Specil Report on Led Poisoning in Children Cost of Child Led Poisoning to Txpyers in Mhoning County, Ohio Mtthew Stefnk, MPH,b Joe Diorio, MS Lrry Frisch, MD, MPH,b SYNOPSIS Led poisoning in children imposes both immedite nd long-term finncil burdens on txpyers. The District Bord of Helth of Mhoning County, Ohio, quntified some of the direct costs to txpyers of providing medicl cre nd public helth services to the 279 children dignosed with led poisoning in the county in 2002, using methods described by Ktrin Korfmcher t the University of Rochester. The Bord of Helth lso ttempted to quntify the longer-term costs of specil eduction nd juvenile justice services ttributble to led exposure. The reliztion tht led poisoning costs locl government on the order of $0.5 million ech yer hs mobilized community leders in eduction nd juvenile justice to demnd more ggressive ction ginst rentl property owners who fil to remedite led hzrds. Mhoning County District Bord of Helth, Youngstown, OH b Division of Community Helth Sciences, Northestern Ohio Universities College of Medicine, Rootstown, OH Address correspondence to: Mtthew Stefnk, MPH, Mhoning County District Bord of Helth, 50 Westchester Dr., Youngstown, OH 44515; tel. 330-270-2855 ext.144; fx 330-270-0625; e-mil <mstefnk@mhoning-helth.org>. 2005 Assocition of Schools of Public Helth Public Helth Reports / My June 2005 / Volume 120 311
312 Specil Report on Led Poisoning in Children Led poisoning in children imposes both immedite nd long-term finncil burdens on txpyers. The District Bord of Helth of Mhoning County in northestern Ohio ttempted to quntify some of the direct costs to txpyers of providing medicl cre nd public helth services to the 279 children dignosed with led poisoning in the county in 2002, using methods described by Ktrin Korfmcher t the University of Rochester. 1 Mhoning County, which includes Youngstown nd surrounding communities, hd n estimted 252,800 residents in 2002. 2 The Bord of Helth lso ttempted to quntify the longerterm costs of specil eduction nd juvenile delinquency services ttributble to led exposure. These costs do not ccount for ll of the direct nd indirect costs tht unremedited led hzrds impose on txpyers, including the lost tx revenue from the lower wges of workers with intellectul deficits due to led poisoning, or long-term helth effects such s hypertension, osteoporosis, nd dentl cries in dults exposed to led s children. Others hve estimted the nnul costs to society of led poisoning in Americn children t $43.4 billion. 3 By comprison, estimted 2000 helth costs due to motor vehicle ccidents were just over $32 billion per yer for the entire U.S. popultion. 4 HEALTH CARE EXPENDITURES The direct helth cre costs of led poisoning include the cost of screening, tretment, nd follow-up of severely nd modertely poisoned children. Direct costs lso include the cost of repet blood testing nd environmentl investigtion in these children s homes. As the U.S. Generl Accounting Office hs pointed out, most of these helth cre costs for led-poisoned children re pid by Medicid, stte nd federlly funded helth insurnce progrm for low-income fmilies. 5 Tble 1 presents our most conservtive estimte of direct helth cre costs borne by txpyers for the 279 Mhoning County children with elevted blood led reported to the Bord of Helth in 2002. For this nlysis, elevted blood led ws defined s blood led concentrtion 10 microgrms per deciliter (µg/dl); 10 µg/dl is the Centers for Disese Control nd Prevention s (CDC s) level of concern for blood led. 6 Tble 1 lso tkes into ccount screening costs for the 2,498 children with blood led 10 µg/dl. (These children my hve medicl costs relted to their led exposure tht re not included in the nlyses reported here.) Tble 1. Estimted cost to screen nd tret children for led poisoning, Mhoning County, Ohio, 2002 Estimted per-child Blood Number of cost to screen Estimted led level children nd tret totl cost 10 µg/dl 2,498 $29 $73,102 10 19 µg/dl 232 $69 $6,008 20 45 µg/dl 47 $969 $45,543 Totl 2,777 $124,653 For the per-child costs we used Kemper et l. s cost estimtes, 7 inflted 123.8% from 1996 costs bsed on the medicl cre Consumer Price Index. 