Legislative Program Review and Investigations Committee

Residential Lead Abatement
Chapter I

Chapter I 
Overview

Introduction.  Lead is highly toxic and is considered a serious environmental health threat to children. The most common sources of lead poisoning exposure for children are lead-based paint that has deteriorated into paint chips and lead dust, and soil contaminated with lead. Lead dust settles quickly, is difficult to clean up, and can be invisible to the naked eye. Young children are often poisoned through normal hand-to-mouth activity after they get lead dust on their hands and toys.

The sale of lead-based paint for residential use was banned in 1978.  Less common sources of exposure include lead gasoline (which was banned in 1978), lead in household pipes, food cans (banned in the U.S. in 1995), imported ceramics and miniblinds, and some traditional folk remedies.  In addition, parents who work in certain high-risk occupations may bring lead dust into the home.  Lead serves no purpose in the human body.  Lead poisoning occurs because the body cannot distinguish between lead and calcium, which is a mineral that strengthens bones. When lead is absorbed into the body it remains in the bloodstream for several weeks before it is absorbed into the bones, where it can collect over a lifetime.  Exposure to lead hazards is especially dangerous for children under the age of six because their brains and nervous systems are still developing, and, therefore, are particularly sensitive to the effects of lead. 

Blood lead levels are used to measure the presence of lead in the body, and even low lead levels are associated with decreased intelligence, reduction in attention span, reading and learning disabilities, and behavioral problems.  At high BLLs, lead poisoning can cause seizures, coma, and death.  Elevated BLLs in pregnant women are also dangerous and are associated with an increased chance of illness during pregnancy as well as causing harm to the fetus.

CDC Guidance

Although the CDC does not mandate states screen children for lead poisoning, it issues guidelines, followed by most states including Connecticut, on lead screening and treatment.  As the adverse health effects of lead poisoning have become known, CDC has decreased the level of lead in blood it considers harmful. In 1985, CDC lowered the level for diagnosing childhood lead poisoning by 40 percent from 40 to 25 micrograms (mcg) of lead per deciliter (dL) of blood.  (A microgram is a millionth of a gram; a deciliter is about one-fifth of a pint.)  In 1991, CDC  moved away from a specific definition of lead-poisoning and substituted the term "level of concern" for blood lead levels equal to or greater than 10 mcg/dL.

CDC screening policy.  Current screening guidelines were published in November 1997 in a document called Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials.  The 1997 policy recognizes that lead exposure is highly variable across the country, with some children at high risk and others at very low risk. As a result, CDC recommends state and local health departments assess local data on lead risks and develop lead screening recommendations for health care providers in their jurisdictions, especially focusing on one- and two-year old children.  Depending on state and local risk data, in some places it is appropriate to universally screen all children at ages one and two, and screen all children from 36 to 72 months of age who have not been screened previously.  In other places, it is appropriate to screen only some children based on specific risk factors (targeted screening).

 The CDC’s document provides detailed guidance for state and local health departments in establishing their state lead screening plans, including advice on assessing lead risks, promoting the participation of affected constituents in developing recommendations, and communicating the screening recommendations clearly.  In its guidelines, the CDC recommends states focus on three groups because of their high risk for lead poisoning.  They are children:

·       living in geographic areas with a high concentration of old housing;

·       receiving public assistance under programs for the poor, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and

·       with other identified individual risk factors. 

However, if states do not have the necessary data needed to develop a statewide plan and target screening, CDC recommends states adopt a CDC-developed interim policy or continuation of its 1991 policy of universal yearly screening for all children ages six months to 72 months. 

Treatment policy.  The CDC’s guidelines recommend all screening results equal to or greater than 10 mcg/dL be confirmed with a diagnostic test (venous) and various actions be taken at specific elevated blood lead levels.  These guidelines are enumerated in Table I-1.  In general, confirmed BLLs of 10 to 19 mcg/dL require monitoring the child by further testing and providing family education on how to reduce ongoing lead exposure.  More aggressive measures, including a full medical evaluation and the need to have a complete environmental investigation (which may require abatement of lead hazards from the child’s residence and are discussed in Chapter Three), are recommended at BLLs of 20 mcg/dL and above.

National Statistics

Blood lead level trends.  The CDC’s National Health and Nutrition Examination surveys (NHANES), an ongoing series of national examinations of the health and nutritional status of the civilian noninstitutionalized population, have been the primary source for monitoring BLLs in the U.S. population.  These surveys have shown a marked decline in the prevalence of elevated BLLs in recent years, primarily attributed to the ban on lead in: paint; gasoline; food and drink cans; and plumbing systems in the United States during the 1970s.

Comparison of the data contained in the NHANES II survey performed between 1976–1980, and NHANES III (1991-1994), indicates the percentage of U.S. children less than age six with elevated BLLs dropped from 88.2 percent in the late 1970s to 4.4 percent in the early 1990s (see Figure I-1).   In addition, the overall mean BLL for children one to five years old decreased from 15.0 to 2.7 mcg/dL during this time period.

