A.4
Prototype Indicator Set: Environmental and Occupational Lead Poisoning

BACKGROUND

Decreased levels of lead in gasoline, air, food, and industrial releases have been linked to an overall lowering of mean blood lead levels in the United States from more than 15 µg/dL in the 1970s to less than 5 µg/dL in the 1990s. However, elevated blood lead level continues to be a prevalent childhood health problem (CDC, 1988). In addition, elevated blood lead levels pose an occupational risk to employees in a variety of industries. The problems of childhood and occupational lead poisoning and strategies to address these problems are discussed below.

Child Lead Intoxication

Elevated blood lead level is one of the most prevalent environmental threats to the health of children in the United States (CDC, 1988). Extremely elevated lead levels in children can result in serious medical conditions such as coma, convulsions, potentially irreversible mental retardation, seizures, and death (CDC, 1988). Lower levels of exposure may result in delayed cognitive development; reduced IQ scores; impaired hearing; adverse effects on hematocyte, vitamin D, and calcium production; and growth deficits (CDC, 1988).

Lead in and around the home environment remains a major



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Improving Health in the Community: A Role for Performance Monitoring A.4 Prototype Indicator Set: Environmental and Occupational Lead Poisoning BACKGROUND Decreased levels of lead in gasoline, air, food, and industrial releases have been linked to an overall lowering of mean blood lead levels in the United States from more than 15 µg/dL in the 1970s to less than 5 µg/dL in the 1990s. However, elevated blood lead level continues to be a prevalent childhood health problem (CDC, 1988). In addition, elevated blood lead levels pose an occupational risk to employees in a variety of industries. The problems of childhood and occupational lead poisoning and strategies to address these problems are discussed below. Child Lead Intoxication Elevated blood lead level is one of the most prevalent environmental threats to the health of children in the United States (CDC, 1988). Extremely elevated lead levels in children can result in serious medical conditions such as coma, convulsions, potentially irreversible mental retardation, seizures, and death (CDC, 1988). Lower levels of exposure may result in delayed cognitive development; reduced IQ scores; impaired hearing; adverse effects on hematocyte, vitamin D, and calcium production; and growth deficits (CDC, 1988). Lead in and around the home environment remains a major

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Improving Health in the Community: A Role for Performance Monitoring source of childhood exposure in the United States (USDHHS, 1995). An important route of exposure in young children is the ingestion of lead-based paint chips, lead-impregnated plaster, and contaminated dirt or dust found in homes built before 1950 (NCHS, 1984). Although all economic and racial subgroups of children are at risk of exposure, the prevalence of elevated lead levels remains highest for poor children living in the inner city. It is unlikely that childhood lead intoxication can be eliminated without further reductions in the lead content of paint, dust, and soil in inner-city areas (IOM, 1995). The problem of childhood lead intoxication is reflected in Objective 11.4 of Healthy People 2000: National Health Promotion and Disease Prevention Objectives (USDHHS, 1991): Reduce the prevalence of blood lead levels exceeding 15 µg/dL among children aged 6 months through 5 years to no more than 500,000 by the year 2000. In addition, reduce blood lead levels exceeding 25 µg/dL among children (6 months through 5 years) to zero by year 2000. At the time this objective was established, data for 1984 showed that 3 million young children had blood lead levels exceeding 15 µg/dL, and 234,000 had levels exceeding 25 µg/dL. Current strategies to reduce the exposure of children to lead include abatement of lead hazards in homes and further reduction of lead levels in soil and drinking water. Abatement of lead in homes requires substantial resources, since the cost of abatement of a single residential structure can range from $3,000 to $15,000 (CDC, 1991). Title X of the Housing and Community Development Act of 1992 makes some provisions for funding residential lead abatement in communities. In addition, the act creates a process for involving federal agencies (e.g., the Department of Housing and Urban Development [HUD] and the Environmental Protection Agency [EPA]), local governments, and private owners in the abatement process. Population-based strategies to reduce the availability of lead in soil and drinking water are under way in communities across the United States. Implementing these strategies is expensive and may raise controversies that position residents against government officials (or the business community). For example, soil remediation at Smuggler Mountain, a Superfund site near Aspen, Colorado, caused public outcry when residents learned that current blood lead levels of children were relatively low and that the process of soil remediation might result in a temporary increase in

