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Overview Vision: To eliminate childhood lead poisoning in New Jersey. Mission: To promote the health and well-being of people in New Jersey so that lead poisoning is eliminated*. Purpose: To provide a blueprint to eliminate lead poisoning through the development of collaborative partnerships among public and private organizations that support and promote comprehensive community-based services. Related Objectives Healthy People 2010 Objectives: Eliminate elevated blood lead levels in children. Increase the proportion of persons living in pre-1950’s housing that has been tested for the presence of lead-based paint. Healthy New Jersey 2010 Objectives: Increase the percentage of children screened for lead poisoning by two years of age to 85.0 percent. (Baseline: FY 2000 33.0 percent) Reduce the percentage of tested children whose initial blood lead level is >10 ug/dL by 50 percent. (Baseline: FY 2000 5.0 percent) *”Eliminated” means no children with blood lead levels >10 ug/dL. 1 Introduction The New Jersey Department of Health and Senior Services (DHSS) is the recipient of federal funding for childhood lead poisoning, through a Childhood Lead Poisoning Prevention Cooperative Agreement with the U.S. Centers for Disease Control and Prevention (CDC). In Healthy People 2010, the U.S. Department of Health and Human Services, of which CDC is a part, set forth a national goal of eliminating childhood lead poisoning by the year 2010. In 2003, CDC required all States receiving Childhood Lead Poisoning Prevention funding to develop a State Plan to Eliminate Childhood Lead Poisoning. This document has been developed in response to that mandate. But this Plan is more than just the fulfillment of a requirement for federal funding. It sets forth a call to action and a road map for achieving a very significant public health milestone. And the process of developing this Plan has promoted cooperative working relationships between multiple State and local, public and private agencies that will be vital to the achievement of this ambitious goal. The State of New Jersey and the DHSS have a long history of responding to lead poisoning in children. The Department’s Laboratory has been testing children’s blood for lead since 1956. In 1958, Jersey City was the first community in the State to launch a screening and follow-up program after three children died from lead poisoning within two days. Newark, Paterson, Camden and Trenton also initiated lead poisoning programs during this period. In order to coordinate childhood lead poisoning prevention (CLPP) activities throughout the State, the Department established the Accident Prevention and Poison Control Program in 1967. In 1971, the federal Lead Based Paint Poison Prevention Act made funds directly available to highrisk cities to establish CLPP programs. Ten New Jersey cities received grants from CDC during the period 1971-1982. When the Maternal and Child Health Block Grant was created in 1981, the DHSS devoted a significant amount of its allocation to continuing support of these CLPP programs. Since the direct CDC CLPP grants were re-established in 1991, DHSS has received funding and been a partner with CDC in the national campaign to reduce and eliminate lead poisoning in children. New Jersey’s efforts to address childhood lead poisoning have been facilitated by strong, often landmark, legislation. In 1971, New Jersey adopted one of the first State laws prohibiting the use of lead paint on toys, furniture and dwellings, and empowering public health agencies to order the removal of lead hazards. This was seven years before the national ban on the sale of lead paint issued by the Consumer Product Safety Commission. In subsequent years, additional State laws and regulations have been adopted addressing lead poisoning in children. In 1977, the DHSS adopted regulations incorporating childhood lead poisoning prevention as a core activity under Minimum Standards of Performance for all local health departments in the State. In 1986, a law was passed requiring the DHSS to establish a program for screening children at high risk of lead poisoning through local health departments and other agencies. This was superseded in 1996 by a law requiring health care providers to screen all children in their care under six years of age. A companion law required health care insurers to cover lead screening. A law adopted in 1993 requires that anyone who performs lead paint inspections or abatement to be certified by the State and to follow State-specified work practices. 2 The most recent legislation addressing childhood lead poisoning in New Jersey is Public Law 2003, Chapter 311, the Lead Hazard Control Assistance Act. This law passed the Legislature on January 12, 2004 and was signed by Governor James E. McGreevey on January 20, 2004. The purpose of the Act is to provide a comprehensive program to identify lead hazards in residential housing and also to identify housing which is safe from exposure to lead hazards in order to eradicate the major source of lead exposure to our State’s children. The comprehensive program will emphasize methods to safeguard children residing in rental housing and require the State to track the progress of making all of New Jersey’s rental housing stock more lead safe. It also created the Lead Hazard Control Assistance Fund, with a dedicated funding mechanism, to assist property owners with the cost of removal of lead paint and/or making their properties lead safe. This law promotes primary prevention of childhood lead poisoning and provides the resources needed to make it possible. The most significant provisions of the Act are: • requires the New Jersey Department of Community Affairs (DCA) to promulgate regulations requiring all multiple-unit dwellings with three or more units be maintained in such a manner as to be free of lead-based paint hazards and provide standards and specifications for such maintenance; • establishes the assessment of a $20 per unit fee to inspect multi-family housing for leadbased paint hazards; • requires the DCA to create and maintain a registry of residential housing that provides information on the lead status of each housing unit; • establishes the Lead Hazard Control Assistance Fund; • sets aside $.50 from the sales tax on each can of paint sold in New Jersey and places it in the Lead Hazard Control Assistance Fund; • establishes the Emergency Lead Poisoning Relocation Fund; • removes the payment limitations set forth in the Relocation Assistance Act for the purposes of relocating a lead poisoned child; • establishes a training requirement for persons for hire who seek to engage in lead safe maintenance work or lead hazard control work; and requires the DCA to establish guidelines for interim control methods. These laws provide a strong basis for action by State government, as well as by local health departments and housing agencies. Given the extent of lead poisoning in New Jersey, no one agency can successfully deal with all the issues involved in addressing this problem. A combination of the State laws cited above and Executive Branch directives has distributed the responsibility for addressing lead poisoning among a number of agencies of New Jersey State government. The agencies directly involved in addressing lead poisoning are: • Department of Health and Senior Services - screening, surveillance, oversight of local health departments follow-up of children with elevated blood lead, occupational lead poisoning, regulation of lead inspectors and abatement workers, and licensure of laboratories, lead curricula development and certification of training facilities; • Department of Community Affairs - all housing issues including the administration and enforcement of uniform construction codes and property maintenance codes, the 3 administration of federal and state funded housing acquisition and renovation initiatives including lead hazard control grants and full implementation of the Lead Safe Housing Rule, and the administration of other housing assistance programs