Committee Membership Misc. ------ -------------------- Preventing Lead Poisoning in Young Children (April 1978-ACCLPP) Chairperson Needleman, Herbert L. (M.D.) Executive Secretary Houk, Vernon N. (M.D.) Members Billick, Irwin H. (Ph.D.) Buchart, Ellen (R.N.) Chadzynski, Lawrence (R.S.) Challop, Roger (M.D.) Chisolm, J. Julian, Jr. (M.D.) Curran, Anita S. (M.D.) Davidow, Bernard (Ph.D.) Field, Patricia (Ph.D.) Graef, John (M.D.) Greenberg, Nahman H. (M.D.) Lin-Fu, Jane S. (M.D.) Melia, Edward P. (M.D.) Piomelli, Sergio (M.D.) Reigart, J. Routt (M.D.) Robinson, Betty Sayre, James W. (M.D.) Sobolesky, Walter J. Welcome, Mary ======== Preventing Lead Poisoning in Young Children (January 1985-ACCLPP) Childhood Lead Poisoning Prevention Ad Hoc Advisory Committee (May 17, 1984–September 28, 1984) Chairperson Rosen, John F., M.D. Executive Secretary Houk, Vernon N., M.D. Members Braud, Sara M., M.D. Beljan, John R., M.D. Cole, Jerome F., Sc.D. Davidson, Cliff I., Ph.D. Davis, Devera Lee, Ph.D. Field, Patricia H., Ph.D. Gebbie, Kristine M., R.N. Jackson, Rudolph Ellsworth, M.D. MacLean, Robert A., M.D. Piomelli, Sergio, M.D. Reigart, J. Routt, M.D. ======== Statement on Childhood Lead Poisoning (1987-AAP) Committee on Environmental Hazards, 1984–1986 Landrigan, Philip J. (Chairman) DiLiberti, John H. Gehlbach, Stephen H. Graef, John W. Hanson, James W. Jackson, Richard J. Nathenson, Gerald Falk, Henry (Liaison) Miller, Robert W. (Liaison) Rogan, Walter (Liaison) Rowley, Diane (Liaison) Committee on Accident and Poison Prevention, 1984–1986 Greensher, Joseph (Chairman) Aronow, Regine Bass, Joel L. Boyle, William E., Jr. Krassner, Leonard Mack, Ronald B. Micik, Sylvia Widome, Mark David l’Archeveque, Andre (Liaison) Breitzer, Gerald M. (Liaison) Williams, Chuck (Liaison) Foster, Jerry (AAP Section Liaison) Schild, Joyce A. (AAP Section Liaison) ======== Strategic Plan for the Elimination of Childhood Lead Poisoning. (February 1991-ACCLPP) PRINCIPAL AUTHORS Sue Binder, M.D. (Centers for Disease Control, Center for Environmental Health and Injury Control) Henry Falk, M.D., M.P.H. (Centers for Disease Control, Center for Environmental Health and Injury Control) CONTRIBUTORS FEDERAL Max Lum, E.D. (Agency for Toxic Substances and Disease Registry, Division of Health Education) Susanne Simon (Agency for Toxic Substances and Disease Registry, Division of Health Education) James L. Pirkle, M.D., Ph.D. (Centers for Disease Control, Center for Environmental Health and Injury Control) Joel Schwartz, Ph.D. (Environmental Protection Agency) William McC. Hiscock (Health Care Financing Administration, Program Initiatives Branch) Jane Lin-Fu, M.D. (Health Resources and Services Administration, Maternal and Child Health Bureau) Donald T. Ryan (National Institute of Environmental Health Sciences) STATE AND LOCAL Charles G. Copley (Office of the Health Commissioner, City of St. Louis, Department of Health and Hospitals) PRIVATE SECTOR Anne Elixhauser, Ph.D. (Human Affairs Research Center, Battelle) Mark S. Kamlet, Ph.D. (Carnegie Mellon University, Department of Social and Decision Sciences) Paul A. Locke, Esq. (Environmental Law Institute) Stephanie Pollack, Esq. (Conservation Law Foundation of New England) PEER REVIEWERS Anita S. Curran, M.D. (Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey) Richard J. Jackson, M.D. (California Department of Health Services, Hazard Identification and Risk Assessment Branch) James C. Keck (Baltimore City Health Department, Lead Poisoning Prevention Program) John F. Rosen, M.D. (Albert Einstein College of Medicine, Montefiore Medical Center) ACKNOWLEDGEMENTS We appreciate the assistance of the following individuals who reviewed and commented on drafts of this report: FEDERAL Vernon N. Houk, M.D. (Centers for Disease Control, Center for Environmental Health and Injury Control) Robert W. Amler, M.D. (Agency for Toxic Substances and Disease Registry) Elizabeth Cochran (Centers for Disease Control, Center for Environmental Health and Injury Control) Gene Freund, M.D. (Centers for Disease Control, National Institute for Occupational Safety and Health) Teri Guilmette (Centers for Disease Control, Center for Environmental Health and Injury Control) Daniel A. Hoffman, Ph.D. (Centers for Disease Control, Center for Environmental Health and Injury Control) Robert S. Murphy, M.S.P.H. (Centers for Disease Control, National Center for Health Statistics) Danie! C. Paschal, Ph.D. (Centers for Disease Control, Center for Environmental Health and Injury Control) Jeffrey J. Sacks, M.D., M.P.H. (Centers for Disease Control, Center for Environmental Health and Injury Control) Sandra C. Eberlee (Consumer Product Safety Commission) Brian C. Lee, Ph.D. (Consumer Product Safety Commission) Robert W. Elias, Ph.D. (U.S. Environmental Protection Agency, Office of Research and Development) Renate D. Kimbrough, M.D. (U.S. Environmental Protection Agency, Office of the Administrator) Ronnie Levin (U.S. Environmental Protection Agency, Office of Research and Development) Dave E. Schutz, M.S., M.P.P. (U.S. Environmental Protection Agency, Office of Toxic Substances) P. Michael Bolger, Ph.D., D.A.B.T. (U.S. Food and Drug Administration, Division of Toxicological Review and Evaluation) Ellis Goldman, M.C.P. (U.S. Department of Housing and Urban Development, Office of Policy Development and Research) Ronald J. Morony, P.E. (U.S. Department of Housing and Urban Development, Office of Policy Development and Research) Steve Weitz, M.U.P. (U.S. Department of Housing and Urban Development, Office of Policy Development and Research) Kathryn Mahaffey, Ph.D. (National Institute of Environmental Health Sciences) Mary McKnight (U.S. Department of Commerce, National Institute of Standards and Technology) STATE AND LOCAL Mary Jean Brown (Massachusetts Department of Public Health, Childhood Lead Poisoning Prevention Program) Mark Matulef, Ph.D. (Massachusetts Executive Office of Communities and Development, Office of Program and Policy Development) Lewis B. Prenney (Massachusetts Department of Public Health, Childhood Lead Poisoning Prevention Program) PRIVATE SECTOR John B. Moran (Laborers’ National Health