8 We included costs for ll children listed in the Mhoning County STELLAR dtbse s hving received initil blood led testing in 2002. (STEL- LAR is n cronym for Systemtic Trcking of Elevted Led Levels nd Remedition, led poisoning mngement dtbse developed by the CDC nd dpted by the Ohio Deprtment of Helth for use sttewide.) The mjority of children tested hd reported blood led levels 10 µg/dl. We ttributed only the ctul test cost to these children. For children with higher led levels, we included costs for medicl evlution, follow-up, nd for the highest levels (25 µg/dl) medicl tretment. Korfmcher cutions tht costs clculted by this method underestimte current direct medicl costs becuse behviorl nd lerning problems relted to led poisoning but not directly ssocited with tretment of led poisoning my result in dditionl visits to helth cre providers. On the other hnd, she lso observes tht becuse some children do not receive ll recommended services or testing following initil screening, the ctul community costs incurred for testing nd follow-up my be somewht lower thn those reflected in Tble 1. SPECIAL EDUCATION EXPENDITURES Long-term studies of children exposed to led erly in life hve ssocited led poisoning with lower clss stnding in high school, greter bsenteeism, lower vocbulry nd grmmticl-resoning scores, nd poorer hnd-eye coordintion reltive to other children. 9 This impired neurobehviorl function ccounts for mny led-poisoned children requiring specil eduction services. Schwrz hs estimted tht 20% of children with blood led levels 25 µg/dl will need specil eduction (ssistnce from reding techer, psychologist, or other specilist) for n verge of three yers. 10 In 2003, the verge nnul cost of specil eduction ws $18,000 per pupil in the city of Youngstown (compred with $7,700 per pupil overll), ccording to the superintendent of the Youngstown City School District (Personl communiction, Ben McGee, Jnury 2, 2004). Tble 2 presents our estimte of specil eduction costs for 20% of the 25 Mhoning County children with blood led levels 25 µg/dl reported in 2002 s well s 20% of the estimted 54 children with blood led 25 µg/dl not detected by screening progrms. To estimte this ltter number, we obtined from the locl STELLAR dtbse the percentge of children ged 12 71 months in clendr yer 2002 whose mximum venous blood led levels recorded were 25 µg/dl: 1.0% of children ged 12 71 months. Since the mjority of these children in the dtbse resided in the city of Youngstown, we pplied this percentge to the 2000 Census popultion ges 12 71 months of Youngstown. 11 For the remining county popultion, we used the 2001 Ntionl Helth nd Nutrition Exmintion Survey (NHANES) estimte 12 tht 0.3% of children 72 months hd blood led concentrtions 25 µg/dl nd reduced this number by 33% to reflect the seculr decline in high blood levels tht hs likely occurred since the NHANES dt were collected s well s to compenste for our use of 25 µg/dl Public Helth Reports / My June 2005 / Volume 120
Cost of Child Led Poisoning, Mhoning County, Ohio 313 Tble 2. Estimted cost of specil eduction services for children with blood led levels 25 µg/dl, Mhoning County, Ohio, 2002 Additionl specil eduction cost per child per yer $10,330 Estimted number of children ges 12 71 months with blood led 25 µg/dl in 2002 79 Estimted number of children needing specil eduction services 16 Totl cost per yer of needed services $164,800 Discounted cost per yer $142,158 Discounted cost for three yers of specil eduction services $426,474 Discounted cost for ech one-yer cohort of children $85,295 20% of children with blood led 25 µg/dl (for consistency with Schwrz 10 ) in contrst to the NHANES cutoff of 25 µg/dl. These specil eduction costs hve been discounted t 3% rte for five yers on the ssumption tht they re incurred n verge of five yers in the future. The discounting for specil eduction nd juvenile justice costs (see below) ws bsed on discount fctor 13 clculted s the inverse of (1+discount rte) number of yers which for eductionl costs (bsed on 3% discount rte) ws the inverse of (1.03) 5 or 0.8626. The nnul specil eduction cost of $164,800 ws discounted by 0.8626, leding to the figure of $142,158 shown in Tble 2. Since the 16 children requiring specil eduction would need n verge of three yers of service, their lifetime specil eduction cost is three times the discounted vlue shown in Tble 2, or $426,474. This cost, however, pplies to the entire five-yer cohort of children ges 12 to 71 months, so tht the cost for one-yer cohort is one-fifth of the totl, or $85,295. The specil eduction costs in Tble 2 re bsed only on the probbility of lerning disbility for children with blood led 25 µg/dl. Since child s bility to lern is impired by led exposure t levels fr below 25, Tble 2 likely underestimtes the true cost of specil eduction, lthough no longterm studies hve yet been published on whether children with non-zero blood led levels 25 µg/dl incur significntly more specil eduction costs thn non-led-poisoned children. JUVENILE JUSTICE EXPENDITURES A recent study by Herbert Needlemn t the University of Pittsburgh hs mde it possible to estimte the extent of led s contribution to juvenile delinquency. 