such as rental assistance; • Department of Human Services - Medicaid, licensed child care centers, and foster children; • Department of Environmental Protection - environmental hazards in soil, air, and water; and • Department of Banking and Insurance - health insurance and property liability insurance. Communication and cooperation among these agencies is facilitated through the Interagency Task Force on the Prevention of Lead Poisoning. The Task Force includes representatives of the State agencies involved in addressing lead poisoning. It also includes representation from professional, medical, environmental and community-based organizations. The Task Force meets bi-monthly. The Chair is the Director of the Division of Codes and Standards in the Department of Community Affairs. A list of the agencies and organizations participating in the Task Force is attached (Appendix 1). The Task Force was created in 1988. It is a committee of the Governor’s Council on the Prevention of Mental Retardation and Developmental Disabilities, and its Chair sits on the Council. This gives the Task Force access to the highest levels of State government. The Task Force has previously produced documents to guide statewide planning and policy, including a “Lead Poisoning Prevention Action Agenda” in 1989, and “Recommendations for the Primary Prevention of Lead Poisoning” in August 1995. In 1996, in response to the report of HUD’s Lead-Based Paint Hazard Reduction and Financing Task Force, the Task Force created a Title X Committee, which included representatives of rental property owners, real estate agents, the insurance industry, and attorneys. The committee’s recommendations were incorporated into amendments to the State multiple-unit dwelling code that were adopted by the Department of Community Affairs. In 2003, the Task Force undertook a review of the progress towards achievement of the 1995 Recommendations. This resulted in the preparation and approval of a Strategic Plan for the Prevention of Lead Poisoning in New Jersey. The Task Force’s Strategic Plan became the basis for the development of this Elimination Plan. 4 Why is Lead Poisoning in Children a Priority for New Jersey? Lead is a heavy metal that has been widely used in industrial processes and consumer products. When absorbed into the human body, lead affects the blood, kidneys and nervous system. Lead’s effects on the nervous system are particularly serious and can cause learning disabilities, hyperactivity, decreased hearing, mental retardation and possible death. Lead is particularly hazardous to children between six months and six years of age because their neurological system and organs are still developing. Children who have suffered from the adverse effects of lead exposure for an extended period of time are frequently in need of special health and educational services in order to assist them to develop to their potential as productive members of society. Failure to identify and assist these children can produce an economic and social impact, not only on the individual for the rest of their lives, but also on society as a whole. Research indicates that lead poisoning in childhood can result in school failure, violence and criminal behavior, reduced earning potential and health problems later in life. As the most densely populated state of the Union, and among those states with the oldest housing and an extensive industrial heritage, New Jersey contains a substantial amount of lead, subjecting its residents to the dangers of lead poisoning. New Jersey’s demographics are consistent with the known high risk factors for childhood lead poisoning. Although a relatively small state in size, with a population of nearly 8.5 million people New Jersey is the most densely populated state in the nation, with 1,134 people per square mile. Thus 94.3 % of New Jersey’s population lives within urbanized areas. The least “urbanized” county still has 46.9 % of the population living in an urbanized area. Of the 135,549 families living in poverty, there were 48,730 families with children under 5 years old. The primary method for lead to enter the body is through the ingestion of lead containing substances. Lead was removed from gasoline in the United States in the early 1980’s. This action is credited with reducing the level of lead in the air, and thereby, the amount of lead inhaled by children. However, significant amounts of lead remain in the environment, where it poses a threat to children. Some common lead containing substances that are ingested or inhaled by children include: lead-based paint; dust and soil in which children play; tap water; food stored in lead soldered cans or improperly glazed pottery; and traditional folk remedies and cosmetics containing lead. Due to the fact that lead-based paint and other lead-containing substances are present throughout the environment in New Jersey, all children in the State are at risk. Some children, however, are at particularly high risk due to exposure to high dose sources of lead in their immediate environment. For example, the rates of lead poisoning remain high among lowincome and/or minority children and children in urban areas. These potential high dose sources include: - leaded paint that is peeling, chipped, or otherwise in a deteriorated condition; - lead-contaminated dust created during removal or disturbance of leaded paint in the process of home renovation; and - lead-contaminated dust brought into the home by adults who work in an occupation that involves lead or materials containing lead, or who engage in a hobby where lead is used. 5 Today, the primary lead hazard to children comes from lead-based paint. In recognition of the danger that lead-based paint presents to children; such paint was banned for residential use in New Jersey in 1971, and nationwide in 1978. These bans have effectively reduced the risk of lead exposure for children who live in houses built after 1978, but any house built before 1978 still may contain leaded paint. Housing built prior to 1950 presents the greatest risk due to the high percentage by volume of lead. Statewide, there are nearly one million housing units built before 1950, which is 30.2% of all housing units in the State (Appendix 3). Every county in the State has more than 9,000 housing units built before 1950. 6 The Extent of Childhood Lead Poisoning in New Jersey United States Centers for Disease Control and Prevention (CDC) guidelines state that a blood lead test of 10 micrograms per deciliter (ug/dL) or greater should be considered elevated. In addition, the CDC guidelines state that a confirmed blood lead test result of 20 ug/dL or greater should trigger public health follow-up, including an environmental investigation to determine the source of the lead, and case management assistance to the family. While 97% of the children tested in New Jersey in State Fiscal Year (SFY) 2003 had blood lead levels below the CDC threshold of 10 ug/dL, there were 5,230 children with a blood lead test result above this level, which was 3% of all children tested. This included 832 children who had at least one test result of 20 ug/dL or greater (Appendix 4, Table 1). While every county in New Jersey had children with elevated blood test results in SFY 2003, the number and percentage of children with elevated blood lead were highest in the urban counties of Camden, Essex, Hudson, Mercer, Passaic and Union. The numbers were highest in Essex, where there were 1,879 children with blood lead levels > 10 ug/dL, seven percent of all Essex County children tested. This was 36% of all children in New Jersey with elevated test results. The percentage of children with elevated blood lead in Essex County is more than double the statewide percentage, and significantly higher than in any other county. However, elevated test results were not limited to urban areas. High percentages of children with elevated test results were also found in rural Cumberland and Salem counties in South Jersey. This documents that childhood lead poisoning continues to be a statewide problem. As expected, the older