DHS- FinalPresentation- Kevin_SlideShare

Lead Poisoning in Milwaukee –Effects of Home Lead Abatement

Kevin Smith, MPH

Joseph J. Zilber School of Public Health &

City of Milwaukee Health Department

Acknowledgements• Amy Kalkbrenner – Joseph J. Zilber School of Public Health

• Elise Papke – Joseph J. Zilber School of Public Health

• Joyce Whitebsky – School of Architecture and Urban Design

• Lisa Lien – City of Milwaukee Health Department: Lead Poisoning Prevention Program

• Robert Colla – City of Milwaukee Health Department: Lead Poisoning Prevention Program

• Sanjib Bhattacharyya – City of Milwaukee Health Department: Public Health Laboratories

• Steve Gradus - City of Milwaukee Health Department: Public Health Laboratories

• Kristen Grimes – Children’s Health Alliance of Wisconsin

• Chuck Warzecha – Bureau of Environmental and Occupational Health

• Margie Coons – Wisconsin Childhood Lead Poisoning Prevention Program

Introduction to Lead Based Paint• 24 million homes in USA have lead

paint (CDC, 2014)

• ~3 million metric tons of lead paint in US homes (CDC, 1991)

• Nearly 4 million homes with children living in them have lead based paint (CDC, 2014)

• *Leaded Gasoline Emissions*

5.5–6.7 million metric tons in soil (CDC, 1991)

75% remains

Introduction to Lead Based Paint

• 14.1% of pre-1940 housing >1200 ppm

• 1% of post-1960 housing >1200 ppm

http://www.usgs.gov/blogs/features/usgs_top_story/getting-the-dirt-on-soil/

Introduction to Lead Based Paint• Homes built before 1978 most likely to have lead based paint (HUD, 2011)

Introduction to Lead Based Paint• 1940s: Manufacturers began to remove lead from paint voluntarily

• 1971: Lead Based Paint Poisoning Prevention Act

Prohibited paint ≥ 1% lead by weight

Allowable levels

0.5% until 12/31/1974

0.06% (600 ppm) after 12/31/1974

• 1978: Consumer Product Safety Commission

Banned use of leaded paint in homes

Childhood Lead Poisoning• Approximately 535,000 children currently have elevated blood lead

levels ≥ 5μg/dL (CDC, 2014)

2012: Standard for lead poisoning was lowered

Previously ≥ 10μg/dL

Now ≥ 5μg/dL

• Children ages 1 – 6 years old are at highest risk for lead poisoning (CDC, 2014)

• Children living in Renter occupied units are at greater risk for significant exposure to lead based paint (HUD, 2011) Renter: 30% of homes

Owner: 23% of homes

Childhood Lead Poisoning• Learning Impairments

4th grade standardized tests (Amato, 2012)

Reading

Mathematics

Language Arts

IQ Reductions (Nevin, 2012)



Reading

Mathematics

Language Arts


• Behavioral Impairments 4th grade suspension rates (Amato, 2013)

2.66 times more likely

23% of the racial discipline gap

Crime (Nevin, 2012)

Violent Crime – 23 year lag time



Reading

Mathematics

Language Arts


• Behavioral Impairments 4th grade suspension rates (Amato, 2013)

2.66 times more likely

23% of the racial discipline gap

Crime (Nevin, 2012)

Violent Crime – 23 year lag time

Homicides – 21 year lag time

Childhood Lead Poisoning

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

% O

F C

HIL

DR

EN

TE

ST

ED

YEAR

Percent Children Tested with Elevated BLLs (≥10 µg/dL )

U.S. Totals Wisconsin Milwaukee, WI

Data Sources: 1 Centers for Disease Control and Prevention: Childhood Lead Poisoning Data, Statistics, and Surveillance. 2 City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports

Objectives• Identify risk of lead poisoning in:

1. Children that live in Unabated Pre-1940 Homes

Age stratification

2. Families that live in Non-owner Occupied, unabated Pre-1940 Homes

3. Children living in Previously Abated Pre-1940 Homes

Stratified by

Age

Time after abatement

Type of abatement

Methods – Incidence (1996 – 2011)

• Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)