14 Needlemn clculted n djusted odds rtio of 4.0 (95% CI 1.4, 11.1) for hving bone led levels 25 ppm (mesured by K-line X-ry fluorometry) for dolescents ged 12 18 who hd been rrested nd djudicted s delinquent reltive to nondjudicted high school controls. There is no estblished stndrd for relting blood levels (which hve hlf-life of bout 30 dys nd reflect very recent exposures) with bone levels, but we ssumed for the nlyses reported here tht Mhoning County children with documented blood led levels 10 µg/dl hve neurologicl dmge comprble to tht experienced by the subjects of Needlemn s study. We used two estimtes of the number of children 12 71 months of ge in Mhoning County with blood led levels 10 µg/dl in 2002 to quntify the popultion t risk for lter delinquency. One estimte (490 children) ws bsed on n ssessment by the Environmentl Working Group, which estimted conservtively tht 44% of children with blood led levels 10 µg/dl were missed in Mhoning County in 2002 becuse of incomplete screening. 15 We performed seprte nlysis for Mhoning County bsed on 7,150 children in the 2002 ge cohort of 12 71 months who hd blood led levels recorded in the locl STELLAR dtbse. Eleven percent of these children most of whom lived in the city of Youngstown hd levels 10 µg/dl. Applying this frction to the 5,940 children ges 12 71 months reported by the 2000 Census s residents of Youngstown, 11 we derived n estimte of 653 prevlent led-poisoned children ges 12 71 months within the city with blood led concentrtions 10 µg/dl. For the reminder of the county popultion ges 12 71 months (9,775), we used the ntionl NHANES rte of 2.2% to produce n estimte of 131 children, for totl county-wide estimte of 784 children. 12 While we believe tht the higher of these two estimtes is more ccurte prevlence mesure, we chose conservtively to use the men of the two estimtes, 637 children, for the clcultions tht follow. Applying Levin s formul for popultion ttributble risk s outlined by Gordis 16 nd the prevlence estimte of 637 children, we estimted popultion ttributble risk of 11% for led poisoning mong djudicted delinquents. Levin s formul clcultes popultion ttributble risk from the odds rtio of the exposure in djudicted vs. non-djudicted children (in this cse, 4.0 for elevted bone led nd delinquency) nd the proportion of the popultion with the risk fctor (in this cse, blood led levels 10 µg/dl: 637 of 15,715 children). Attributble risk is, strictly speking, mesure of ssocition rther thn custion. Studies such s Needlemn et l. s tht show strong ssocition between led poisoning nd delinquency do not estblish with certinty tht led poisoning cuses delinquent behvior, nor do they offer ny gurntee tht in the bsence of led hzrds the risk of delinquency would be reduced by 11% (or t ll). Nonetheless, bsed on the results of Needlemn s multivrite nlysis, it is resonble to clculte popultion ttributble risk on the ssumption tht confounding by other socil vribles ws reduced by multivrite nlysis. Tble 3 presents our estimte of the future costs imposed on the juvenile justice system in Mhoning County for ledpoisoned children who were 12 71 months of ge in 2002 using this vlue for ttributble risk. We discounted juvenile justice costs 17 by 3% over 15 yers using the discount fctor formul cited erlier. 13 The 15-yer period for discounting ws chosen becuse juvenile justice costs re most commonly ccrued in the 15 18 yer ge rnge (Personl communiction, Keith M. Hnni, MA, Probtion Officer, Mhoning County Court of Common Ples Juvenile Court Division, Public Helth Reports / My June 2005 / Volume 120
314 Specil Report on Led Poisoning in Children Tble 3. Estimted cost of juvenile justice services for children with blood led levels 25 µg/dl, Mhoning County, Ohio, 2002 2002 juvenile justice expenditures $5,276,967 Frction ttributble to led poisoning 11% Led poisoning ttributble cost per yer $580,466 Discounted cost per yer $372,560 Discounted cost for three yers of juvenile justice services $1,117,680 Discounted cost for ech one-yer cohort of children $223,536 Led poisoning defined s blood led 25 µg/dl My 2004), i.e., 12 to 15 yers beyond the men ge of this study s cohort of 12- to 71-month-old children. We do not currently hve dt bout the length of time children remin involved