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Improving Health in the Community: A Role for Performance Monitoring the level of exposure (IOM, 1995). This concern encouraged community members to become active participants in the remediation process and to work with officials to design strategies that minimize the risk of exposure during remediation. Adult Lead Intoxication Lead intoxication is a less prevalent problem among adults than among children. Among adults, lead exposure is associated most commonly with work at battery manufacturing plants, smelting operations, construction sites, radiator repair shops, ceramics production shops, firing ranges, and foundries (Pirkle et al., 1985; CDC, 1988). The exposure of adults to lead can affect a variety of organ systems, including cardiovascular, reproductive, renal, neurological, hematological, and musculoskeletal (CDC, 1988). In addition to personal health risks, adults who are exposed to lead in the workplace may "take home" lead dust on work clothes and shoes, thereby contributing to the exposure of family members. According to the lead standard enforced by the Occupational Safety and Health Administration (OSHA, 1995), any worker with an average blood lead level greater than 50 µg/dL must be removed from exposure to lead. However, the medical literature suggests that serious health hazards such as neurological abnormalities, hypertension, and adverse reproductive effects for both genders are associated with blood lead levels as low as 30 µg/dL (CDC, 1988). Concern about the health hazards that occur at blood lead levels less than 50 µg/dL is reflected in Objective 10.8 of Healthy People 2000 (USDHHS, 1991): Eliminate exposures resulting in workers having blood lead concentrations greater than 25 µg/dL by the year 2000. As a comparison, there were 4,804 workers with elevated blood lead levels in seven states in 1988. "FIELD" SET OF PERFORMANCE INDICATORS By using the domains of the field model, it is possible to identify a variety of measures that might serve as performance indicators for a community's efforts to reduce the magnitude and sources of lead exposure for children and adults, thereby reducing the burden of lead intoxication in the United States. Because of the nature of lead intoxication, both the health outcomes and the exposure sources must be addressed. Educational efforts and

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Improving Health in the Community: A Role for Performance Monitoring strategies that modify the risk of exposure play an important role in community-based prevention efforts. Achieving the childhood lead poisoning prevention objective requires coordination among federal, state, and local health agencies; environmental agencies; housing agencies; community residents (including parents); and the medical care community. In addition, coordination with occupational health groups is necessary to ensure safe removal of lead-containing paint from homes and other buildings. The prevention of adult lead exposure requires surveillance, evaluation, and control activities to identify high-risk industries and occupational groups. Control measures for high-risk occupations may include the substitution of less hazardous materials (e.g., using water-based instead of lead-based paint) or the use of personal protective measures (e.g., air filters and uniforms for hazardous work sites). Through collaborative efforts of public agencies, private organizations, and community members, the dual goals of preventing childhood and workplace lead intoxications can be achieved. The following material reviews various types of health and exposure indicators that may be monitored in the community. Disease and Health Care Reducing the deleterious effects of lead intoxication for children and adults is the health outcome of primary interest. As mentioned earlier, lead intoxication in children can lead to serious conditions with lifelong impacts such as coma, potentially irreversible mental retardation, delayed cognitive development, reduced IQ scores, impaired hearing, and growth deficits. In adults, lead intoxication can lead to cardiovascular, reproductive, renal, neurological, hematological, and musculoskeletal system problems. The serious nature of lead-related medical conditions emphasizes the importance and need for primary prevention efforts. Through prevention, a community can avert potentially devastating and long-term health problems for its residents and can conserve health care, social service, and educational resources. As part of an effort to reduce adverse health effects of lead, a community will need to compile accurate surveillance information about the extent of lead intoxication among its residents. The following indicators might be used: 1. Proportion and number of children (under 6 years of age)

