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Statement on Lead Poisoning by Dr. Richard J. Jackson
Director, National Center for Environmental Health
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the Senate Health, Education, Labor, and Pensions Committee, Subcommittee on Public Health
Rhode Island Hospital George Auditorium
September 7, 1999


Thank you very much for allowing me the opportunity to speak to you on behalf of the Centers for Disease Control and Prevention's (CDC) Childhood Lead Poisoning Prevention Program. In 1991, the U.S. Department of Health and Human Services (DHHS) called for a society-wide effort to eliminate childhood lead poisoning in 20 years, and eight years later, we remain committed to this goal. The elimination of this preventable disease will be one of the major public health accomplishments of the next century. Steps taken this century have laid the foundation for success, although we still face significant challenges. I will describe the important accomplishments in this area and will discuss how these accomplishments are shaping our efforts for the future. I will then focus on the key lessons we have learned over the past decade of work in lead poisoning prevention. And finally, I would like to emphasize the importance of effective partnerships and collaboration to confront our challenges and bring about our vision of lead-free children.

It is clear that lead can do great harm, especially to young children. Lead exposure can have serious health effects, including a variety of neurologic and behavioral disturbances as well as delayed development. We have been successful in documenting that childhood lead poisoning is an important public health problem, affecting a significant number of children. The CDC's analysis of children's blood lead levels as part of the National Health and Nutrition Examination Survey (NHANES II) conducted between 1976 and 1980 revealed that 88% of American children between the ages of 1 and 5 had elevated blood lead levels ($10Fg/dL). Further, CDC analyses were instrumental in revealing that decreasing lead in gasoline resulted in parallel declines in blood lead levels. This information contributed to the subsequent U.S. Environmental Protection Agency (EPA) decision to remove lead from gasoline. This decision, along with the removal of lead from paint and other sources has resulted in a dramatic decline in the amount of lead in the blood of all Americans. According to CDC's NHANES data from 1991-1994, the proportion of children age 1-5 years with elevated blood lead levels had fallen to 4.4%.

Through this work, CDC has recognized that having good measures of the actual exposure of the American public to lead was going to be critical to achieving our goals. NHANES has allowed us to focus on identifying children who are at higher risk for lead poisoning. Children who have been found to be at higher risk include children from low income families and children who live in older deteriorated housing; many are minority children. CDC data also indicate that there are an estimated 890,000 American children under the age of 6 who have elevated blood lead levels.

I will now turn to the describing the activities of CDC's Childhood Lead Poisoning Prevention Program. This program was authorized under Section 317A of the Public Health Service Act as amended in 1988. The program was reauthorized in 1992 by the Senate Health, Education, Labor, and Pensions Committee under the Preventive Health Amendments Act, and in 1998, reauthorization was extended to 2002. The program received its first appropriation of $4 million in fiscal year 1990, and has grown to its current size of $38 million in fiscal year 1999. CDC currently provides funding to 56 states, cities and counties for childhood lead poisoning prevention and surveillance efforts, including the Rhode Island Childhood Lead Poisoning Prevention Program (RICLPPP), which has received funding since 1990.

CDC's grant programs support the development, implementation, and evaluation of state and local childhood lead poisoning prevention programs. In particular, these programs support: (1) screening of children who are potentially exposed to lead, environmental inspections of the homes of children who are identified with elevated blood lead levels, and referral to services for these children; (2) the collection of information about the number of children who have been identified as having elevated blood lead levels; (3) awareness and action among the general public and health care professionals to prevent childhood lead poisoning; and (4) primary prevention of childhood lead poisoning in high-risk areas in collaboration with other government and community-based organizations.

CDC grants also support the development of a national Childhood Blood Lead Surveillance System by building the capacity of state health departments to conduct surveillance of elevated blood lead levels in young children. More than 40 states, including Rhode Island, now participate in this effort, which will assist states and communities in using data to help focus their efforts in areas of greatest need.

CDC's activities in these areas have evolved over time, and one of the lessons that we have learned is that in order to meet our goal, we must pay attention to changes in our environment and adopt new approaches. The public health and health care delivery systems are changing, and this requires us to change as well. Many more children are enrolled in managed care programs, through both private and federal insurance programs. State and local health departments are moving away from conducting screening and follow-up services themselves. Instead, health departments must now facilitate and ensure screening and follow-up by managed care organizations, network with private providers, establish data management and tracking systems, identify high-risk areas and high-risk children, and evaluate policies and program performance based on established goals and objectives.

These trends, coupled with the changes in the distribution of childhood lead poisoning in the population, are causing us to think about new approaches to this public health problem. In November 1997, CDC issued new guidance on screening young children for lead poisoning that takes into account the new environment in which our programs are operating. While the original 1991 plan called for screening all children, CDC data indicated that only about 10-20% of all young children were being screened. Even more troubling was the fact that less than 20% of poor children were being screened, even though they are at higher risk for lead poisoning. However, the facts are more encouraging here in Rhode Island. A 1997 cohort study indicated that 65% of the state=s newborn children have had a lead screening by 18 months of age. And even more encouraging is that among high-risk children, 73% are screened by 18 months of age.

