Advisory Committee On Childhood Lead Poisoning Prevention (ACCLPP): Mee= ting Minutes - March 9-10, 2004 - Baltimore, Maryland

March 9,= 2004

Open= ing Session
Update on LPPB Activities
Update on the Strategic Planning Proce= ss by State and Local CLPPPs
High Intensity Screening in Chicago's Strategic Elimination Plan=
Lead in Drinking Water
Update on the Pr= imary Prevention Document
Demonstration of= a Web-Based Housing Registry
Update on National Center for Environmental Health/Agency for T= oxic Substances and Disease Registry Activities
Update on the Adverse Healt= h Effects of BLLs <10 =C2=B5g/dL Workgroup Report
Update by the Ad Hoc Policy Workgroup
PublicComment Period

March 10, 2004

Unfinished ACC= LPP Business

Lead Exposure and Pregnancy
- Overview
- <= a href=3D"http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/nceh/lead/acclpp= /meetings/minutes/2004marminutes.htm#Management%20of%20Pregnant%20Women%20w= ith%20EBLLs" class=3D"tp-link-policy tp-external-link-fix" target=3D"_self"= >Management of Pregnant Women with EBLLs
- Clinical Care
- = L= ead Exposure During Pregnancy Studies
- Panel Discussion
New ACCLPP Business
Public Comment Period=
Clos= ing Session

The D= epartment of Health and Human Services (HHS) and the Centers for Disease Co= ntrol and Prevention (CDC) convened a meeting of the Advisory Committee on = Childhood Lead Poisoning Prevention (ACCLPP). The proceedings were held on = March 9-10, 2004 at the Admiral Fell Inn in Baltimore, Maryland.

Opening Session

Dr. Carla Campbell, the ACCLPP= Chair, called the meeting to order at 8:47 a.m. on March 9, 2004. She welc= omed the attendees to the proceedings and opened the floor for introduction= s. The following individuals were present for the deliberations.

Dr. Mary Jean Brown,
Executive Secretary

<= strong>ACCLPP Ex-Officio/Liaison Members
Mr. Byron Baile= y (HRSA)
Dr. Michael Bolger (FDA)
Ms. Anne Guthrie (AHH)
Dr. Krist= ina Hatlelid (CPSC)
Dr. Ezatollah Keyvan-Larijani (CSTE)
Dr. David Ja= cobs (HUD)
Ms. Patricia McLaine (NCHH)
Ms. Jacqueline Mosby (EPA)
= Dr. George Rodgers, Jr. (AAPC)
Dr. Walter Rogan (NIH)
Mr. Robert Rosc= oe (NIOSH)
Dr. Jan Towers (AANP)

CDC Representat= ives
Dr. Henry Falk, NCEH/ATSDR Director
Ms. Bonnie Dyck=
Ms. Crystal Gresham
Ms. Janet Henry
Mr. Rob Henry
Dr. David Ho= ma
Mr. Penn Jacobs
Mr. Jeff Jarrett
Dr. Thomas Matte
Mr. James = Rabb
Dr. Nimia Reyes
Ms. Barbara Rogers

Pr= esenters and Guests
Dr. Victoria Binetti (EPA)
Dr. Craig= Boreiko (International Lead
Zinc Research Organization, Inc.)
Ms. Ba= rbara Conrad (Maryland DOH)
Ms. Anne Evens (Chicago DOPH)
Dr. Howard = Hu
(Harvard School of Public Health)
Jane Luxton, Esq. (King & Sp= alding)
Reuben Koclyk, Esq. (Arnold & Porter)
Mr. Russell Riggs (= National Association
of Realtors)
Dr. Michael Shannon (Harvard Medica= l
School) [via conference call]
Timothy Sparapani, Esq. (Dickstein,Shapiro, Morin & Oshinsky)

The attendees joined Dr. Campbell in r= ecognizing and applauding the valuable contributions of three members whose= terms will expire in May 2004: Drs. Helen Binns, Richard Hoffman and Sergi= o Piomelli. The outgoing members will receive a plaque and thank-you letter= in appreciation of their service on ACCLPP. Dr. Piomelli noted that the AC= CLPP charter states members are appointed for four years, but the three out= going members have only served 18 months. He was insulted and would have re= fused the appointment if he had prior knowledge that the term would be shor= ter than four years. Dr. Piomelli plans to write a letter to the HHS Secret= ary asking for an extension of his appointment and will resign if the reque= st is not granted. Dr. Campbell explained that due to a freeze on appointin= g new members, a lapse occurred between ACCLPP positions being vacated and = new appointments being made. The lapse resulted in some members being appoi= nted for shorter terms. She advised Dr. Piomelli to express his concerns to= the HHS Secretary.

Dr. Mary Jean Brown, the Lead Poisoning Preventi= on Branch (LPPB) Chief and ACCLPP Executive Secretary, asked that the recor= d reflect LPPB=E2=80=99s appreciation of the time, attention, dedication an= d expertise the three outgoing members have contributed. She reminded the m= embers of their responsibility to recuse themselves from discussions that p= resent an actual or perceived conflict of interest.

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Update on LPPB Activities

Dr= . Brown provided a status report on projects LPPB initiated or completed si= nce the previous ACCLPP meeting. One, a Window Symposium was convened in No= vember 2003 with a multi-disciplinary panel of ~40 experts to discuss the c= ost, energy and housing benefits, and health effects related to window repl= acement. The symposium also focused on the need to quantify energy savings = for public health departments and to estimate and demonstrate property valu= es. Participants were from the health, energy, construction, rental propert= y and public housing fields and represented the decision analysis, economic= s, public health, clinical medicine and policy development disciplines. The= participants were asked to specifically focus on the following questions d= uring the deliberations.

What outcomes should be included in a c= ost-benefit analysis of window replacement in existing single and multi-fam= ily dwellings, such as energy savings and lead hazard reduction?
Wh= at are reasonable estimates and ranges of costs that could be used in a dec= ision analysis?
What essential research should be conducted to capt= ure the relationship between window replacement and each outcome, such as d= ecreased asthma, lower blood lead levels (BLLs), lead poisoning prevention = and energy efficiency?
What are the barriers and incentives to part= icipation for property owners and managers who are interested in participat= ing in a window replacement program?
What new legislative initiativ= es or modifications to existing legislation are needed to support this acti= vity?
What public monies or other funding could be mobilized for wi= ndow replacement, particularly in distressed or subsidized housing?

What types of work practices could be recommended?

The symposium participants raised several important points during the d= iscussion. Window replacement can prevent or reduce a child=E2=80=99s BLL a= nd also plays a role in asthma. Leaky, poorly maintained or improperly inst= alled windows can cause moisture and may lead to mold-related asthma trigge= rs. Windows serve as high-risk surfaces for childhood lead poisoning becaus= e window sills and a young child=E2=80=99s mouth are approximately at the s= ame level and window troughs are highly leaded. Substantial evidence has be= en collected demonstrating that window replacement successfully reduces lea= d contamination.

For example, an evaluation of the U.S. Department o= f Housing and Urban Development (HUD) Lead Hazard Control Grant Program was= published in 1999 and showed that dust lead levels (DLLs) on window sills = and troughs significantly declined after replacement. Follow-up of the same= houses until the present showed that the decrease in DLLs was persistent o= ver time. No evidence has been collected demonstrating that DLLs in window = sills or troughs substantially increased since window replacement. However,= the impact of window replacement on BLLs and other health conditions is le= ss clear and more difficult to capture, particularly the relationship among= moisture, mold and asthma. Mold acts as a trigger for persons with asthma,= but the role of exposure to mold in causing asthma in children is uncertai= n.

The symposium participants reached the following conclusions. Tar= geted window replacement in low-income homes that makes housing more energy= -efficient and affordable is worthy of government support and incentives. S= uccessful strategies include using tax incentives, blending existing federa= l funding, involving manufacturers and retailers in educational activities,= and engaging the insurance industry. Window replacement can satisfy histor= ic preservation concerns if these issues are identified early in the proces= s. To advance this activity, LPPB and the National Center for Healthy Housi= ng will jointly develop a white paper to describe the Window Symposium outc= omes and outline responses of the expert panel to the questions. The white = paper will serve as a reference document for health department and housing = personnel who have an interest in pursuing window replacement.

