State of Oregon Childhood Lead Poisoning Elimination Plan Update March 2010

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1 State of Oregon Childhood Lead Poisoning Elimination Plan Update March 2010 Oregon Department of Human Services Childhood Lead Poisoning Prevention Program 800 NE Oregon St, Suite 640 Portland, OR (971) (971) Fax

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3 Background: Childhood Lead Poisoning in Oregon The purpose of the Oregon Childhood Lead Poisoning Prevention Program (OCLPPP) is to eliminate childhood lead poisoning as a public health problem. Unfortunately, risk factors for exposure to lead hazards are still relatively common in many parts of the US. Two major factors place children at higher risk for lead poisoning, living in poverty and living in older housing (primarily pre-1950). According to the National Health and Nutrition Examination Survey NHANES III, Part 2, poor children were four times as likely to have elevated blood lead levels (EBLLs) as middle income children and eight times as likely as high income children. In the same survey, children living in pre-1946 housing were five times as likely to have EBLLs as children living in housing built after To make the problem worse, poor children often live in older housing. Previous studies done in Oregon have documented that children living in older housing are at increased risk for EBLLs. A case-control study done in four Oregon counties during 1992 and 1993 showed that children living in houses built before 1930 had a 2.5 greater odds (95% confidence intervals: ) of having an EBLL than children living in houses built after A special project in Multnomah County in 2003 found that 1 year-olds living in pre-1950 housing were more than four times as likely to have EBLLs as 1 year-olds living in newer housing. In the 2000 U.S. Census, Oregon s population was 3,400,000 of which 267,000 were children under the age of 6 years. In Oregon, where Medicaid eligibility is defined as 170% of poverty or less, an average of 79,500 children less than 6 years of age were Medicaid eligible in any given month. This is 30% of the under six population. The Medicaid status of children is changing constantly as families gain and lose eligibility. In a study of Medicaid eligible children during a 19-month period, 142,000 children under age six had eligibility for some time during the period; nearly double the number of eligibles in any given month. Recent estimates have also indicated that as many as 14% of Oregon s children are uninsured, representing an additional at-risk group. Of Oregon s children living at or below the poverty level, 33.7% live in census block groups where at least 22% of the housing units were built before These children are also more likely to live in the older housing units, due to their poverty status. According to the 2000 U.S. Census, Oregon s share of pre-1950 housing stock (20.6%) closely parallels the national average of 22.2%. The nearly 275,000 pre-1950 housing units are found in all 36 counties, each of which have census block groups and zip codes where at least 22% of the housing stock was built prior to Although older housing is found throughout the state, the largest concentration is found in Multnomah County, which contains 19% of the state s under 6 population and 39% of the state s total pre-1950 housing stock. Thirty-nine percent of the housing in Multnomah County and 46% of the housing in the City of Portland were built prior to In a risk prioritization project, the United States Environmental Protection Agency (EPA) ranked each of the 3,141 counties in the country using a targeting formula that incorporated: number of housing units containing lead-based paint (LBP), total number of children 6 years of age, the percent of children 5 years of age who are in poverty and the percent of low income housing that contains LBP. Multnomah County ranked 48 th in the nation and is one of only two counties in the Pacific Northwest ranked in the top 50 high-risk counties for childhood lead exposure. 3

4 Blood Lead Testing and Surveillance 2009 Elimination Plan Objective: Ensure that all at-risk children are screened for lead poisoning. In 1991, EBLLs became a reportable condition under Oregon Administrative Rules (OAR) (23), (2) (d) and Reportable levels were 10 µg/dl for children under 18 years of age and 25 µg/dl for persons 18 years of age and older. At the time that EBLLs first became reportable in Oregon, the national recommendations for childhood blood lead screening was the universal model requiring blood lead testing of all children under the age of six regardless of risk factors. Oregon s medical community was very much against universal screening, saying, from their experience, childhood lead poisoning was not a problem in Oregon. As a result, comparatively little screening was conducted, except in the pilot area of Multnomah County where Centers for Disease Control and Prevention (CDC) funded screening, prevention and surveillance activities for a period of 5 years (1992 to 1997). During this period, only EBLLs were required to be reported, so OCLPPP did not know the total number of children actually screened in a given year. Through the years, the program gradually increased the number of private laboratories who voluntarily reported all blood lead levels (BLLs). Since 1997, both in and out-of-state labs voluntarily reported all BLL test results to the program. Since March 2002, all Oregon blood lead test results have been reportable to OCLPPP within seven days. Public health reporting rules give specific details on what information must be reported and by whom. Reporting rules require that both providers and laboratories report all test results, regardless of level. Providers are required to report: provider s name, address and phone number; patient s name, address, telephone number, date of birth, specimen collection date and blood lead level. Laboratories are required to report the same information except patient address and phone number is not required, only county of residence. Since OCLPPP depends on the labs for most reports, the lack of address information creates great difficulty in tracking screening efforts in particular communities or areas. Since 1992, OCLPPP has used a CDC created data management system (STELLAR) as the child-specific relational database allowing us to track multiple tests and multiple addresses for individual children. In 2010, STELLAR data will be migrated into the new Healthy Housing Lead Poisoning Surveillance System (HHLPSS) developed by CDC. The program surveillance system currently receives automated BLL reports for adults and children and stores the information in a database created by OCLPPP (Lead Poison). BLLs results are reported to OCLPPP via paper, electronic formats and automated reports in standardized reporting formats. The automated reporting is coordinated through the National Electronic Disease Surveillance System Electronic Lab Reporting (NEDS-ELR) program located in the Office of Disease Prevention and Epidemiology (ODPE) in the Oregon Public Health Division. Currently 90% of all reports are submitted to OCLPPP electronically. 4