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Improving Health in the Community: A Role for Performance Monitoring who have blood lead testing as recommended by the Centers for Disease Control and Prevention (CDC). CDC (1991) recommends universal screening of children at 12 months of age using a blood lead test, except in communities where no childhood lead poisoning problem exists. Children at high risk should receive earlier and more frequent testing. This recommendation is consistent with those of many organizations. For example, the American Academy of Pediatrics (1993) guidelines recommend that (a) all children should be screened for lead exposure at 12 months and again at 24 months of age; (b) providers should take a history of lead exposure for children between the ages of 6 months and 6 years to identify children living in high-risk situations; and (c) parents should receive educational materials on safe environmental, occupational, nutritional, and hygiene practices to protect their children from lead exposure. In addition, Medicaid's Early Periodic Screening, Diagnostic, and Treatment Program, which provides services to many poor innercity children in high-risk environments, requires periodic screening of children with a blood lead measurement. The American Medical Association, the American Academy of Family Physicians, and the Canadian Task Force on the Periodic Health Examination are consistent and recommend less in the way of testing than CDC and the groups mentioned above. The three organizations recommend blood lead testing for children who are at high risk of exposure (as found through history taking) as opposed to all children. The U.S. Preventive Services Task Force (1996) considered this option and decided against it, concluding that there is insufficient evidence to recommend a specific community prevalence level below which targeted screening can be substituted for universal screening. 2. Proportion and number of employees who have blood lead testing as recommended by the Occupational Safety and Health Administration (OSHA). Occupational lead exposures are associated most commonly with work at battery manufacturing plants, smelting operations, construction sites, radiator repair shops, ceramics production shops, firing ranges, and foundries (Pirkle et al., 1985; CDC, 1988). OSHA has developed standards (29 CFR 1910.1025 and 29 CFR 1926.62) that provide medical surveillance guidelines for groups that are exposed to lead in the workplace (e.g., California Department of Health Services, 1995). In any workplace where

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Improving Health in the Community: A Role for Performance Monitoring air concentrations of lead exceed the OSHA standard, employees should have a blood lead monitoring program. 3. Proportion and number of tested children and adults with an elevated blood lead level. Medical laboratories and health care providers have information about the proportion and number of elevated blood lead level tests. CDC has suggested that all blood lead tests for children be reported to state and local health agencies, and there is a growing national movement to make such reporting mandatory. Currently, about 35 states require that blood lead levels be reported to a state authority by medical laboratories. However, the reporting requirements vary from state to state. Most states require reporting to the health department, although in Maryland, for example, the Department of the Environment is the designated agency. It is noteworthy that in some states, all blood lead tests of children, including those that show no evidence of lead, are reportable to state authorities. Generally, this is not true for adults. In some states, reporting is required at specific levels (e.g., all blood lead test results above 20 µg/dL must be reported). Communities may be interested in monitoring a variety of blood lead levels. For instance, a community may want to compile information about blood lead levels that correspond to national health objectives so that its progress can be compared to that of the nation, and it may want to compile information about the type of environmental or medical intervention required so that the performance of clinical, public health, and social service organizations can be measured. Some of the blood lead levels for children that should be considered follow: Less than 10 µg/dL: 10 µg/dL is the current level of concern at CDC. CDC considers children's blood lead levels less than 10 µg/dL to be ''normal." Greater than 15 µg/dL and greater than 25 µg/dL: These levels correspond to health objectives for the nation's children. 10–19 µg/dL, 20–39 µg/dL, and 40 µg/dL or greater: These correspond to levels at which CDC recommends environmental or medical interventions (discussed under item 4, below). At levels of 10–19 µg/dL, CDC suggests that health agencies provide educational information to parents about lead poisoning prevention. At levels of 20–39 µg/dL, CDC recommends environmental and medical management. At levels of 40 µg/dL or greater, CDC sug-