LPPB = will create an easy-to-read and short companion document to the white paper= and will also develop a decision tool to assist contractors and others in = determining whether window replacement is cost-efficient for a particular h= ome. LPPB will design activities to address barriers that were identified b= y the participants. In particular, the U.S. weatherization program is well = accepted by property owners of low-income units and other types of housing.= However, consideration should be given to justifying the benefits of windo= w replacement in an effort to raise the $2,500 cap per unit for weatherizat= ion activities. LPPB was pleased to convene a successful forum that allowed= multi-disciplinary experts and representatives of disparate communities co= llectively address housing and health issues.

Two, CDC and HUD will = jointly issue a letter to health and housing departments to confirm the aut= hority of these agencies to share addresses where lead-poisoned children cu= rrently live or addresses where a series of lead-poisoned children lived in= the past. The letter will contain the following language. The Privacy Rule= authorizes local entities to release the information because CDC, HUD and = the U.S. Environmental Protection Agency (EPA) are authorized by statute to= conduct lead poisoning prevention activities. Release of the information i= s consistent with the missions and capabilities of the agencies and address= es the public health problem of lead poisoning. Programs may disclose to th= e Office of Healthy Housing and Lead Hazard Control, without parental autho= rization, the addresses of housing units that have a history of lead-based = paint hazards or children with elevated BLLs (EBLLs). HUD will use the data= to determine whether these properties are in compliance with the federal L= ead Disclosure Rule.

EPA, HUD, the Department of Justice and local h= ealth programs have completed 34 enforcement settlements related to the fai= lure of property owners to adhere to the disclosure rule. In these cases, l= arge property owners did not inform tenants of potential lead-based paint h= azards. To date, $561,000 in penalties has been collected and commitments w= ere given to test and abate lead-based hazards in >166,000 high-risk ren= tal units. An additional $421,750 has been made available to fund a series = of projects, such as the purchase of portable blood lead testing devices, p= rovision of lead hazard abatement training, and implementation of outreach = programs.

Three, LPPB=E2=80=99s recent research and surveillance act= ivities include the publication of several articles in the Morbidity and Mo= rtality Weekly Report (MMWR). Ayurveda is a traditional system of medicine = primarily practiced in India and South Asian countries; minerals, herbs, an= imal products or any combination of the three are used. LPPB=E2=80=99s MMWR= article on this issue focused on lead poisoning in adults associated with = the use of ayurvedic medications. A case was reported from New Hampshire wi= th a BLL of 81 =C2=B5g/dL. An analysis of the patient=E2=80=99s medications= showed lead contents of 12,000 and 17,000 ppm. In addition to New Hampshir= e, the investigation led to the identification of 12 other ayurveda cases w= ith exceptionally high BLLs in California, Massachusetts, New York and Texa= s. LPPB was particularly concerned because some of the highly leaded medica= tions were being used to treat infertility in women. An ayurveda health ale= rt will be released in the next two months.

A lead screening study w= as conducted among prenatal patients in two low-income clinics in Monterey = County, California along the U.S./Mexico Border. Of 214 women tested, all w= ith EBLLs were seen in one clinic, 27 had BLLs >10 =C2=B5g/dL and 8 had = BLLs >20 =C2=B5g/dL. The women represented 13% of the prenatal populatio= n screened at the clinic and most were from Oaxaca, Mexico. Dried grasshopp= ers or =E2=80=9Cchapulines=E2=80=9D with lead levels of 47,000 ppm were amo= ng the potential foods identified as sources of the EBLLs.

Four, LPP= B is using geographic information systems (GIS) technology for program plan= ning and evaluation of a study in Cleveland. The project will combine tax a= ssessor, blood lead screening and Medicaid data to identify under-served ar= eas of the city. The goal of the study is to present data in a meaningful, = useful, simple and quick format to best serve the needs of pediatric health= care providers. LPPB is preparing a manual to describe common data errors t= hat prevent geocoding as well as techniques to avoid these errors. LPPB wil= l also post GIS 2000 census data on its web site to allow childhood lead po= isoning prevention programs (CLPPPs) to quickly collect census data on old = housing, poverty, rental property and other issues.

LPPB used GIS to= detect an unexpected number of EBLLs around the Charleston, South Carolina= Naval Yard. This area did not have a large amount of old housing and would= not have been routinely tested, but lead paint dust was distributed in loc= al neighborhoods from shipyard work and by workers who brought paint home f= or residential use. LPPB is using GIS in conjunction with the Washington, D= C health department to evaluate the impact of recent changes in water chemi= stry on BLLs of resident children.

Five, LPPB and CDC=E2=80=99s othe= r communicable disease programs are adopting the National Electronic Diseas= e Surveillance System (NEDSS). State health departments will use the electr= onic and laboratory-based reporting system to obtain data on STDs, tubercul= osis, bacterial meningitis and other diseases from laboratories and forward= the information to CDC. NEDSS will also maintain addresses, patient demogr= aphics and disease types. Release 1 of NEDSS is expected to be issued by th= e end of 2004, but lead will not be included in this version. However, Nebr= aska and South Carolina are currently deploying NEDSS to transmit data to C= DC on vaccine preventable conditions, hepatitis and other diseases. To date= , 29 other states have also expressed an interest in implementing NEDSS by = the end of 2004. NEDSS will provide LPPB with a wealth of information and c= apacity to identify risk factors at geographic and population levels.
Six, LPPB is in the process of developing a lead program area module (PAM= ) that will be the first environmental health condition included in the NED= SS-based system. LPPB completed the prioritization of PAM features by conve= ning meetings to obtain input from state and local partners that use other = computerized database systems to manage cases. Joint application developmen= t sessions were also held with state and local program staff to discuss dev= elopment of the lead PAM and usefulness of the system at state and local le= vels. Over the next 18 months, LPPB expects to migrate data from the System= atic Tracking of Elevated Lead Levels and Remediation system into the lead = PAM.

Seven, LPPB is currently focusing on several electronic laborat= ory reporting issues. Most notably, efforts are being made for health depar= tments to agree on using HL7 and other conventional techniques in submittin= g data to NEDSS. The overarching goal of these activities is to develop a r= apid, common and less labor-intensive electronic laboratory reporting syste= m.

Eight, LPPB is designing health education initiatives due to surv= ey results that show 17 of 37 funded states have no laws to enforce remedia= tion of homes with children who have EBLLs. LPPB is partnering with the All= iance for Healthy Homes (AHH) and the National Conference of State Legislat= ors to compile health education information for state legislators. The mate= rials will contain specific data for each state, including the total number= and percentage of pre-1950 housing units; the total number of children <= ;72 months of age and those in poverty; the total number of children tested= in 2001 and those with confirmed BLLs >10 =C2=B5g/dL; requirements for = dust clearance testing; the proportion of lead paint abatement completed or= ordered by the health department; and the existence of a local or state or= dinance requiring home inspection and repair of lead hazards in the home of= a child with an EBLL. LPPB acknowledges the importance of health education= projects because capacity to enforce remediation in states with a signific= ant amount of high-risk housing and large populations of lead-poisoned chil= dren will be critical in reaching Healthy People 2010 goals.

Nine, L= PPB is engaging in efforts to improve its vocabulary because =E2=80=9CEBLLs= ,=E2=80=9D =E2=80=9Cundue lead absorption,=E2=80=9D =E2=80=9Clead poisoned= =E2=80=9D and similar terms may not be understood by parents and other care= givers of children with EBLLs. LPPB will convene a series of focus groups = to improve and obtain reactions to the current lead poisoning terminology. = Input from the focus groups will be used as a basis in developing a new lea= d vocabulary that will be meaningful to LPPB=E2=80=99s target audience. One= white, one Hispanic and two black focus groups with non-college educated m= others or female care givers of children <6 years of age who have an ann= ual income <$35,000 will be conducted by telephone. Each of the U.S. reg= ions in urban areas will be represented.

Ten, LPPB will release a vi= deotape in May 2004 in an effort to improve blood lead sampling techniques.= The videotape will illustrate errors that can cause contamination of capil= lary blood lead samples and preventive measures.

Eleven, LPPB taught= a five-day classroom course and convened a five-day activity in the field = to engage individuals in program evaluation. Harvard School of Public Healt= h students collaborated with LPPB project officers to learn more about prog= ram evaluation, review the public health process, obtain practical skills a= nd include this experience on resumes. The project officers and students co= nducted several field activities throughout the country.