and Safety Fund, Occupational Safety and Health) Herbert L. Needleman, M.D. (University of Pittsburgh School of Medicine) Margery Turner (The Urban Institute) ======== Preventing Lead Poisoning in Young Children (1991) (October 1991–ACCLPP) Centers for Disease Control Leadership William L. Roper, M.D., M.P.H, Director• Vernon N. Houk, M.D., Director, National Center for Environmental Health and Injury Control Henry Falk, M.D., Director, Division of Environmental Hazards and Health Effects Sue Binder, M.D., Chief, Lead Poisoning Prevention Branch Advisory Committee on Childhood Lead Poisoning Prevention Chair John F. Rosen, M.D. Executive Secretary Henry Falk, M.D. Members Evelyn S. Bouden, M.D. Beverly Coleman-Miller, M.D. Ronald L. Fletcher, M.D. Lynn R. Goldman, M.D. Dwala S. Griffin Richard J. Jackson, M.D. Rudolph E. Jackson, M.D. James C. Keck Herbert L. Needleman, M.D. Sergio Piomelli, M.D. Stephanie L. Pollack, J.D. Knut Ringen, Dr.P.H. Noel V. Stanton Consultants David Bellinger, Ph.D. James J. Chisolm, Jr., M.D. Charles G. Copley Anita S. Curran, M.D. John W. Graef, M.D. Phillip J. Landrigan, M.D. John R. Reigart, M.D. Treatment Guidelines for Lead Exposure in Children (1995) AAP Committee on Drugs (1993–1994) Chairperson Cheston M. Berlin, Jr, MD. Committee Members: Richard L. Gorman, MD. D. Gail May, MD. Daniel A. Notterman, MD. Douglas N. Weismann, MD. Geraldine S. Wilson, MD. John T. Wilson, MD. Liaison Representatives Donald R. Bennett, MD, PhD representing the American Medical Association. Joseph Mulinare, MD, MSPH representing the Centers for Disease Control and Prevention. Paul Kaufman, MD representing the Pharmaceutical Research and Manufacturers Association of America. Sam A. Licata, MD representing the Health Protection Branch, Canada. Paul Tomich, MD representing the American College of OB/GYN. Gloria Troendle, MD representing the Food and Drug Administration. Sumner J. Yaffe, MD representing the National Institutes of Health. Additional Contributors AAP Section Liaison: Charles J. Cote’, MD, from the Section on Anesthesiology. Consultant: William Banner, Jr, MD, PhD. Managing Elevated Blood Lead Levels Among Young Children (2002) (2002-ACCLPP) AUTHORS Assessment and Remediation of Residential Lead Exposure, NCEH, Kennedy Krieger Institute Thomas D. Matte, MD, MPH (NCEH) Dennis Kim, MD, MPH (NCEH) Mark R. Farfel, PhD, KKI Developmental Assessment and Interventions, Harvard Medical School David Bellinger, PhD, MSc. Leonard Rappaport, MD Educational Interventions for Caregivers, University of Rochester School of Medicine and Dentistry James R. Campbell, MD, MPH, Michael L. Weitzman, MD, Medical Assessment and Interventions, Medical University of South Carolina James R. Roberts, MD, MPH J. Routt Reigart, MD Acting Chair Carla C. Campbell, MD, MS (Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania) Executive Secretary Gary P. Noonan, MPA (Acting Chief, Lead Poisoning Prevention Branch, National Center for Environmental Health, CDC, Atlanta, Georgia) Members Cushing N. Dolbeare (Housing and Public Policy Consultant, Washington, D.C.) Anne M. Guthrie, MPH (Alliance to End Childhood Lead Poisoning, Charlottesville, Virginia) Birt Harvey, MD (Pediatrician, Palo Alto, California) Richard E. Hoffman, MD, MPH (Physician, Denver, Colorado) Amy A. Murphy, MPH (City of Milwaukee Health Department, Milwaukee, Wisconsin) Estelle B. Richman, M.A. (Philadelphia Department of Public Health, Philadelphia, Pennsylvania) Joel D. Schwartz, PhD (Harvard School of Public Health, Boston, Massachusetts) Michael W. Shannon, MD, MPH (Children’s Hospital Boston, Boston, Massachusetts) Michael L. Weitzman, MD (University of Rochester, Rochester, New York) Ex Officio Members Olivia Harris, MA (Agency for Toxic Substances and Disease Registry) Jerry Zelinger, MD (Centers for Medicare and Medicaid Services) Byron P. Bailey, MPH (Health Resources and Services Administration) Robert J. Roscoe, MS (National Institute for Occupational Safety and Health, CDC) Walter Rogan, MD (National Institute of Environmental Health Sciences) John Borrazzo, PhD (U.S. Agency for International Development) Lori Saltzman (U.S. Consumer Product Safety Commission) David Jacobs, PhD (U.S. Department of Housing and Urban Development) William H. Sanders, III, DrPH (U.S. Environmental Protection Agency) Michael P. Bolger, PhD (U.S. Food and Drug Administration) Liaison Representatives J. Routt Reigart, II, MD (American Academy of Pediatrics) George C. Rodgers, Jr., MD, PhD (American Association of Poison Control Centers) Steve M. Hays (American Industrial Hygiene Association) Rebecca Parkin, PhD, MPH (American Public Health Association) Henry Bradford, Jr., PhD (Association of Public Health Laboratories) Karen Pearson (Association of State and Territorial Health Officials) Ezatollah Keyvan-Larijani, MD, DrPH (Council of State and Territorial Epidemiologists) Pat McLaine, MPH (National Center for Healthy Housing) ======== PREVENTING LEAD EXPOSURE IN YOUNG CHILDREN (2004) A Housing-Based Approach to Primary Prevention of Lead Poisoning (October 2004)-ACCLPP Chair Carla Campbell, MD, MS (The Children's Hospital of Philadelphia) --- Executive Secretary Mary Jean Brown, ScD, RN (Centers for Disease Control and Prevention) --- Members William Banner, Jr., MD, PhD (The Children's Hospital at Saint Francis) Helen J. Binns, MD, MPH (Children's Memorial Hospital) Cushing N. Dolbeare (Housing and Policy Consultant) Anne M. Guthrie, MPH (Alliance for Healthy Homes) Walter S. Handy, Jr., PhD (Cincinnati Health Department) Birt Harvey, MD (Pediatrician) Ing Kang Ho, PhD (University of Mississippi Medical Center) Richard E. Hoffman, MD, MPH (Physician) Jessica Leighton, PhD, MPH (New York City Department of Health & Mental Hygiene) Tracey V. Lynn, DVM, MS (Alaska Department of Health and Social Services) Sergio Piomelli, MD (Columbia Presbyterian Medical Center) Michael W. Shannon, MD, MPH (Children's Hospital, Boston) Catherine M. Slota-Varma, MD (Pediatrician) Kevin U. Stephens, Sr., MD, JD (New Orleans Department of Health) Kimberly M. Thompson, ScD (Harvard School of Public Health) --- Ex-Officio Members Olivia