De-Identified 222,804 children

Cases: ≥ 10μg/dL

Non-Cases: < 10μg/dL

Date first confirmed

Address

Age at test

Methods – Property Information

• City of Milwaukee Master Property Records (MPROP)

Address

Taxkey

Year of Construction

Pre-1940

Post-1940

Owner Occupancy

• Parcel Base - Property Map

Methods – Home Abatement (1996 – 2011)

• Lead Safe Housing Registry (LSHR) – City of Milwaukee

Address of Abated Unit

Date of Abatement

Abatement Type

Primary Prevention

Secondary Prevention

Methods – Analysis and Mapping

• Addresses matched for each record at date first confirmed

• Geocoded with ArcGIS 10.2.2. software

Cases: N = 21,317

Non-Cases: N = 141,478

Abated Homes: N = 16,886 units

Methods – Analysis• Relative Risks calculated (1996 – 2011)

15 year aggregate risk

Year of Construction (Pre-1940 vs. Post-1940)

Stratified by Age at test

Owner vs. Non-owner occupied

Date of Abatement

Stratified by:

Age at test

Prevention Type

Time After Abatement

Annual risks

Year of Construction

Occupancy

Abatement

4 year aggregate risk

Primary/Secondary Prevention

Results – Seasonal Variation of Incidences

Data Source: Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)

New cases occur most frequently

during summer months every year

Overall decrease in new cases from

1996 - 2011

Results – Annual Cases and Home Abatement

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

CU

MU

LA

TIV

E #

OF

UN

ITS

AB

AT

ED

CH

ILD

RE

N W

ITH

EL

EV

AT

ED

BL

OO

D L

EA

D

YEAR

Elevated Blood Lead Levels and # of Units Abated

Pre-1940 Units Abated Total Units Abated Prevalance Incidence

Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee

Incidence and prevalence of cases

decrease each year as more pre-1940

units are abated

Results – Annual Cases and Home Abatement

• Each Year:

Prevalence decreased 13.4% (R2 = 0.98)

Incidence decreased 10.8% (R2 = 0.95)

An estimated 984 homes were abated - 821 were Pre-1940 homes

Results – Cases and Home Abatement

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

0 2000 4000 6000 8000 10000 12000 14000

NU

MB

ER

OF

CA

SE

S P

ER

YE

AR

TOTAL NUMBER OF ABATED UNITS

Case Reduction per Unit Abated (1996 - 2011)

Incidence Prevalence

Data Sources: City of Milwaukee Health Department: Lead Poisoning Prevention Data & Reports & Lead Safe Housing Registry (LSHR) – City of Milwaukee

Incidence decreases by 10.8% &

prevalence decreases by 13.5% for every

1,000 units abated

Results – Cases and Home Abatement

• Per 1,000 units abated:

Prevalence decreased 13.5% (R2 = 0.97)

Incidence decreased 10.8% (R2 =0.93)

Data Source: Lead Safe Housing Registry (LSHR) – City of Milwaukee & Wisconsin Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR)

New Cases = 21,317New cases from 1996 – 2011 spatially

correlate with pre-1940 homes


New Cases = 21,317Abated Units = 16,886

Prevention efforts successfully

targeted homes in high-risk areas

New Cases = 5,816


In 1996, 5,816 new cases were reported to

Milwaukee Health Department prior to

Childhood Lead Poisoning Prevention efforts

New Cases = 5,816

New Cases = 381


After 15 years of Childhood Lead Poisoning Prevention

Program targeted efforts, new cases were reduced 381 in 2011

As targeted

abatement

efforts increase,

new cases in

that region

decrease each

year

Results –Relative Risk for Lead Poisoning based on key factors

Results – Annual Risk in Unabated Units

y = 0.2076x - 409.99

R² = 0.4299

0

1

2

3

4

5

6

7

8

9

10

11

12

13

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Rela

tive R

isk

Ra

tio

Year

Unabated Pre-1940s Homes

Annual Risk 15 yr Aggregate Risk Annual Regression

Results – Annual Risk in Rental Units

0

0.5

1

1.5

2

2.5

3

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Rela

tive R

isk

Ra

tio

Year

Renter Occupied Pre-1940 Units

Annual Risk 15 yr Aggregate Risk

Results – Annual Risk in Abated Units

y = 0.0049x - 8.6599

R² = 0.0049

0

0.5

1

1.5

2

2.5

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Rela

tive R

isk

Ra

tio

Year

Abated Pre-1940 Units

Annual Risk 15 yr Aggregate Risk Annual Regression

Summary – Risk for Lead Poisoning• Pre-1940 homes were 5.8 times higher than Post-1940 homes

