Epidemiological study of childhood incidence of elevated lead levels in Crawford CountyProject OverviewThis project is designed to identify the incidence of elevated lead levels (BLL) in children in northwestern Pennsylvania, and to hire a Community Lead Liaison at a regional service agency to coordinate training of social service providers, educators and community leaders about preventive efforts to reduce exposure to lead. The results of this project can be extended to other rural low-income regions from Appalachia to the Northeast. The CDC recommends that all children be screened for lead at one and two years of age, yet economic realities often force states to make difficult decisions. Urban areas have long been targeted for screening and preventive efforts due to the concentration of at-risk children. Pennsylvania has focused funds for screening and prevention on high-density urban areas through 11 Urban Lead Initiatives. However, children in rural regions, also at-risk due to housing age and socio-economics, have not received the same efforts. In Crawford County, fewer than 1% of children (n=223) had screening results reported to PA DOH, compared to 35% of children screened in one Urban Lead Initiative region (US Census 2000, Rudich 2004). Consequently, accurate incidence data on lead poisoning are not available for rural regions. Rural exposure to lead has been identified as a top environmental concern by The Center for Rural Pennsylvania (CRP 2003), and the Environmental Health Working Group of the Pennsylvania Consortium of Interdisciplinary Environmental Programs considers rural lead exposure a top issue of concern (PCIEP 2004). This project will determine the incidence of elevated BLLs in children in rural Crawford County, Pennsylvania, and provide community outreach efforts to train regional social service agencies and targeted community members about strategies to reduce lead exposure. To meet the first objective, a prospective epidemiology study of children under two years from a regional pediatrics practice will be conducted. All qualifying patients will be advised to be screened for lead, and nutritional analyses and BLLs will be correlated with descriptive assessments on potential exposure for all patients. This study will make every effort to track patients lost to follow-up initially through phone contacts, and subsequently through visiting nurses who can draw blood in the home for lead screening. While this pediatrics practice serves 75% of Crawford County’s children (4,082 patients under age six), to ensure that the study is demographically representative, we will evaluate all enrolled participants during the first two quarters to ascertain if all socio-economic strata are represented. If not, partner agencies will help to enroll additional children. We will provide all participants found to have elevated BLLs with information about treatment for insured and uninsured patients and personalized discussions on household management strategies to reduce lead exposure. A comprehensive educational effort, comprised of service agencies, housing agencies and community leaders, will collaborate to distribute educational materials and to publicize the information in the region. A dedicated ½ FTE Community Lead Liaison (CLL) will be trained as an EPA-certified Lead Risk Assessor. While the CLL will not conduct in-home assessments, s/he will train agency workers and educators in strategies to prevent lead exposure during client interactions and in non-traditional settings, such as tenant meetings and maternity classes. The use of bottom-up avenues to disseminate information about childhood lead risk and prevention efforts is critical in rural regions, since state and regional agencies devote their resources to urban areas. Problem Statement: Lead exposure in rural low-income communities has been poorly documented, and few resources have been made available for prevention, in part because within any state, focusing on urban regions reaches more children more efficiently. Moreover, 13.8% of all children under 18 are living below poverty in rural regions (US Census 2000). While this figure is lower than for urban children, it still represents more than 15 million children. In sparsely populated rural regions, children are spread out across county and state boundaries, resulting in lower political incentive to address even this widespread issue. Children are at high risk from lead because their neurological systems are still developing, they engage in high-risk behavior, such as placing their hands in their mouths, and they absorb lead via the gastro-intestinal track more efficiently (50% relative absorption) than adults (15%) (Xintaras 1992). Risks are exacerbated for impoverished children as nutritional deficiencies increase the absorption and toxicity of lead (Bloch 2000, Eu 2001). Annual costs of treatment and parental time off work for lead poisoning in children have been estimated at $43 billion nationwide (Landrigan et al., 2002), excluding possible long-term decreased earning potential in affected children. Efforts to identify the incidence of lead poisoning and develop risk reduction strategies are vital to protect the health of children in rural low-income communities. Crawford County (pop. 90,366) is located 66.5 km south of Erie and 170 km north of Pittsburgh in rural northwestern Pennsylvania. Key indicators of lead poisoning—housing age, population in poverty, and tenant-occupied housing—suggest that this region is likely to have a high percent of children with elevated BLLs. More than 80% of county homes were built before 1978, and 24.5% of county housing is tenant-occupied (US Census 2000). Approximately 5.9% of the population is under age five (n=5,366), and of those families with young children, 18.7% are at or below the federal poverty level, with a median annual household income of $33,650 (US Census 2000). More than 20% of pregnant women in the county receive no prenatal care (PA DOH 2003). Other factors, such as parent’s occupational exposure to lead, place additional children at risk (McDiarmid and Weaver 1993, Roscoe et al. 1999). A study to assess lead content of the homes and yards of 60 low-income families in Crawford County is underway (Waggett 2004). Preliminary results of soil analyses have shown that more than 50% of all yard samples have elevated lead levels (>100 ppm), and 10% are highly elevated (>500ppm). More than 60% of yards tested had at least one of five samples with elevated lead. Dust samples have not been analyzed. While assessments are not complete, the presence of lead in soils reveals at least one possible lead exposure source. Individually, these indicators suggest the presence of lead in the built environment; collectively, they suggest that many children may be at elevated risk (Francek et al. 1994). Identification of the incidence of lead poisoning in children is critical to assess how many and which children are at risk so targeted prevention measures can be implemented. Crawford County is similar to hundreds of rural counties throughout the Northeast and Appalachia with failing industrial bases and aging housing. Effective prevention methods that can be transferred to these communities are urgently needed. Specific Goals and Objectives: This project is designed to: (1) increase the percent of children screened from a regional pediatrics practice; (2) determine the incidence of elevated BLLs in children under age six in rural northwestern Pennsylvania; (3) establish a regional CLL position through a community social service organization; (4) train social service agency staff in prevention techniques that can be taught to clients to reduce childhood lead exposure, including nutritional training, household management techniques, childhood behaviors that might indicate concern, and resources available; and (5) disseminate information about this effort through social-service channels to other communities throughout Appalachia and the Northeast. CollaboratorsCaryl Waggett, PhD, Principal Investigator, is an Assistant Professor of Environmental Science at Allegheny College and Director of the Environmental Health Initiative. She has extensive training in epidemiology and ecology of public health concerns. She was awarded a Shanbrom Family Foundation pilot study grant in 2004 to examine lead content in dust and soils of low-income homes in Crawford County. For the epidemiological studies, she will collaborate with Dr. Raymond Leung, MD, of Meadville Pediatrics, a regional practice of four pediatricians who serve 9,041 children. Three social service agencies will assist in enrolling participants in the epidemiological study as needed. Their staffs will participate in outreach efforts and collaborate on dissemination of materials and lead prevention efforts in other communities. Center for Family Services, which provides housing counseling, rental assistance and advocacy, and in-home parenting and nutritional counseling, will sponsor the CLL and coordinate outreach efforts. Staff from Community Health Services, an umbrella organization representing Visiting Nurses Association / Mothers and Babies; Early Intervention Program; Women, Infants and Children (WIC) Program; Family Planning Services; Conneaut Valley Health Center; and Valley Dental Health Center, will assist in educational outreach and dissemination. The Meadville Redevelopment Authority will offer educational outreach through tenant programs. Financial support
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