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Improving Health in the Community: A Role for Performance Monitoring gests chelation therapy in addition to appropriate environmental and medical management. For adults, communities may want to monitor blood lead levels greater than 25 µg/dL (the maximum level targeted by national health objectives) and greater than 50 µg/dL (the level at which workers are removed from workplace lead exposures under the OSHA Lead Standard). If health care providers in the community adhere to CDC's recommendation for universal testing of children for blood lead levels, then the indicator provides an accurate measure of disease burden in the community for children at 12 months of age (recommended age of testing). If clinicians do not adhere to the CDC recommendation, the data may underrepresent the magnitude of lead poisoning in the community (for children 1 year of age). However, the indicator will contain additional testing results as well. Clinicians are likely to test blood lead levels of children living in high-risk environments, adults working in high-risk environments, and patients with symptoms of lead poisoning. The additional tests are important for disease surveillance. Since lead poisoning is a reportable condition in most states, state and local health agencies should have additional epidemiologic data for all children and adults who test positive for lead poisoning. With these data, communities can examine issues that are relevant to better identifying the geographic areas and populations at high-risk and designing intervention strategies. The availability of this information will vary from state to state. Communities that conduct surveillance and follow-up activities may encounter many complex problems, such as public misunderstanding of the problem and prevention strategies; inadequate health care provider knowledge of prevention, diagnosis, and treatment; inadequate blood lead testing of high-risk groups (including children and workers); inadequate medical or public health case management; and incomplete surveillance information. To address problems such as these, a community may choose to use the indicators below. 4. Proportion of children and adults with elevated blood lead levels who receive follow-up services (monitoring, treatment, and reduction of exposure) in accordance with CDC guidelines. Appropriate medical and public health case management is essential for minimizing the impact of lead exposure on the health

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Improving Health in the Community: A Role for Performance Monitoring of children and adults. In most states, case management is provided by the local health agency or managed care organization (MCO), although it may be coordinated through the state health or environmental agency. Follow-up procedures will vary from state to state. However, CDC recommends the following: At levels of 10–19 µg/dL, CDC suggests that health agencies provide educational information to parents and caretakers about lead poisoning prevention. At levels of 20–39 µg/dL, CDC recommends environmental and medical management. The local health agency should make a home visit to examine the environment for hazards and to work with the child's parents and caretakers to remove such hazards. Environmental management may also involve working with other state agencies, landlords, HUD, and EPA to coordinate the abatement of lead paint from houses, if that is the source of a child's lead poisoning. Health department staff should provide parents and caretakers with information about lead poisoning, hygienic practices that can reduce risk, and nutritional or dietary factors that modify risk. Medical management includes an extensive history for the child, a careful physical exam for possible sequelae of lead poisoning, a nutritional assessment, and possible intervention. The nutritional status of the child can modify his risk of lead poisoning, thereby presenting an opportunity to intervene. The absorption of lead into a child's body is less likely if the child has frequent meals because an empty stomach facilitates lead absorption. Adequate calcium, which competes with lead for absorption, and sufficient iron also reduce the risk of lead poisoning. At levels of 20–39 µg/dL, decisions about chelation therapy should be made by an informed health care provider. Although most providers would agree that chelation therapy is not beneficial at blood lead levels of 20–25 µg/dL, there is no consensus about its benefits at levels of 26–39 µg/dL. Medical management should include follow-up blood tests within three to four months to monitor lead levels. At levels of 40 µg/dL or greater, CDC suggests chelation therapy in addition to appropriate environmental and medical management. In chelation therapy, drugs are administered that bind and remove lead from the body (through the liver or kidneys). Chelation is generally performed in the hospital. Untreated children with levels greater than 40 µg/dL are at risk for coma, convulsions, and death.