Children 24 months or younger were 7.91 times higher in Pre-1940 homes

Children older than 24 months were an average of 3.99 times higher in Pre-1940 homes

• Children living in non-owner occupied homes were 2.02 times higher risk for lead poisoning than in owner occupied homes

• Lead abatement in Pre-1940 homes reduced the risk to 0.69 times that of an unabated Pre-1940 home Primary Prevention was 0.56 times lower than an unabated Pre-1940 home

Secondary Prevention was 1.15 times higher than an unabated Pre-1940 home

No difference in risk was present for 9 month cut off period

Children older than 48 months may have greater reduced risk – small sample

• Prevalence reduced by 13% per 1,000 units abated

• Incidence reduced by 11% per 1,000 units abated

Future Directions – Risk Analysis & GIS

• Few studies have investigated home paint abatement and BLLs Most studies look at Secondary Prevention

Primary Prevention are lacking

Long term integrity of prevention efforts are lacking

• This investigation has one of the most complete data sets Lead Abatement records per home

Blood Lead test results for every test taken

• Innovative data analysis and powerful risk calculations

• GIS data analysis and case surveillance

• Provides the ground work for future studies, education and policy

• Integration with soil remediation

References• Center for Disease Control and Prevention (1991, October 1). Preventing Lead

Poisoning in Young Children: Chapter 3. Retrieved from: http://www.cdc.gov/nceh/lead/Publications/books/plpyc/chapter3.htm

• Center for Disease Control and Prevention (2014, June 19). Lead – Home Page. Retrieved from: http://www.cdc.gov/nceh/lead/

• Center for Disease Control and Prevention (2014, October 30). LCDC’s national Surveillance Data (1997-2013). Retrieved from: http://www.cdc.gov/nceh/lead/data/national.htm

• Center for Disease Control and Prevention (2014, October 30). LCDC’s national Surveillance Data (1997-2013). Retrieved from: http://www.cdc.gov/nceh/lead/data/national.htm

• City of Milwaukee Health Department (2014, September, 12). Lead Poisoning Prevention Data and Reports. Received from: http://city.milwaukee.gov/Lead-Poisoning-Prevention-Data#.VI88wqecteU

• Cox, D.C., Dewalt, G., O’Haver, R., and Salatino, B. American Health Homes Survey; Lead and Arsenic Findings. U.S. Department of Housing and Urban Development: Office of Healthy Homes and Lead Hazard Control, April, 2011.Mielke, 2010

http://www.cdc.gov/nceh/lead/Publications/books/plpyc/chapter3.htm

http://www.cdc.gov/nceh/lead/

http://www.cdc.gov/nceh/lead/data/national.htm

http://www.cdc.gov/nceh/lead/data/national.htm

http://city.milwaukee.gov/Lead-Poisoning-Prevention-Data#.VI88wqecteU

Appendix 1

Appendix 2

Year of Construction, Owner Occupancy and Prior Abatement Relative Risk Calculations with 95% Confidence Intervals for Aggregate and Annual Lead Poisoning RatesRelative Risk (95% CI) 15 year Aggregate (1996 - 2011) 1996 1997 1998 1999 2000 2001 2002

Pre-1940 Unit 5.83 (5.57, 6.11) 3.64 (3.32, 3.98) 3.79 (3.42, 4.20) 5.68 (4.78, 6.75) 4.77 (4.04, 5.63) 4.55 (3.87, 5.36) 5.45 (4.51, 6.59) 5.43 (4.45, 6.64)Non-Owner Occupied 2.01 (1.96, 2.08) 1.73 (1.65, 1.84) 1.76 (1.65, 1.88) 1.89 (1.71, 2.10) 1.85 (1.67, 2.05) 1.64 (1.47, 1.82) 1.77 (1.58, 1.99) 1.77 (1.57, 2.01)

