resources include:

Permitting tenants to establish court ordered rent escrow accounts until lead hazards are remediated in their rental unit;
Denial of District Court rent court access for the collection of rent for non-compliant property owners until their property is brought into compliance;
Requiring that non-compliant rental property owners pay up to $2,500 in relocation benefits to assist tenants in permanently moving to a new, lead certified home; and
Creation of a lead preference for Housing Choice Vouchers that provides vouchers to permanently relocate families with lead poisoned children who reside in hazardous housing to lead certified housing.

Other Responsibilities of the Lead Poisoning Prevention Program

The Maryland Department of the Environment assures compliance with mandatory requirements for registration and lead risk reduction in rental units built before 1978; maintains a statewide listing of registered and inspected units; and provides a blood lead surveillance database of children tested in Maryland.

The Maryland Department of Health and Mental Hygiene oversees blood lead testing initiatives in the state. All children living in at-risk areas for lead poisoning or receiving medical assistance must be screened for lead poisoning at 12 and 24 months of age, with children between 24 months and six years old in these at-risk areas required to be screened if the child has not previously tested or if documentation cannot be verified. Maryland recently adopted universal blood lead testing for children under age 6 for a period of three years in order to better measure actual blood lead testing rates in Maryland and to assess the accuracy of the methodologies utilized in Maryland’s previous targeted testing plan.

The Maryland Department of the Environment’s Lead Poisoning Prevention Program is also responsible for:

Overseeing case management follow-up by local health departments for children with elevated blood levels;
Certifying and enforcing performance standards for inspectors, risk assessors, and abatement contractors;
Performing environmental investigations for lead-poisoned children; and
In cooperation with the Maryland Department of Health and Mental Hygiene, providing oversight for community education to parents, tenants, rental property owners, homeowners, and healthcare providers to enhance their role in lead poisoning prevention.

Results

Since the Maryland Reduction of Lead Risk in Housing Act’s enactment, the rate of high blood lead levels has declined by 98 percent in Maryland. In 1993, 14,564 children (23.9 percent) of the 60,912 children under 6 who were tested had blood lead levels of 10 µg/dl or higher. By 2015, that rate had declined to 377 children of the 110,217 children 0-72 months tested (0.3 percent) for blood lead in Maryland. The declines in percent of children with blood lead levels equal to or greater than 10 µg/dL and between 5-9 µg/dL in 2014 compared to 2013 were 4.6 percent and 10.8 percent, respectively.

In 2013, there were approximately 28,000 affected rental properties that met the risk reduction standard. With the law’s expansion to include all pre-1978 rental properties the number of properties treated and receiving risk reduction inspection certification more than doubled to over 57,603 properties in 2014.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Peoria’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In the early- to mid-2000s, Illinois had an estimated 81,000 children with elevated blood lead levels, among the highest in the nation. Several sources of lead exposure can impact children, but windows have the highest levels of lead paint and lead dust compared to any other building component.

Using a unique state-financed bond, the Comprehensive Lead Education, Reduction, and Window Replacement Program (Clear-Win) was enacted in 2007 to prevent poisonings and improve children’s health. Illinois declared that the primary purpose was “to assist residential property owners to reduce lead paint hazards through window replacement in pilot communities.” The program provides grants and loans for low-income properties to participate in a window replacement program. Clear-Win also fixes additional lead-based paint hazards and allows for other minor repairs.

The pilot was conducted in Peoria and in the Englewood and West Englewood neighborhoods of Chicago, communities selected by the state legislature that encompass rural and urban settings and, along with high rates of childhood lead poisoning, had a large quantity of homes built before 1940.

In addition to the program’s health and environmental benefits, it was also designed to support the state’s economy by training workers in lead-safe work practices and carpentry skills and creating market opportunities for Illinois window manufacturers, assemblers, and installers.

Clear-Win Program

The Illinois Department of Public Health administers the program in Peoria in partnership with:

The Peoria City/County Health Department is responsible for operating the program;
Two Illinois-based window manufacturers supply the replacement windows at a low bulk purchase price; and
Building contractors perform the installations.

A certified third party performs clearance testing on all projects by dust wipe sampling to make sure that cleanup has been done properly. If the dust levels are still too high, the contractor has to re-clean until reaching compliance.

Besides Clear-Win, the Peoria City/County Health Department has worked for more than 10 years to eliminate lead poisoning in children in recognition of the fact that three Peoria ZIP codes ranked in the top 10 urban ZIP codes in Illinois for the rate of elevated lead levels in children under age six.

