Good afternoon. I am Dr. Richard Jackson, Director of the National Center for Environmental Health (NCEH), of the Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. I would like to thank Senator Reed and the Senate Banking Subcommittee on Housing and Transportation for inviting me here today. It has been an honor for me to take part in the collaboration between CDC, CMS, HUD, EPA and DOJ that has formed around this effort. I am pleased to be here to discuss CDC's 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 eleven years later, we remain committed to this goal. The elimination of this preventable disease will be one of the major public health accomplishments of this century.
It is clear that lead can do great harm, especially to young children. A child's exposure to lead can produce serious health consequences, including a variety of neurologic and behavioral disturbances as well as delayed development. Over the past 25 years, we have been successful in reducing our children's blood lead levels nationwide. 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 (EBLL) (10g/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 from 88% 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 who live in older deteriorated housing; many are minority children. CDC data also indicate that there are currently an estimated 890,000 American children under the age of 6 who have elevated blood lead levels.
I will now turn to 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 as part of the Preventive Health Amendments Act, and in 1998, reauthorization was extended to 2002. The program received its first appropriation in 1990, and is currently funded at $41 million for fiscal year 2002. With these funds, CDC provides guidance, technical support and resources to 43 states and 17 local health departments for childhood lead poisoning prevention and surveillance efforts. These CDC supported programs include three main components which I will describe in detail, in addition to other elements. The main components are: (1) Primary Prevention; (2) Effective Screening and Surveillance; and (3) Public and Professional Health Education and Communication.
Primary Prevention CDC supports innovative approaches to identifying children at risk for lead exposure and ensuring their housing is lead-safe before they are exposed to lead. In addition, CDC supports the development, improvement, and oversight of policies and strategies to bring about primary prevention within all funded programs. For example, Maryland law mandates a paint maintenance standard-of-care for all rental units built before 1950, with third-party inspection prior to each rental turnover. Over half of the Maryland's 159,000 pre-1950 rental units have registered with the Maryland Lead Rental Registry. Over 75,000 third-party inspections to certify that pre-1950 rental units meet the lead standard-of-care have been conducted and reported to the state. Tenants can now call to check if a property has been registered and inspected before they rent. Through its cooperative agreement with Maryland, CDC provides expertise and funding to assist the state with this innovative approach.
Effective Screening CDC provides national guidance for the prevention of childhood lead poisoning, including Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. This document provides general guidelines about the roles and responsibilities of child health-care providers in preventing childhood lead poisoning, screening and follow-up testing, clinical management, chelation therapy, and family education about EBLLs. For example, as recommended by CDC guidance, North Carolina has a statewide screening plan that targets 1- and 2-year-olds and other high-risk populations, especially Medicaid and Women, Infants and Children (WIC) program recipients. Since the targeted screening plan was adopted in October 1998, the annual screening rate among all 1- and 2-year-olds in the state has increased from 25% (53,390 tested in 1998) to 35% (81,988 tested in 2001). Essential to this effort have been promotional efforts by the state Medicaid agency and a statewide WIC screening initiative targeting children who have never been tested.
However, a U.S. General Accounting Office (GAO) report from February 1998 entitled, "Medicaid: Elevated Blood Lead Levels in Children,"suggests that many states are not screening children at risk for lead exposure. CDC recognizes this challenge, and the new screening guidance addresses the issue of reaching children enrolled in Medicaid and other health care programs.
One way CDC is addressing this issue is by providing technical assistance to funded states for developing and enhancing the states' Childhood Blood Lead Surveillance (CBLS) system. The inclusion of state data in CDC's CBLS database provides a national picture of childhood blood lead levels. Establishing childhood lead surveillance systems at the state levels allows the use of surveillance data to estimate the extent of EBLLs among children, assess the follow-up of these children, and help allocate resources for lead poisoning prevention activities within each specific state. Minnesota Department of Health (MDH), for example, maintains an extensive blood lead surveillance system for monitoring trends in blood lead testing and BLLs in children. MDH matches lead surveillance data with Medicaid data to analyze screening trends and determine the percentage of Medicaid children screened with EBLLs. Through this analysis, MDH has been able to determine that in Minnesota 72% of children with EBLLs were enrolled in Medicaid. In addition, Medicaid-enrolled kids had nearly twice the rate of EBLLs than kids not enrolled in Medicaid (9.8% vs. 5.0%).
CDC provides screening and case management guidelines to all CDC funded programs. Working in conjunction with CDC, all funded programs develop, implement, and evaluate their activities to assure that children receive the best care possible. For example, Rhode Island uses the KIDSNET system, an automated tracking and follow- up tool, that links pediatric public health programs to each other and to health care providers. KIDSNET provides contextual information about the number of children who should be screened to determine screening rates and provides data which enables the state to evaluate the quality of screening and follow-up at the provider level.
Public and Professional Health Education and Health Communication CDC conveys the negative health effects of elevated blood lead levels to a child and the importance of screening through public outreach and professional education. CDC supports and provides oversight to funded programs to target
audiences such as parents, doctors, nurses, public health professionals, and rental property owners. Information is dispersed through TV and radio announcements, educational pamphlets, training courses, and policy briefings. Salt Lake Valley (UT) Health Department's Lead Free Kids program has identified realtors and landlords as a target audience. The goals of the project include providing unaware landlords and realtors with information on disclosure regulation requirements and raising tenant awareness of lead-based paint hazards. Some of the outreach components include direct mailing of a lead disclosure brochure to area realtors, pre-1978 multi-family property owners and members of the Utah Apartment Association (UAA), and submitting articles in the realtor and apartment owners' trade journals.
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. In 2001, CDC developed the High-Intensity Targeted Screening (HITS) approach for improving the nation's ability to target and screen children for lead poisoning and prevent exposure to lead. The goals of HITS are to identify children missed by routine screening; improve surveillance and estimate the burden of lead poisoning in a specific locale; evaluate current screening plans; develop partnerships; and increase local capacity. HITS teams, which are made up of staffers from local childhood lead poisoning prevention programs and community members, assisted by CDC, visit homes in high-risk communities to screen children for lead. When children are found to have EBLLs, the families are offered appropriate medical treatment and a home lead evaluation. Local programs will use HITS data to improve lead screening plans, better direct resources, increase technical capacity, and monitor progress toward lead poisoning elimination. The HITS approach requires partnerships to be developed between community members and multiple federal, state, and local agencies, resulting in a more comprehensive approach to eliminating childhood lead poisoning at the local level.
In November 2001, the first HITS project in two inner-city communities in Chicago was completed. Preliminary analyses indicate that 67% of the children had never been previously tested, and approximately 30% of the children who were tested had EBLLs. Data analysis is ongoing. CDC plans to implement HITS in additional communities over the next several years in order to improve the nation's ability to target and screen children for lead poisoning and prevent exposure to lead.
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 (particularly CMS), EPA, and U.S. Department of Housing and Urban Development (HUD) taking leadership roles.
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 duplicating 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. CDC also funds 35 states to track the problem of adult lead exposure through the Adult Blood Lead Epidemiology and Surveillance (ABLES) program. This program helps prevent lead exposures in children whose parents are exposed to lead at work and who may inadvertently bring contaminated clothing into the home. 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.
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 and attention focused on a problem over time. It is important to remember that no child in this country should be adversely impacted by environmental exposure to lead. The improvement in quality of life for the children freed from the threat of possible damage caused by exposure to lead cannot be overstated. Our children, the most important resource for the future, deserve our every effort. We have come a long way in making children lead-free, and I appreciate your interest and support in continuing to make this vision a reality.
That concludes my written statement. At this time, I would be happy to answer your questions.
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