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.
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
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
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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