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Improving Health in the Community: A Role for Performance Monitoring For adults, workers are removed from the workplace at blood lead levels greater than 50 µg/dL, and they cannot return until their levels drop to 40 µg/dL or less. Chelation therapy protocols are more variable in adults. Eliminating lead exposures at the work site and using personal protective measures (e.g., respirator, goggles, protective work clothes, boots) may decrease the occurrence of occupational lead poisoning. 5. Existence of standard professional training opportunities for health care staff, public health staff, and environmental staff in areas related to child and adult lead poisoning. Communities should ensure that professional staff who are responsible for issues related to lead poisoning receive adequate training in state-of-the-art approaches to the problem. Communities may want to consider the following: Are clear guidelines disseminated to area clinicians by medical associations and public health departments to ensure appropriate diagnosis, treatment, and reporting of lead poisoning in the community? What proportion and number of medical and related training programs provided by hospitals, MCOs, or other organizations incorporate state-of-the-art education into the curriculum? What proportion and number of courses that provide continuing medical education (CME) credit or other relevant and mandatory professional education credit incorporate state-of-the-art education into the curriculum? What proportion and number of state licensing examinations for physicians, nurses, and related providers include lead poisoning questions? The answers to these questions may provide some direction for potential interventions. 6. Per capita public funding (state and local governments) for lead poisoning prevention that is dedicated to case management: identification of source, medical monitoring, treatment, and reduction of exposure. One approach to monitoring performance is to review and compare the number and complexity of tasks (e.g., case management), the resources allocated to those tasks, and their outcomes. Information about public-sector funding for case management of lead poisoning prevention provides a starting point for such inquiries.

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Improving Health in the Community: A Role for Performance Monitoring However, it is difficult to track the allocation and use of funds from state coffers in local programs. Communities should approach this measure with some caution. Additional issues that are relevant to the disease and health care discussion include the level at which pregnant women are considered to have elevated blood lead, whether blood lead results should be based on confirmed (venous) or screening (capillary) blood tests, and whether ICD-9 diagnostic codes are adequate to identify health care provider visits for lead-associated health conditions. Although these issues are of vital interest and relevant, they were not included in the indicator set because they have not been resolved by the scientific community and reliable data are not available. Physical Environment Lead poisoning can be prevented by reducing exposure to lead in the environment (IOM and National Institute of Public Health, 1996). Recent efforts to reduce the number of lead exposure sources, focused on the physical and social environments, have been relatively successful. According to the midcourse review of the national objectives described in Healthy People 2000, the number of children who have blood lead levels greater than 15 µg/dL has been reduced from 3 million to 503,000, and the number of children who have blood lead levels greater than 25 µg/dL has been reduced from 234,000 to 93,000 (USDHHS, 1995). Communities can further reduce the risk of lead exposure among children by reducing the remaining sources of exposure in and around the home. Consideration should be given to the lead content of paint, dust, and soil in inner-city structures and outdoor areas that children may frequent. Various obstacles exist in trying to ameliorate lead exposure in homes and other buildings. Communities that embark on lead poisoning prevention projects will be faced with many issues such as inadequate lead hazard identification and remediation, liability insurance, rental property issues, financial incentives for lead abatement or control, inadequate public information, poor coordination of public agencies, and potential for exposure at public schools and child care facilities. Communities may want to consider indicators such as the following: 1. Proportion (and number) of pre-1950 housing units in the

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Improving Health in the Community: A Role for Performance Monitoring community; proportion (and number) of high-risk work sites in the community. This indicator addresses the potential high-risk environments for children (i.e., homes that are likely to have lead-based paint or plaster) and adults (i.e., work sites with lead). In communities that find a substantial lead poisoning problem in children or adults, monitoring efforts should involve more than merely quantifying the number of high-risk sites. For instance, in addition to the proportion of pre-1950s housing, communities may want to map the location of high-risk housing and examine whether the location is correlated with lead poisoning cases among children. Surveys of residents can be conducted to learn more about whether lead-based paint has been abated (also see item 8 below). The local health department can provide information about the number of children who live in high-risk areas, so that prevention strategies can be developed. Information about high-risk work sites can be monitored in a similar way. 2. Proportion of housing units with identified lead hazards that have been remediated; proportion that are in the process of remediation; proportion that have been referred for legal enforcement. Abatement of lead hazards in homes eliminates an important source of childhood lead poisoning. This indicator also measures the performance and coordination of federal agencies (e.g., HUD and EPA) with local housing and regulatory agencies, private owners, and other community stakeholders. 3. Proportion of local housing programs, weatherization programs, rehabilitation programs, and local building codes that include provisions for lead hazard control. Lead hazards are more common in older housing; therefore, programs that target such housing should include provisions for lead hazard control. Programs that do not do so represent a "missed opportunity" for prevention and for addressing potential environmental hazards. 4. Proportion of lead inspectors, risk assessors, supervisors, project designers, and abatement workers certified through accredited training courses. This measure is relevant to the safety of workers and their families as well as the identification and remediation of lead hazards in homes and other buildings. The presence of training

