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

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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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.

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.

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.

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

“We started asking about lead, and what is the safe level of lead, and there isn’t one, especially for kids. So we said the prudent thing to do is to improve the testing and start getting these lead pipes out. Get the lead out.”

Virgil Bernero, Mayor of Lansing

Background

In 2004, then-Michigan State Senator Virg Bernero encouraged local officials to work with Lansing Board of Water and Light (BWL) Commissioners to speed up the removal of lead service lines (LSLs). The BWL, a municipally-owned utility, funded the program as an infrastructure investment, and utility customers shared the cost through an increase in their water rates. BWL gave priority to lines serving schools and licensed day care facilities, areas where children had elevated blood lead levels, households with pregnant women or children under age 6, and other places with high concentrations of LSLs.

From 2004 to 2016, Lansing, Michigan, replaced 12,150 LSLs with copper lines, becoming only the second city in the country to remove all its active lead service lines. The total cost was $44.5 million.

Lead Service Line Replacement

BWL has developed a faster, more efficient way to replace pipes; what had been a nearly 8-hour job, $9,000 job requiring a trench to be dug from the main in the street to the foundation of the house, has been streamlined to 4 hours at a cost of $3,600. Instead of trenching, BWL now digs a hole in the street and another where the shut-off valve is, pulls the old pipe out from underground and slides in the new one.

Additionally, where possible, the lead service line replacement program has followed planned street, sewer, and other infrastructure improvement projects to minimize street closures and reduce the cost of street reconstruction.

Service line replacements were scheduled to prioritize replacing any lead service lines serving schools and licensed day care centers, areas having children with elevated blood lead levels, households with pregnant women or children under age six, and other areas with large concentrations of lead service lines.

The lead service line replacement program engages customers through outreach (distribution of brochures and articles in bills, open houses at schools and community centers, and information inserted in routine water quality reports).

BWL water quality reports indicate a decrease in lead levels in the water over 10 years, from 2005 to 2015, with 90 percent of homes at or below 7.8 parts per billion in 2015 (down from 11.3 parts per billion in 2005). Although the BWL completed its lead service line replacement program, it will continue its corrosion control process.

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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.

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

Background

Lead is a significant environmental health hazard to children in Omaha, home to the nation’s largest residential U.S. Environmental Protection Agency (EPA) Superfund site– a program that provides resources to address lead contamination in soil caused by an old refinery. In 1998, after it was revealed that nearly 10 percent of the children tested in Douglas County had blood lead levels higher than 10 µg/dL, the Omaha City Council requested assistance from the EPA. In 2003, Omaha was added to the Superfund National Priorities List, with approximately 14 square miles of residential property in East Omaha considered at high risk.

Superfund

In 1998, when the Omaha City Council requested EPA assistance to address the high frequency of children in eastern Omaha found by the Douglas County Health Department to have elevated blood lead levels, the EPA began investigating the lead contamination in the Omaha areas under the authority of the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), also known as the Superfund law.

After blood tests revealed elevated lead levels in nearly 600 children, the EPA formed the Omaha Lead Superfund Site in 1999, which has become the largest residential lead remediation in the country. Cleanup of residential properties included testing a wide array of soil in places like child care facilities, schools, playgrounds, parks, and homes; removal and replacement of contaminated soil; and planting new sod and grass seed.

The Douglas County Health Department Childhood Lead Poisoning Prevention Program offers free inspections to families in Douglas County living in pre-1978 housing where children under seven-years-old live and play. Families with children who have been found to have elevated blood lead levels are given top priority. They also administer an EPA-funded interior dust program where residents who have had their soil remediated can receive education and a free HEPA vacuum.

EPA’s work is ending after it completed testing soil samples from 40,000 properties and cleaned up more than 12,000 properties that were contaminated with lead; however, the work of lead remediation will continue in partnership with the city. In May 2015, the EPA awarded $40 million to the City of Omaha through a cooperative agreement to address the final phases of the work, including ongoing attempts to collect soil samples and clean up the remaining properties. The rationale is that the owners of remaining properties will feel more at ease working with the city than with the federal government.

Updated Nuisance Ordinance

In December 2010, the Omaha City Council amended the “nuisance” chapter of the Omaha Municipal Code, adding lead-based paint to the list of specific examples of situations declared to be nuisances. Under the revised law, lead-based paint or other lead-based coating materials (such as liquid coatings on furniture) is a hazard and a “nuisance” on the interior or exterior of a home when it is accessible, or may become accessible, to ingestion or inhalation.

Once notified of a lead-based paint “nuisance,” a designated city officer and/or health director of the health department gives written “notice to abate” to the property owner and/or occupant or to the person causing the nuisance. If the person ordered to remove the hazard neither requests a hearing nor abates it within the specified time, the city will take care of it and bill the responsible party. In addition, that person may be fined up to $500 and/or imprisoned for up to six months for each day the nuisance remains.