Harris, MA (Agency for Toxic Substance and Disease Registry) Robert J. Roscoe, MS (Centers for Disease Control and Prevention) Jerry Zelinger, MD (Centers for Medicare and Medicaid Services) Michael P. Bolger, PhD (Food and Drug Administration) Byron P. Bailey, MPH (Health Resources & Services Administration) Walter Rogan, MD (National Institute for Environmental Health Sciences) John Borrazzo, PhD (U.S. Agency for International Development) Lori Saltzman (U.S. Consumer Product Safety Commission) David Jacobs, PhD, CIH (U.S. Department of Housing and Urban Development) Ronald J. Morony, PE (U.S. Environmental Protection Agency) --- Liaison Representatives J. Routt Reigart, II, MD (American Academy of Pediatrics) George C. Rodgers, Jr., MD, PhD (American Association of Poison Control Centers) Steve M. Hays, CIH, PE (American Industrial Hygiene Association) Patricia Nolan, MD, MPH (American Public Health Association) Henry Bradford, Jr., PhD (Association of Public Health Laboratories) Karen Pearson (Association of State and Territorial Health Officials) Ezatollah Keyvan-Larijani, MD, DrPH (Council of State and Territorial Epidemiologists) Pat McLaine, RN, MPH (National Center for Healthy Housing) --- Primary Prevention Work Group Pat McLaine, RN, MPH, Chairperson (National Center for Healthy Housing, Columbia, Maryland) Amy Murphy, MPH, Chairperson (November 2001 – March 2003) (City of Milwaukee Health Department, Milwaukee, Wisconsin) Richard Bunner, MPH (Ohio Department of Health, Columbus, Ohio) Carla Campbell, MD, MS (The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania) Cushing Dolbeare (Housing Policy Consultant, Mitchellville, Maryland) Anne M. Guthrie, MPH (Alliance for Healthy Homes, Washington, D.C.) David Jacobs, PhD, CIH (U.S. Department of Housing and Urban Development, Washington, D.C.) Susan Klitzman, DrPH (Hunter College, New York, New York) Bruce P. Lanphear, MD, MPH (Children's Hospital Medical Center, Cincinnati, Ohio) Pamela Meyer, PhD (Centers for Disease Control and Prevention, Atlanta, Georgia) Ronald Morony, PE (U.S. Environmental Protection Agency, Washington, D.C.) Tim Morta (Centers for Disease Control and Prevention, Atlanta, Georgia) --- ======== Committee on Environmental Health (2004–2005) of the American Academy of Pediatrics (2004-2005 AAP) Chairperson Michael W. Shannon, MD, MPH Committee Members: Dana Best, MD, MPH Helen Jane Binns, MD, MPH Janice Joy Kim, MD, MPH, PhD Lynnette Joan Mazur, MD, MPH William B. Weil, Jr, MD Christine Leigh Johnson, MD David W. Reynolds, MD James R. Roberts, MD, MPH Liaisons Elizabeth Blackburn (US Environmental Protection Agency) Robert H. Johnson, MD (Agency for Toxic Substances and Disease Registry) Martha Linet, MD (National Cancer Institute) Walter J. Rogan, MD, (lead author of 2005 policy statement) who also served as a liaison from the NIEHS. Staff Paul Spire ======== PREVENTING LEAD Poisoning IN YOUNG CHILDREN (2005) (AUGUST 2005)-ACCLPP Acting Chair Carla C. Campbell, MD, MS (Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania) Executive Secretary Mary Jean Brown, ScD, RN (Chief, Lead Poisoning Prevention Branch, National Center for Environmental Health, CDC, Atlanta, Georgia) Members William Banner, Jr., MD, PhD (The Children's Hospital at Saint Francis, Tulsa, Oklahoma) Helen J. Binns, MD, MPH (Children's Memorial Hospital, Chicago, Illinois) Cushing N. Dolbeare (Housing and Public Policy Consultant, Mitchellville, Maryland) Anne M. Guthrie, MPH (Alliance for Healthy Homes, Washington, D.C.) Walter S. Handy, Jr., PhD (Cincinnati Health Department, Cincinnati, Ohio) Birt Harvey, MD (Pediatrician, Palo Alto, California) Ing Kang Ho, PhD (University of Mississippi Medical Center, Jackson, Mississippi) Richard E. Hoffman, MD, MPH (Physician, Denver, Colorado) Jessica Leighton, PhD, MPH (New York City Department of Health and Mental Hygiene, New York, New York) Tracey V. Lynn, DVM, MS (Alaska Department of Health and Social Services, Anchorage, Alaska) Sergio Piomelli, MD (Columbia Presbyterian Medical Center, New York, New York) Michael W. Shannon, MD, MPH (Children's Hospital Boston, Boston, Massachusetts) Catherine M. Slota-Varma, MD (Pediatrician, Milwaukee, Wisconsin) Kevin U. Stephens, Sr., MD, JD (New Orleans Department of Health, New Orleans, Louisiana) Kimberly M. Thompson, ScD (Harvard School of Public Health, Boston, Massachusetts) Ex Officio Members Olivia Harris, MA (Agency for Toxic Substances and Disease Registry) Robert J. Roscoe, MS (National Institute for Occupational Safety and Health, CDC) Jerry Zelinger, MD (Centers for Medicare and Medicaid Services) Michael P. Bolger, PhD (U.S. Food and Drug Administration) Byron P. Bailey, MPH (Health Resources and Services Administration) Walter Rogan, MD (National Institute of Environmental Health Sciences) John Borrazzo, PhD (U.S. Agency for International Development) Lori Saltzman (U.S. Consumer Product Safety Commission) David Jacobs, PhD, CIH (U.S. Department of Housing and Urban Development) Ronald J. Morony, PE (U.S. Environmental Protection Agency) Liaison Representatives J. Routt Reigart, II, MD (American Academy of Pediatrics) George C. Rodgers, Jr., MD, PhD (American Association of Poison Control Centers) Steve M. Hays, CIH, PE (American Industrial Hygiene Association) Patricia Nolan, MD, MPH (American Public Health Association) Henry Bradford, Jr., PhD (Association of Public Health Laboratories) Karen Pearson (Association of State and Territorial Health Officials) Ezatollah Keyvan-Larijani, MD, DrPH (Council of State and Territorial Epidemiologists) Pat McLaine, RN, MPH (National Center for Healthy Housing) REVIEW OF EVIDENCE FOR EFFECTS AT BLLS <10 µg/dL WORK Group Work Group Chair Michael L. Weitzman, MD (Center for Child Health Research, University of Rochester) --- Tom Matte, MD, MPH (National Center for Environmental Health, Centers for Disease Control and Prevention) David Homa, PhD (National Center for Environmental Health, Centers for Disease Control and Prevention) Jessica Sanford, PhD (Battelle Memorial Institute) Alan Pate (Battelle Memorial Institute) Joel Schwartz, PhD (Department of Environmental Health, Harvard