The development of statewide plans for childhood lead poisoning screening form the core of CDC's new guidance, which describes a comprehensive approach to childhood lead poisoning prevention. The purpose of the plans is to increase screening and follow-up care for children who most need these services, and to ensure that screening is appropriate for local conditions. Statewide screening plans are now being developed by newly organized state advisory Committees - like the Lead Screening Workgroup formed in Rhode Island in June 1998 - that include health care providers, representatives from local health departments, managed care organizations, Medicaid Administrators, private insurance organizations, advocates and community members. These plans take into account that in some areas, the level of risk for lead exposure may not justify the screening of all children. In other areas, increased screening will be necessary based on risk of lead exposure. The issuance of this new guidance represented an important milestone in the intensification of our efforts to eliminate childhood lead poisoning by the year 2010. To date, about 80% of CDC=s state-level grantees have formed advisory Committees as the first step in their statewide planning process to ensure that high-risk children are screened for lead exposure.

However, we continue to face challenges in attaining this goal. A recent report by the U.S. General Accounting Office (GAO) underscores the fact that many children at risk for lead exposure are not being screened. CDC recognizes this challenge, and the new screening guidance addresses the issue of reaching children enrolled in Medicaid and other health care subsidy programs.

The Rhode Island Childhood Lead Poisoning Prevention Program (RICLPPP), a CDC grantee, has been successful at beginning to incorporate Medicaid Managed Care as a stakeholder in the solution to this public health problem. For example, a Lead Center was developed in October 1998 and was designed specifically for children referred for lead-related medical and environmental case management.

Just as we have emphasized the importance of collaborative activities at the state and local level to develop a successful statewide screening plan, we have redoubled our efforts to collaborate with other Federal agencies to make the goal of eliminating childhood lead poisoning a reality. Since 1990, there has been a Federal partnership to focus our efforts toward this goal, with DHHS, EPA, and U.S. Department of Housing and Urban Development (HUD) taking leadership roles. The EPA and HUD focus on primary prevention by using their regulatory powers to reduce lead in homes, the workplace, schools and the outdoor environment. In addition, EPA and HUD also distribute grants to state and local governments for prevention activities. EPA focuses on certification and accreditation of contractors, setting standards for lead in paint, soil, and dust, and mandating disclosure of lead risks to home buyers and renters.

HUD provides funding to develop and implement cost-effective methods for the inspection and reduction of lead-based paint hazards in pre-1978 owner-occupied and rental housing for low-income families. HUD estimates that with funding provided since 1993, at least 50 thousand privately-owned low-income housing units have been abated. Additionally, tens of thousands of public housing units have been abated. HUD has funded the education of hundreds of thousands of families concerning steps that parents can take to prevent childhood lead poisoning. HUD also leverages its impact by mandating inspections and lead-safe rehabilitation of HUD-funded housing.

CDC and its grantees work very closely with HUD and HUD=s grantees to ensure the prevention of childhood lead poisoning. The close coordination maximizes the resources of each organization without a duplication of services. Each grant program draws upon its unique expertise and service delivery networks. CDC grantees have expertise in technical issues related to screening and blood lead testing, as well as programmatic expertise in following up on the needs of high-risk children. HUD grantees have expertise in lead-based paint and lead dust hazard identification and in the physical interventions needed to make homes lead-safe.

HUD grantees concentrate their primary prevention activities in neighborhoods where children are at risk for lead poisoning. Data from CDC and its grantees are essential for HUD grantees to appropriately target their primary prevention efforts. Furthermore, HUD grantees work closely with CDC grantees to reduce lead hazards in housing where children are identified as lead-poisoned. This serves the goal of secondary prevention, as well as the goal of preventing additional children from being lead-poisoned. Together, CDC and HUD can identify and intervene with both at-risk children and at-risk home environments, moving us closer to eliminating childhood lead poisoning by 2010.

CDC is also participating in a DHHS lead poisoning prevention initiative along with HCFA, the Health Resources and Services Administration (HRSA), the Administration for Children and Families (ACF), and other DHHS agencies. This initiative is designed to improve collaboration among DHHS programs involved in activities related to childhood lead poisoning prevention. In support of this effort, CDC, HCFA, and HRSA recently developed and disseminated a model data-sharing agreement between state Medicaid agencies and health departments.

In closing, I would like to emphasize that we will continue to face challenges in the elimination of childhood lead poisoning prevention, but CDC and our partners in this effort have learned many lessons over the past decade that have prepared us well. In any public effort such as this, one of the biggest challenges we face is to keep resources focused on the problem as it becomes smaller. It is important to remember that no child should be lead-poisoned. The improvement in quality of life for the children freed from the threat of damage caused by environmental lead cannot be overstated. Our children, the most important resource for the future, deserve nothing less. We have come a long way in making children lead-free, and I appreciate your time and interest in continuing to make this vision a reality.


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