urban centers, which have the largest portion of high risk housing units, also have the highest levels of lead poisoning. Data for the largest municipalities (population > 35,000) are presented in Appendix 4, Table 2. The municipality with the highest percentage of children with elevated blood lead test results was East Orange, with 9.9%, followed closely by Irvington at 9.4%. Other municipalities with percentages of children with elevated blood lead significantly higher than the statewide percentage of 3% included Atlantic City (3.9%), Camden (3.9%), Montclair (4.3%), New Brunswick (4.3%), Newark (8.1%), Passaic (3.8%), Paterson (6.5%), Plainfield (4.4%) and Trenton (8.1%). Of the 60 municipalities for which the data were analyzed, there were only four (Berkeley Township, Bridgewater, Manchester Township, and Mount Laurel) where no children with elevated blood lead were reported. New Jersey has already made significant progress towards eliminating childhood lead poisoning. In the past decade (1994-2003), the number of children reported to the DHSS with blood lead levels > 20 ug/dL has declined from 4,757 in SFY 1994 to 832 in SFY 2003, an 82.5% decrease (Appendix 4, Figure 1). Since the reporting of all blood levels began in July 1999, the number of children reported with blood lead levels > 10 ug/dL has declined from 6,847 in SFY 2000 to 5,230 in SFY 2003, a 23.6% decrease. While progress is being made, even one child with lead poisoning is one child too many. Therefore it is our State’s goal to reduce the number of children with lead poisoning, at or above 10 ug/dL, to zero by 2010. 7 Process for Development of the Elimination Plan The Department of Health and Senior Services (DHSS) has been an active partner in the Interagency Task Force on the Prevention of Lead Poisoning since its inception. Through the Task Force, DHSS staff has worked with their colleagues of other State agencies and representatives of statewide and community-based organizations to develop and implement policies and initiatives to reduce childhood lead poisoning in New Jersey. As described previously, the Task Force has produced a series of documents guiding State policy and actions on childhood lead poisoning, culminating in the Strategic Plan for the Prevention of Lead Poisoning in New Jersey in 2003. CDC’s mandate to develop a State plan for the elimination of childhood lead poisoning included a requirement to create an advisory committee, including representatives of all the key constituencies required to implement the Plan. Given its history and track record, the DHSS decided to turn to the Task Force to assist it in developing this plan, rather than create a separate advisory committee. All of the key constituencies were already involved with the Task Force. The 2003 Strategic Plan provided a baseline and framework for development of the New Jersey Elimination Plan. Most importantly, as a long-established and on-going group, the Task Force provides a structure for coordinating collaboration not only in writing the Plan, but in its implementation and evaluation as well. At a retreat held in November 2003, vision, mission and purpose statements were generated. At the end of the retreat, working groups were established for the four key areas of the Plan: • Screening and follow-up of children with elevated blood lead • Public and Professional Education • Lead-Safe Housing • Other Environmental Lead Sources A fifth working group on Surveillance was developed later. A call went out through the Task Force’s email list to any other members who were unable to attend the retreat, but who wanted to participate in the plan development through joining a working group. Each group chose leadership and an appropriate name for itself. Appendix 2 lists the working groups and their members. Between December 2003 and June 2004, each working group met to develop objectives and strategies in their area. DHSS Childhood Lead Poisoning Prevention staff was assigned to each working group to provide guidance and technical assistance. Starting with its March 2004 meeting, the evolving drafts were shared with the entire Task Force for review and comment. The final Plan was approved by the Task Force at its meeting on September 2, 2004. The Plan was then submitted to the Commissioner of Health and Senior Services for formal approval. Each of the participating agencies and organizations was requested to obtain endorsement from its senior leadership. Letters from those agencies and organizations formally endorsing the Plan are attached (Appendix 5). 8 Elimination Plan 9 Section 1: Surveillance Surveillance is the acquisition of data on the incidence and prevalence of lead poisoning Goals: • Maintain a Surveillance System for New Jersey capable of tracking all blood lead tests and follow-up of children with elevated blood lead. • Monitor progress in preventing childhood lead poisoning and in reducing exposure to lead hazards in the environment. • Ensure that public resources devoted to childhood lead poisoning prevention are used effectively and efficiently by local health departments and community partners. Current Status: New Jersey has had a system for reporting children with elevated blood lead, and tracking of environmental investigations, since the mid-1980’s. This system was significantly upgraded in 1993 with the development of a PC-based environmental investigation tracking system. Public Law 1995, Chapter 328 authorized the Department of Health and Senior Services (DHSS) to require the reporting of all blood lead tests performed on children. In response, the DHSS developed specifications for a comprehensive Childhood Lead Poisoning Prevention Surveillance System (CLPPSS) to process these reports. This system has been partially, but not fully, implemented as described below. At present, several data systems have been assembled in order to provide the data, reports and analyses necessary to perform childhood lead poisoning prevention activities. DHSS is currently investigating the acquisition of an integrated data system for childhood lead poisoning activities to replace our current systems. The Childhood Lead Poisoning Prevention Surveillance System (CLPPSS) provides the base for New Jersey’s surveillance system for childhood lead poisoning. This system is built on a database which contains all blood lead test results reported since July 1999, all elevated blood lead tests reported since 1975, and all environmental actions reported by local health departments since 1985. The system is capable of processing both electronically and hard copy reported results, printing notices to local health departments for children with elevated blood lead test results residing in their jurisdiction, printing standard reports, and performing a variety of data analyses. The State lead screening law requires clinical laboratories to report all blood lead test results to the DHSS. About 90% of the blood lead test results are reported electronically. Blood lead test results are loaded into CLPPSS, where the results are initially evaluated for completeness of information, with adult results forwarded to the Occupation Health Program. The child and address information is either matched to an existing record or creates a new record. The final step standardizes addresses to the US Postal Service standard and adds geographic information, e.g., county and municipality. Hard copy, non-elevated blood lead test results are entered into a temporary database before being batch processed by CLPPSS. All blood lead test results undergo routine processing to extract reports where the blood lead level was > 20 ug/dL. The elevated results currently are processed by a stand-alone, SAS-based, system, and then processed to determine whether a notice needs to be sent to the local health 10 department. Multi-part forms are printed for those children for whom an environmental investigation may be required. The information in the databases is constantly updated, based on information from laboratories and local health departments. Data tables containing information on local