Lead Hazard Control Program

A HUD-funded initiative, the City of Omaha Lead Hazard Control program, repairs interior lead-based paint hazards, including window and door replacement and paint stabilization, in homes occupied by children under age 7 within the boundaries of the Superfund site. The Omaha Healthy Kids Alliance (OHKA) works in tandem with this program to address additional environmental hazards and structural concerns, to provide education and referrals, and to monitor the program’s impact on health and track data.

OHKA is a nonprofit children’s environmental health organization working to improve children’s health through their Healthy Homes initiative. OHKA evaluates residences for health, safety, and environmental risks, works with families to create individual plans for a healthy home environment, and advocates for policies and best practices that promote health and protect children. It assists clients by delivering supplies, repairing houses, and referring them to community partners.

Grassroots Latino Environmental Education Program

OHKA partnered with the University of Nebraska Medical Center’s College of Public Health, Omaha community-based organizations, and the EPA in 2014 to launch the Grassroots Latino Environmental Education (GLEE) program. GLEE’s goal is to make information about environmental hazards more easily available in Spanish. Understanding that promotoras – community health workers – are effective at disseminating information to the Latino population, it was important to teach them about the connections between a person’s personal health and the environment in which they live. Through GLEE, OHKA trained more than 40 promotoras who educated over 1,000 Spanish-speaking Omaha residents in two years.

Lead Education Action Program

In 2016, OHKA received 6 years of funding from the EPA and the City of Omaha for the Lead Education Action Program (LEAP). The goal of the $5.4 million LEAP program is to support the City’s efforts to take over the Superfund cleanup activities, to educate the community about lead and healthy homes, and to direct residents to use the Omaha Lead Registry website, which is kept up-to-date with new information provided by government agencies, community groups, and private citizens.

One LEAP’s key initiatives is the Lead Free in Five campaign. Launched in October of 2016, with a convening of over 100 community leaders, the campaign aims to address childhood lead poisoning in Omaha through a community-wide strategy of policies, education, and infrastructure.
Results

In 2012, the Douglas County Health Department reported 119 children had tested positive for elevated blood lead levels, compared to 451 children in 1998. Not only were more children tested (17,294) in 2012 than had been previously but only 0.5 percent of the children showed blood lead levels higher than 9.5 µg/dL, a marked decrease from 13 percent in 1998. As of June 2013, fewer than two percent of eastern Omaha children tested showed elevated lead levels, compared to 33 percent before the Superfund cleanup.

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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.

New York State’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

Although rates of childhood lead poisoning in New York have steadily declined since 1998, childhood lead poisoning remains a significant public health problem, where rates outside of New York City remain above national averages. New York State also consistently ranks high on key risk factors associated with lead poisoning, including many young children living in poverty, a large immigrant population, and an older, deteriorated housing stock.

Since 1993, New York State’s lead poisoning regulations have included a Notice and Demand (N&D) component that requires property owners to address lead hazards to prevent exposure. After inspecting a unit for lead-based paint hazards (including deteriorated lead paint and contaminated dust and bare soil), the local health department can issue a written N&D, which outlines the lead-based hazards present and requires owners to submit a corrective work plan within a fixed number of days. The Commissioner of Health or a designated representative determines the location and methods of controlling the hazards. Property owners are responsible for complying with federal, state, and local laws governing building construction, housing, worker health and safety, and disposal of lead-containing wastes and must provide documentation showing their compliance upon request. Individuals who fail to remedy issues within the specified time frame may face fines or prosecution.

Primary Prevention Program

The state-funded New York State Childhood Lead Poisoning Primary Prevention Program (NYS CLPPPP) was established in 2007 (under New York State Public Health Law1370-a [3]) to combat New York’s high rates of childhood lead poisoning through primary, rather than secondary, prevention methods.

Unlike most other existing lead programs, the NYS CLPPPP takes action to reduce lead hazards in housing units before a child’s blood lead-level exceeds federal standards. Under the program, local health departments receive funds to find and correct lead hazards in homes where children could be at risk. The New York State Department of Health (NYSDOH) is responsible for:

Coordinating with local health departments to implement the NYS CLPPPP and identifying housing at greatest risk of lead-based paint hazards;
developing partnerships and engaging with communities to promote primary prevention;
Promoting interventions to create lead-safe housing units;
Building workforce capacity to implement lead-safe work practices; and
Identifying community resources for lead-hazard control.

The New York State Department of Health uses surveillance data to find communities in the state with a high burden of childhood lead poisoning, then provides grants to local health departments in these communities to implement approved primary prevention programs.