In Alabama,= case management was evaluated to determine the extent to which protocols a= re followed and whether case management contributes to decreased BLLs in re= ferred children. In California, education of public health nurses who are n= ot currently involved in lead was assessed to determine if nurses have time= to inform families about lead poisoning prevention during home visits and = whether changes in practice decreased lead exposure in high-risk families. = Other program evaluations included a screening and outreach program by a co= mmunity-based organization (CBO) in Connecticut; new abatement referral pro= cedures in Detroit; case management in Indiana; an evaluation template for = media campaigns in New York City; a housing-oriented primary prevention pro= ject in North Carolina; and the =E2=80=9CLead-Safe Baby Program=E2=80=9D in= Philadelphia. Over the next six to eight months, project officers will beg= in implementing project evaluations the students wrote in methodology paper= s. The course was extremely beneficial to project officers, students and le= ad programs.

Dr. Hoffman inquired about the role of LPPB=E2=80=99s G= IS projects in improving screening of all Medicaid children. He also asked = whether NEDSS will present confidentiality problems since the system will r= eveal the specific address of a child with lead poisoning, tuberculosis or = another condition. Dr. Brown replied that LPPB will use GIS in the Clevelan= d study to pinpoint specific locations in communities where Medicaid childr= en have or have not been screened. The initiative will be designed to resul= t in active outreach. To the second question, she clarified that NEDSS will= not raise confidentiality issues because state health departments are requ= ired to report these diseases. Data will be submitted to CDC through NEDSS = with no identifiers.

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Update on the Strategic Planning Process by State and Local CLPPP= s

Mr. Rob Henry, the Program Services Section Te= am Leader, reported that LPPB funded 42 CLPPPS in 37 states and five cities= in FY=E2=80=9903 as a step in reaching the Healthy People 2010 goal of eli= minating childhood lead poisoning. LPPB also convened workgroups with inter= nal staff and federal, state and local partners to discuss strategies to en= sure success in this area. In response to this input, LPPB changed several = program requirements in the cooperative agreement for state and local progr= ams. Funding is now targeted to areas in the country with populations at hi= ghest risk. The five state CLPPPs with the highest number of children at ri= sk for EBLLs were previously asked to address primary prevention, but all C= LPPPs are now required to focus on this issue. LPPB and CLPPPs will strengt= hen collaboration to support protective policies in 17 states that have no = laws to protect children with EBLLs.

The most significant change in = the cooperative agreement is the requirement for CLPPPs to develop lead poi= soning elimination plans. In general, CLPPPs will be expected to strengthen= capacity in identifying and reaching vulnerable populations; target resour= ces to high-risk children even in states with universal screening; place he= avy emphasis on Medicaid matching; develop strategies to link BLL data to i= nformation on children who are at high risk for other conditions; design pr= imary prevention activities; and establish policies to address and protect = children.

In particular, LPPB established several guiding principles= to assist CLPPPs in creating the plans. =E2=80=9CElimination=E2=80=9D shou= ld be defined at the state level due to differences in populations and prob= lems by neighborhood, city, jurisdiction and other geographic areas of the = state. Participation by leadership in strategic planning activities should = be demonstrated and a wide range of stakeholders should be engaged as well,= including EPA, HUD, public health departments, Medicaid and environmental = regulatory agencies. Data should be compiled to clearly describe the proble= m. Existing policies or enforcement actions that currently protect children= and assist in lead poisoning prevention should be thoroughly reviewed.
=
Resources for strategic plans should be identified and matched to a wor= k plan with measurable goals and objectives. A strong evaluation component = that can be revised and improved over time should be incorporated into stra= tegic plans. In terms of the time-line, CLPPPs are required to submit non-c= ompeting continuation applications and draft elimination plans to CDC on Ma= rch 19, 2004; final elimination plans are due on June 30, 2004. LPPB will u= se the April 2004 CDC Partners Conference as an opportunity to provide tech= nical assistance to CLPPPs in finalizing the elimination plans. Implementat= ion and evaluation of the plans will continue throughout 2005 and the progr= am announcement will be re-competed in 2006.

Throughout the strategi= c planning process, LPPB will remain actively involved with CLPPPs; ensure = that project officers are regularly informed; and provide technical and sci= entific assistance through site visits, conference calls, training, confere= nces, meetings, special projects and evaluation. These activities will iden= tify staff who can assist CLPPPs in resolving problems and will also help C= LPPPs to improve surveillance activities and develop work plan goals and ob= jectives. LPPB has released a request for proposals to redesign its nationa= l lead training center to be more dynamic, thorough and specialized. The pr= oject will provide general and focused training to CLPPP personnel with spe= cial skills, including case managers, new program managers and epidemiologi= sts.

Dr. Keyvan-Larijani suggested that LPPB consider a different ap= proach in the strategic elimination plans. For example, resources could be = initially allocated to high-risk jurisdictions only to provide an opportuni= ty for these CLPPPs to reach the same BLLs as other areas in the state. All= CLPPPs in the state could then collectively take actions toward achieving = elimination. Dr. Brown expressed concern with this suggestion because lead = poisoning elimination requires considerable infrastructure and support. If = resources are only targeted to high-risk areas, infrastructures would most = likely need to be reestablished in low-prevalence jurisdictions in the futu= re.

Dr. Hoffman inquired about the ability of the 13 non-funded stat= es to successfully compete in the 2006 program announcement with grantees t= hat have maintained stronger infrastructures and developed elimination plan= s. Mr. Henry confirmed that LPPB is currently considering strategies to clo= sely collaborate with non-funded states, particularly those that have not b= een funded in recent history and for which there are no data available to d= escribe childhood lead poisoning problems. LPPB has also discussed the poss= ibility of developing a passive surveillance system for those states that h= ave low prevalence. Dr. Stephens conveyed that a progressive approach may b= e more practical in which cities, states and counties would first reduce BL= Ls and then focus on elimination. He also raised the possibility of LPPB cr= eating and distributing a legislator handbook that describes relevant laws = and policies for lead poisoning elimination. To assist in this effort, ACCL= PP could identify and suggest laws for each state.

Mr. Henry reporte= d that LPPB is currently collaborating with AHH to collect examples of prim= ary prevention activities from CLPPPs and publish these models in a manual.= The section of the manual that will be devoted to policy and enforcement c= ould perhaps be designed as a stand-alone document for legislators. Dr. Cam= pbell added that a wealth of information currently exists for state legisla= tors to access, such as model laws on the National Conference of State Legi= slators web site.

Dr. Rogan noted that LPPB=E2=80=99s activities act= ually target the =E2=80=9Cfrequency=E2=80=9D of EBLLs among screened childr= en rather than =E2=80=9Cprevalence=E2=80=9D of EBLLs. He also pointed out t= hat some of the strategic activities LPPB will evaluate do not have support= ing research. He asked if any of the initiatives can be designed to produce= information that can be generalized to other settings. Dr. Brown clarified= that some of LPPB=E2=80=99s activities are research projects, while others= are program evaluation projects. For example, some of LPPB=E2=80=99s evalu= ation projects are randomized control trials, while the Chicago High Intens= ity Targeted Screening (HITS) program was intended to obtain prevalence dat= a on EBLLs using a clustered stratified sample. LPPB and EPA have been disc= ussing the feasibility of conducting a similar project in Mississippi. Howe= ver, Dr. Brown did not see the purpose of attempting to obtain prevalence r= ates from Massachusetts and other well-established lead programs.

Dr= . Binns suggested other information for LPPB to include in the state legisl= ator report cards, such as whether the lead program is a CDC grantee, the n= umber of years of funding received, and contact information for the state e= nvironmental leader. She also advised LPPB to begin outreaching to and part= nering with unfunded states by conducting small studies on prevalence rates= of EBLLs, housing descriptions and similar issues. Dr. Brown noted on the = one hand, LPPB has a strong interest in analyzing a surveillance system in = a state that has either achieved elimination or low prevalence. On the othe= r hand, LPPB has received level funding for the past eight years and will n= ot cut program services to conduct these types of special projects.

= Dr. Lynn urged LPPB to carefully consider the presentation of information a= nd tone of messages that will be conveyed in the state legislator report ca= rds. Similar to federal agencies, states also have considerable budget cons= traints and may not view lead issues as a priority compared to other compet= ing activities. Moreover, many states may be reluctant to accept guidance f= rom federal agencies. Dr. Brown confirmed that LPPB will consider these imp= ortant comments and structure the report cards to illustrate the resource i= ntensity of taking different approaches. Dr. Hoffman announced that health = institutes are privately funded organizations for legislators to access hea= lth data in one location. The health institutes provide legislators with vi= tal statistics, surveillance data, Medicaid costs and similar information. = He encouraged LPPB to collaborate with these groups in disseminating the st= ate legislator report cards.