School of Public Health) David Bellinger, PhD (Neuroepidemiology Unit, Children’s Hospital; Harvard Medical School) David A. Savitz, PhD (Department of Epidemiology, University of North Carolina School of Public Health) Carla Campbell, MD, MS (Division of General Pediatrics, The Children’s Hospital of Philadelphia) Patrick J. Parsons, PhD (Wadsworth Center for Laboratories and Research, New York State Department of Health) Betsy Lozoff, MD (Center for Human Growth and Development, University of Michigan) Kimberly Thompson, ScD (Department of Health Policy and Management, Harvard School of Public Health) Birt Harvey, MD (Pediatrician, Palo Alto, California) ======== General Comments Develop a more concise and succinct document by decreasing thenumber of pages from 19 to five. Explain the rationale, briefly describe them context of primary prevention and list recommendations. Move all othertext into an appendix. Use the case management document as a model and incorporate introductory pages that highlight key points and recommendations for each chapter. Describe the magnitude of childhood lead poisoning in more detail to reach audiences that may not be familiar with this issue. For example, clearly explain why childhood lead poisoning is "a major public health problem" at the beginning of the document. Use more basic terminology such as "prevention of lead poisoning of children who live in older housing" rather than "primary prevention." Cite references, solid research and data needs to support key statements, models and strategies described in the document, such as the HIV Testing Survey that compares prevalence-wide screening data and door-to-door samples. Include epidemiological evidence on EBLLs by region and age of housing to strengthen the rationale for focusing the document on housing as the primary source of lead exposure. Present rigorous evidence on lead dust exposure and other risk factors in children who develop EBLLs to compensate for the lack of data on interventions. Explicitly state that variability exists in communities at local, national and international levels and between urban and rural environments. For example, some programs may not view housing as a major problem in lead exposure. Outline a strong approach that authorizes entry into lead-contaminated homes and mandates repairs. Place this language in the "Regulatory Infrastructure and Incentives" section. Reference Massachusetts and other states that take civil or criminal actions to enforce compliance with lead-safe housing standards. Add these examples to the living appendix. Ensure that ACCLPP's position on primary prevention is emphasized in the document by listing recommendations on a particular issue at the end of each chapter. Acknowledge that primary prevention efforts will differ based on variability among private, public or rental housing stock. Recommend that fiscal incentives be provided to property owners who reduce risks by complying with lead-safe housing standards. Develop a transparent process to clearly identify homes with lead hazards when a regulatory public health approach is taken. Take a strong primary prevention position by advocating the elimination of lead into the environment by industries that can economically and viably make substitutions. Clearly identify target audiences, messages, expected outcomes and the most effective delivery methods of the document. For example, target the document to reach legislators who protect children. Maintain a narrow focus on housing as the primary source of lead exposure; create a companion document to focus on non-housing sources. Recommend that pediatricians be an active component in the primary prevention process when birth certificates are issued or when high-risk housing with children has been identified. Cite the recommendation in the case management document that supports temporary relocation of families when a home is being remediated and a child has been identified with an EBLL. Obtain CDC's full endorsement of the document to ensure credibility, support, cooperation and implementation by EPA, HUD and other agencies. For example, ACCLPP could present its primary prevention guidelines to the Federal Interagency Task Force on Children's Environmental Health. Incorporate guidance to empower individuals to identify risk factors and immediately become involved in the primary prevention process. Delete "secondary prevention" and "tertiary prevention" throughout the document. Focus on the window of opportunity to prevent lead exposure during a young child's development. Add strong and clear recommendations from ACCLPP about the need for local housing programs and non-HHS agencies to provide adequate resources for primary prevention. Ensure that the FY'03 lead poisoning prevention cooperative agreement contains language for CLPPPs to play a leadership role in both primary prevention and overall childhood lead poisoning prevention. Achieve this goal by providing CLPPPs with adequate information to make appropriate decisions and evaluate priorities at the local level. Add "health departments" and other appropriate agencies to each reference of CLPPPs in the document. Add supporting data to illustrate the cost effectiveness of primary prevention interventions described in the document. Specific Comments Page 1: Develop and include a three-page executive summary to highlight the key points of the document for non-technical audiences. Page 3: Review data cited in the second and third paragraphs because this information is not consistent with data previously reported by Dr. David Jacobs of HUD. Page 4: Delete references to the Treatment of Lead-Exposed Children Trial since the study demonstrated no changes in outcome. Page 4: Add "were chelated" after the first phrase in Section II(2) to make a complete sentence. Page 4: Include comparative data to the finding of a "24% decline in children's BLLs after paint abatement was completed." Page 4: Revise the "Rationale for Primary Prevention" section to focus more on the importance of prevention exposure, i.e., longevity of lead in the human body and the inability to reverse damage caused by lead. Page 