health departments, clinical testing laboratories, and medical providers are periodically updated as new information becomes available. CLPPSS has several built-in standard reports for monitoring the activities of local health departments, while ad hoc reporting is performed using customized SAS programs. CLPPSS is linked with the New Jersey State Immunization Information System (NJSIIS), through which lead screening results are uploaded to the NJSIIS. This enables participating medical providers to use NJSIIS to track both immunization and lead screening in children. The law requiring screening of all of New Jersey’s children for lead poisoning also mandates that an annual report on childhood lead poisoning be produced. DHSS wrote its first report for FY 1998. The reports describe testing results, environmental activities performed by local health departments, actions taken by agencies to reduce childhood lead poisoning, and planned activities for the upcoming years. FY 2000 was the first report based upon universal reporting of all blood lead test results, which began in July 1999. The FY 2002, report presented data at the municipal level for the first time. These reports are sent to the Governor’s Office, State Legislature, and local health departments. They also are available to the general public. The reports from SFY 2000 forward are available on the Department’s web site. DHSS collaborates with the Division of Medical Assistance and Health Services in the Department of Human Services in matching of Medicaid enrollment records with records of children tested for lead poisoning. Since SFY 2000, matches were performed for the state fiscal year and the federal fiscal year. CLPPSS is also being used to measure the effectiveness of the pilot projects to increase the screening of Medicaid-enrolled children. In addition, DHSS is working with the Division of Youth and Family Services (DYFS), New Jersey’s child protection agency, to identify children in their foster care program who have been tested for lead poisoning. A variety of ad hoc analyses are done to assist public and private agencies in grant applications, provide information on smaller geographic regions than in the annual reports, assist public and allied health students in class projects, and provide information to consultants hired by public and private entities. The data have been used to create mailing lists that were used to recruit participates into studies that were designed to reduce environmental exposure to lead. CLPPSS was being developed for DHSS by the New Jersey Office of Information Technology (OIT). However, the system is not currently fully operational as designed. Currently, CLPPSS is used for receipt, geocoding, and storage of electronic laboratory reports. All of the other key functions of the surveillance system - loading of laboratory records, environmental reporting and tracking, and report creation, are still being done manually through SAS programs written by DHSS staff. After working with OIT for seven years to resolve these problems, the DHSS is currently investigating other alternatives, including the potential for purchasing a working surveillance system already operational in other states. 11 Objective 1: By June 2005, obtain and install software capable of providing a fully integrated surveillance system. Strategies: • Research childhood lead poisoning surveillance systems that have been developed for other States and are available for purchase, to determine if any of them meet, or could be modified to meet, New Jersey requirements. • Select and contract with a data system vendor to provide New Jersey with a surveillance system. • Install, test, and implement the new surveillance system. • Train appropriate DHSS and local health department staff in system operations, including confidentiality/privacy guidelines. 12 Objective 2: By December 2005, provide local health departments with access to the surveillance system. Strategies: • The specifications for purchase or development of the surveillance database will require that the system be capable of tracking environmental activities and case management, including home visits. • Create jurisdiction-specific standard reports and maps. • Establish access and security protocols that will allow local health departments to access the records of children in their jurisdiction, while limiting access to other records in the surveillance database. • Provide training and technical assistance to local health department staff that will have access to records of children in their jurisdiction. • Modify DHSS protocols for notification of local health departments of children with elevated blood lead. Instead of printing and mailing hard copy forms, email notices will be sent to designated local health department staff, alerting them to new cases in their jurisdiction. • In the last phase, local health departments will be able to manage their childhood lead poisoning cases electronically. Designated staff will be able to update the electronic records in CLPPSS for any environmental activities that they have completed, create secondary environmental investigations, update child demographics, and medical case management activities. 13 Objective 3: By June 2005, improve quality and increase electronic reporting of blood lead test results to 95%. Strategies: • Work with DHSS Clinical Laboratory Improvement Services (CLIS) in DHSS to identify all clinical laboratories licensed to perform lead testing on blood samples. • Identify clinical laboratories who still report via hard copy reports. • Work with laboratory directors to encourage electronic reporting of test results. • Work with clinical laboratory directors and medical providers to improve the quality of the reported data. 14 Objective 4. By October of each year, complete the Annual Report on Childhood Lead Poisoning in New Jersey for the preceding State Fiscal Year (July 1 - June 30). Strategies: • Complete processing of blood lead test results for the Fiscal Year • Complete entry of all reports from local health departments of environmental inspections and abatements completed during the Fiscal Year. • Utilize the surveillance database to generate reports on screening, children with elevated blood lead, and environmental actions. • Send Report to Commissioner for transmittal to Governor and Legislature. • Distribute report to press, partner organizations, and public. • Post report on DHSS website. • Present Annual Report findings to the Interagency Task Force on Prevention of Lead Poisoning; obtain feedback from Task Force members on usefulness of Report and recommendations for improvements in future years. 15 Objective 5: On an on-going basis, provide and compare surveillance system data with data from other databases that have information related to children at risk of lead poisoning Strategies: • Quarterly provide the New Jersey State Immunization Information System with lead data. When matches are identified, blood lead test result data will be imported into the immunization registry, and birth certificate number will be exported to CLPPSS. • Match blood lead test reports with Medicaid enrollment database on a quarterly and annual basis, including both the State Fiscal and Federal Fiscal years. • When requested by DYFS, match blood lead test reports with the foster care enrollment database. • Utilize information from the electronic birth certificate database. Birth certificate numbers exported from the immunization registry will be used to obtain information from the electronic birth certificate data, which will be used to clean records in the surveillance system. 