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<= /a> High Intensity Screening in Chicago's Strategic Elimination Pla= n

Ms. Anne Evens, the Chicago Department of Publ= ic Health Lead Poisoning Prevention Program Director, described methods to = assess BLLs and screening of high-risk children in Chicago. Based on 2001 d= ata, Chicago had 308,415 children <6 years of age. Of those, 28% of chil= dren 1 year of age and 51% of children 2 years of age had received a BLL te= st; 12% of those tested had BLLs >10 =C2=B5g/dL; and 45% of children bor= n in Chicago each year are enrolled in Medicaid. Chicago has 660,000 pre-19= 50 housing units and 88,000 housing units that are hazardous to children. O= ne in three children tested has an EBLL in some Chicago neighborhoods. Howe= ver, childhood lead poisoning has been eliminated as a public health proble= m in 14 of 77 jurisdictions in Chicago.

The Chicago CLPPP is a multi= faceted program with 72 staff who focus on surveillance, blood lead screeni= ng, medical case management, environmental inspections and enforcement, and= the HUD abatement grant. The Chicago CLPPP incorporated four major strateg= ies in its elimination plan. Additional funding is leveraged for abatements= related to window replacement in a lead-safe manner, paint stabilization a= nd other lead hazard interventions. Efforts are currently underway to enfor= ce laws at federal, state and local levels to increase the interest of prop= erty owners in making properties lead safe and to provide financial incenti= ves. Projects are designed to increase identification of young children wit= h EBLLs and improve screening, particularly in high-risk neighborhoods. An = evaluation component is incorporated into the plan to measure progress towa= rd elimination.

The Chicago CLPPP implemented the first HITS in 2001= to determine the prevalence of children <6 years with EBLLs and to eval= uate screening efforts. The activity was later expanded to collaborate with= the immunization program and CBOs to assess other health indicators, to in= crease awareness of EBLLs in communities, and to improve screening of child= ren enrolled in Medicaid. HITS has been conducted three times in six commun= ities. These communities account for nearly 33% of BLLs >20 =C2=B5g/dL i= n the city according to city surveillance data. The fourth HITS will be lau= nched on April 3, 2004. The effectiveness of screening widely varies by nei= ghborhood in Chicago.
Surveillance data shows a range of children < 6= years screened as low as 26% to a high of 47% in high-risk communities.
The HITS components include development of a protocol, review by an In= stitutional Review Board, staff training, blood lead testing, measles and r= ubella titers, informed consent, health data surveys, cleaning and hepa vac= uum training, medical case management, home inspections, abatement, data an= alysis, evaluation, and recommendations for CLPPP screening initiatives. On= the one hand, HITS validated prevalence estimates; gathered baseline data = for sentinel surveillance of high-risk neighborhoods; identified 27% of chi= ldren with BLLs >10 =C2=B5g/dL who would have been missed by routine scr= eening efforts; resulted in new and improved screening efforts; played a ro= le in enrolling children into primary care and increasing measles and rubel= la immunization rates to 85%-90%; raised community awareness of EBLLs; stre= ngthened knowledge of other health indicators; and served as an activity th= at was accepted by community groups and residents. The most significant out= come from HITS activities has been that 61% of children tested in these hig= h-risk neighborhoods had not been previously screened. Of those, 70% were e= nrolled in Medicaid.

On the other hand, HITS is complex to manage, r= equires challenging work hours, and raises safety and security concerns. Mo= reover, the ability to generalize HITS to other settings is questionable. H= ITS is also costly and will be impractical for a citywide project. On avera= ge, $300 was required to screen each child, $320,840 was needed to implemen= t the first three HITS, and $52 per child was allocated for fixed outreach.= These costs were found to be much higher than those in pediatric offices o= r public clinics.

After gathering HITS data, the Chicago CLPPP focus= ed on reasons why 61% of children tested had not been previously screened f= or blood lead. The analysis showed that children were not presenting for we= ll child visits and physicians were failing to screen during well child vis= its. The Chicago CLPPP=E2=80=99s review of Medicaid billing records showed = that 25%-33% of children <6 years of age had not had a well child visit = in the previous 12 months. Since adherence to well child visits was found t= o be better among children 0-12 months of age, the Chicago CLPPP is partner= ing with the immunization program to increase well child visits among child= ren 13-24 months of age.

The Chicago CLPPP also collaborated with th= e immunization program to audit >20,000 physician charts of lead screeni= ng and immunization rates in >300 clinical settings. Citywide results sh= owed that 67% of providers in high-risk neighborhoods in Chicago are testin= g children according to the guidelines. However, physicians still cited sev= eral barriers to testing, including insufficient staff to draw blood on sit= e, the cost to parents for off-site testing, the lack of free blood lead te= sting throughout the state, problems associated with drawing blood from you= ng children, and insufficient time to test during well child visits. Surpri= singly, providers did not perceive =E2=80=9Clead poisoning is no longer a p= roblem=E2=80=9D as a barrier to testing.

Overall, HITS was found to = be an effective educational tool because most providers have no lead poison= ing data on their patients. As a result, the Chicago CLPPP implemented seve= ral activities that have resulted in improved screening rates. Recommendati= ons are made and follow-up assessments are conducted for providers with the= lowest screening rates. Healthcare providers are educated through conferen= ces, data mailings and web-based classes with continuing medical education = credits. Pediatric and family planning medical residents are invited to par= ticipate in the Chicago CLPPP for one day and conduct a site visit with an = inspector.

Charts of blood lead testing, immunization rates and well= child care visits will continue to be reviewed in providers' offices. Feed= back and recommendations for improvement will be given based on these asses= sments. Educational activities will be specifically targeted to certified n= ursing assistants and medical technicians as well. The Chicago CLPPP also d= esigned initiatives for parents to increase well child visits, including ed= ucational materials distributed through birth certificate inserts, mailings= and community meetings; targeted outreach to untested children 13-24 month= s of age enrolled in Medicaid; free blood lead testing at Women, Infant and= Children sites, day care centers and churches; and incentives for testing = in certain settings.

Dr. Hoffman remarked that due to seasonality, A= pril 3, 2004 may not be the best date to launch the fourth HITS. Children w= ith EBLLs may not be identified at this time of the year and the overall EB= LL rate may be affected. He noted that June-August are the optimal months t= o obtain EBLLs because windows are more likely to be open and children part= icipate in more outdoor activities during this time of year. Dr. Hoffman al= so raised the possibility of the Chicago CLPPP using the second dose of mea= sles, mumps, rubella immunization to measure adherence to well child visits= since older children receive this dose.

Ms. Evens conveyed that the= Chicago CLPPP selected April for the fourth HITS since children will be ho= me for spring break. Based on the earlier HITS, late summer and early fall = were not found to be optimal times due to a high refusal rate. Many childre= n are tested during these seasons and most parents are reluctant to have th= eir children undergo another blood draw. However, the Chicago CLPPP will be= mindful of seasonality. Dr. Piomelli explained that blood drawn from a fin= ger stick and placed onto filter paper is a successful method to test child= ren and can be used by providers. This technique may address the issue of i= nsufficient staff to draw blood onsite. He emphasized the need for CDC to e= ducate providers in using this procedure. Dr. Piomelli also underscored the= importance of the members collectively reviewing and commenting on the HIT= S results because the study is pertinent, relevant and germane to ACCLPP=E2= =80=99s function. Dr. Campbell confirmed that ACCLPP will discuss outstandi= ng issues related to HITS during the =E2=80=9Cunfinished business=E2=80=9D = agenda item on the following day.