 Prevalence of lead poisoning in children.  Despite public health goals to reduce lead poisoning and accompanying declines in lead poisoning, in 1997 the CDC estimated 890,000 (4.4 percent) of U.S. children under the age of six still have BLLs equal to or greater than 10 mcg/dL.  Therefore, lead poisoning still remains a serious threat for many children.[1] Recent studies conducted by the U.S. General Accounting Office (GAO)[2] as well as results of the NHANES III survey have found children who are poor, non-Hispanic Black, and/or living in urban areas where older housing is deteriorated have a greater prevalence of lead poisoning.  A discussion of these factors and their link to lead poisoning is discussed below. 

Age factors.  Table I-2 shows the results of the NHANES III survey by age group. Children in the one and two year age group are those most at risk from lead poisoning, and the survey indicated almost 6 percent in that age group had BLLs equal to or greater than 10 mcg/dL.  This is somewhat higher than the prevalence in children overall, which is 4.4 percent.  In addition, among children age one to five years, 1.3 percent had BLLs greater than or equal to 15 mcg/dL, and only 0.4 percent had BLLs greater than or equal to 20 mcg/dL.   

Race/Ethnicity factors.  Information from NHANES III (shown in Table I-3) depicts a strong relationship between blood lead levels and race/ethnicity.   For example, the table shows the percent of Black children with elevated BLLs (11.2 percent) is almost five times greater than White children (2.3 percent). 

 Income factors.  Figure I-2 depicts the prevalence of children with elevated BLLs by family income (defined as the ratio of total family income to the poverty threshold for the year of the interview).  Although all children are at risk for lead poisoning, the NHANES III survey indicates the prevalence of elevated BLLs for low-income children is much greater than for high-income children.   Furthermore, the percent of children with elevated blood lead levels for middle-income children  (1.9 percent) was almost double the high-income children (1 percent).

  Children receiving federal health care programs.  A January 1999 study by GAO based on NHANES III survey data, found the prevalence of elevated BLLs for children enrolled in federal health care programs was 8.4 percent, nearly five times the rate for children not in these programs.  GAO analyzed the data by individual health programs for children ages one through five and found the prevalence of elevated BLLs for children receiving Medicaid was 8 percent and WIC was almost 12 percent.  In its report, GAO estimates 688,000 (77 percent) of the estimated 890,000 children who have elevated blood lead levels nationwide are enrolled in Medicaid or WIC, or are within the target population served by the Health Center Program (targeted to uninsured and low-income families).

Age of housing stock.  The age of housing stock is another important factor in determining risk for exposure to lead hazards.  Although the primary cause of lead poisoning in children is lead-based paint in pre-1978 housing, the mere presence of lead-based paint is not a hazard.  Rather, childhood exposure to lead usually occurs in two ways: deteriorated paint (and resulting dust) in poorly maintained housing, and repainting and remodeling projects that disturb leaded paint without appropriate safeguards to control, contain, and clean up lead dust.

All homes built prior to 1978 are considered to be potential sources of exposure to lead-based paint, however housing built before 1950 generally contains the highest amount of lead-based paint, since paint used at that time had a high lead content.  A 1990 report issued by the Department of Housing and Urban Development (HUD) estimated full removal of lead-based paint in U.S. housing stock would cost $500 billion.[3]

Table I-4 compares New England’s housing stock built before 1950 with the total housing units in each state as well as with the United States.  As shown in the table, New England has a much higher percent of older housing stock compared to the U.S. total.  Massachusetts has the greatest percentage of housing units built before 1950 (47 percent of total housing units), followed by Rhode Island (44 percent) and Maine (41 percent).  In Connecticut, 35 percent of the state’s total housing units were built prior to 1950.

Connecticut Statistics

Screening.  Blood lead screening of children is an important element in detecting lead poisoning since most children display no obvious symptoms.  The state Department of Public Health maintains a childhood Lead Surveillance System (LSS) as part of the Childhood Lead Poisoning Prevention Program.  The system contains information on children under the age of six who have been tested for lead poisoning.  However, there are several limitations to the database including:

·       mandated reporting of all lead screening tests was not required until October 1998, thus data on the total number of children screened prior to that date are incomplete;
·       the system does not distinguish between new lead poisoning cases and those carried over from a prior year;
·       CDC guidelines do not mandate every child be screened annually up to age six, therefore, lower screening rates for older children do not mean poor state performance;
·       data are maintained on a calendar year (CY) basis rather than for birth cohorts, and therefore calendar screening rates can be lower;
·       no information is collected on children’s health insurers or family income, therefore, comparisons to national data cannot be performed; and
·       although required by statute, race/ethnicity data are incomplete, therefore, incidence rates cannot be compared among various ethnic groups in Connecticut. 

Screening rates.  Given these caveats, Table I-5 shows screening rates for all children under the age of six as well as the percent of children age one and two screened in CY 1998.  Based on 1990 census data, there were 272,294 children less than six years old in Connecticut, of which 87,503 were age one or two.  Twenty percent of children under the age of six (54,850) had a valid screen for lead poisoning in 1998.  Furthermore, 30 percent of children age one and two statewide had a valid lead screen in CY 1998.  Children living in Hartford had the highest screening rate overall and those in Stamford the lowest.