One tool used by the Health Department is funding from the Department of Housing and Urban Development to create the Lead Hazard Control Program, which provides grants in targeted Peoria ZIP codes for lead mitigation in pre-1978 homes. Once children with lead poisoning are identified and the source is confirmed as household exposure, the grant helps to relocate families to lead-safe homes temporarily while lead hazards are removed.

Between January and August 2016, the lead-abatement program, currently funded by a three-year, $3 million federal grant, has helped the county clean up roughly 47 homes–with more than 700 made lead-safe over the past decade.

The Peoria City/County Health Department also has focused on educating families about the importance of lead testing, highlighting the need for children to be tested for lead poisoning at 9-12 months of age and again at 18-24 months of age.

Results

A recent study of 96 of the more than 400 households served by Clear-Win, including 49 in Peoria, that participated in the original Clear-Win initiative found that average lead dust declined by 44 percent and that, one year later, the levels remained substantially below what they were before the window replacements. Both children and adults pointed to health improvements, including fewer headaches, ear infections, and respiratory allergies for children and fewer cases of sinusitis and hay fever among adults.

Economic benefits were estimated at $5,912,219 compared with a cost of $3,451,841, resulting in a net monetary benefit of $2,460,378. A related evaluation shows that this includes energy saving benefits of $1.5 million, additional market value benefits of nearly $1.57 million, lead poisoning prevention health benefits of nearly $3.6 million, and tax benefits from job creation of $51,000.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Boyle Heights’ Efforts to Prevent and Respond to Childhood Lead Exposure

Background

A Vernon, California, lead-battery acid recycling plant, which opened in 1922, contributed to air pollution in Boyle Heights, a nearby Los Angeles neighborhood, for more than 90 years. The plant logged at least 88 violations of emissions standards between 1996 and 2015. Exide Technologies, which purchased the facility in 2000, ran it seven days a week and processed 25,000 batteries a day. It emitted lead, arsenic and other pollutants into the air.

Ensuring Clean Air and Clean Soil

In 2013, after the South Coast Air Quality Management District found the plant “posed a higher cancer risk to more people than any of 450 operations the agency has regulated in the last 25 years,” state regulators temporarily shut it down. Unfortunately, Exide was able to get the closure overturned, forcing advocates to take further action.

In 2014, the U.S. Environmental Protection Agency (EPA) found that Exide violated new Clean Air Act emissions standards more than 30 times. These were the same violations found by the South Coast Air Quality Management District. But, because of the new Clean Air Act rules, EPA was able to step in and use those violations to fine Exide up to $37,500 per day for each violation.

These regulations forced the plant to close, yet the state continued to find that it emitted lead into the environment. And, in 2015, inspectors found additional issues, namely improperly labelled containers of hazardous materials and holes in the walls and roof of the facility.

At the same time, the company was also under criminal investigation for pollution related matters. To resolve that situation, the company entered into an agreement with the U.S. attorney’s office to, among other things, permanently close the plant.

Under the deal, Exide and its employees would avoid prosecution if they paid $50 million to tear down and clean the plant, with $9 million set aside specifically for removing lead-contaminated soil from homes.

In April 2016, California appropriated an additional $177 million to cleanup about a 2 mile radius surrounding the Exide plant. The state will be looking to Exide to pay this money back.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Rochester’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In Rochester, New York (Monroe County), 87 percent of the housing units were built before 1950 (federal law banned the use of lead in residential paint in 1978), and 60 percent of housing is tenant-occupied, which is more likely to have lead hazards.

In 2000, 1,293 children under age six had blood lead levels of at least 10 µg/dL, which was then the Centers for Disease Control and Prevention’s (CDC) action level— a proportion substantially higher than in high-risk neighborhoods in New York State or in the broader United States. Moreover, there were disparities in both health outcomes (the proportion of children with elevated blood lead levels (EBLs) and risk factors (housing units that were most likely to contain lead hazards from deteriorating paint were home to low-income families).

This led, that year, to the founding of the Coalition to Prevent Childhood Lead Poisoning by a group of individuals and organizations to end childhood lead poisoning in Monroe County.