with the juvenile justice system in Mhoning County, but county probtion nd intke officers report tht serious cses remin open for t lest three yers. Consequently, s with specil eduction, we ssumed tht these delinquent children would need n verge of three yers of intervention; thus, the totl cost would be three times $372,560, or $1,117,680. This cost, however, pplies to the entire five-yer cohort of children ged 12 71 months, so s with the specil eduction costs the cost for oneyer cohort is one-fifth of the totl, or $223,536. PUBLIC HEALTH EXPENDITURES The stte of Ohio funds locl efforts in Mhoning County to educte residents bout led poisoning nd prevent nd respond to cses of childhood led poisoning through trgeted outrech to prentl clinics, preschools, nd elementry schools; led wreness home visits; nd btement progrms. Funding provided to the Mhoning County District Bord of Helth in 2002 for these purposes totled $66,000. Most of this public funding would no longer be necessry if led poisoning were eliminted. In ddition to these public helth expenditures, the U.S. Deprtment of Housing nd Urbn Development provides significnt mount of federl funding to Mhoning County to ssist low-income homeowners nd lndlords in remediting led hzrds. COMMUNITY IMPACT OF THIS ANALYSIS Tble 4 presents summry of yerly costs to txpyers of childhood led poisoning in Mhoning County in 2002 bsed on Korfmcher s model. 1 We hve clculted costs both for led-poisoned children ctully detected by screening nd for those who remined undetected becuse of incomplete screening. Summing these costs provides the totl 2002 nd future costs for the cohort of led-poisoned children (with blood led 10 µg/dl) ged 12 71 months in 2002 ($1,610,154). However, this simple summtion is problemtic becuse medicl nd public helth costs in Tble 4 ccrue yerly, wheres the specil eduction nd juvenile justice costs in Tbles 2 nd 3 re time-limited, delyed in onset, nd occur over severl yers. To mke these costs more strictly comprble, we chose to express eductionl nd juvenile justice costs in Tble 4 per one-yer ge cohort. As we hve stressed, these clcultions lmost certinly underestimte some costs nd do not include other direct nd indirect short- nd long-term costs imposed on txpyers nd society by childhood led poisoning. As Schwrz hs noted, property owner concerns bout the cost of led hzrd remedition must be blnced with the burdens plced on txpyers by property owners filure to remedite these hzrds in the homes of children who become led-poisoned. 10 While there is very wide rnge of cost estimtes for led btement, Needlemn cites 1991 CDC 30-yer cost estimte of $33.7 billion to remedite 18.4 million housing units ($2,519 per unit in 2004 dollrs). 18 A cost-benefit nlysis suggests tht under some ssumptions, strict enforcement of housing ordinnces cn be significntly cost-sving. 19 We hve used these estimtes to brief members of locl colition of public nd privte orgniztions tht serve children (the Mhoning County Fmily First Council); Youngstown City Council nd Bord of Eduction members; juvenile court officils; child welfre dvoctes; nd others who hve n interest in the problem of child led poisoning in Mhoning County. Prompted by reveltions bout property owner noncomplince with led btement orders (300 rentl property owners in Youngstown ignored btement orders in 2003), the Fmily First Council obtined privte foundtion funds to convene series of regultory negotition ( reg-neg ) meetings with the locl lndlord nd reltors ssocitions; City Council nd Bord of Helth members; locl regultory officils; nd other stkeholders. Through the reg-neg process, the Fmily First Council hopes tht these stkeholders will rech consensus on n ction pln to eliminte led poisoning from the community by 2010. Reports in the Youngstown news medi bout lndlord noncomplince with btement orders nd the cost to txpyers hve lso drwn the ttention of federl gencies responsible for enforcement of led hzrd disclosure lws. Enforcement officils from the U.S. Environmentl Protection Agency nd Deprtment of Housing nd Urbn Development hve begun interviewing mny of the rentl property owners in Mhoning County who hve not complied with orders to remedite led hzrds on their properties. Tble 4. Estimted costs to screen nd tret children for led poisoning, Mhoning County, Ohio, 2002, including projected future costs Screening nd tretment $124,653 Specil eduction services b,c $85,295 Juvenile justice services,c $223,536 Public helth services for ll screened children $66,000 Totl $499,484 Led poisoning defined s blood led 10 µg/dl b Per one-yer cohort of children c Led poisoning defined s blood led 25 µg/dl Public Helth Reports / My June 2005 / Volume 120