4: Describe effective strategies to strengthen the "Rationale for Primary Prevention" section. Revise the text to be evidence-based. Page 10: Delete paragraphs 2-5 under the "Options for targeting high-risk families with young children" section. Detailed descriptions of these programs are unnecessary for a primary prevention document; the options can be summarized in one sentence. Page 12: Decrease the "Existence of Comprehensive Secondary Interventions" section from three paragraphs. Page 12: Modify ACCLPP's recommendation for "HHS and DOA to fund research and demonstration projects" to encourage CDC to immediately undertake this activity in the FY'03 lead poisoning prevention cooperative agreement. Page 12: Add language to more strongly emphasize condition of paint, maintenance, housekeeping and other basic housing factors in the "Development of an Evidence-Based, Cost-Effective Lead Safe Housing Standard" section. Include data in the "Development of an Evidence-Based, Cost-Effective Lead Safe Housing Standard" section to assist CLPPPs or health departments in making a stronger case when requesting resources from other agencies. For example, the information could contrast costs for primary prevention versus treatment of EBLLs. Page 17: Revise the "Collaboration with Multiple Stakeholders" section to be more realistic. CDC can achieve this goal by convening a primary prevention workshop with potential collaborators to discuss interests, issues, lessons learned and best practices of local groups. Other: Add an appendix citing the scientific literature to support the "Rationale for Primary Prevention" section on page 4. October 2002 Minutes of the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) http://www.cdc.gov/nceh/lead/ACCLPP/Minutes/October2002.htm A summary of the project and Alliance's paper on Making Lead-Safe Housing the Central Focus of Strategic Plans to Eliminate Childhood Lead Poisoning are collectively appended to the minutes as Attachment 1.In an effort to move toward consensus of the primary prevention document, Dr. Campbell asked ACCLPP to make specific and concrete comments. She reminded the. members that the primary target audience is health environmental and housing professionals at state and local levels. A shorter document was also distributed that serves as a preface. She conveyed that the workgroup is discussing the posibility of developing a glossary to clarify terms. Dr. Campbell mentioned that a workgroup meeting is scheduled on the following day for further editing of the document. Comments made during the discussion by ACCLPP members are outlined below. Rewrite the document to be less bureaucratic, more concise and with a stronger focus. Emphasize the primary prevention message and clarify the purpose of the document. Include a section that explicitly states primary prevention extends beyond screening and an active search should be conducted in communities to identify high-risk children. Revise the technical language and concepts into laymen's terms since the document also serves as a marketing tool for communities, legislators and health care providers. Outline solutions that can now be taken to reduce risks of lead exposure to children, i.e., improving diets and overall health, reducing ETS, enforcing regulations and remediating homes with lead hazards. Use this approach to partner rather than compete with the Vaccines For Children Program and other federal initiatives that focus on childhood health. Delete "primary prevention" and strengthen the focus on housing issues. For example, the document could be renamed as Prevention of Lead Poisoning in Young Children Associated with Housing Exposures. Remove non-housing lead exposures from the primary prevention document. Cite the ACCLPP case management document and other references for other lead sources. Reformat the eight key elements in the text box summary, narrative, subcategories and Appendix 5 to be parallel in all sections of the document. Strengthen political will for primary prevention by including the cost-benefit to society and offering incentives to landlords. This approach will minimize resistance by property owners to shift to a primary prevention strategy. Redefine the target audience as CLPPPs and state and local health departments. Provide practical guidance for grantees to effectively implement the eight elements of a comprehensive primary prevention childhood lead poisoning program. Distribute detailed and concrete recommendations and other tools to assist grantees in better responding to the FY'03 program announcement and effectively interacting with housing agencies to implement the primary prevention guidelines. Issue a shorter document in the future to submit to journals. Decide on the publication venue and then format the document accordingly. Refrain from using "lead-safe" because the term de-emphasizes the need for continued maintenance of an abated home and implies intact lead is safe. Separate key roles and responsibilities of health and housing departments in Appendix 5 because these agencies have completely different missions and functions. Provide explicit guidance, particularly for tasks that will require extensive resources and political support. For example, the establishment of a statewide regulatory structure at the state level and enforcement of housing standards at the local level are recommended on page 22, but no advice is provided for CLPPPs and housing agencies to conduct these activities. Avoid presenting a detailed implementation strategy for each guideline in the document. Present the recommendations as options for CLPPPs to address local problems with appropriate partners, including housing agencies, health departments, legislators, insurance companies and landlords. Emphasize the critical role of landlords in the shift to primary prevention. For example, 95% of landlords in a Maryland Eastern Shore county adhered to the new legislation to register all rental properties built before 1950. The high compliance rate is due to the belief by these landlords that protection of children and safe properties are important. Develop an appendix of model