16 Objective 6: On an on-going basis, provide DHSS childhood lead poisoning prevention staff, and partners, with data to evaluate the effectiveness of activities to reduce/eliminate lead poisoning in New Jersey. Strategies: • Address data will be regularly cleaned and processed to have a standardized format with geocoding for county, municipality, FIPS codes, zip +4 codes, census tracts and blocks, longitude and latitude. • Screening prevalence and incidence rates will be calculated for a variety of geographic boundaries: state, county, municipality, zip code, and local health department jurisdiction. For the urban areas, it will also calculate rates by census tract. The information will be presented in tabular form and visually as maps. • Records will be linked with U.S. Census data to provide analyses based upon parameters contained within the Census. • These analyses will provide a profile of who is currently affected by lead poisoning and where they live. This information will be used, along with Census data, to assess screening penetration throughout the State. Particular emphasis will be placed upon those geographic areas where there are high numbers of children with elevated blood lead and the presence of known risk factors, (e.g., percentage of pre-1950 housing units). • Collaborate with the OIT Geographic Information Systems (GIS) unit to develop maps that visually highlight areas of concern. • The results will be compared to the data collected in previous periods to measure the effect of activities. Surveillance data will be used to develop program evaluation plans before implementing new activities within communities. • Continue to provide each local health department with a quarterly report on all open cases of children reported with elevated blood lead. • Provide each local health department with a quarterly summary report of follow-up blood lead tests of all children in case management for elevated blood lead. • Provide each local health department with access to data files of all blood lead tests performed on children resident in their jurisdiction on a quarterly basis. 17 Objective 7: By June 2007, provide public access to user-created summary reports. Strategies: • Develop software to enable the general public to do queries against a copy of the data base that is missing individual identifier information using predefined reports to produce summary tables or maps. 18 Section 2: Identification and follow-up of children with elevated blood lead. Children already exposed to lead hazards need to be identified through screening, and referred for follow-up services - environmental investigation and case management assistance to their families, Goals: • Increase the percentage of children screened for lead poisoning by two years of age to 85.0 percent. (Baseline: FY2003, 40.4 percent) • Reduce the number of children whose blood lead level is >10 ug/dL to zero. (Baseline: FY 2003 - 5,230 children) • All children identified with elevated blood lead will receive follow-up services in accordance with the CDC case management guidelines. Current Status: Identification: New Jersey State law (N.J.S.A. 26:2-137.4) requires all physicians, nurse practitioners, and health care facilities to perform lead screening on each patient under six years of age to whom they provide health care services. The law also requires clinical laboratories licensed by the DHSS to report the results of all blood lead tests. The DHSS adopted regulations (N.J.A.C. 8:51A) implementing this law in 1997. These regulations, which follow federal Centers for Disease Control and Prevention (CDC) guidelines, require health care providers to do a blood lead test on all one and two-year old children. Older children, up until six years of age, are to be tested only if they have never been previously tested, or are assessed to be at high risk. While it is recommended that children be tested at or about their first and second birthdays, the regulations specify that children be tested between nine and 18 months of age, and again between 18 and 26 months of age. In addition, children determined to be a high risk should be tested starting at six months of age. During FY 2003, laboratories reported 183,379 blood lead tests to the DHSS. Based on these reports, 172,932 individual children, ages birth through 16 years of age, were identified as having been tested for lead poisoning. This represents a 25% increase over the number of children tested during FY 2000, when reporting of all tests was initiated. However, the total number of children tested in FY 2003 increased only by 1,220 (0.7%) over the number of children tested in FY 2002 (Appendix 4, Table 3). All children in New Jersey who were between six months and two and one-half years of age during FY 2003 should have received a blood lead test. There were 90,112 children in this age range with reported blood lead tests that year. This number represents 40.4% of the estimated 222,837 children in this age group, based on the 2000 U.S. Census. Table 4 shows the number and percentage of children in this age group who were tested, by county. The percentage of children tested ranges from a high of 48% in Passaic County to a low of 19% in Burlington County. 19 The DHSS has records on 76,494 children who were born between July 1, 2000 and June 30, 2001 for whom at least one blood lead test has been reported in their lifetime. This number is 68.6% of the estimated number of two-year-old children in New Jersey, based on the 2000 Census. Likewise, there were 54,417 children who were one-year old as of June 30, 2003, who had at least one blood lead test reported, which is 48.9% of the estimated number of one-yearolds in New Jersey. And 84,321 children who were three years of age as of that date, 74.1% of the estimated number of three-year-olds, have also been tested (Table 5). Follow-up: U.S. Centers for Disease Control and Prevention (CDC) guidelines state that a blood lead test of 10 micrograms per deciliter (ug/dL) or greater should be considered elevated. In addition, the CDC guidelines state that a confirmed blood lead test result of 20 ug/dL or greater should trigger public health follow-up, including an environmental investigation to determine the source of the lead, and case management assistance to the family. Following these guidelines, blood lead test reports to the DHSS are analyzed to see if the result is above either of these thresholds. If the result is 20 ug/dL or greater, the local health department covering the community where the child resides is notified. State law and DHSS regulations require the local health department to conduct an environmental investigation of each of these cases and to provide case management for the families of these children. New Jersey law (N.J.S.A. 24:14A) requires local boards of health to investigate all reported cases of lead poisoning within their jurisdiction and to order the abatement of all lead paint hazards identified in the course of the investigation. A home visit by a public health nurse is conducted to educate the parents about lead poisoning and the steps that they can take to protect their child. The nurse provides on-going case management services to assist the family in getting follow-up testing and medical treatment. DHS/DMAHS Medicaid HMOs provide case management services for lead burdened children with blood lead levels of 10 ug/dL or greater. DHS/DMAHS conducts case tracking for fee-for-service lead burdened children with blood lead levels of 10 ug/dL or greater. The DHSS maintains a system for notifying each local health department of all children with elevated blood lead reported in its jurisdiction. During FY 2003, 76 of the 112 local health departments in the State (68%) received at least one notice of a child with elevated blood lead residing within its jurisdiction. However, 71% of reported cases of children with reported elevated blood lead test results resided within the jurisdictions of only 13 local health departments (Table 6). Looking at all cases reported to local health departments over the past six years, more than 90% of investigations had been completed, and 77% of properties with lead hazards had been abated, by the end of FY 2003 (Table 7). This illustrates that it can take several years to complete abatement of a property where lead hazards have been identified. 