5 Blood Lead Testing and Surveillance Table 1. Number of Children with Elevated Blood Lead Levels (EBLLs) YEAR TOTAL SCREENED EBLL CASES % EBLLs % % % % % % % % % % % % Total % Table 1 shows the number of children under age six with confirmed elevated lead levels and the number of children screened each year from From the number of children screened stopped increasing at the rates observed between 1995 and 2003 and leveled off. With an average of 10,677 children screened per year between 2004 and 2008, OCLPPP estimate that approximately 3.8% of Oregon s population under age six is screened annually. The number of confirmed EBLL cases dropped to their lowest levels in between 2004 and Beyond normal variation, a number of factors may be contributing to the lower numbers of EBLLs observed. These include but are not limited to increased public awareness of lead risk hazards, changes in housing stock, changes in the population screened, as well as short-term efforts to screen highrisk populations that may have lead to higher numbers of EBLL in 1999 and As the data above show, Oregon is a state with a relatively low overall prevalence of lead poisoning and prevalence rates have declined through the years. This decline in prevalence is consistent with national trends. Although the prevalence of childhood lead poisoning in Oregon may sound low, it translates into an estimated 1,000-2,000 children with lead levels 10 µg/dl. However, recent studies have documented that adverse health effects exist in children at BLLs less than 10 µg/dl. Of the 101,797 children screened in the last 12 years ( ) 12,527 (12.3%) had blood lead levels in the 5-9 µg/dl range. Program staff regularly generate public reports and presentations, and respond to data requests from partners and other stakeholders. OCLPPP has a formal data sharing agreement with the state Environmental Public Health Tracking (EPHT) program, and staff provide them with deidentified childhood lead surveillance data. Childhood blood lead is one of the data elements in the EPHT system and EPHT has a Web portal where people can view health information, including chart, maps and tables. The Web portal also allows people to run data queries. The link to the site is located at 5

6 Blood Lead Screening and Case Management of Children with EBLLs Oregon Lead Screening Plan 2009 Elimination Plan Objective: Ensure that all at-risk children are screened for lead poisoning. The goals of lead screening are to identify children exposed to lead, provide appropriate interventions and reduce the risk of exposure. Shortly after CDC published new screening guidelines in 1997, Oregon issued preliminary guidelines that closely followed the CDC recommendations. Oregon s recommendations included universal screening of children under age six receiving Medicaid or other governmental assistance, other children living in zip codes with more than 27% pre-1950 housing and individual risk questions for children who did not meet these criteria. In 2001, OCLPPP established a Screening Advisory Group to develop Oregon specific guidelines. The Advisory Group was comprised of a broad range of stakeholders; including physicians, managed care organizations, state Medicaid, county health departments, housing agencies, and community-based organizations. The Advisory Group reviewed national and Oregon specific surveillance data and CDC screening guidelines in developing recommendations for an Oregon lead screening plan. In 2004, the Medical Advisory Group finalized the Oregon Screening Plan. The Oregon Lead- Screening Plan recommends use of a lead risk assessment questionnaire to target screening efforts. All children should be assessed for risk of lead exposure by administration of the questionnaire at 1 and 2 years of age and between 3 and 5 if not previously assessed. If the answer to any question is yes or don t know, a blood lead test is required. Providers should also perform a blood lead test if signs and symptoms consistent with lead poisoning are present or if a child s lead exposure changes. The risk questions and accompanying guidance are available on the OCLPPP Web site. The state Medicaid program incorporated the screening plan into guidance documents and forms used by providers serving Medicaid children through the Oregon Health Plan. The risk questions are available in English, Spanish, Russian and Vietnamese. Prior to plan implementation, a pre-implementation survey was sent to more than 1,500 pediatric providers throughout the state. The survey was sent to a sample of providers in each of the following pediatric specialties (medical, osteopathic, and naturopathic physicians; nurse practitioners; physician assistants and medical residents). The purpose of the survey was to determine screening and medical practices related to lead, barriers to screening and knowledge of lead risk factors. Information from this survey helped in the development of a training curriculum for medical providers and provided a baseline measure for program evaluation. OCLPPP annually reviews and revises the Oregon Lead Screening Plan with input from partners and advisories groups. In 2009, the Medical Advisory Group met to discuss and review the current screening plan. At the meeting, the group reviewed surveillance data to evaluate the effectiveness of the plan in identifying and screening children at highest risk. The group discussed results from a Multnomah County Health Department EPA funded project that focused on increasing screening rates in community clinics. The group went through each question to 6