<= i class=3D"icon-angle-up"> Top= of Page

<= /a>Lead in Drinking Water

Dr. Victori= a Binetta of EPA described recent events related to water quality in the Di= strict of Columbia (DC). The Corps of Engineers owns and operates the Washi= ngton Aqueduct and uses the treatment plant to draw and treat water from th= e Potomac River and distribute treated water to ~1 million DC and northern = Virginia residents through the Water and Sewer Authority (WASA). EPA regula= tes drinking water quality under the Safe Drinking Water Act and also manag= es lead in drinking water under the Lead and Copper Rule. The maximum conta= minant level (MCL) is the maximum allowable concentration of a contaminant = in treated water. However, MCLs and MCL goals frequently differ because MCL= s are determined on the basis of feasibility and cost of treatment, while M= CL goals are established by health-based levels. EPA=E2=80=99s MCL for lead= was 50 ppb in 1975, but the MCL goal has been revised since that time.
=
Lead in water is generally caused by plumbing systems in buildings, but= is rarely a problem in the water source or treated water. As a result, EPA= regulates water quality for lead differently than for other contaminants. = Most notably, action levels rather than MCLs have been established for lead= and treatment technology is used to regulate lead. Water suppliers must ad= just water chemistry to make water as non-corrosive as possible and ensure = that lead is not leached from lead pipes or other lead fixtures. Despite th= e differences for lead, water suppliers must still achieve the objectives o= f other water quality regulations. Utility companies must monitor water fro= m taps that is distributed in individual homes to ensure corrosion is contr= olled and lead in residential faucets is minimized. For purposes of monitor= ing, a pool of homes are selected to represent =E2=80=9Cworst-case=E2=80=9D= scenarios. If lead-bearing or lead service lines connect a house to a wate= r main within a city, 50% of the sample must be homes with lead service lin= es. Sample homes are also selected based on vintage, such as construction d= uring a time when lead sodder was more commonly used.

In monitoring = homes, water suppliers are expected to achieve a regulatory threshold and m= ust not exceed the action level for lead of 15 ppb. For example, 90% of hom= es in the sample may have lead levels of <15 ppb, but no more than 10% c= an have lead levels of >15 ppb. Utility companies have different monitor= ing schedules based on the size of the water system; however, monitoring is= primarily conducted by homeowners who obtain and bottle water samples for = pick-up and analysis by the utility company. WASA offered a $25 incentive f= or homeowners to provide samples, but many individuals volunteered to parti= cipate.

Based on early sampling results, the worst-case homes showed= a mean level of 37 ppb and triggered the development of a corrosion contro= l plan. Extensive studies were also conducted to determine optimal corrosio= n control strategies for DC, such as controlling PH and alkaline levels or = adding a corrosion inhibitor. EPA conditionally approved DC=E2=80=99s corro= sion control plan, but sampling results from the worst-case homes in June 2= 002 showed a dramatic increase in lead levels from 8-75 ppb. The cause for = the change in water chemistry is still unknown at this point.

DC too= k several actions to comply with EPA regulatory requirements after the acti= on level of 15 ppb was exceeded. Corrosion control treatment was reviewed a= nd optimized and tap water monitoring was intensified. Brochures, public se= rvice announcements and targeted outreach initiatives to pregnant women, ch= ildren and other high-risk populations were used to educate customers about= lead health effects, the occurrence of lead in drinking water and actions = to reduce lead exposure. Removal of lines that connect water mains to homes= was initiated since the utility company had lead service lines and already= optimized corrosion control. To date, <7% of 23,000 lead service lines = have been replaced in DC, but utility companies are not required to replace= pipes if water samples contain <15 ppb of lead. The monitoring schedule= was increased from sampling 50 worst-case homes per year to 100 every six = months.

Of every six single-family residences in DC, ~1 is served by= a lead service line. WASA began taking one-liter water samples from lead s= ervice lines to identify those of highest priority in which lead leached fr= om immediate plumbing fixtures nearest to faucets. WASA saw very high lead = levels and an extraordinary amount of leaching based on 2003 sampling resul= ts from water in lead service lines. From March-September 2003, WASA tested= 4,613 lead service lines and determined that only 27% of samples were belo= w the action level of 15 ppb, while 18% were >100 ppb. The previous educ= ational campaigns and other public outreach activities were not effective b= ecause the seriousness of the problem was not known at that time and had no= t been conveyed. Moreover, press coverage heightened public awareness.
<= br>Follow-up actions were taken in response to the more recent information = on changes in water chemistry. DC, EPA, WASA and the Washington Aqueduct re= ached consensus on issuing new guidance. Consumers were generally advised t= o flush taps for 60 seconds after an inactive period, draw cold water for d= rinking and cooking, and clean faucet strainers once per month. WASA survey= ed historical housing records to identify lead service lines, but admits a = 10% level of uncertainty in detecting all lines. Consumers who may have lea= d service lines were specifically advised to flush taps for ten minutes aft= er significant water use before drawing water for drinking or cooking. Info= rmation was mailed to residents in these households to encourage water samp= ling. Disinfection practices were revised to reduce compounds in the water = supply and better control biofilm in distribution pipes. Water meters were = replaced in 18,000 homes in 2002-2003.

An advisory was issued on Feb= ruary 26, 2003 recommending that pregnant women, nursing mothers or childre= n <6 years of age in homes with actual or potential lead service lines n= ot drink unfiltered tap water or use the water to prepare formula or concen= trated juices. The DC Department of Health (DOH) is offering free BLL testi= ng for residents in homes with actual or potential lead service lines; cond= ucting follow-up with home visits and case management of target populations= ; and collaborating with CDC to assess BLLs throughout DC. EPA expects WASA= to accelerate the testing schedule and lead service line replacement. WASA= will provide filters or an alternate water source for highest-risk populat= ions.

A preliminary report will soon be completed identifying the ne= xt series of studies that need to be conducted. EPA Headquarters and region= al offices as well as state regulatory agencies were contacted to determine= if high lead levels in water had been seen in other parts of the country. = To date, similar water quality problems have not been reported outside the = DC area, but EPA will still conduct a national compliance review to ensure = the action level is not exceeded in other states. For example, all water sa= mples taken in Falls Church, Virginia were found to be <4 ppb, but lead = levels in water above the action level were detected in 50% of samples from= Arlington, Virginia. Both Falls Church and Arlington are conducting additi= onal sampling in schools and households. EPA will review its regulatory req= uirements for public education since the outreach and guidance were not suc= cessful in DC. As a result, more urgent messages on reducing lead exposure = will be communicated to the public.

Dr. Brown confirmed that CDC is = closely partnering with the DC and Arlington, Virginia health departments t= o respond and continue to monitor the lead in drinking water emergency by r= eviewing existing data and assisting in identifying new data. CDC is also s= upporting the DC lead advisory that recommended pregnant women and children= <6 years of age not drink water from houses with known lead header pipe= s or service lines unless the water was filtered or bottled. The Brita Wate= r Company supported the lead advisory as well by donating 10,000 water filt= ers for distribution to DC residents.

Dr. Brown also reported that C= DC is collaborating with the DC DOH to match water and BLL tests from 1998.= Pregnant women, children <6 years of age and all residents in homes wit= h lead levels in water of 300 ppb are being actively targeted for lead test= ing. However, any individual who requests a BLL test in an emergency room o= r other setting will receive the test. Dr. Binns was concerned that the lea= d advisory did not specifically mention =E2=80=9Cwomen of child-bearing age= =E2=80=9D as a population of concern. She encouraged EPA and the DC DOH to = partner with the media to effectively communicate health risks from lead to= adults.

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Update on the Primary Prevention Document<= /p>

Dr. Campbell reported that the latest version of the d= ocument was distributed to ACCLPP in December 2003 and revised based on com= ments from the members. At the time of the meeting, the document was to be = submitted soon to CDC for clearance. She thanked the members for their comm= ents, diligence and dedication in finalizing the document. By the next ACCL= PP meeting, the primary prevention document will have been published as a s= tand-alone CDC document and distributed to grantees for guidance.

= ;Top of Page

Ms. Patricia McLaine is the ACCLPP liaison for the National = Center for Healthy Housing. She announced that =E2=80=9CLeadSafeHomes.info= =E2=80=9D (LSH) is a web-based housing registry of property information for= Baltimore, Boston and Chicago. Several city agencies, EPA regional offices= and community groups were instrumental in developing the HUD-funded activi= ty. The project period was extended for one year to create the web site; th= e initiative is expected to be launched in March 2004. The LSH web site wil= l provide public access to the lead status of homes and lead educational ma= terials. Specific information will be displayed for each city, including a = home page, property report, community report and contacts for additional in= formation.