state laws for CLPPPs to present to state legislators and health departments. Other resources that could be included in the appendix are contact information for national agencies and relevant web sites. Appropriately reference these resources in the document as "(see resource X)." Reword the document to recommend that CLPPPs "initiate" statutory and regulatory guidelines rather than "take the lead." Revise the introduction to immediately identify the target audience; explain the intended use of the document; emphasize the need for health and housing agencies to closely collaborate; and recommend that CDC grantees begin to shift the focus from secondary to primary prevention. Integrate the standalone preface into the main primary prevention document. Modify the document based on ACCLPP's most recent comments. Authorize LPPB staff and contract editors to refine the revised draft. Distribute the document to three to five CLPPPs for review and comment and circulate this feedback to ACCLPP. Distribute this version to ACCLPP for review and comment before the document is placed for a vote at the October 2003 meeting. Ensure that the following statement in the document is accurate and supported by data: The "vast majority" of childhood BLLs >10 Fg/dL is associated with exposure to deteriorated lead-based paint and other factors. Several follow-up comments were made in response to the above suggestions. Dr. Jacobs clarified that the document is an attempt to encourage local health and housing agencies to prevent exposures and exposure pathways in housing. This effort is consistent with the 1992 Congressional definition of a lead-based paint hazard as deteriorated paint and contaminated dust and soil. The primary prevention document offers guidance to local health and housing agencies to make housing safe, conduct follow-up of children and intervene before exposures occur. Several members requested that Dr. Jacobs’s comments be formalized and included in the introduction of the document.Dr. Meehan explained the process to finalize the document. After ACCLPP formally approves a draft, LPPB staff and contract editors will further refine the document into a professional and high-quality product. Before additional progress can be made, however, ACCLPP must now agree on the target audience and the publication venue. For example, CDC’s Reports and Recommendations (R&Rs) are standalone documents published in the MMWR. R&Rs are longer than regular MMWR articles and are broadly disseminated to clinicians through web-based subscriptions. The primary prevention document can also be issued as a journal article or standalone publication outside of the MMWR.Dr. Meehan mentioned that resolution of these issues will dictate whether public health jargon or laymen’s terms would be more appropriate. ACCLPP authorized the workgroup to define a time-line to finalize the document and circulate a draft to CLPPPs for preliminary review and comment. Agreement was reached to place the document for a formal vote by ACCLPP during the October 2003 meeting. Dr. Jacobs indicated that the primary prevention document may need to be distributed before the next meeting, particularly if CLPPPS will use the guidelines as reference materials for the July 1, 2003 cooperative agreement. Dr. Meehan returned to one of the recommendations and expressed concern with ACCLPP formally requesting that CLPPPs shift from screening to primary prevention. CDC would be more comfortable with ACCLPP emphasizing the critical role of primary prevention in a comprehensive public health program that includes screening, case management and other important components. He explained that CDC is mandated by legislation to fund screening programs. Dr. Campbell clarified that the document recommends primary prevention strategies be prioritized since secondary prevention efforts have traditionally failed in detecting children with lead exposures and toxicities. However, the guidelines do not ask programs to abandon secondary prevention. For example, continued case management of children with EBLLs is suggested. The document further recommends that resources and staff be redirected as the focus shifts from secondary to primary prevention. Several members returned to the proposed timeline to finalize the primary prevention document. Concern was expressed due to the three-month delay between the July 1, 2003 program announcement and ACCLPP’s formal vote on the draft in October 2003. Dr. Campbell asked members to consider the possibility of approving the document by e-mail, regular mail or conference call. To expedite the approval process, Dr. Harvey suggested that only major changes be circulated to the voting members. ACCLPP passed several consensus recommendations to address issues raised during the deliberations. Ms. Guthrie-Wengrovitz placed the following motion on the floor for a vote. CLPPPs should serve as the primary target audience of the document. Health agencies, community groups and other partners of CLPPPs that will be needed to implement the primary prevention recommendations should serve as the secondary target audience. The focus of the document should remain on housing-based primary prevention interventions. Ms. Guthrie-Wengrovitz accepted Dr. Campbell’s amendment of the motion to also include local and state health departments as a primary target audience, particularly agencies without a CLPPP. The motion was seconded by Dr. Binns and unanimously approved with no further discussion. Dr. Lynn placed the following motion on the floor for a vote. The primary prevention document should be issued as detailed standalone guidelines that can be tailored to a shorter and more concise journal article in the future. The motion was seconded by Dr. Binns and unanimously approved with no further discussion. Dr. Banner placed the following motion on the floor for a vote. The motion was for conditional approval of the present draft of the PPWG document. The revised primary prevention draft should be distributed to voting members via e-mail for further approval after further editing by the workgroup, LPPB staff and contract editors. ACCLPP should be