7 review language, effectiveness and ease of use. The group decided to revise the Oregon Screening Plan to more accurately identify at-risk children. Since 2008, OCLPPP has been meeting and working with state and local Head Start programs to address the reiterated requirement from national Head Start that all enrolled children have blood lead tests. The Medical Advisory Group helped Head Start representatives identify labs, establish screening protocols and find screening resources. As part of this process, OCLPPP brought state Medicaid into the process to clarify and strengthen state Medicaid blood lead screening guidance and recommendations. Head Start testing, how to address blood lead levels less than 10 µg/dl and the definition of childhood lead poisoning elimination for Oregon were major topics of discussion at this meeting. As previously mentioned only 3.8% of Oregon s population under the age of six is screened annually. The Elimination Plan objective to increase blood lead screening of at-risk children by increasing awareness of the Oregon Lead Screening Plan among medical providers statewide has been unmet due to lack of funding even though the Medical Advisory Group established this as a high priority. The only statewide educational tool for medical providers is the OCLPPP Web site that receives approximately 150 visits per month. However, visitors to the state medical provider pages are down from previous years due to the reduction in education and outreach to this target audience. One outreach project that focused on medical provider education was an EPA funded program to develop and pilot test a Medical Provider Lead Screening Toolkit to increase screening rates in community clinics in Multnomah County. Blood Lead Testing Resources 2009 Elimination Plan Objective: Ensure that all at-risk children are screened for lead poisoning. Currently several county health departments provide free blood lead testing for children at-risk if other resources are unavailable. In the Portland metro area, the Josiah Hill III Clinic provides lead screening services for uninsured children. The reiterated requirement from national Head Start that all enrolled children have blood lead tests has also increased the availability of blood lead testing for families with limited resources. OCLPPP worked with Head Start programs to identify blood lead testing resources. In several instances, programs purchased portable lead analyzers so they can provide this service in-house, and other Head Starts collaborated with local medical providers and clinics in their area to ensure testing of Head Start children. Case Management of Children with EBLLs 2009 Elimination Plan Objective: Ensure children with identified EBLLs receive appropriate medical, environmental and case management follow-up care. The follow-up care for children with EBLLs is a priority activity for OCLPPP. When an EBLL test result is received, program staff contact the child s medical provider to obtain full demographic information and then send the completed report to the local county health department. The county health department has primary responsibility for case management in their jurisdiction. County health department staff perform the home investigation to determine probable source or sources of lead exposure and identify remediation strategies and resources. Case managers determine if other members of the family are at risk, especially other young 7