Cost of Child Led Poisoning, Mhoning County, Ohio 315 Our estimtes of the burden on txpyers from led poisoning, however incomplete, hve helped to mobilize key stkeholders in our locl eductionl nd juvenile justice communities to demnd ction on behlf of led-poisoned children. Subsequent to the involvement of these key stkeholders, the myor of Youngstown ppointed specil prosecutor to pursue noncomplint lndlords; we hve lso documented 14% reduction from My 2003 to My 2004 in the number of rentl properties with unremedited led hzrds, the most significnt decline since the Bord of Helth begn enforcing led hzrd reduction mesures in 1995. REFERENCES 1. Korfmcher KS. Long-term costs of led poisoning: how much cn New York sve by stopping led? [cited 2004 My 25]. Avilble from: URL: http://www.fhh.org//_stte%20_locl_led _costs_nyrep.pdf 2. Census Bureu (US). Annul estimtes of the popultion for counties of Ohio: April 1, 2000, to July 1, 2003 [cited 2004 Jul 12]. Avilble from: URL: http://www.census.gov/popest/counties /tbles/co-est2003-01-39.pdf 3. Lndrign PJ, Schechter CB, Lipton JM, Fhs MC, Schwrtz J. Environmentl pollutnts nd disese in Americn children: estimtes of morbidity, mortlity, nd costs for led poisoning, sthm, cncer, nd developmentl disbilities. Environ Helth Perspect 2002;110:721-8. 4. Blincoe LJ, Sey AG, Zloshnj A, Miller TR, Romno EO, Luchter S, et l. Deprtment of Trnsporttion (US), Ntionl Highwy Trffic Sfety Administrtion. The economic impct of motor vehicle crshes 2000. Wshington: Deprtment of Trnsporttion, Ntionl Highwy Trffic Sfety Administrtion; DOT HS 809 446; My 2002. 5. Generl Accounting Office (US). Led poisoning: federl helth cre progrms re not effectively reching t-risk children. Pub. No.: GAO/HEHS-99-18. Wshington: GAO; 1999. Also vilble from: URL: http://www.go.gov/rchive/1999/he99018.pdf 6. Centers for Disese Control nd Prevention (US), Ntionl Center for Environmentl Helth. About childhood led poisoning [cited 2004 Jul 12]. Avilble from: URL: http://www.cdc.gov/nceh/led /reserch/kidsbll.htm#defining%20the%20problem 7. Kemper, AR, Bordley WC, Downs SM. Cost-effectiveness nlysis of led poisoning screening strtegies following the 1997 guidelines of the Centers for Disese Control nd Prevention. Arch Peditr Adolesc Med 1998;152:1202-8. 8. Deprtment of Lbor (US), Bureu of Lbor Sttistics. Tble 1. Consumer Price Index for ll urbn consumers (CPI-U): U.S. city verge, by expenditure ctegory nd commodity nd service group [cited 2004 June 30]. Avilble from: URL: http://www.bls.gov /cpi/cpid0405.pdf 9. Needlemn HL, Riess JA, Tobin MJ, Biesecker GE, Greenhouse JB. Bone led levels nd delinquent behvior. JAMA 1996;275:363-9. 10. Schwrz J. Societl benefits of reducing led exposure. Environ Res 1994;66:105-24. 11. Census Bureu (US). Americn FctFinder. Census dt summry file 1 [cited 2004 June 30]. Avilble from: URL: http:// fctfinder.census.gov/servlet/dtsetminpgeservlet?_progrm= DEC&_lng=en 12. Meyer PA, Pivetz T, Dignm TA, Hom DM, Schoonover J, Brody D. Centers for Disese Control nd Prevention. Surveillnce for elevted blood levels mong children United Sttes, 1997 2001. MMWR Surveill Summ 2003;52:1-21. 13. Ntionl Librry of Medicine (US), Ntionl Informtion Center on Helth Services Reserch nd Helth Cre Technology. Helth economics informtion resources: self-study course. Module 4: n introduction to the principles of criticl pprisl of helth economic evlution studies. Key res for criticl pprisl 4. Discounting [cited 2004 June 30]. Avilble from: URL: http:// www.nlm.nih.gov/nichsr/edu/helthecon/04_he_07.html 14. Needlemn HL, McFrlnd C, Ness RB, Fienberg SE, Tobin MJ. Bone led levels in djudicted delinquents. A cse control study. Neurotoxicol Tertol 2002;24:711-7. 15. Environmentl Working Group. Estimted risk of led poisoning. County nd locl dt: Mhoning County [cited 2004 My 13]. Avilble from: URL: http://www.ewg.org/reports/ohioled /figures /mp_stte_risk.php 16. Gordis L. Epidemiology. Phildelphi: W.B. Sunders; 1996. p. 162. 17. Tblck GJ. Mhoning County, Ohio, comprehensive nnul finncil report for the fiscl yer ending December 31, 2002. Youngstown (OH): Mhoning County, Office of the Auditor; 2003. 18. Needlemn H. Led poisoning. Annu Rev Med 2004;55:209-22. 19. Brown MJ. Costs nd benefits of enforcing housing policies to prevent childhood led poisoning. Med Decis Mking 2002;22:482-92. Public Helth Reports / My June 2005 / Volume 120