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Improving Health in the Community: A Role for Performance Monitoring courses and certification processes provides two opportunities for communities to monitor and influence the quality of technical training and the skill level and knowledge of technicians working in the community. 5. Environmental lead exposure as measured by sources such as the Toxic Release Inventory, Air Quality Management Districts, public water supply sources, contaminated food, and consumer product listings. Community sources of lead exposure may include construction waste, lack of recycling, poor air quality, hazardous consumer products, and contaminated soil and water. Data relevant to these concerns are collected routinely in many communities by a number of state and local authorities. A periodic review of the diverse measures provides an opportunity to identify trends, problems, emerging problems, and signs of progress, and generally to determine if these sources are lead poisoning hazards to the community. To prevent occupational lead poisoning, communities may have to address issues such as inadequate outreach, education, and technical assistance; lack of appropriate regulations, compliance and legislation; and lack of financing. Possible indicators in these areas follow. 6. Number of citations of companies by OSHA or state agencies for noncompliance with lead standards. This indicator should be used with caution since OSHA investigations are initiated in response to employee complaints. If employees are unaware of the presence of lead in their workplace, feel that a complaint will jeopardize their job, or are unaware of the OSHA complaint option, no complaint will be filed. Thus, this indicator may not accurately reflect the extent of workplace hazards. However, communities may be able to use this measure in concert with other measures to monitor the performance of work site and environmental regulatory agencies. 7. Per capita state and federal matching funds devoted to work site training, technical assistance, and enforcement. One approach to monitoring performance is to review and compare the number and complexity of tasks (e.g., work site training, technical assistance, and enforcement), the resources allocated to those tasks, and the outcomes of the tasks. Information about public-sector funding for work site training, technical assistance,

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Improving Health in the Community: A Role for Performance Monitoring and enforcement activities provides a starting point for such inquiries. However, it is difficult to track the allocation and use of funds from state coffers in local programs. Communities should approach this measure with some caution. One of the barriers to providing adequate outreach, education, technical assistance, and regulatory activities is the lack of funding. Social Environment Many sectors of the community, in addition to the medical, public health, and environmental sectors, can influence and be influenced by lead poisoning prevention activities. For example, social service agencies play a potentially important liaison role between community members who need lead prevention services and service providers. When communities are not successful in prevention efforts, the demands on social service agencies, the health care system, and the educational system for services may increase (i.e., children and adults with lead-related conditions). Community resources can be used more efficiently when coordination exists between community agencies and organizations and when information is disseminated appropriately. To facilitate coordination and dissemination activities, communities may want to monitor the following indicators: 1. Per capita funding from state and local governments that is dedicated to education of the public and the medical community regarding lead poisoning. As mentioned above, one approach to monitoring performance is to review and compare the number and complexity of tasks (e.g., educational activities for the public and medical community), the resources allocated to those tasks, and their outcomes. Information about funding for educational activities provides a starting point for such inquiries. Again, however, it is difficult to track the allocation and use of state funds in local programs. Communities should approach this measure with some caution. There are many opportunities for providing effective prevention messages in the social environment. For instance, parents and caretakers can be educated about the risk posed by lead paint and the increased risk of lead poisoning for children with poor nutrition (i.e., infrequent meals, calcium deficiency, and iron deficiency) during physician visits and, in a less formal way, dur-