8 children or pregnant women. In 1991, child and adult lead poisoning programs were consolidated in order to coordinate surveillance, case management, educational outreach and prevention efforts. When OCLPPP receives a report of an adult with an EBLL, the person is contacted to see if there are children and/or pregnant women in the household that might be exposed to the same source of lead or through take-home exposure. Prior to 2005, OCLPPP reimbursed county health departments for conducting on-site environmental investigations of confirmed cases. Grant funds from CDC covered the cost of home investigations and environmental sampling. However, this was discontinued in 2005 because CDC grant funding could no longer be used for environmental investigations, supplies and lab analysis, and alternative funds to reimburse county health departments for investigations was not identified. Most county health departments are now conducting the home investigations even though they are no longer receiving reimbursement from OCLPPP. The EPA funded Lead- Based Paint Program is currently providing funding for the environmental sampling supplies and lab analysis. If counties are unable to provide staff for investigations, OCLPPP or the Lead- Based Paint Program staff are able to perform the environmental investigation. Starting January 1, 2010, the Division of Medical Assistance Program (DMAP, the agency that administers the Oregon Health Plan), will be providing financial reimbursement of environmental investigations and case management for Medicaid children with confirmed elevated blood lead levels. DMAP recently incorporated the new rule into the Early Periodic Screening, Diagnostic and Treatment (EPSDT) program guidelines. OCLPPP case management guidelines include procedures identifying cases appropriate for EPA/HUD enforcement actions. The EBLL investigation questionnaire includes two questions regarding possible disclosure and pre-renovation rule violations. Disclosure and pre-renovation infractions are referred to local and regional EPA and/or HUD offices. In 2008, the OCLPPP and the Oregon Lead-Based Paint Program referred a total of 35 pre-renovation notification and five disclosure (1018) complaints to Region 10 EPA. In some cases, the family does not wish to report a violation due to fear of property owner retaliation. Housing authorities throughout the state submit addresses of public and Section 8 housing managed by their agency to OCLPPP. Program staff match these addresses with confirmed lead poisoning cases in the area as required by HUD Lead-Safe Housing With the new EPA RRP rule going into effect April 22, 2010, program staff expect to work more closely with housing agencies to deal with complaints about renovation activities that create lead hazards, especially for children. In 2002, the Oregon Lead Poisoning Case Management and Investigative Guidelines were revised in accordance with recommendations from the CDC Managing Elevated Blood Lead Levels among Young Children and the Oregon Lead Poisoning Medical Advisory Group. The Oregon Medical Advisory Group meets annually to review the Lead Poisoning Guidelines and revise them as needed. In 2009, the Medical Advisory Group reviewed and revised the Oregon Lead Poisoning Case Management and Investigative Guidelines and added guidance to address blood lead levels above 5 µg/dl. Every two years, OCLPPP conducts a Lead Poisoning Case Management and Environmental Investigation Training for county health department nurses and environmental health specialists. Case management and environmental investigation materials are available on the OCLPPP Web site. All case management and environmental investigation information, including environmental lab sampling results are entered in the childhood lead poisoning database. An examination of environmental investigations conducted since 2000, found although lead paint was identified as the probable source in 63% of the cases, over 40% were related to remodeling or renovation and 8

9 only 23% were attributed to general paint deterioration. This corresponds with the dramatic increase in gentrification occurring in recent years in older neighborhoods that were traditionally home to the poor and racial/ethnic minorities. With these changes, middle and upper income families, buying and remodeling older housing are placing their children at increased risk for lead poisoning. Lead Poisoning Prevention Legal and Regulatory Framework 2009 Elimination Plan Objective: Improve regulatory tools and compliance efforts to prevent lead poisoning. EBLL s became a reportable condition under Oregon Administrative Rules (OAR) (23), (2) (d) and in Reportable levels are 10 µg/dl for children under 18 years of age and 25 µg/dl for persons 18 years of age and older. Since March 2002, all Oregon blood lead test results have been reportable to OCLPPP within seven days. Public health reporting rules give specific details on what information must be reported and by whom. OAR states that each report of a childhood or non-occupational EBLL shall be investigated by the local health department to confirm diagnosis and to provide information to the individual s physician, to help identify the environmental source of lead exposure and to prevent further exposures. OCLPPP provides consultation and assistance to the local health department in conducting these investigations and follow-up. OCLPPP refers all childhood EBLL reports directly to the local county health department for follow-up. The time frame for beginning case management or providing environmental investigations begins as soon as confirmatory EBLL results are received. Case management duties are outlined in the Oregon Lead Poisoning Disease Guidelines. Oregon Revised Statute was enacted into law by the Legislative Assembly giving authority to the Department of Human Services to develop accreditation programs to train and certify individuals and firms engaged in lead abatement and inspection and to assess penalties when an individual or firm fails to comply with prescribed work standards. The Department of Human Services, Office of Public Health Systems is the state agency authorized by the U.S. Environmental Protection Agency (EPA) to implement the Oregon Lead-Based Paint Program (LBPP). The Lead-Based Paint Program has a Lead Enforcement, Training, and Certification Grant for the administration and enforcement of a state Certification and Accreditation program under Section 404 of Title X. The LBPP conducts oversight and investigations of lead-based paint activities involving abatement, inspections, risk assessments, and responds to complaints. The LBPP certifies contractors for lead-based paint activities, accredits training providers, provides lead-safe work practices training and consultations and performs education and outreach to communities and affected industries. The Oregon Revised Statutes and Administrative Rules have established work practice standards for the performance of lead-based paint inspection, risk assessment, and paint removal and stabilization activities for individuals and firms performing lead-based paint activities. These rules apply expect for persons who perform these activities within residential dwellings that they own and occupy at the time of the lead-based paint activity. All EPA and HUD approved techniques must be utilized for preparation, cleanup, disposal and clearance testing activities following an abatement project. Only certified individuals and legally 9