20 Objective 1: Identify barriers to lead screening services. Strategies: Continue the Lead Screening Improvement Pilot Projects. These projects are a collaborative effort among Department of Human Services (DHS)/Division of Medical Assistance and Health Services (DMAHS), DHSS, American Civil Liberties Union Foundation (ACLU), Association for Children of New Jersey (ACNJ), New Jersey Chapter of the American Academy of Pediatrics (NJ/AAP), local health departments, University of Medicine and Dentistry of New Jersey (UMDNJ), regional Maternal and Child Health consortia and the HMOs under contract with DHS to provide health services to children enrolled in Medicaid. The purpose of the pilot projects is to increase lead screening percentages among Medicaid-enrolled children in the target cities. This lead screening pilot was implemented in the cities of Camden and Irvington from August 2002 through December 2003. Starting in July 2004, the projects were expanded to include the cities of Paterson, Jersey City and Bridgeton/Millville. Barriers that have been identified and are being addressed during the pilot projects include: • Physician reluctance to provide in-office blood lead testing. • Child care providers not consistent in collecting/keeping records of blood lead test results. • Health insurer policies requiring physicians to refer clients to blood collection stations operated by the major clinical laboratories. These laboratory operations can have limited operating hours, and/or are located in areas that are not convenient for families to get to, some are minimally staffed resulting in long waiting times. • Lack of parental awareness of importance of blood lead testing in young children. Continue to assess individual medical practice screening rates. To date a limited amount of assessment has been done of lead screening rates in individual medical practices. On behalf of the DHS/DMAHS, the Peer Review Organization of New Jersey (PRO/NJ) conducted audits of large pediatric practices in several communities to determine how many of the children in their care who were enrolled in Medicaid had received a blood lead test. DHS/DMAHS staff also audited the records of all of New Jersey’s Federally Qualified Health Centers (FQHCs). Medical records of Medicaid-enrolled children between six and 26 months of age were reviewed. The FQHC audits will be continued on an annual basis. Individual practice audits will be conducted as resources and opportunity permit. The Physicians Lead Advisory Committee (PLAC) will continue to serve as an advisory group to the DHSS on policy and actions to address childhood lead poisoning. The PLAC consists of physicians with expertise and/or interest in childhood lead poisoning. It includes representatives from the New Jersey Chapter of the American Academy of Pediatrics, the University of Medicine and Dentistry of New Jersey, and at least one physician from each of the Maternal and Child Health Consortia regions. The PLAC meets on a formal basis at least once per year. A primary barrier noted by members of the PLAC in recent meetings is that many physicians no longer collect blood samples in their offices for any type of test. Several factors and trends in medical care have combined to discourage the collection of blood samples. 21 These include: • • • New federal rules regarding blood-borne pathogens and disposal of medical waste have increased the cost of blood sample collection. A law requiring federal (as well as State) licensing of all clinical laboratories has resulted in many physician practices discontinuing in-office laboratories for simple analyses. The evolution of insurance payments from fee-for-service to capitation means that many insurers no longer reimburse physicians for the cost of blood sample collection. However, the Medicaid HMO contract provides financial incentives to providers who perform inoffice screenings. The Interagency Task Force for the Prevention of Lead Poisoning (Task Force) will establish a statewide Lead Screening Advisory Group whose members include but are not limited to representatives from DHS/DMAHS, DHSS, local health departments, DCA, at least one DCA HUD grantee, Medicaid HMOs, commercial health insurance carriers, and the New Jersey Physician Lead Advisory Committee. The role of the advisory group will be to: • Identify lead screening services stakeholders including but not limited to parents, health care providers and State agencies with regulatory authority. • Develop and conduct a comprehensive assessment of barriers and successes with representatives of each stakeholder group. • Develop a universal statement listing perceived and real barriers to performing lead screenings. • Identify national and statewide best practices that address barriers to obtaining lead screening services. 22 Objective 2: Develop interventions to address and eliminate barriers. Strategies: DHS/DMAHS Lead Screening Improvement Pilot Projects will continue to be implemented in Camden and Irvington, and will be expanded to include Jersey City, Paterson and Bridgeton/Millville in 2004/2005. Lessons learned will be applied to other high-risk municipalities. All of the pilot project cities will continue to incorporate the following strategies: • Medicaid HMO Medical Directors will write letters to health care providers, reviewing federal and State screening requirements and encouraging the performance of blood lead screenings in the physician’s office by using either the filter paper, venous, or capillary methods for collection of blood lead samples. As needed, the Medicaid HMO Medical Directors will meet with providers who are non-compliant with lead screening requirements. Medicaid HMO representatives will continue to visit medical practices to reinforce written correspondence from the Medical Directors. • Promote the use of filter paper as a means of collecting blood lead samples in the physician’s office. All Medicaid HMOs will contract with Medtox laboratories to analyze filter paper samples. • Additional reimbursement for all blood lead tests done in the physicians’ office. • Child Care Health Consultants associated with the Unified Child Care Agencies and Abbott District nurse consultants will continue to conduct lead education training programs for child care centers directors, Abbott district family workers, family child care providers and Head Start staff. Child care center directors will continue to distribute lead education packets to the parents/guardians of child enrollees and will inquire and document the lead screening status of age-appropriate enrollees. Documentation will be kept with immunization records to facilitate audits. • Local Health Officers will communicate with health care providers and child care directors/providers encouraging lead screenings for children under six years of age. Local health department personnel who perform immunization audits will review enrollee records for documentation of lead screening status. • Continue to sponsor various community health events to provide the general public with lead poisoning prevention information. DHSS and DHS/DMAHS will adopt, on a statewide basis, those strategies shown to be effective in the pilot projects. Based on the results so far in Camden and Irvington, the following strategies have already been implemented statewide: • Promotion of the use of filter paper as a means of collecting blood lead samples in the physicians office. All Medicaid-contracted HMOs are required to contract with Medtox laboratories for the analysis of filter paper samples. DHSS has sent a letter to all physicians doing lead screening, promoting the use of filter paper for in-office sample collection. • Enhanced reimbursement for blood lead tests done in the physicians’ office. Explore the feasibility of performing lead screenings at WIC (Women, Infants and Children Supplemental Feeding) program sites. • The Newark Department of Health and Human Services CLPP Program is currently 23 • • • collaborating with the Newark WIC program to provide on-site lead testing at the primary WIC sites in Newark. This pilot project is funded by CDC through the DHSS. A phlebotomist schedules site visits with the WIC Program Coordinator and conducts screenings on a monthly basis. Children will be screened during