The property report will illustrate age and risk of housi= ng, list recommendations, describe the lead inspection history, outline add= ress and blood lead summaries, and provide links to additional information = of interest. The community report will contain a color-coded map to illustr= ate violation rates and BLLs by census tract, areas with insufficient data,= and high-risk block groups within census tracts. For example, no census tr= acts in Boston had 12% of BLLs >10 =C2=B5g/dL. The LSH web site will con= tain an interactive matcher to allow users to scan the entire city for prop= erties that were identified, inspected and de-leaded. Topics of special int= erests will be categorized by groups, including landlords, parents, healthc= are providers, city and state officials, community organizations and tenant= s. For example, the landlord page will provide information on lead contract= ors.

Each web page will be tailored for the respective city. For exa= mple, distinct symbols will be displayed on the Baltimore property report t= o illustrate the status in the Maryland lead rental registry program, such = as receipt of a full or provisional lead-free certificate, compliance with = a full or modified risk reduction standard, or program registry only. City = agencies, rental registries, abatement data and GIS mapping files were used= as data sources for the LSH web site. Overall, the web site will serve as = a powerful tool and allow data to be reviewed differently for neighborhoods= , block group areas and specific properties.

Dr. Lynn mentioned that= users may interpret the =E2=80=9Ccheck mark=E2=80=9D symbol to mean all as= pects of the home are in compliance and concern is not needed. However, she= pointed out that a de-leaded home is not necessarily a permanent solution.= Ms. Barbara Conrad, of the Maryland Department of the Environment, explain= ed that the LSH web site will have a number of potential uses. The housing = market may be impacted since landlords and other property owners may be mor= e inclined to meet lead risk reduction standards in units. Prospective home= owners and tenants will have a solid source of information to aid in the de= cision-making process about a particular property. Homeowners and tenants w= ho can document unsafe units may be able to strengthen court cases against = landlords. Advocacy groups for lead safe homes can more effectively assist = tenants and homeowners.

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Update on National C= enter for Environmental Health/Agency for Toxic Substances and Disease Regi= stry (NCEH/ATSDR) Activities

Dr. Henry Falk, = the NCEH/ATSDR Director, covered the following items in his status report. = First, the consolidation of NCEH and ATSDR was initiated in August 2003 in = response to agreement by the HHS Secretary, CDC Director, Office of Managem= ent and Budget, Congressional committees and various external groups. Maint= aining two environmental agencies in HHS that both report to the CDC Direct= or/ATSDR Administrator was not found to be an efficient process. NCEH was c= reated as a formal CDC center in 1980 after providing environmental health = expertise in response to the Three Mile Island accident. ATSDR was establis= hed by the Superfund legislation to specifically address lead and other env= ironmental health issues at Superfund sites.

Leadership, management = and administrative functions of the two agencies were consolidated rather t= han fully merged because the Superfund law still requires ATSDR to be maint= ained as a separate agency. However, the consolidation is expected to promo= te greater coordination and collaboration between NCEH and ATSDR. To date, = administrative offices of the agencies were realigned with a common leaders= hip and similar management positions were streamlined. The consolidation is= expected to be completed by the end of 2004. The consolidation will not af= fect CDC=E2=80=99s lead activities due to strong support of and continued c= ommitment to LPPB by the CDC and NCEH/ATSDR Directors. Most notably, Dr. Fa= lk was extensively involved in CDC=E2=80=99s early lead studies in the 1970= s, participated in the development of the 1991 strategic plan for childhood= lead poisoning elimination, and served as the ACCLPP Executive Secretary p= rior to his appointment as the ATSDR Assistant Administrator.

Second= , CDC=E2=80=99s Futures Initiative is a broad strategic planning effort tha= t will have a significant impact on the agency-wide structure and resources= . Due to the 9/11 terrorist attacks, anthrax episodes and outbreaks of monk= eypox and severe acute respiratory syndrome, CDC has received more media at= tention in the last two years. As a result, the CDC Director launched the F= utures Initiative to provide an opportunity for CDC to respond to public he= alth priorities as quickly as possible. The Futures Initiative is designed = to guide CDC's future directions in terms of its organization as a public h= ealth agency and issues to address. In particular, CDC will broaden its fun= ction from supporting state and local health departments to becoming more e= ngaged with the general U.S. public.

The four Futures Initiative pri= orities are partnerships, CDC's role in the U.S. health care system, applie= d research to support extramural activities, and global health. CDC spent a= considerable amount of time gathering input on these issues from partners,= stakeholders, researchers and representatives of the health care system. N= CEH/ATSDR also discussed strategies to strengthen capacity in these areas f= rom an environmental health perspective. CDC will begin implementing the Fu= tures Initiative in January 2005 by focusing on its role in preventing dise= ase and protecting public health from threats. Detailed goals for these two= focus areas will be submitted to the CDC Director by the end of March 2004= .

Dr. Hoffman inquired about the role of the consolidation in reduci= ng NCEH/ATSDR resources. Dr. Falk clarified that administrative savings wer= e distributed to programs. The consolidation did not place NCEH/ATSDR resou= rces at risk; instead, wars, tax cuts, Department of Homeland Security acti= vities and other competing priorities at the federal level are the cause of= budget constraints.

Dr. Banner asked if the consolidation will allo= w ACCLPP to become more involved with ATSDR activities, particularly lead i= ssues at the Tar Creek Superfund site. Dr. Falk explained that ACCLPP=E2=80= =99s focus depends on its charter. For example, ACCLPP is charged with addr= essing broad lead issues at the national level rather than those for specif= ic sites. In lieu of changing the charter, he suggested that updates on lea= d issues at Superfund or mining sites be provided at future ACCLPP meetings= . In terms of Tar Creek, ATSDR is currently reviewing BLL and other environ= mental data gathered from the site and will submit a report of its findings= in July 2004. Dr. Falk offered to provide an update on Tar Creek at the ne= xt ACCLPP meeting.

Dr. Ho was extremely pleased that CDC will adopt = the National Institutes of Health (NIH) model for research programs. He req= uested more details on this activity. Dr. Falk replied that the research me= chanism will be launched in the next few months. Efforts are currently bein= g made to structure a substantive extramural research program throughout CD= C and leverage funds to ensure that the activity grows and flourishes in th= e future. CDC will place emphasis on distinguishing between basic research = and applied research that will be needed to strengthen its programs.

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Update on the Adverse Health= Effects of BLLs <10 =C2=B5g/dL Workgroup Report

Dr. Thom= as Matte of CDC summarized comments that were submitted for the workgroup t= o consider while revising the report. Questions raised by these comments in= cluded; whether a policy discussion should be included in the background se= ction, whether non-significant results should be considered, whether origin= al data should be analyzed, whether the threshold discussion should be modi= fied, whether non-peer reviewed results should be cited; how the report sho= uld address the unexpected outcome of the BLL relationship becoming steeper= at lower levels; whether the term =E2=80=9Clead Poisoning=E2=80=9D should = be used; what the format and tone of the conclusions should be; and how con= clusions that can be drawn from studies on children=E2=80=99s BLLs and heal= th status are impacted by the fact that BLLs can only be measured at certai= n time points. Dr. Matte noted that minor wording changes that were suggest= ed that did not impact the overall conclusion, as well as suggested additio= nal references were not included in his presentation. Dr. Matte then review= ed changes to the October 2003 draft workgroup report made in response to s= pecific comments. His presentation can be found in attachment A.

To = guide the discussion on the workgroup report, Dr. Carla Campbell asked ACCL= PP to specifically consider whether the document should be finalized and pu= blished at this point or if additional changes need to be made. ACCLPP=E2= =80=99s deliberations focused on the process of developing the workgroup re= port and the content of the document. In terms of process, Dr. Banner=E2=80= =99s understanding was that the workgroup would create a product for ACCLPP= to use as a guidance document or scientific commentary; instead, it seemed= to him that a stand-alone report will be published without ACCLPP ownershi= p. He added that the workgroup=E2=80=99s decisions were made independent of= ACCLPP. Dr. Hoffman requested that a statement be incorporated to explain = whether or not ACCLPP supports the document. He was not in favor of publish= ing the report as a workgroup product. Dr. Lynn noted that the workgroup is= heavily populated with non-ACCLPP members.