provided an opportunity to review and approve the final draft. The motion was seconded by Dr. Binns and unanimously approved with no further discussion. Dr. Meehan confirmed that all drafts will continue to be circulated to ACCLPP ex officio and liaison representatives for review and comment. He asked non-workgroup members to submit additional comments on the document in writing to Mr. Morta. March 2003 Minutes of the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) http://www.cdc.gov/nceh/lead/ACCLPP/Minutes/March2003.htm Dr. Campbell reconvened the ACClPP meeting at 8:40 a.m. on October 20,2004 and yielded the floor to the first presenter. Dr. Walter Rogan is ACClPP's ex officio member for NIH/National Institute of Environmental Health Sciences (NIEHS). He provided an overview of the TlC Trial. The study is a formal clinical trial to evaluate the use of succimer as an oral chelating drug in preventing or reducing lead-associated cognitive, behavioral and neuropsychological deficits in toddlers. Nationally representative prevalence data of 16.4 million U.S. homes were reviewed to determine the number of homes and percentage of children ~6 years of age with a lead hazard based on age of home. The number of homes built in the time periods of pre-1940, 1940-1959, 1960 1977 and 1978-1998 ranged from <58,000--2 million. Of these homes, the percentage of lead hazards was estimated to range from <1 %-81 %. Of homes in which children ~6years of age resided, 25% had lead hazards in 2000. μg/dL In 1976, the mean Bll was 15 μg/dL among U.S. children 1-6 years of age, the prevalence of Blls >10 μg/dL was 88%, and 13.5 million children had Blls >10 μg/dL. Significant progress has been made since that time as evidenced by nationally representative prevalence data. In 1999-2000, the mean Bll was 2.2 μg/dL, the prevalence of Blls >10 μg/dL was 2%, and <500,000 million children had Blls >10 μg/dL. In 1991 , the broad scientific consensus was that cognitive impairment followed lead exposure at low levels and blood lead at two years of age was associated with deficits beginning at four years of age and continuing thereafter. Data showed that Blls at birth were not associated with defects and 10 in children five years of age. Blls at two years of age begin to be associated with full-scale 10 at five years of age. The postnatal mean was strongly influenced by the peak Bll and associated with 10 at five years of age. The overall size of the effect was -3 10 points per 10 jJg/dl of blood lead, particularly in Blls 10-20 μg/dL. CDC redefined "lead poisoning" in 1991 as Blls ~10 jJg/dl and also recommended universal screening. Because the published guidance created thousands of new cases, several agencies were concerned that children would be given succimer inappropriately. The drug is orally administered and only licensed for children with Blls >45 jJg/dl, but can be given in an outpatient setting in a controlled lead-safe environment. Succimer is a white crystalline powder that is extremely difficult to administer to children due to the large size and unpleasant odor and taste of the capsule. NIEHS and a drug manufacturer sponsored TlC to demonstrate that oral administration of succimer would lower Blls. TlC is a mufti-center, randomized, placebo-controlled and double-blind clinical trial of succimer among 780 children for the prevention of lead induced cognitive and neuropsychological impairment, growth retardation and behavior disorders in toddlers. All children in TlC received vitamin and mineral supplementation and home cleanup for lead dust suppression. TlC sites included Baltimore, Cincinnati, Newark and Philadelphia because these cities represented large volumes of pediatric lead poisoning cases. The cohort was 12-33months of age at randomization with referral Blls of 20-44 μg/dl and no disqualifying medical conditions. During the pre-treatment phase, field investigators drew two Blls that were confirmed by CDC to be between 20-44 μg/dl; obtained consent; distributed vitamins and minerals; and conducted an evaluation to determine whether the house could be cleaned according to the TlC protocol. Of the succimer group in 1994, 55% were male, 5% had Spanish speaking parents, 76% were black, 72% had parents without partners, 41 % had parents with less than a high school education, and 96% were on public assistance. The randomized subjects were 24 months of age with a mean Bll of 26 μg/dl, mean birth weight of 3.1 kg, a Bayley Mental Developmental Index of 84 and parental IQ of 81. The baseline characteristics were comparable to the placebo group. The succimer group had a Bll that was 0.5 μg/dl higher than the placebo group at baseline, but this difference was statistically indistinguishable. Blls of the succimer group decreased to a mean of 13 μg/dl after one week of receiving the drug compared to the mean Bll of 23 μg/dl of the placebo group. However, Blls of the succimer group increased at week 20 as lead mobilized from bone. Of children who received the first round of succimer, 80% did not have Blls <15 μg/dl on day 43 of TlC. At 36 months of follow-up, the TlC cohort was five years of age and was tested for full scale IQ, behavioral index as well as attention/executive and sensorimotor functions. These functions measure the child's hand-to-eye coordination and ability to pay attention to a task, suppress the urge to answer prior to knowledge of a question, and answer immediately after hearing a question. No differences were seen between the succimer and placebo groups for any of the tests. The psychometric tests were not administered until 36 months of age because instruments to measure brain function are unreliable and unstable in children ~3 years of age. The children were followed until school entry and sophisticated tests were performed to identify deficits in cognitive, attention/executive and sensorimotor functions. The data showed an extremely small statistical difference in attention/executive function of children seven years of age in the succi mer group. The findings also suggested that the attention of the succimer group was a little better than the placebo group. However, TlC