Grantees are required to establish a housing inspection program that prioritizes units for inspections, corrects identified hazards using lead-safe work practices, and provides appropriate oversight of remediation work and clearance by certified inspectors. Grantees are also required to perform additional primary and secondary prevention actions beyond applicable Notice & Demand requests. If a child under the age of six in an inspected unit has not received required blood lead tests, the grantee is required to refer them to a primary care provider or local health department lead prevention program for follow-up. Grantees must also collect and report data to the NYSDOH to aid in continued program evaluation.

Although the NYS CLPPPP does not provide funding to property owners for repairing identified hazards, grantees coordinate available financial and technical resources to assist property owners with remediation and must also develop and implement lead-safe work practices training for property owners, contractors and residents. Previous NYS CLPPPP evaluation reports have identified this lack of funding for required repairs as a primary barrier to timely remediation in N&D cases, making this grantee task essential to the overall success of the program.

Lastly, grantees are required to develop formal partnerships and agreements with other county and municipal agencies/programs—possibly including code enforcement offices, local housing agencies, HUD Lead Hazard Control grantees, weatherization programs, and community groups. As a result, nearly one-third of all inspections in 2015 were conducted by staff of a code enforcement agency, not local health department officials.

Results

In the first eight years of the program, grantees visited and inspected the interiors of 37,731 homes, impacting over 23,000 children, and have cleared 75 percent of the units found to have at least one confirmed or potential interior lead hazard (roughly a third of the units inspected).

Over this same time frame, the state has invested $52.76 million in the program, equating to roughly $4,800 for each of the 11,020 children living in homes with confirmed or potential lead hazards (not including the homes into which other children will move in the future).

From 2007 to 2015, the percentage of children tested with confirmed blood lead levels (BLLs) greater than 10 µg/dL in New York dropped from 0.99 percent to 0.47 percent. Rates have dropped among both children tested in New York City and Upstate New York; however, the rates of children tested with confirmed elevated BLLs remains over three times higher in Upstate New York compared to New York City (0.91 percent versus 0.29 percent). Overall, rates dropped from 1.45 percent to 0.91 percent from 2007 to 2015 in Upstate New York and 0.68 percent to 0.29 percent in New York City.

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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.

Access a story on New York City’s efforts here.

Access a story on Rochester’s efforts here.

New Orleans’ Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In New Orleans, Louisiana, more than 90 percent of housing structures were built prior to 1978 – the year lead was decreased in residential paint – making city residents vulnerable to lead-based paint hazards. In addition to deteriorating paint and the lead contaminated dust it generates, the lead dust from the use of leaded gasoline contributed significantly to elevated soil lead levels.

While leaded gasoline was phased out in the 1970s through the 1990s, the lead dust remains in soil, particularly within transit-heavy areas of the city. Researchers estimate that vehicles deposited more than 10,000 metric tons of lead dust in New Orleans soil between 1950 and 1985. In 2004, more than 40 percent of New Orleans soils exceeded the EPA’s cleanup standard for play areas.

Lead in soil can disproportionally impact children because they are more like to inhale and ingest dust and dirt.

Hurricanes Katrina and Rita

In August, 2005, storm surges from the Hurricanes flooded 80 percent of the homes of New Orleans and deposited massive quantities of low lead sediments into the city. The sediments created a natural barrier on top of the pre-existing high-lead soil establishing a cleaner, less hazardous landscape. This, combined with citywide cleanup and remediation efforts, reduced lead dust in homes and surrounding soil. Lead assessments conducted in Katrina’s immediate aftermath found a 46 percent reduction in median soil lead levels. And the declines continued. Before the storm, 15 of the city’s 46 census tract neighborhoods exceeded the EPA’s regulatory soil lead standards; by 2010, only 6 neighborhoods exceeded standards.

At the same time, there was a decrease in children’s BLL. Prior to the Hurricanes, 50 percent of New Orleans’s children had BLL’s equal or greater that the federal reference value of 5 µg/dL. Ten years after the Hurricanes, about 5 percent of the children’s BLL exceed that exposure value.

Lead-Safe Soil Emplacement Interventions

Inspired by the city’s unique natural experiment, researchers used a similar approach to clean up soil at 10 childcare centers in New Orleans, covering lead-contaminated surface soils with a water-permeable barrier and 6-inch layer of low-lead soil. Since 2005, nine of the 10 federal public housing projects were rebuilt using this process—landscaped with low lead soil to raise the elevation of the housing. This intervention was expanded to all New Orleans’s childcare center play areas and public playgrounds that tested high for lead.

Challenges Remain

These efforts, combined with the potential reduction of lead from fresh topsoil deposited by the storm surge during Hurricane Katrina, led to a decrease in the percentage of children with elevated BLLs in high-lead communities (mainly inner city) from 64 percent in 2005 to 19 percent by 2015. In short, household restoration and cleaning reduced lead-based paint hazards and washed-in sediments reduced soil lead. The remaining challenge is to reduce exposure in high lead communities by conducting more “soil emplacement interventions and continuing lead paint hazard reduction strategies.”

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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.