Alliance Alert

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Understanding New National Data on Lead Poisoning

In the May 27, 2005, Morbidity and Mortality Weekly Report (MMWR), the Centers for Disease Control and Prevention (CDC) published new national data on lead poisoning (MMWR 54(20); 513-16) (available online at www.cdc.gov/mmwr/preview/mmwrhtml/mm4950a3.htm). This report reports various blood lead statistics for 1999 through 2002, the first significant update since the National Health and Nutrition Examination Surveys (NHANES) data report from 1991 through 1994. These new data document that further gains have been achieved in protecting children from lead poisoning—and that disparities still exist in lead poisoning rates across races and income levels.

New National Data

The report examines new NHANES data collected in 1999-2002. NHANES, conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention (NCHS/CDC), is designed to assess the health and nutritional status of adults and children in the United States through interviews and direct physical examinations.

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Arsenic-Treated Wood

Arsenic-treated wood is the result of a chemical process in which wood is treated with a pesticide/preservative called chromated copper arsenate (CCA) to prevent rotting in lumber designed for outdoor use. CCA contains arsenic, chromium, and copper and was widely used for residential purposes in the United States from the 1970s until EPA phased it out in 2003.

CCA-treated wood can be hazardous to human health because arsenic is classified as a known carcinogen. Exposure to arsenic can cause cancer of the lung, bladder, skin, kidney, prostate, and nasal passage. Data released in November 2003 by the US Environmental Protection Agency (EPA) show that 90 percent of children repeatedly exposed to arsenic-treated wood face a greater than one-in-one million risk of cancer. (One-in-one million is the EPA’s historic threshold of concern about the carcinogenic effects of toxic chemicals.) Arsenic exposure can also lead to nerve damage, dizziness, and numbness. Arsenic has been linked to immune diseases, cardiovascular disease, diabetes, and changes in hormone function. Lung and bladder cancer are the two health effects most often related to exposure to CCA-treated wood. For information on other cancer risks in the home environment, please see Cancer Risks.

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Lead Poisoning

Exposure to lead in housing poses a significant health risk to young children. Lead is a heavy metal used in many materials and products. When absorbed into the body, it is highly toxic to many organs and systems and seriously hinders the body’s neurological development. Lead is most harmful to children under age six because it is easily absorbed into their growing bodies and interferes with the developing brain and other organs and systems. Pregnant women and women of child-bearing age are also at increased risk, because lead ingested by the mother can cross the placenta and affect the unborn fetus.

Lead poisoning causes irreversible health effects and there is no cure for lead poisoning. At very low levels of exposure in children, lead causes reduced IQ and attention span, hyperactivity, impaired growth, reading and learning disabilities, hearing loss, insomnia, and a range of other health, intellectual, and behavioral problems. At low levels, lead poisoning may not present identifiable symptoms, and a blood test is the only way to know if a child is poisoned. At very high levels of exposure, which are now very rare in the U.S., lead poisoning can cause mental retardation, coma, convulsions, and even death.

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Lead

The major remaining cause of lead poisoning is lead-based paint in housing, especially housing built before 1950, when lead paint was commonly used. Most children with elevated lead levels are poisoned in their own homes by peeling lead-based paint and the lead dust it generates. The mere presence of lead-based paint in a home is not a hazard, as about 40 percent of all U.S. housing contains some leaded paint, and the vast majority of children live safely in these homes and apartments.

Housing age is an important predictor of risk, because the lead content of paint varied substantially over the past century. During the first half of the twentieth century, the lead content of paint was marketed as a measure of its quality—the more lead the better. Prior to about 1940, leaded paints typically contained high amounts of lead, ranging from 10 percent to as much as 50 percent. Lead was added to make paint durable, so lead paint was frequently used in high-traffic and high-moisture areas, including kitchens and bathrooms, exterior siding and trim, window and door trim, stairs, porches, etc. In the early 1950s, the paint industry began reducing lead content, although many paints still contained harmful amounts of lead. Federal regulations limited lead content in 1972 and effectively banned lead in residential paints in 1978.

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The Foundations of Better Lead Screening for Children in Medicaid: Data Systems and Collaboration

The Foundations of Better Lead Screening for Children in Medicaid: Data Systems and Collaboration was developed with the support of The Commonwealth Fund and showcases strategies from five states where intense effort has gone into improving lead screening among the high-risk population of children who are Medicaid beneficiaries. The report’s practical how-to information is of immediate importance to administrators and staff of state Medicaid agencies and state and local health departments, as well as to advocates and policy makers. Among the various topics covered are: combining lead screening data with Medicaid data; state policies that support screening and follow-up care; and using maps to simplify complex information on screening.