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Improving Health in the Community: A Role for Performance Monitoring ing visits to related businesses (hardware stores, supermarkets, science museums, etc.). 2. Existence of periodic lead-related disease meetings between different public agencies at the state and local levels (e.g., health departments; the Special Supplemental Food Program for Women, Infants, and Children [WIC]; Head Start) and meetings that include private health care community representatives. This measure suggests one way in which information might be disseminated across agencies and organizations. However, it does not measure the quality of the information that is provided or the effectiveness of the strategy. SAMPLE SET OF INDICATORS Although all of the indicators discussed above are relevant to monitoring lead poisoning prevention efforts in communities, the nine measures listed below represent a minimal proposed set of indicators. Communities can supplement this list according to their interests and circumstances. Proportion of children (under 6 years of age) who have blood lead testing as recommended by CDC. These data are not currently available but could be collected in a community survey. Proportion and number of tested children and adults with an elevated blood lead level. About 35 states require that blood lead test levels be reported to a state authority by medical laboratories. However, reporting requirements vary from state to state. Medical laboratories may be required to report only positive lead test results. Proportion of children and adults with elevated blood lead levels who receive follow-up services (monitoring, treatment, and reduction of exposure) in accordance with CDC guidelines. These data may be available through a state's designated agency for lead reporting. Obtaining them may, however, require a review of medical records or a survey of health care providers. Proportion (and number) of pre-1950 housing units in the

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Improving Health in the Community: A Role for Performance Monitoring community; the proportion (and number) of high-risk work sites in the community. The housing authority in a community should be able to provide this information. The health department and environmental agency may be able to provide supplementary information. Proportion of housing units with identified lead hazards that have been remediated; proportion that are in the process of remediation; proportion that have been referred for legal enforcement. The local housing authority and the local environmental agency should be able to provide data. Proportion of local housing programs, weatherization programs, rehabilitation programs, and local building codes that include provisions for lead hazard control. The local housing authority and the local environmental agency should be able to provide data. This information is also available through a survey of such programs. Proportion of lead inspectors, risk assessors, supervisors, project designers, and abatement workers certified through accredited training courses. The local housing authority and the local environmental agency should be able to provide data. Environmental lead exposure as measured by sources such as the Toxic Release Inventory, Air Quality Management Districts, public water supply sources, and contaminated food and consumer product listings. The state environmental and health agencies should be able to provide such information. Number of citations of companies by OSHA or state agencies for noncompliance with lead standards. OSHA or state agencies can provide this information. The proposed indicator set includes measures of population-based risk factors (elevated blood lead in children, high-risk sites); medical care delivery (health care treatment and follow-up services); measures of lead in the environment (OSHA citations, air quality, toxic release inventory, water quality, foods); and prevention or risk reduction measures (blood testing, housing units un-

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Improving Health in the Community: A Role for Performance Monitoring der abatement, training). These measures also address the two major populations at highest risk for lead intoxication (children and workers) and a variety of exposure routes (air, water, and food; work sites; paint in older buildings; toxic releases). The population-based health measure indicates whether the community as a whole has a problem with lead exposures. Children with elevated blood levels (> 10 µg/dL) are directly indicative of a chronic, low-level, but still serious problem. Those with a higher blood lead level (> 20 µg/dL) signal the need for immediate treatment and indicate a possible chronic, low-level problem in the population from which the people with the most serious problems come. Measures of air and water lead levels also relate to the community as a whole. A number of the measures indicate the performance of broad sectors in the community. The proportion of children who have blood lead testing is a measure of the combined efforts of private physicians and health care plans, public health departments, and schools in providing the highly recommended clinical preventive service. The indicator on contaminated food and related products reflects the performance of federal, state, and local food and consumer regulatory agencies as well as product manufacturers and importers. Other measures are more specific for particular segments of the community. The number of housing units with lead abatement completed is a direct measure of the performance of public and private housing agencies and regulatory agencies (at the national, state, and local levels). OSHA citations relate to employers who use lead in production and, indeed, can indicate specific employers that are cited. Similarly, EPA Toxic Release Inventories address the total amount of lead released by manufacturing companies into the community's environment and identify the specific companies involved. Certification of lead abatement inspectors, contractors, and workers relates to a specific group that is responsible for both the safety of lead workers and minimizing lead exposure in the immediate environment. REFERENCES American Academy of Pediatrics. 1993. Lead Poisoning: From Screening to Primary Prevention. Pediatrics 92:176–183. California Department of Health Services. 1995. The Lead-Exposed Worker. OLPPP/HESIS Medical Guidelines. Berkeley: California Department of Health Services, Occupational Lead Poisoning Prevention Program and Hazard Evaluation System and Information Service. October.