10 registered firms may conduct abatement activities. Abatement does not include renovation, remodeling, landscaping or other activities when such activities are not designed to permanently eliminate lead-based paint hazards. Clearance testing is required upon completion of abatement projects in targeted housing. From 2008 through 2010, OCLPPP and the Oregon Lead-Based Paint Program, worked with the Housing Advisory Group and other stakeholders to develop legislation and administrative rules to seek approval from U.S. Environmental Protection Agency (EPA) for Oregon to administer and enforce the Renovation, Repair and Painting Rule (RRP). On May 3, 2010, Oregon became the eighth state to be authorized by EPA to administer the Renovation, Repair and Painting (RRP) Rule for EPA. Oregon is also authorized to administer the EPA Pre-Renovation Education program. These rule are the most significant change in federal lead-based paint regulations in more than ten years. It regulates the 95% of lead-based paintwork that had not been regulated under abatement rules. Since 2000, Oregon has consistently found renovation to be the most common source of exposure in lead poisoning cases, accounting for 43% of cases from With this background, OCLPPP realized this was the most important thing that could be done to prevent childhood lead poisoning in Oregon. With out the political will to address the issue of requiring remediation of lead hazards at the state level, local municipalities in two cities in Oregon (Portland, Gresham) adopted plans to address this issue. OCLPPP staff served as one of the lead poisoning prevention consultants on the Portland Quality Rental Housing group that developed procedures to enforce remediation of identified lead hazards in rental housing in Portland. These two city inspection programs are using existing building codes to require landlords to remediate lead hazards identified by the county health department when investigating EBLL cases and when they receive tenant complaints. The City of Gresham conducts annual mandatory inspections of rental housing units selected by statistical sampling so tenants do not have to complain and repairs are made without retaliation. A complaint-driven component is also included with the highest possible protections for those reporting the violations. Violations found in one unit of a multi-unit complex will trigger additional inspections on the same property. Inspections focus on a broad range of habitability standards, and the primary focus are on fire/life/safety issues. OCLPPP worked with the City of Portland inspectors on refining enforcement protocols, and plan on approaching the Oregon State Building Code office to see if these procedures could be implemented statewide. Lead Poisoning Prevention Education and Outreach 2009 Elimination Plan Objective: Develop lead education and outreach strategies targeting atrisk populations, medical providers, and other identified stakeholders. It is very difficult for OCLPPP to maintain a major leadership role in the development and implementation of lead poisoning prevention education and outreach activities around the state due to limited resources and staffing. Currently, OCLPPP receives CDC funding to maintain blood lead testing surveillance and no longer receives funding to conduct education and outreach activities. OCLPPP depends on other agencies and organizations to do the bulk of the work on many education and outreach initiatives. For example, the Portland Water Bureau continues to support community-based lead poisoning prevention projects throughout the Portland area. These projects include support of the statewide lead poisoning prevention hotline; free blood lead testing for the uninsured; landlord, midwife and medical provider outreach; workshops on 10

11 preventing lead poisoning and lead safety for small home remodeling projects, and a HEPA vacuum lending service. The Portland area also has a Housing and Urban Development (HUD) Lead Hazard Control Program that provides housing remediation and education and outreach. Unfortunately, the rest of the state has few resources to play a major role in implementing lead poisoning prevention education and outreach activities. However, agencies, community-based organizations and other health programs continue to look to OCLPPP for lead poisoning consultation and guidance for education and outreach initiatives. This year OCLPPP worked with multiple stakeholders, including county health department staff, maternal-child health programs, Head Start and various other organizations, on specific lead screening and medical management issues, and the program regularly generates and provides blood lead testing data for partners and other interested parties. This past year, OCLPPP collaborated with the Oregon Public Health Division s Office of Family Health (administers state maternal-child health programs) on an EPA funded healthy homes type program and on lead poisoning prevention issues. OCLPPP also partnered with state programs such as, WIC, immunization, vital records, and other health data systems to link child health data across multiple programs. The purpose of this pilot project is to create a data system to link child-health information across multiple programs and deliver the content on demand to medical providers statewide. Lead poisoning prevention educational materials are routinely mailed to stakeholders and the public, and are available on our Web site ( There are many partners such as tenant advocacy groups, child care providers, Head Starts, WIC and maternal/child visiting home nurses who distribute OCLPPP educational materials to pregnant women and families with young children. OCLPPP currently has two lead poisoning prevention brochures targeting child care providers, (1) Protecting Kids from Lead Paint: A Guide for Child Care Providers and (2) Lead-Safe Child Care: A Child Care Provider s Guide to Protect Kids. The educational materials are distributed to providers by county health department staff and child care provider training programs. Lead poisoning prevention educational messages have been incorporated into the Oregon Child Care Health and Safety Handbook and are included in the mandatory training for all licensed and certified child care providers. Inspectors and child care certifiers distribute the materials to child care providers when inspecting homes and centers and when lead hazards are identified at these facilities. Following OCLPPP lead in child care protocols, inspectors and child care certifiers also contact OCLPPP when lead hazards are identified. OCLPPP is currently working with the Oregon Department of Education, the Child Care Division (state agency that licenses/certifies child care providers), local schools, school districts, child care centers, and landlord/property manager groups to provide them with information on the RRP rule and how to comply with the new rule. OCLPPP has received multiple requests for presentations and educational materials on RRP, and staff are currently reviewing and revising program educational materials and the Web site to reflect the RRP rule. Housing agencies such as weatherization and housing rehabilitation, and contractions also contact the program to request RRP, and pre-renovation educational materials During National Lead Poisoning Prevention Week 2009, educational materials and over 10,000 Halloween/Harvest bags with a lead poisoning prevention message were distributed through WIC, child welfare, Head-Start, child care centers, schools, other community-based organizations and given out at lead poisoning prevention workshops and events. OCLPPP staff 11