Young Medicaid beneficiaries comprise 83% of children in the US with lead levels high enough to require professional follow-up care. Even so, screening among these children remains astonishingly low. In fact, of 42 states reporting Medicaid screening rates for 1999, 25 reported screening fewer than 10% of enrolled children. These rates are even more startling given that a federal requirement for lead screening has been in for nearly a decade.

The Foundations of Better Lead Screening for Children in Medicaid: Data Systems and Collaboration describes promising strategies to improve lead screening for this high-risk group. Free copies can be obtained from the links below or by contacting the Alliance at info@afhh.org or 202-543-1147.

This report can be downloaded entirely in three PDF files:

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Carbon Monoxide Poisoning

You cannot see, smell, or taste carbon monoxide, which is a poisonous gas. When carbon monoxide (CO) enters the bloodstream, it reduces the amount of oxygen received by the body’s organs and tissues. Unborn babies, children, the elderly, and people with respiratory problems or heart disease are especially sensitive to carbon monoxide. Even at low levels, carbon monoxide causes serious health problems, and the longer the exposure, the more damage that occurs.
Low levels of carbon monoxide can cause flu-like symptoms, headaches, dizziness, and make it difficult to think clearly. Often a family may not realize that their illnesses are related to chronic exposure to carbon monoxide in the home.

At higher levels of exposure, carbon monoxide is related to visual impairment, reduced work capacity, poor learning ability, and difficulty in performing complex tasks. At very high levels, carbon monoxide can also kill. Each year, more than 200 Americans accidentally die from carbon monoxide poisoning in the home, unrelated to fires and engine exhaust (other sources of carbon monoxide poisoning). Seventy-six percent of these deaths are from carbon monoxide released from heating systems. Another eight percent are from gas water heaters. Many victims of carbon monoxide poisoning die in their sleep. An additional 10,200 people visit the emergency room due to accidental carbon monoxide poisoning from consumer products.

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About Building Blocks

The Lead Poisoning Prevention Branch of the Centers for Disease Control and Prevention (CDC) is fulfilling its commitment to the 2010 goal through its grant program requiring that jurisdictions develop and implement a strategic plan for elimination that includes primary prevention, partnering, and program evaluation.  Through this Building Blocks publication, the Branch now offers grantees and others access to promising approaches, including protective public health policies to reduce lead hazards and other promising strategies.

State and local childhood lead poisoning prevention programs (CLPPPs) universally acknowledge the importance of primary prevention and are beginning to address it in their strategic plans and funding applications.  However, many programs’ primary prevention efforts are confined to parent education about hygiene, nutrition, and housekeeping, despite research that makes clear the limitations of these interventions for families whose homes pose significant hazards.  Inability to institute durable primary prevention is caused in part by the pressure to focus resources and attention on secondary prevention: identifying and managing individual cases of elevated childhood BLL.  Indeed, in communities where follow-up on actual poisonings is limited to educating family members about lead hazards and behavioral change (because public resources are not available to control identified lead hazards and halt further exposure), meaningful primary prevention can seem like an extremely remote target. Programs facing these circumstances need ideas for sharing responsibility within the jurisdiction for stopping repeat offenders, expanding access to lead-safe housing, and ultimately arresting the cycle of inferior housing continually producing new poisonings.

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Rodents

Exposure to rodents (mice and rats) has been linked to increased asthma symptoms among laboratory workers who handle rodents and are sensitized to them. Other studies have established links between rodent allergies and asthmatic symptoms in lab workers. Research published in 2004 found similar linkages in residential settings. Rodent allergens are likely from rodent urine, saliva, or skin.

It is clear that many inner-city residents are exposed to and allergic to rodents. A major study on asthma among inner-city children found that nearly 20 percent of asthmatic children had been sensitized to rats and 15 percent were sensitized to mice. This is important to note, as research has found mouse allergen in 82 percent of US homes.

Rodents can also expose humans to diseases such as hantavirus. Exposure to such disease vectors is rare but can cause severe health problems.

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Pesticides

Pesticides are substances designed to kill, repel, or mitigate pests. They include a number of chemical and biological agents commonly used in and around the home to control a broad range of pests: insecticides (for insects, including cockroaches, ants, and termites), rodenticides (for mice and rats), fungicides (for mold and fungi), herbicides (for plants), and antimicrobials (for bacteria and viruses).