Rochester’s Lead Ordinance

In December 2005, the Rochester City Council unanimously passed a new lead poisoning prevention ordinance that required regular inspections for lead paint hazards as part of the city’s certificate of occupancy process for most rental properties (Chapter 90, Property Code – Article III Lead-Based Paint Poisoning Prevention). The law took effect on July 1, 2006. Rochester also passed “three accompanying resolutions to the lead law prioritizing inspections in target areas (Resolution 2005-23); encouraging public education and establishing a citizen advisory group to inform implementation (Resolution 2005-24); and requesting that the city establish a voluntary program for owner occupants (Resolution 2005-25).”

While the goal was to inspect nearly all rental properties by 2010, Rochester made initial inspection efforts on properties at highest risk – the areas of highest concentration of EBL cases – its highest priority. The city worked with the Monroe County Department of Public Health to establish the designated areas of “high-risk” within the city.

Under the ordinance:

Most pre-1978 rental housing is subject to a visual inspection for deteriorating paint or bare soil at the time of a city housing inspection. Housing inspections may be triggered by a number of factors, including a new or renewed Certificate of Occupancy (C of O), a neighborhood survey, a referral by an outside agency, or a complaint. Some housing units are exempt (for instance, if an EPA-certified risk assessor certifies that the unit does not contain lead paint).
All deteriorated paint in pre-1978 housing units is assumed to contain lead unless testing, conducted at the owner’s expense, confirms otherwise.
Properties in “high risk” areas – as determined by past blood lead data – that pass the visual inspection (e.g., do not appear to have interior deteriorating paint) also undergo a dust wipe test to make sure that the home is safe.
Properties with deteriorated paint above U.S. Department of Housing and Urban Development (HUD)-required levels or bare soil within three feet of the house fail the visual inspection.
Lead-safe work practices must be used for all lead hazard control activities, and owners must follow the Renovation, Repair and Painting (RRP) rule.
Dust wipe tests (e.g., clearance tests) are required for properties after repairs have been completed.
To pass inspection, homes must be lead-safe but not necessarily lead-free.
Residents can request a free inspection by the city at any time.

In addition, ongoing monitoring is required—one- and two-family rentals are inspected every six years. Properties in a designated high-risk zone where a lead hazard is identified and the owner opts to use a temporary measure to control it, are inspected every three years, as are multiple dwellings and mixed use occupancies. The city maintains a public database of all residential properties where lead hazards have been identified, reduced, and controlled with federal HUD funds. The city also maintains online accessible databases of all lead safe units and all properties granted a C of O.

To receive a C of O, property owners must correct any identified lead hazard violations. Owners or workers trained in lead-safe work practices are allowed to complete repair work and use less expensive interim controls (e.g., components with paint hazards may be fixed and repainted rather than replaced or permanently encapsulated) to reduce compliance costs.

Results

To implement the ordinance, Rochester initially hired four new inspectors. Since then, due to budgetary constraints, the city consolidated all code enforcement staff and cross-trained building and housing inspectors to assess lead hazards.

According to a recent journal article, the lead law has had a positive impact on children’s health– possibly because nearly every unit was inspected in the first four years of implementation. In addition, the number of units that passed was higher than expected, likely signaling that landlords had made remediation a priority before inspections occurred. Notably, the article also states that the law does not appear to have significantly impacted the housing market in Rochester.

In the decade since the law passed, the City of Rochester Office of Inspection and Compliance Services has inspected 89,935 structures (exterior inspections) 86 percent of which had no lead violation. Of those with a violation, 88 percent were remediated by June 30, 2016. Of the 141,474 interior inspections conducted, 95 percent passed the initial visual inspection. Among those with an interior violation, 86 percent had complied with remediation. Ninety percent of the units subjected to dust wipe testing (over 30,000 units) passed. Also, during the same 10-year period, the city issued 651 vacate orders for situations with severe hazards and 2,715 tickets for noncompliance. In the first five years alone, all target units in high-risk areas were inspected.

Experts describe Rochester’s lead poisoning prevention laws as one of the “smartest” in the nation.

Since the city ordinance was implemented, the number and proportion of children with EBL has decreased countywide. In 2004, 900 children out of the 13,746 tested in Monroe County had blood lead levels above 10 µg/dL, while in 2015, 206 of the 14,283 tested had blood lead results above this level. Between 1997 and 2011, the number of children with blood lead over 10 µg/dL decreased roughly twice as fast in Monroe County as it did in New York State and nationwide.

Despite this significant progress, however, in 2015, 988 of the 14,233 children tested—enough to fill 40 kindergarten classrooms—had blood lead levels above the current CDC reference value of 5 µg/dL, indicating that more effort is needed in Rochester.

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

There is also a case study on New York State and another one on New York City.