12 work with the Oregon Office of Family Health and annually review and revise the Prenatal and Newborn Resource Guide for Oregon Families, a document that includes lead poisoning prevention information. Medical providers, hospitals and childbirth educators distribute this booklet to pregnant women throughout the state. Program Partners 2009 Elimination Plan Objective: Develop strategies to mobilize health and housing community partners. OCLPPP continues to develop and maintain partnerships with a variety of strategic partners including, governmental agencies such as the Construction Contractors Board, OR-OSHA and the Department of Environmental Quality. OCLPPP also collaborates with stakeholders including schools, real estate, landlord/property management groups, and tenant advocacy organizations by attending meetings, conducting lead poisoning prevention presentations, providing educational materials, and serving as a consultant for lead-based paint and lead poisoning prevention issues. OCLPPP maintains partnerships with maternal child health programs by attending meetings, providing lead presentations and technical assistance, and collaborating on special projects such as the EPA grant, Building Capacity to Address Environmental Hazards during Pregnancy. This grant project addressed environmental health issues, including lead, among low-income pregnant women. As previously mentioned, OCLPPP is working with the Office of Family Health on the development of a Child Health Profile database that medical providers can access as needed. This year OCLPPP worked with multiple stakeholders, including county health departments, the Oregon Child Care Division, WIC, Head Start and various other organizations. In 2008 and 2009, program staff worked with the Oregon Division of Medical Assistance Programs (DMAP), and federal, regional, local and migrant Head Start programs, to assist Oregon Head Start programs in responding to the renewed emphasis from federal Head Start requiring all children enrolled in Head Start and early Head Start are tested for lead. OCLPPP also worked with DMAP to obtain financial reimbursement for case management and environmental investigations for Medicaid children with confirmed elevated blood lead levels. Financial Resources OCLPPP currently receives CDC funding to maintain blood lead testing surveillance and no longer receives funding to provide blood lead testing resources, education and outreach or primary prevention activities. Therefore, OCLPPP is continually trying to identify funding and resources for lead education and outreach, follow-up of children with EBLL s, and lead hazard remediation. In Oregon, EBLL case management and environmental investigations are an unfunded mandate and many counties have limited resources and staff to fulfill this role. However, the Division of Medical Assistance Program (Medicaid agency) is currently in the process of implementing a rule change for the Early Periodic Screening, Diagnostic and Treatment program. Starting January 1, 2010, DMAP will be financially reimbursing county health departments for one-time environmental investigation and case management of Medicaid children with confirmed elevated blood lead levels. In some cases, county health departments 12