Use and Exposure

Approximately 4.4 billion pesticide applications are made each year to American homes, gardens, and yards. According to surveys by the Environmental Protection Agency (EPA), more than three-quarters of U.S. households use pesticides, with 66 percent treating major living areas in the home one or more times per year. Cockroaches and ants are the most common targets. More than one-third of households used insecticides in the absence of a major insect problem.

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Cancer Risks

Exposure to several substances found in the home can increase the risk of cancer, which is the second leading cause of death among adults and children in the U.S. According to the American Cancer Society, environmental factors including tobacco, chemicals, infectious diseases, and radiation are responsible for three-quarters of all cancer deaths in the U.S. While many adult cancers can be traced to these environmental factors, the causes of most childhood cancers are unknown. Like many environmentally related diseases, cancer takes a greater toll on African-Americans, who are more likely to develop and die from cancer than persons from other racial and ethnic groups.

According to the American Cancer Society, smoking, unhealthy diet, and physical inactivity play a greater role in determining cancer risk than exposure to trace levels of pollutants in food, air, and drinking water. However, the degree of risk from chemical exposure depends on the concentration and duration of exposure. Individuals exposed to high concentrations of cancer-causing substances bear a significantly higher risk of developing cancer. At the same time, widespread exposure to low concentrations of carcinogens can increase the risk of cancer across the population as a whole. For environmentally related cancers, ten or more years typically pass between exposure to cancer-causing substances and detectable cancer.

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Mold

Molds are simple, microscopic organisms that can grow virtually anywhere, both in homes and outdoors. Along with mushrooms, yeasts, and mildew, molds are classified as fungi. Molds typically consist of a network of threadlike filaments that infiltrate the surface on which the mold is growing. Molds reproduce by releasing spores, which are lightweight and small enough to travel through the air. Spores can resist dry, adverse environmental conditions, allowing them to outlive the mold that produced them.Molds play an important ecological role in breaking down dead organic matter and returning nutrients to the environment. They require moisture and food to grow, and they typically thrive in warm, moist environments. Moisture is the key factor determining mold growth in the home, influencing both the types of mold present and the extent of mold colonization. A variety of materials found in the home, including insulation, wallpaper, glues used to affix carpet, backing paper on drywall, dust, and dirt, can serve as a food source for mold. Mold colonies can go dormant under adverse conditions and revive when favorable conditions return.

Mold growth often appears as green, gray, black, brown, or other discoloration. Eventually, mold growth results in the breakdown of the substrate. More than 1,000 types of molds have been found in US homes.

Exposure and Health Impacts

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Disparities in Risk

Introduction

Although the health of most Americans has improved significantly over time, not all racial and ethnic groups have benefited equally. African-Americans and Hispanics, for example, are more likely than whites to suffer from poor health and to die prematurely. Minority and low-income families are more likely to live in substandard housing and polluted communities, increasing their risk of childhood lead poisoning, asthma, cancer, and other environmentally related diseases. In addition to being disproportionately affected by disease, minorities often lack adequate insurance and access to health care due to financial and cultural barriers.

To a large extent, disparities in health and access to care among minorities reflect disparities in socioeconomic status. In fact, according to the Health Resources and Services Administration, the connection between socioeconomic status and health disparities is so strong that income and education levels often serve as proxies for health status. The fact that minority populations on average are poorer than whites underlies many health disparities.

Insurance Coverage and Access to Health Care

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Health Hazards

Many homes fall short of the basic requirements of a healthy home and contain one or more hazards that adversely affect human health. Among the health hazards we may encounter in our homes are those that cause and contribute to asthma (such as dust allergens, mold, and pests), toxic materials (such as lead, asbestos, and chemical pesticides), and poisonous gases (such as carbon monoxide and radon).

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Dust Mites

Dust mites are microscopic creatures that belong to the same class (Arachnida) as spiders and ticks (they have eight legs, not six like insects). They feed primarily on dead skin cells regularly shed by humans and animals. Dust mites thrive in places where their primary food source is most likely to be found: on mattresses, pillows, bedcovers, carpets, upholstered furniture, stuffed toys, clothes, or other fabric items in the home.Unlike insects such as cockroaches, mites are not capable of ingesting water; in order to obtain water, they must absorb it from the air. For this reason, they thrive in humid environments, ranging from 55% to 75% relative humidity. Ideal temperatures for dust mites are between 68º and 77º F. The growth of dust mites can vary on a seasonal basis, or from room to room within a house, depending largely on variations in relative humidity, availability of food sources, and temperature. Mites take about one month to develop from an egg into an adult and have an adult life span of about two to four months. A single adult female may lay up to 100 eggs.