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Improving Health in the Community: A Role for Performance Monitoring CDC (Centers for Disease Control). 1988. The Nature and Extent of Lead Poisoning in Children in the United States: A Report to Congress . Atlanta, Ga.: U.S. Department of Health and Human Services. CDC. 1991. Preventing Lead Poisoning in Young Children. A Statement by the Centers for Disease Control—1991. Atlanta, Ga.: U.S. Department of Health and Human Services. IOM (Institute of Medicine). 1995. Lead: A Public Health Policy Case Study. K.A. Brix, D.R. Mattison, and M.A. Stoto, eds. Washington, D.C.: National Academy of Sciences. IOM and National Institute of Public Health. 1996. Lead in the Americas: A Call for Action. C.P. Howson, M. Hernandez-Avila, and D.P. Rall, eds. Washington, D.C.: National Academy Press. NCHS (National Center for Health Statistics). 1984. Blood Lead Levels for Persons Ages 6 Months to 74 Years: United States, 1976–1980. Data from the National Health and Nutrition Examination Survey. Vital and Health Statistics. Series 11, No. 233. Pub. No DHHS(PHS) 84-1683. Washington, D.C.: U.S. Department of Health and Human Services. OSHA (Occupational Safety and Health Administration). 1995. OSHA Lead Standard. 29 CFR 1910.1025 (k) (l) (i) (o), App. C (7-1-95 Edition). Washington, D.C.: U.S. Department of Labor, Office of Occupational Medicine. Pirkle, J.L., Schwartz, J., Landis, J.R., and Harlan, W.R. 1985. The Relationships Between Blood Lead Levels and Blood Pressure and its Cardiovascular Risk Implications. American Journal of Epidemiology 121(2):246–258. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. USDHHS. 1995. Healthy People 2000: Midcourse Review and 1995 Revisions . Washington, D.C.: USDHHS. U.S. Preventive Services Task Force. 1996. Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams and Wilkins.

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Improving Health in the Community: A Role for Performance Monitoring TABLE A.4-1 Field Model Mapping for Sample Indicator Set: Environmental and Occupational Lead Poisoning Field Model Domain Construct Sample Indicators Data Sources Stakeholders Disease, Health Care Reduce the impact of lead-related morbidity Proportion of children who have blood lead testing as recommended by CDC Community surveys required Health care providers Health care plans State health agencies Local health agencies     Proportion and number of tested children and adults with an elevated blood lead level Laboratory reports, medical record reviews Community organizations Special health risk groups Parents and care givers General public     Proportion of children and adults with elevated blood lead levels who receive follow-up services in accordance with CDC guidelines State health department or other designated agency, medical record reviews   Physical Environment Identify and remediate sources of lead exposure Proportion (and number) of pre-1950 housing units in the community; proportion (and number) of high-risk work sites in the community. State and local agencies (e.g., environment, housing and community development) State health agency State environmental agency State housing agency State and federal occupational safety agencies Local health agencies

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Improving Health in the Community: A Role for Performance Monitoring Field Model Domain Construct Sample Indicators Data Sources Stakeholders Physical Environment Remediate lead hazards through legal mechanisms (regulatory and court actions) Proportion of housing units with identified lead hazards that have been remediated; proportion that are in the process of remediation; proportion that have been referred for legal enforcement State and local agencies Local government Landlords, homeowners Business, industry Employees General public   Improve coordination of community programs to address lead hazards Proportion of local housing programs, weatherization programs, rehabilitation programs, and local building codes that include provisions for lead hazard control State agencies, survey of programs       Proportion of lead inspectors, risk assessors, supervisors, project designers, and abatement workers certified through accredited training courses State agencies, survey of programs  

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Improving Health in the Community: A Role for Performance Monitoring       Periodic review of environmental lead data from sources such as Toxic Release Inventory, Air Quality Management Districts, etc. Federal, state, and local environmental quality agencies         Number of citations of companies by OSHA or state agencies for noncompliance with the lead standards State or federal occupational safety agencies   NOTE: CDC, Centers for Disease Control and Prevention; OSHA, Occupational Safety and Health Administration.