13 may not have trained staff to conduct case management and environmental investigations and therefore, OCLPPP staff members, who are certified lead-based paint inspectors and risk assessors will perform these duties. There are currently only remediation resources for low-income families in three Oregon counties: Clackamas, Multnomah and Washington. The Portland Metro area has lead poisoning prevention resources including blood lead testing for the uninsured or underinsured, and education and outreach programs targeting landlords, midwifes, medical providers, and the public. Unfortunately, the rest of the state has few funding resources to play a major role in implementing lead poisoning prevention activities and initiatives. History of the Elimination Plan In 2003, the U.S. Centers for Disease Control and Prevention (CDC) directed its Childhood Lead Poisoning Prevention Program (CLPPP) grantees to develop a plan to eliminate statewide (and therefore, national) childhood lead poisoning by This activity became a program requirement for the CDC s Childhood Lead Poisoning Prevention Programs. The Oregon CLPPP, as a recipient of the CDC award, therefore assumed responsibility for developing and implementing a statewide lead elimination plan. During 2004, the Oregon CLPPP invited potential work group members to participate in the planning process. Work group members were specifically recruited who could make decisions and commit resources for the agencies or organizations they represented. OCLPPP recruited members representing a broad range of perspectives including agencies and groups that deal with: child health, medical and case management, housing, lead remediation and community involvement. Regional EPA, local HUD lead programs and state Medicaid were committed to the process. Several members of the Lead Screening Task Force were also asked to participate in the new advisory group, including providers, county health department representatives and community based organizations. The agencies and organizations that were involved with this process included: HUD Region X EPA Region X Oregon Department of Housing and Community Services Oregon Occupational Safety and Health Administration Oregon Health Plan Oregon Lead-Based Paint Program Construction Contractor s Board Multnomah County Health Department City of Portland Housing and Community Development City of Portland Water Bureau City of Portland Neighborhoods Bureau City of Salem Housing and Community Development City of Corvallis Housing and Community Development Portland Housing Authority Portland Development Commission Children s Pediatric Clinic Oregon Remodelers Association Community Energy Project 13

14 Community Alliance of Tenants Josiah Hill III Clinic Oregon Child Development Coalition The first advisory group meeting was held on May 11, During the first meeting, the advisory work group reviewed the CDC elimination plan components and the OCLPPP draft mission statement. Since the initial meeting, two separate groups, the Housing and Medical/Health subcommittees were established and they meet on a regular basis. Both subcommittees developed strategies designed to eliminate lead poisoning in children based on their particular focus and in recent years have been working on specific tasks in their focus area. Elimination Plan Evaluation In 2009, OCLPPP staff reviewed and revised the Elimination Plan with input from partners. OCLPPP held regular Advisory Group meetings; however, both the Medical Advisory and Housing Advisory Committees worked on specific tasks such as developing/implementing RRP rules and evaluating the lead screening plan. Participants in both groups felt it was more important to work on the specific tasks and they did not have additional time to commit to more meetings to conduct a comprehensive review and update of the Elimination Plan so feedback and input were collected via . As previously mentioned, as a surveillance-only program, OCLPPP has limited resources and staff (current funding for.8 FTE technical staff) for coordination and evaluation of Elimination Plan activities. 14

15 Oregon Lead Elimination Plan 2010 Mission: To eliminate childhood lead poisoning as a major public health problem in Oregon. Elimination Definition: Lead poisoning will be considered eliminated when zero percent of children who are less than 72 months of age have blood lead levels >10 µg/dl. Goal I: Ensure at-risk children are screened for lead poisoning and children with EBLLs receive appropriate case management. Objective A: Maintain and improve the statewide blood lead surveillance system. Activity 2: Identify strategies to require all labs to report blood lead testing results electronically. (Ongoing) Identify funding resources to continue surveillance of blood lead testing in Oregon and incorporate into Oregon Lead Poisoning Prevention Program Sustainability Plan. (6/30/2011) Objective B: Link information on at-risk children and children with EBLLs with other data sources. Activity 2: Activity 3: Activity 4: Geocode new lead surveillance records. (Annually) Geocode new Medicaid eligibility records. (Annually) Continue to merge lead surveillance and Medicaid records. (Quarterly) Partner with WIC, immunization, vital records, and other health data systems to link child-health data across multiple programs. (6/30/2011) Objective C: Link information on at-risk children and children with EBLLs with housing data. Activity 2: Activity 3: Activity 4: Identify and characterize individual housing units with multiple EBLL cases. (Ongoing) Identify elevated blood lead level cases living in federally funded housing as required under HUD Lead-Safe Housing Rule. (Ongoing) Identify counties with geocoded property records that contain age of housing information. (6/2010) Encourage additional tax assessors and housing agencies to provide age of housing information on individual properties for geocoding. (Ongoing) 15