Mite waste products contain an allergen (a substance that causes an allergic immune reaction) that, according to the Asthma and Allergy Foundation of America, adversely affects about 20 million Americans. Sensitive individuals become exposed to this allergen when they inhale household dust, which contains dust mites and their waste products. Exposure to dust mites can trigger an attack in an asthmatic who is sensitive to the dust mite allergen. (Other asthmatics may not be affected by dust mites.) For persons allergic to dust mite allergen, exposure can cause allergic rhinitis (hay fever), which is characterized by nasal congestion, itching, and sneezing. In addition, exposure to dust mites may cause children who are predisposed to develop asthma to do so. (This predisposition is not fully understood, but appears to depend upon a combination of hereditary and environmental factors.) For more information on asthma and allergies, see Asthma, Allergies, and Respiratory Illnesses.

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Essential Maintenance Practices

The concept of “essential maintenance practices” (EMPs) was developed to deal with lead-based paint in older housing in recognition that “an ounce of prevention is worth a pound of cure.” While some homes need dedicated “lead abatement projects” by certified contractors, in most cases, hazards can be avoided in the first place through good maintenance and common sense safeguards. Some EMPs are specific to lead safety, such as avoiding paint removal practices that generate and spread dangerous lead dust. Others address conditions that can cause multiple problems. For example, water leaks, water damage, and excessive moisture can encourage the growth of mold, mildew, and pests, which can cause asthma and other health problems, in addition to causing paint to deteriorate. Periodic visual inspections can identify clues to and causes of water leaks and moisture problems so that low-cost repairs “nip problems in the bud.” The concept of “enlightened maintenance practices” is at the foundation of healthy homes. The EPA/HUD five-hour training course in lead-safe work practices (LSWP) offers a model for conveying practical information to existing trades and can benefit all those whose work encounters painted surfaces in older housing.

Essential Maintenance Practices to Reduce Lead Hazards

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Ventilation and Indoor Air Quality

Proper ventilation helps improve indoor air quality. Ventilation can control indoor humidity and airborne contaminants, both of which either contribute to or act as health hazards. The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and several states (Minnesota, Washington, and Vermont) have ventilation standards designed to ensure acceptable indoor air quality.

High indoor humidity can spur mold growth. High humidity may result from poor construction/rehabilitation, site design that does not properly manage water, and/or inadequate air exchange. A reasonable target for relative humidity is 30-60 percent. A low cost hygrometer, available at hardware stores, can be used to measure relative humidity. In cool climates, inadequate ventilation in the winter can contribute to excessive moisture and humidity because normal activities create moisture (cooking, bathing, breathing), and there is insufficient natural ventilation (opening windows) or mechanical ventilation (fans, exhaust systems) to remove the moisture. In warmer climates, the heating, ventilation, and air conditioning (HVAC) system can pull warmer, humid air inside. In this case, the ventilation system may help create indoor humidity problems unless the system also dehumidifies the air.

Common sources of airborne contaminants include:

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Cockroaches

Cockroaches in homes are a health hazard to many children and families because of the risks cockroach antigens pose to asthma sufferers. Traditionally, cockroaches were controlled because they are offensive, leave behind an awful smell, and cause gastrointestinal and respiratory illness. However, research shows that cockroach debris (old shells, saliva, body parts, and droppings) triggers asthma attacks in people who are sensitized to cockroach antigen (proteins found in the debris). In homes where several allergens are present, including dust mites, mold, furry pets, tobacco smoke, and certain chemicals, children may experience severe and frequent asthma attacks from high airborne concentrations of these allergens.

Any home with food or moisture can have cockroaches. Kitchens and bathrooms typically have the highest number of cockroaches due to the presence of food products and moisture from plumbing fixtures. Apartment buildings often have the worst infestations. The goal is to keep cockroaches out of the home and to eliminate existing pests. Reaching this goal is not always easy, especially in multi-unit housing that is already infested. For most apartment buildings, the landlord must take a building-wide approach to controlling these pests. Moreover, a coordinated effort by the landlord and all tenants is required to eliminate cockroaches.

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