did not produce evidence to demonstrate that succi mer is beneficial to children. Treatment was not found to lead to better scores on cognitive, neuropsychological or behavioral tests at 36 months of follow-up when the children were five years of age or additional follow-up at seven and 7.5 years of age. TlC did not generate data on the use of succimer, but 41% of families reported difficulties in administering the drug. The succimer group was associated with unexplained, excess trauma based on hospitalization, history and physical examination data. Events reported in the succimer group included a near drowning, asthma attacks and head injury from an iron. Succimer is an expensive drug that is taken for six months and resulted in symptoms in children who were previously asymptomatic. The findings do not support conducting another trial to determine if succimer would be effective in children with Blls <45 μg/dL. The investigators reasonably inferred that the prevention of lead exposure at the outset is the most effective approach to preventing lead-associated defects. ACCLPP suggested that the TlC investigators use animal models to identify expression or repression of genes in response to lead, determine pathways and locate small molecules to enhance repair. TlC data should be used to emphasize the importance of improving the environment, particularly housing-based problems that cause lead poisoning. Dr. Brown has learned from one state that Medicaid will not reimburse for succimer if the child's Bll is 44 μg/dL or lower. October 2004 Minutes of the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) http://www.cdc.gov/nceh/lead/ACCLPP/Minutes/October2004.htm Rogan: "When Ken Olden came, he had an interest in moving the institute in a more clinical direction and also in I believe the old term was minority health. He had an interest in minority health. The institute had supported the development of a drug that lowered blood lead called Succimer. We proposed to Dr. Olden that we do a clinical trial, because lowering blood lead might be a good thing, but it might not be a good thing in the sense of reversing any effect that lead had already had, and it exposed you to the side effects of drug, which you might or might not need. The only thing wrong with you from these low levels of lead that we were going to treat was you'd lost some IQ points, two or three per every 10 micrograms per deciliter of blood lead. So, we wanted to see if we found kids when they were two with these moderately elevated blood leads who otherwise would not have been treated and treated them with this drug to lower their blood lead, would we get their IQ points back? So, we went to where you might imagine we went. Where was the other centers? Philly, Newark, Baltimore, and Cincinnati. We followed 780 kids, half of whom had gotten Succimer, half of whom got placebo for Succimer. Treated them at around age two, followed them till they were five years old. We lowered their blood leads pretty dramatically, and we changed their IQs not at all. That study ended drug treatment, which had been being promoted as something that you ought to do to these kids. It also stopped the idea of what we call secondary prevention. That is, finding kids who have elevated blood leads and then moving them out of a house or and then doing whatever you were going to do and moved the attention back to primary prevention, not letting them get exposed to lead in the first place. We didn't anticipate that that would sort of be fallout from that study, but it may turn out, in the very long term, to be the more important contribution that it made, because that sort of search out kids as an indicator of bad housing philosophy had been in place for a long time. Nobody liked it, but people sort of thought, well, it must be a good thing to get kids out of the houses. It turns out it's not as good a thing as keeping them from getting exposed in the first place." Interviewer: "Would you say that study was your most important discovery?" Rogan: "It's not the most cited [...] I believe that study is probably the most influential. It was a much more simple question to ask and answer and pretty much settled something. Other things don't really settle something, but that study pretty much settled something. It pretty much ended drug treatment of kids with these low levels, relatively low levels. Still too high, but relatively low levels." Walter J. Rogan, NIH Oral History, 2016 Well, ah shucks! He didn't know that would happen! .... "The regimen is expensive and a significant burden on the families. In addition, the slight slowing of linear growth and the evidence of more frequent trauma in children receiving succimer are not reassuring. Since lead poisoning and its sequelae are entirely preventable, our inability to demonstrate effective treatment lends further impetus to efforts to protect children from exposure to lead in the first place." Rogan WJ, Dietrich KN, Ware JH, Dockery DW, Salganik M, Radcliffe J, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. 2001. "We believe that, because of that inconsistency, the data do not indicate that lead-induced cognitive defects are reversible. Primary prevention and preventing additional increases in blood lead levels among children whose blood lead levels are high remain the only effective means of dealing with lead poisoning." Liu X, Dietrich KN, Radcliffe J, Ragan NB, Rhoads GG, Rogan WJ. Do children with falling blood lead levels have improved cognition? Pediatrics. 2002. "A previous report in the Journal indicated that chelation therapy given to lower moderately elevated blood lead levels in preschool children from environments similar to those studied by Canfield and colleagues had no beneficial effects on tests of cognition, behavior, or neuropsychological function. Prevention is thus the only plausible strategy. Children should not live in housing that exposes them to hazardous amounts of lead, and children who are already exposed need to be identified and their source of exposure interrupted." Rogan WJ, Ware JH. Exposure to lead in children-how low is low enough? N Engl J Med. 2003.