the parent/guardian certification and/or re-certification visits to the WIC program. The Lead Care portable lead analyzer is utilized to conduct initial capillary tests on children, with results available to parents within three minutes. If necessary, a venous confirmatory test is conducted at the time of the visit. Depending on the child’s health insurance status either the physician is contacted stating that his/her patient is being seen at WIC that day and needs to be screened or if the child is found to be uninsured he or she will be enrolled in the health department’s pediatric clinic. A NJ FamilyCare application will be completed for children found to be uninsured. If the pilot project proves successful, it will be expanded to additional WIC sites in Newark as resources permit. UMDNJ in Newark will also conduct a pilot project of lead screening at its WIC sites, using a different model. With the support of private funding, UMDNJ will hire a phlebotomist for the WIC site. This person will draw venous samples which will be sent to the hospital laboratory for analysis. DHSS and its partners will evaluate these pilot projects, as well as examine similar pilots at WIC sites in other States. If any of these prove to be cost-effective in increasing the percentage of lead screening among children served by WIC, DHSS will attempt to identify resources to expand these services to other WIC sites in the State. The DHSS will develop and implement a targeted screening plan. The plan will identify those communities with the highest number of children at risk with particular emphasis on communities whose percentage of children screened is lower than the statewide average. It will delineate additional activities to reach the parents of these children. The Physician Lead Advisory Committee provided medical consultation to the DHSS in the development of the plan and will continue to provide guidance during its implementation and evaluation. • For FY 2005, 16 communities have been identified as potential targets: Atlantic City, Bridgeton, Camden, East Orange, Elizabeth, Irvington, Jersey City, Montclair, Newark, New Brunswick, Orange, Passaic, Paterson, Perth Amboy, Plainfield and Trenton. • DHSS will use its blood lead reporting database to develop GIS maps of each target community to assist in identifying those areas with the highest rates that should be particularly targeted for screening and educational outreach. • DHSS will reach out to safety net providers in these communities, including the Federally Qualified Health Centers (FQHC), hospital outpatient clinics, and local health departments, to develop systems for screening and referral of children who may have “fallen through the cracks” because they do not have health insurance and/or a medical home. DHSS will begin this initiative in September 2004 with a pilot project in the City of Camden through a collaboration with the CAMCare FQHC. • DHSS will seek resources to purchase, or to assist community providers in the purchase, of LeadCare portable lead analyzers to facilitate walk-in and community-based outreach screening. DHSS staff will develop and disseminate model protocols and forms for the use of these analyzers and for reporting of results to primary care providers and to the DHSS surveillance system. 24 The DHSS partnered with the New Jersey Chapter of the American Academy of Pediatrics (AAP/NJ) in the development and implementation of a tool kit for physicians and their staffs entitled Educating Physicians in Their Communities (EPIC). The purpose of the tool kit, developed in 2004, is to encourage physician practices that serve young children to conduct onsite blood lead testing. The program includes a Powerpoint presentation with speaker notes that is presented by a physician and nurse/health educator team. The practice is given an accompanying binder which includes federal and state resources, AAP policy statements, summaries of State laws and regulations, and suggested anticipatory guidance for each well child visit starting at the first visit with a family, at the time of birth. Results of the pilot which was conducted in 11 physicians offices in Trenton, shows that many of the physicians were fairly knowledgeable of their responsibility to assess and screen children. However, office staff required basic lead education to better serve their patients and their families. DHSS and AAP/NJ will continue to seek funding to reproduce and distribute the curricula statewide and to provide consultation to trainers in implementing and evaluating the program. Target child care facilities as places to promote lead screening. Healthy Child Care New Jersey, a collaboration among DHSS, DHS and AAP/NJ, will develop and implement programs targeted to child care providers and their parent clients. Strategies include: • Development of a training curriculum for child care providers. • Training and utilization of the Child Care Health Consultation Coordinators. These Coordinators are full-time nurses employed by each of the Unified Child Care Agencies (UCCAs). There is a UCCA in every county in the State. The Coordinators provide technical assistance and training on health-related matters to child care providers and staff. • Training local health department child health nurses to be local Child Care Health Consultants. • Development of a Uniform Child Health Record (UCHR) for use to keep health records for all children in child care. Blood lead test results are included on the UCHR. Effective in October 2003, DHS rules will require all licensed child care facilities to complete a UCHR on all enrolled children. • DHS/DMAHS has contracted with Scholastic Publications to develop materials on lead poisoning and screening for child care staff and parents. These will be distributed in the Fall of 2004. • DHSS and DHS/DMAHS will seek to encourage collaborations between child care facilities and medical providers to assist in screening the children enrolled in child care. A major component of the Camden pilot project will be a collaboration among CAMCare and Camden Head Start. DHSS will mandate that those local health departments that are eligible to receive State Public Health Priority Funding use a portion of these funds to support activities to promote and/or provide lead screening. These funds can also be used to include assessment of lead screening records as part of the immunization audits of licensed child care facilities. To facilitate these audits, the DHSS has modified the standard immunization record form to include a line to record lead test results. 25 Objective 3: Identify barriers to efficient and effective follow-up and develop interventions that promote the implementation of the CDC guidelines. Strategies: DHSS will continue to maintain a system to notify local health departments of children with EBL, tracking the number of environmental investigations conducted and abatement of environmental hazards by local health departments, and tracking home visits and case management by public health nurses. DHSS will continually review Chapter XIII of the New Jersey State Sanitary Code, and adopt changes as warranted, to assure that environmental investigations in New Jersey are conducted in accordance with CDC and HUD guidelines. Chapter XIII contains the rules that govern local health department activities when children with elevated blood lead levels are identified. DHSS will hire a nurse consultant by October 2004 to coordinate case management activities of local health departments. The nurse consultant will create a working group, including local health department nurse case managers, to develop a State case management plan for children with elevated blood lead that is consistent with the CDC guidelines “Managing Elevated Blood Lead Levels Among Young Children” by June 2005. The DHSS will provide grants to support lead inspections and case management in those jurisdictions with the highest numbers of children with elevated blood lead. DHSS has budgeted $2,613,884 for grants to 15 local health departments in FY2005. The DHSS will also continue to support