16 Oregon Lead Elimination Plan 2010 Activity 5: Identify EBLLs living in federally funded housing as required under the HUD Lead-Safe Housing Rule. (Ongoing) Objective D: Ensure all at-risk children are screened for lead poisoning. Activity 2: Activity 3: Activity 4: Review environmental investigation data and national data for lead exposure trends and revise screening plan as needed. (Annually) Develop risk models that link geocoded child, demographic and housing data, and evaluate and revise lead screening recommendations based on risk model analysis. (Annually) Distribute lead screening guidelines to WIC, migrant and rural health clinics in Oregon. (Ongoing) Assist pediatric and family medical clinics in incorporating lead screening recommendations into practice protocols. (Ongoing) Objective E: Develop strategies to ensure children with identified EBLLs receive appropriate case management and lead hazard remediation as available. Activity 2: Activity 3: Activity 4: Activity 5: Activity 9: Review environmental investigation data and national data for lead exposure trends and revise case management protocols as needed. (Annually) Analyze case management data to ensure case management activities and environmental investigations are conducted within timeframe established in Oregon Lead Poisoning Investigative Guidelines. (Ongoing) Ensure EBLL case siblings and other potentially exposed individuals (including adults) are referred for testing, as appropriate. (Ongoing) Identify lead hazard remediation resources and link with EBLL children. (Ongoing) Provide biennial training to county health departments on case management and environmental investigation protocols. (Ongoing) Identify funding resources to continue case management activities in Oregon and incorporate into Oregon Lead Poisoning Prevention Program Sustainability Plan. (6/30/2011) 16

17 Oregon Lead Elimination Plan 2010 Goal II: Increase awareness of childhood lead poisoning among families, medical care providers, the housing industry and other target audiences. Objective A: Develop educational materials targeting medical providers and at-risk populations. Activity 2: Activity 3: Activity 4: Activity 5: Activity 6: Activity 7: Develop culturally appropriate lead poisoning prevention educational materials. (Ongoing) Develop educational materials and outreach strategies to inform pregnant women of potential lead risks. (12/31/2010) Ensure medical providers statewide are informed about blood lead screening, medical case management, prevention and treatment. (Ongoing) Incorporate lead screening and lead poisoning prevention messages into existing maternal-child health and child care materials, such as the Oregon Prenatal Handbook and the Child Care Provider s Health and Safety Manual. (Ongoing) Develop and maintain effective communication channels to reach immigrant, refugee and foreign adoptee populations. (Ongoing) Reduce childhood lead exposures by educating adults with EBLLs or adults with occupations or hobbies that involve lead about take home lead. (Ongoing) Identify programs and incorporate lead poisoning prevention messages into Healthy Home programs, visiting home programs and other existing programs targeting at-risk populations. (Ongoing) Objective B: Identify emerging sources of lead exposure and develop educational materials for emerging sources as needed. Review environmental investigation data and national data for lead exposure trends, and develop educational materials and outreach strategies to reach populations at highest risk for lead poisoning. (Ongoing) Objective C: Increase awareness of the new Renovation, Repair and Painting Rule among targeted audiences. Activity 2: Develop outreach strategies and educational materials to inform contractors, homeowners, schools, child care providers, landlords and property managers of lead-based paint hazards, how to eliminate hazards and how to comply with the new RRP rule. (Ongoing) Train homeowners in lead-safe work practices and how to hire a lead-safe contractor. (Ongoing) 17

18 Oregon Lead Elimination Plan 2010 Goal III: Improve regulatory tools and compliance efforts to prevent lead poisoning. Objective A: Develop strategies for identifying and implementing regulatory and legislative changes necessary to control exposure to lead-based paint hazards. Activity 2: Activity 3: Activity 4: Activity 5: Activity 6: Collaborate with Oregon Housing and Community Services (OHCS) and ensure lead paint issues are addressed in the Qualified Allocation Plan and the Low Income Housing Tax Credit. (Ongoing) Collaborate with OHCS and local housing agencies to ensure that lead paint issues are adequately addressed in the 5-Year Consolidated Plan. (Ongoing) Investigate feasibility of incorporating statewide regulatory structure and enforcement process for remediation of lead hazards in rental housing into existing housing code structure. (6/30/2011) If statewide regulatory structure and enforcement process for remediation of lead hazards in rental housing is not possible, survey and develop list of cities or local jurisdictions that are using existing housing code to require remediation of lead hazards in rental housing. (6/30/2011) Incorporate prevention of retaliatory eviction for tenants who report lead hazards or elevated blood lead levels into regulatory structure and enforcement process. (6/30/2011) Obtain authorization from EPA to administer and enforce the RRP Rule. (5/1/2010) Goal IV: Build capacity for primary prevention of lead poisoning. Objective A: Develop strategies for mobilizing housing resources for primary prevention. Activity 2: Activity 3: Identify barriers and opportunities for collaboration with housing agencies and the housing industry. (Ongoing) Encourage housing agencies to apply for the HUD Lead Hazard Control and/or Healthy Home funding. (Ongoing) Encourage housing programs such as weatherization, housing rehabilitation, and emergency housing repair programs to address lead hazards. (Ongoing) Objective B: Develop childhood lead poisoning prevention sustainability plan. Meet with elimination plan partners to develop sustainability plan. (6/30/2011) 18