With respect to content,= Dr. Leighton found the document to be excellent because the workgroup addr= essed extremely technical issues, thoroughly analyzed the epidemiologic lit= erature and clarified several complex topics. However she suggested that th= e document be further edited to shorten particular paragraphs. Dr. Towers w= as also impressed with the workgroup=E2=80=99s thorough review of the avail= able evidence. Dr. Piomelli pointed out that during the previous ACCLPP mee= ting, the Workgroup Chair stated =E2=80=9Ccurrent data do not support label= ing children with BLLs <10 =C2=B5g/dl as lead poisoned.=E2=80=9D However= , this important comment is excluded for the current version of the documen= t. The purpose of the report is to emphasize the importance of causality of= BLLs <10 =C2=B5g/dL. The document may be used to make policy decisions = and will serve as a critical tool in ACCLPP advising CDC on whether to lowe= r BLL of concern from 10 =C2=B5g/DL to 5 =C2=B5g/dL. However, the does not = serve as a guidance document because clear and definite conclusions are not= made.

Dr. Piomelli further noted that language is not included in t= he report to emphatically state whether BLLs <10 =C2=B5g/dL are harmful = to children. The conclusions should be clearly stated in bullet points. Dr.= Piomelli also stated that the workgroup report was not sufficiently skepti= cal about the steeper slope of the blood lead IQ relation observed at lower= blood lead levels. He wrote a letter to ACCLPP explaining that the Belling= er and Canfied results are due to an artifact due to classification of chil= dren as never having BLLs above 10 when in fact their levels may have been = above 10 between measurements. He recommended that these findings be reject= ed. Dr. Piomelli also asserted that the document was not consistent with th= e version presented by Dr. Weitzman at the October meeting and questioned w= hether Dr. Weitzman approved of the revised version.

Dr. Matte repli= ed that the workgroup report was modified in response to Dr. Piomelli=E2=80= =99s comments on misclassification of children as never having blood lead l= evels above 10, but that the workgroup could not identify a mechanism where= by the increasing slope closer to 0 could be produced by the classification= bias Dr. Piomelli described. As a result, the workgroup=E2=80=99s change t= o the current version of the document differs from Dr. Piomelli=E2=80=99s o= pinion. Dr. Matte also noted that Dr. Weitzman had reviewed and approved th= e revisions to the workgroup document.

Dr. Banner disagreed with the= workgroup=E2=80=99s approach of citing published data that were not statis= tically valid to form an association. Inclusion of these data may cause ACC= LPP to be perceived as a non-scientific group or the report to be viewed as= an unscientific analysis or a political document. The report will be short= er and more useful if these data are removed. Because the current version i= s voluminous and vague, conclusions about the steeper slope at lower BLLs a= nd other solid points made by the workgroup are minimized. The report refer= ences uncertainty in the data, but the document would be strengthened by ad= ding confidence intervals to actually illustrate uncertainty. The document = should also clearly state that additional research is needed to determine w= hether confounding has been fully addressed in observational and non-experi= mental studies. Dr. Banner questioned whether a potential conflict of inter= est exists because both the Workgroup Chair (Dr. Weitzman) and the author o= f the primary study cited in the report are from the University of Rocheste= r.

Dr. Matte and Dr. Rogan both noted that the use of non-statistica= lly significant findings in reviews of the literature and meta-analyses is = consistent with accepted scientific practice. Also, instead of reviewing ea= ch individuals study in a vacuum, the workgroup took a scientific approach = by interpreting NHANES results, the Canfield study and other relevant data = as a collective body of evidence. The workgroup agrees that the report can = be enhanced by flagging significant studies or adding =E2=80=9Cn=E2=80=99s= =E2=80=9D in figures to illustrate uncertainty in the data. Dr. Matte noted= Dr. Weitzman did not have a conflict of interest because of his affiliatio= n with the University of Rochester because he was not directly or indirectl= y involved with the Canfield study. The workgroup objectively reviewed the = Canfield study and the report raised many questions about the interpretatio= n of these data.

Dr. Lynn recognized the workgroup=E2=80=99s diligen= t efforts in collecting, reviewing and compiling a tremendous amount of dat= a and addressing a considerable number of conflicting comments from ACCLPP.= She was in favor of the document being finalized with additional editing t= o condense the text and remove repetitive references to the Bellinger lette= r and the Canfield study. The document may be perceived as relying too heav= ily on these data sources. An editor should also clarify the discussion on = the steeper slope at lower BLLs. Dr. Lynn also suggested that an executive = summary be developed and incorporated into the report.

Dr. Binns men= tioned that the report will serve as an important source for researchers in= the field. She acknowledged that the workgroup could not make a definite c= onclusion about the steeper slope at lower BLLs because sufficient data hav= e not been gathered to demonstrate this outcome. Her position was that the = data gap is adequately expressed in the document. Dr. Hoffman conveyed that= if ACCLPP votes to approve the workgroup report, comments should not be ma= de to drastically change the document.

Dr. Campbell responded to ACC= LPP comments on process as follows. The <10 Workgroup used the same proc= ess as the Case Management and Primary Prevention Workgroups. ACCLPP and th= e <10 Workgroup had a considerable amount of interaction during several = meetings. The workgroup prepared and presented drafts to ACCLPP for review = and comment and revised documents based on feedback from the members. The w= orkgroup report will list the authors, but the document will be published a= s an ACCLPP product after ACCLPP reaches consensus by a vote. The membershi= p of the <10 Workgroup is similar to other workgroups in which a minimum= of two ACCLPP members served along with several non-ACCLPP consultants. Dr= . Campbell expressed her appreciation of the diligent efforts by Drs. Matte= and Michael Weitzman, the <10 Workgroup Chair, in preparing and revisin= g the report. Similar to Dr. Lynn, she also believed that the document is n= ow in a position to be finalized with editing.

Concerning the critic= ism by some ACCLPP members that the conclusions are vague or equivocal, Dr.= Matte stated that the nature of the workgroup=E2=80=99s finding reflects u= ncertainty in the available evidence. For example, the workgroup was uncert= ain whether confounding has been fully addressed in observational and non-e= xperimental studies and noted the need for additional research in this area= .

Dr. Matte concluded his remarks by advising the ACCLPP to decide w= hether it agrees with the workgroup=E2=80=99s three major conclusions in vo= ting to approve the report. First, the weight of evidence shows an associat= ion between BLLs <10 =C2=B5g/dL and adverse health effects. Second, avai= lable data do not allow definitive conclusion about causation, but the weig= ht of evidence for the studies favors and does not refute a causal interpre= tation. Third, uncertainty in scientific evidence does not point to a thres= hold BLL <10 =C2=B5g/dL above which children should be clinically define= d as =E2=80=9Clead poisoned.=E2=80=9D Dr. Matte emphasized that the workgro= up would likely not endorse the document if it were modified by the ACCLPP = to state radically different conclusions on these three issues.

Dr. = Binns made a motion for ACCLPP to accept and approve the <10 Workgroup r= eports as an ACCLPP document; Dr. Handy seconded the motion. Dr. Campbell a= mended the motion to note that ACCLPP=E2=80=99s approval for the workgroup = report will be provisional based on the following conditions. The introduct= ion will be reformatted as an executive summary that will list conclusions = in bullet points. A =E2=80=9CStatement by ACCLPP=E2=80=9D will be added exp= laining that the workgroup wrote the report, but ACCLPP reviewed, provided = comments and accepted the document as an ACCLPP product. Both the executive= summary and statement will be distributed to ACCLPP for review and comment= in June or July 2004. Appropriate tables will be modified to indicate samp= le size. The report will be submitted to a medical editor for further refin= ement and the final document will be distributed to ACCLPP. With no= further discussion, ACCLPP unanimously approved the <10 Workgroup repor= t with the provisions stated in the amended motion.

Top of Page Update by the Ad Hoc Policy Workgroup=

Dr. Helen Binns, the Workgroup Chair, reported = that dual efforts are being made for this activity. Drs. Brown and Lynn dra= fted Public Health Implications of Adverse Health Effects in Children with = BLLs <10 =C2=B5g/dL (the policy document), while Dr. Binns drafted Under= standing Children=E2=80=99s BLL Results: Information to Aid Decision-Making= and Counseling in the Health Care Setting (the clinical document). Althoug= h the two documents are intended to state ACCLPP=E2=80=99s opinion, readers= are also referred to the case management, primary prevention and <10 Wo= rkgroup reports. The policy and clinical documents have different audiences= , but ACCLPP should consider whether the reports should be maintained separ= ately or combined. Dr. Binns was in favor of continuing to produce two docu= ments to increase readership and reach diverse audiences. For example, the = policy document can be published in a public health journal, while the clin= ical document can be published in a pediatric journal.