all local health departments by providing training, technical assistance and consultation to inspectors and case managers. DHSS will mandate that those local health departments that are eligible to receive State Public Health Priority Funding use a portion of these funds to support activities related to childhood lead poisoning, including environmental investigations and case management. DHS/DMAHS will continue to monitor and audit HMO lead case management. DMAHS will also continue to directly monitor and track children with elevated blood lead in Medicaid fee-forservice and the follow-up care that is provided by the primary care provider. The DHSS and DHS/DMAHS will continue to collaborate with the DHS Division of Youth and Family Services (DYFS) to monitor and track children in foster care who are found to have elevated blood lead levels. DHSS will seek to establish follow-up services for children with elevated blood lead between 10 and 19 ug/dL • Newark CLPP program will continue to receive test results of children tested at Newark DHHS child health clinic and WIC sites and identify children with blood lead levels between 10-19 ug/dL. As workload permits, Newark DHHS Lead Inspectors will conduct visual risk assessment of the residences and will test paint and dust if potential hazards are found. 26 • • • • Inspectors will issue a report to the property owner and parents, with recommendations for hazard reduction and interim controls and will conduct follow-up visits within 3-6 months after initial assessment. DHSS staff will research model programs in other areas of the country that provide education, home visits and follow-up services for families of children with blood leads 10-19 ug/dL (ex. Philadelphia “Lead Safe Babies” project). DHSS will seek to obtain resources to implement follow-up services for these children, based on the results of the Newark pilot project and its research into best practices. DHSS will modify its surveillance and reporting system to notify local health departments of children with blood lead test results > 10 ug/dL. DHSS will encourage local health departments to follow-up children with blood lead test results 10-19 ug/dL as local resources permit. The Lead Screening Advisory Group will develop and conduct a comprehensive assessment of barriers and successes in regard to performing effective and efficient case management that follows CDC guidelines and New Jersey Chapter XIII. 27 Section 3: Education Education is the first step to promote awareness, increase knowledge and provide the skills necessary to prevent lead poisoning. Goal: • Mobilize communities to implement lead poisoning prevention strategies. Current Status: The Interagency Task Force has an ad-hoc Education subcommittee whose primary purpose is to coordinate the annual Childhood Lead Poisoning Prevention Week observance. This group expanded its purpose and membership during the Elimination Plan process and became the Education working group. Many of the members of the working group expressed their enthusiasm to continue their collaborative efforts from the planning phase into the implementation phase. This working group will form the basis for the Childhood Lead Poisoning Prevention Education steering committee. To successfully reach the mission of eliminating childhood lead poisoning in New Jersey, all municipalities, regardless of risk level, must be equipped with the knowledge, skills, and opportunities necessary to create self-sustaining lead-safe environments. Involvement must come from the bottom up starting with grassroots community group members who educate their neighbors to top down with officials who enact local policy and enforce State regulations. Through coordination efforts on the municipal and regional level, supported by State agencies, funding and services can be leveraged so that real change can occur. Educational efforts to date have been disjointed creating a lack of communication among stakeholders, assumptions of need of the target audiences, and limited access to New Jersey’s diverse ethnic and cultural populations. Regional Coalitions were established in January 2003 to coordinate educational initiatives on a regional level. High-risk municipalities have begun to develop capacity to address childhood lead poisoning through the establishment of pilot projects and targeted funding to address lead hazards in housing units. 28 Objective 1: Increase professional and public awareness, knowledge and skills about lead poisoning. Strategies: Establish a statewide Childhood Lead Poisoning Prevention Education steering committee whose members include but are not limited to Federal agencies, State departments and Regional Coalition leadership to determine critical capacity building components. The Childhood Lead Poisoning Prevention Education steering committee will: • perform a biannual needs assessment of educational materials. • identify and secure resources based upon needs assessment results. • create, as needed, educational resources based upon needs assessment. • evaluate audiovisual educational materials, including but not limited to videos, pamphlets and curriculum. • create a clearinghouse of educational resources. • develop a system to identify and provide on an ongoing basis *resources that meet the current educational needs of New Jersey’s ethnically, culturally and linguistically diverse populations. *Resources=audio, visual, web-based, speakers bureau, technical assistance contacts • identify and promote web-based educational materials. The Task Force will establish a web page with information on childhood lead poisoning in New Jersey and links to other State and national websites with additional information and resources. • Annually recommend updates to ongoing trainings, sponsored by Task Force representatives, based upon best practices. • Identify and promote continuing education events, trainings and networking opportunities. • Biannually, hold a statewide conference with built-in networking opportunities. Continue to provide continuing education, training and networking opportunities for professionals who are to include but are not limited to child care providers, real estate personnel, school educators, health and human service staff, and community-based organizations. Continue to seek air time for public service announcements developed by State agencies. Dust testing kits will be distributed to pregnant women living in pre-1978 housing in communities with high levels of lead poisoning. This initiative, proposed by Governor McGreevey in January 2004, will be funded by a one million dollar State appropriation to the DHSS for SFY 2005. The funds will be granted to a non-profit agency, Family Health Initiatives (FHI). FHI will purchase approximately 40,000 kits for distribution to pregnant women through health centers and private providers in these communities. Distribution and provider training will be carried out in collaboration with the regional Maternal and Child Health Consortia. The kits will include educational messages about prevention of lead hazards in housing and instructions for follow-up evaluations of positive results. 29 DHSS will: • Provide training for local health department staff engaged in childhood lead poisoning prevention and follow-up work through the Child Health Regional Network. • Train local health department staff in proper lead abatement, inspection and risk assessment practices. • Identify resources to implement a statewide public awareness campaign as prepared by DHSS CLPP staff. The proposal includes using a mix of media outlets including cable TV, billboards, radio, movie theatres and New Jersey Transit buses and rail. • Promote and distribute the four-minute lead poisoning prevention video, using a rap music format, produced by New Jersey Network (NJN) with DHSS support. The video was developed as an educational tool targeted to parents with children of lead screening age. The final product was premiered during Childhood Lead Poisoning Prevention Week in October 2002. To date over seven hundred copies of the video have been d