The program review committee recognizes 1990 census data are not the most accurate population statistic to use in 1999, especially when measuring a segment of the population not even born in 1990.  However, 1990 census data are the population database DPH uses as its base to calculate the percent of children screened for lead poisoning in each calendar year.  The committee compared the 1990 population with 1998 population estimates and birth statistics statewide and calculated the number of children under the age of six in 1998 was approximately 263,000.  This is a decrease of about 3.5 percent since 1990 but certainly not a significant decline.  Further, the variation between the 1998 estimates and the 1990 census data for any of the individual towns cited did not exceed 5.5 percent in either direction. 

Pilot project.  The state Department of Public Health conducted a pilot project on lead screening rates in Hartford to determine if Medicaid recipients had received a blood lead screening in 1997 as required by Medicaid.  The study examined children born in Hartford in 1995 who were Hartford residents and recipients of Medicaid managed care during all of 1997.  The results show 73.5 percent of the children meeting the study criteria were screened in 1997.  The percent of children screened increased to 93.2 percent when the study criteria were broadened to include children in the study group who were screened at any time since birth.  In addition, the department tracked all Hartford residents born in 1995 and found 90 percent had been screened at least once for lead poisoning.  Similar pilots are being conducted in Bridgeport, Montville, New Haven, Norwich, and Waterbury.  Comparisons with national screening data however, could not be made because of the difference in methodology between this study and national surveys.

            Incidence of lead poisoning.  Table I-6 shows the number of children screened and identified statewide with an elevated blood lead level in 1998 and by the top five towns. (A complete listing for all towns is provided in Appendix B.)  Overall there were 54,850 children less than age six with a valid lead screen -- 4.6 percent had a BLL equal to or exceeding 10 mcg/dL and of those, 1.1 percent were equal to or greater than 20 mcg/dL.  Since CDC’s 1997 screening guidelines specifically recommend targeting children age one and two, incidence data for this age group are also shown in the table. In terms of one- and two-year-old children, there were 26,401 with a valid lead screen -- of those, 4.6 percent had BLLs equal to or greater than 10 mcg/dL and 1.2 percent equal to or greater than 20 mcg/dL. 

            Of the 2,522 screening results with BLLs 10 or greater, 598 (23 percent) had levels equal or greater than 20 mcg/dL – the level at which an epidemiological as well as an environmental inspection must occur under Connecticut’s lead law.  For one and two year olds, 1,220 had levels of 10 mcg/dL or greater and 26 percent of those children had an elevated level of 20 mcg/dL or greater. 

            As depicted in the table, Bridgeport had the greatest number of children with elevated blood lead levels, followed by New Haven, and Hartford.  These three cities, the largest in Connecticut, have the greatest number of children younger than six years old, high poverty rates, and a large portion of their housing stock was built prior to 1950. 

Connecticut’s housing stock.  As noted above, housing built prior to 1950 has the greatest likelihood of containing lead paint, and thus, children residing in those housing units are at a higher risk for lead poisoning.  Thirty-five percent of Connecticut’s housing stock was built prior to 1950 and 84 percent before 1980.  Table I-7 shows those Connecticut towns with the highest percentages of pre-1950 housing by county.

Housing condition is strongly related to the economic status of the people who live in it. Low-income households often cannot afford to adequately maintain and/or repair the units in which they live.  As a result, a large portion of Connecticut’s housing stock presents a potential hazard for lead-based paint poisoning, and the major portion of that stock is found in larger municipalities where low- and very low-income persons are most likely to reside.

In its Consolidated Plan for Housing and Community Development (January 3, 1995), the Department of Economic and Community Development estimated the number of Connecticut housing units at high risk of having lead paint hazards.  These estimates (shown in Table I-8) indicate 17.7 percent of CT’s total housing units present a potential lead-paint hazard to the families who live in them. 

As shown in the table, there are 980,164 total housing units in Connecticut, with low-income households occupying 306,191 units.  Furthermore, the department estimates 77 percent (235,748) of low-income housing units are potentially high risk for containing lead paint hazards.  Thus, a significant portion (24 percent) of Connecticut’s total housing stock presents a potential lead hazard risk.  It is important to note, however, the number of low-income units occupied by children who are at the greatest risk for lead poisoning, is not estimated by the department.

Summary

Although BLLs in the U.S. population have dramatically declined since the late 1970s, the risk for lead exposure remains disproportionately high for some groups.  As a result of the decline in prevalence, and survey data showing age, income level, race/ethnicity, and age of housing are key factors in determining children’s risk for lead poisoning, CDC revised its guidelines in 1997.  The guidelines recommend state health departments assess local data on lead risks and develop either universal or targeted screening recommendations based on the data.  In addition, CDC recommends screening policy be focused on one- and two-year old children, since this age group nationally proved to have the highest prevalence of elevated blood lead levels.

            Connecticut currently recommends, but does not mandate, all children between the ages of one and six be screened for lead poisoning, with particular focus on children ages one and two.  Connecticut’s policy of universal screening is based on the fact 35 percent of the state’s housing stock was built before 1950 and prevalence data needed to develop a more targeted screening guideline are not available.

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