ACCLPP=E2=80= =99s recommendations on the workgroup=E2=80=99s policy and clinical documen= ts are outlined below.

Design a conceptual framework for both do= cuments that includes strategies for public health agencies, medical provid= ers and follow-up testing.
Use common and consistent language withi= n and across both documents. For example, refer to =E2=80=9Cchildren with B= LLs 5-9 =C2=B5g/dL=E2=80=9D as =E2=80=9Cthe group targeted for primary prev= ention and screening.=E2=80=9D
Integrate the two documents as a com= prehensive MMWR article or stand-alone publication and also publish both do= cuments separately in the literature.
Avoid combining the documents= due to different audiences, topics, purposes and messages.
Provide= specific locations of ACCLPP=E2=80=99s case management and primary prevent= ion reports in both documents.
Present the policy, clinical and <= ;10 Workgroup documents with a common linkage, unified message and internal= agreement, particularly to address the disconnect between the policy and &= lt;10 Workgroup reports. For example, incorporate language to recommend tha= t primary prevention be targeted to communities with high rates of children= with BLLs >5 =C2=B5g/dL. Cross-reference the three documents to ensure = consistency.
Consider whether the weight of evidence supports chang= ing the term =E2=80=9Cmanaging elevated BLLs=E2=80=9D to offer guidance to = providers of high-risk populations or if the wording should remain the same= as an option for clinicians.
Develop an abstract or shorten the cl= inical document because busy clinicians will find the paper too long and di= fficult to read.
Maintain the length of the clinical document becau= se all of the issues raised are important for clinicians to know in interpr= eting BLLs.
Maintain the user-friendly format of the clinical docum= ent because the numbered boxes quickly illustrate important points for busy= clinicians.
Include a statement in the clinical document to explai= n the lack of experience and evidence in treating children with BLLs 5-9 = =C2=B5g/dL as lead poisoned.
Add bullet points in the policy docume= nt to advise clinicians in certain high-risk jurisdictions to consult with = local health departments.
Revise the tone of the policy and clinica= l documents to be more positive by highlighting DLL reduction, removal of d= eteriorated paint and other environmental interventions that are known to r= educe BLLs and minimize exposure to lead in housing regardless of the child= =E2=80=99s BLL.
Emphasize in the beginning of the documents that co= mmunities with a high prevalence of BLLs 5-9 =C2=B5g/dL are the same areas = with BLLs >10 =C2=B5g/dL.
Ensure that screening recommendations,= clinical management guidelines and policy implications are distinguished a= nd not interchangeably used.
Include text to strongly emphasize tha= t Medicaid requires all children to be tested and CDC recommends state and = local health departments develop screening guidelines for clinicians. Refer= ence the HITS data and ACCLPP=E2=80=99s Medicaid screening paper that was p= ublished in the MMWR.
Postpone further efforts to finalize the poli= cy document until LPPB gathers and includes feedback from the lead poisonin= g vocabulary focus groups.
Continue efforts to finalize both docume= nts because the focus groups target parents and consumers, while the clinic= al and policy documents target clinicians and the public health community, = respectively.
Revise the policy document to include a table of bull= et points that lists strategies to comply with the recommendations. Extract= bullet points from ACCLPP=E2=80=99s case management and primary prevention= reports in this effort.
Include a diagram in the clinical document= that clinicians can post in the office as a visual aid to assist in interp= reting BLL results.
Highlight the message in the clinical document = that capillary blood samples are accepted by health departments and surveil= lance systems for screening, but appropriate measures must be taken to cont= rol contamination. Provide guidance to clinicians by referencing CDC=E2=80= =99s established protocol for performing capillary blood draws, the videota= pe on improving blood lead sampling techniques and other available resource= s.
Add a brief section in the clinical document to describe researc= h needs in managing children with BLLs <10 =C2=B5g/dL, such as a study t= o identify differences between capillary blood draws and vena-puncture in d= etermining BLL prevalence.
Ensure that messages in the clinical doc= ument are generally consistent with the lead statement on screening the Ame= rican Academy of Pediatrics (AAP) Committee on Environmental Health is curr= ently updating. However, be mindful that ACCLPP=E2=80=99s clinical document= is targeted to a broad audience of providers who serve children, while the= AAP statement specifically focuses on pediatricians.
Replace =E2= =80=9CBLLs 5-9 =C2=B5g/dL=E2=80=9D with =E2=80=9CBLLs <10 =C2=B5g/dL=E2= =80=9D throughout the clinical document.

Dr. Bro= wn made follow-up remarks to ACCLPP=E2=80=99s deliberations. First, CDC has= discussed whether a fundamental recommendation should be made stating that= screening children to identify those with BLLs 5-10 =C2=B5g/dL will be ben= eficial to the individual child. CDC has not made this statement to date an= d agreement was reached during the previous ACCLPP meeting not to lower the= BLL of concern from 10 =C2=B5g/dL. However, CDC has no problem producing a= document explaining that jurisdictions are using local data to monitor low= er BLLs and determine if the Intervention will be effective. Second, CDC no= tes that efforts in 1991 to target primary prevention to communities with h= igh rates of children with BLLs >10 =C2=B5g/dL were unsuccessful.
Third, LPPB expects to complete the final report on the lead vocabulary in= June 2004. The focus group data will inform the process of clinicians comm= unicating with parents, but this activity should not delay efforts to final= ize the policy or clinical documents. Fourth, the policy document does not = describe strategies to comply with the recommendations because this guidanc= e is available in existing well-written reports. Instead, the policy docume= nt references ACCLPP=E2=80=99s primary prevention and case management docum= ents as well as CDC=E2=80=99s 1991 and 1997 statements on screening and fol= low-up of children with EBLLs.

Fifth, Dr. Brown was extremely concer= ned with ACCLPP=E2=80=99s focus on and use of the term =E2=80=9C5-9=E2=80= =9D due to the danger of identifying a new group of children who need and c= an benefit from individual intervention. Since no evidence has been collect= ed to date to support this statement, ACCLPP should use the terms =E2=80=9C= <10" or =E2=80=9C>10.=E2=80=9D To address the issue of BLLs 5-9 =C2= =B5g/dL, however, LPPB supports ACCLPP making the following research statem= ent. Very young children with BLLs 5-9 =C2=B5g/dL may actually be the same = children whose BLLs are in the process of increasing. Efforts will be made = to rigorously evaluate this trend and determine whether health education, D= LL reduction and other interventions will interrupt the cycle. Lead is a po= ison that is not beneficial to the human body and a safe level of lead does= not exist.

Sixth, ACCLPP=E2=80=99s letter to the Centers for Medica= re and Medicaid Services (CMS) on screening waivers was distributed through= out CMS and reviewed, but new staffs are now involved with this process. Dr= . Brown and the new CMS staff will meet on March 10, 2004 to discuss develo= ping consistent guidance. However, CMS has already stated in writing its co= mmitment to creating a waiver process and ensuring screening is performed b= y aggressively targeting states that do not submit waivers.

Dr. Hoff= man placed the following motion on the floor. The <10 Workgroup report s= hould be released in conjunction with the policy document as a collective b= ody of evidence. The policy document should serve as ACCLPP=E2=80=99s offic= ial statement for the <10 Workgroup report. Relevant text from the clini= cal document should be incorporated into the policy document. The clinical = document should remain as a separate paper to reach a specific audience. Dr= . Lynn seconded the motion. With no further discussion, ACCLPP unan= imously approved the motion.

Drs. Binns, Brown and Campbell= described the process to continue developing the policy and clinical docum= ents. Drafts will be distributed to ACCLPP for review by e-mail with a requ= est to submit comments electronically rather than through conference calls.= None of the revised versions will be labeled or referred to as =E2=80=9Cfi= nal;=E2=80=9D instead, dates will be used to distinguish among drafts. A sh= ort abstract will be developed and incorporated into the clinical document.= ACCLPP will submit comments on the policy document to Dr. Brown by April 1= 5, 2004 and comments on the clinical document to Dr. Binns by May 15, 2004.=

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	I hereby certify that to the best of my knowledge, the foregoing= Minutes of the proceedings are accurate and complete.

Date

Advisory Committee On Childhood Lead Poisoning Prevention (ACCLPP): Mee= ting Minutes - March 9-10, 2004 - Baltimore, Maryland

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