Prior Abatement 0.6908 (0.66, 0.73) 1.01 (0.45, 2.25) 0.92 (0.60, 1.41) 1.06 (0.77, 1.47)0.8792 (0.68,

1.13) 1.24 (1.04, 1.48) 1.58 (1.35, 1.85)

Case (≥ 10 μg/dL) 22769 5816 3696 1725 1657 1438 1396 1269No Case (≤ 10 μg/dL) 163398 13709 11352 9534 7373 8123 9364 9908

Relative Risk (95% CI) 2003 2004 2005 2006 2007 2008 2009 2010 2011

Pre-1940 Unit 7.06 (5.51, 9.05) 8.22 (6.32, 10.69) 5.70 (4.48, 7.25) 7.47 (5.43, 10.26) 5.86 (4.37, 7.86) 8.32 (5.81, 11.92)8.33 (5.81,

11.95) 5.98 (4.32, 8.29) 5.66 (4.01, 7.98)Non-Owner Occupied 1.70 (1.48, 1.95) 2.02 (1.75, 2.24) 1.76 (1.51, 2.05) 1.85 (1.53, 2.23) 2.25 (1.85, 2.74) 1.56 (1.28, 1.91) 1.86 (1.49, 2.31) 1.57 (1.23, 1.99) 2.05 (1.56, 2.70)Prior Abatement 1.89 (1.63, 2.19) 1.69 (1.44, 1.99) 1.59 (1.35, 1.87) 1.42 (1.15, 1.75) 1.22 (0.99, 1.51) 1.18 (0.95, 1.47) 1.08 (0.85, 1.37) 0.83 (0.63, 1.10) 1.21 (0.93, 1.55)

Case (≥ 10 μg/dL) 1046 936 838 589 600 520 461 401 381No Case (≤ 10 μg/dL) 9514 9939 9296 8968 10296 10598 11122 12680 11622

Results –Risk by Abatement Type (4-Year Range)

Year Range Abatement

Record

Relative Risk 95% CI

1996 - 1999 Total Abated 0.78 (0.61, 1.00)

Primary 0.69 (0.53, 0.91)

Secondary 3.18 (3.13, 3.23)

1999 - 2003 Total Abated 1.38 (1.27, 1.50)

Primary 1.1 (0.98, 1.23)

Secondary 2.36 (2.1, 2.66)

2004 - 2007 Total Abated 1.45 (1.32, 1.58)

Primary 1.2 (1.07, 1.34)

Secondary 2.25 (1.97, 2.58)

2008 - 2011 Total Abated 1.06 (0.94, 1.20)

Primary 0.86 (0.74, 0.99)

Secondary 1.83 (1.52, 2.20) 0

0.5

1

1.5

2

2.5

3

3.5

1996-1999 2000-2003 2004-2007 2008-2011

Rela

tive R

isk

Year Range

Abatement Type (4 Year Range)

Total Abatement Primary Prevention Secondary Prevention

Total 15 yr risk Primary 15 yr risk Secondary 15 yr risk

Appendix 3

Year Range Abatement

Record

Case

(≥ 10 μg/dL)

No Case

(< 10 μg/dL)

Total Relative Risk 95% CI

1996 - 1999 Total Abated 48 147 195 0.78 (0.61, 1.00)

Primary 41 147 188 0.69 (0.53, 0.91)

Secondary 7 0 7 3.18 (3.13, 3.23)

None 10,982 23,917 34,899

1999 - 2003 Total Abated 443 1,370 1,813 1.38 (1.27, 1.50)

Primary 274 1,135 1,409 1.1 (0.98, 1.23)

Secondary 169 235 404 2.36 (2.1, 2.66)

None 3,897 18,095 21,992

2004 - 2007 Total Abated 482 2,581 3,063 1.45 (1.32, 1.58)

Primary 305 2,036 2,341 1.2 (1.07, 1.34)

Secondary 177 545 722 2.25 (1.97, 2.58)

None 2,094 17,153 19,247

2008 - 2011 Total Abated 303 4,315 4,618 1.06 (0.94, 1.20)

Primary 192 3,441 3,633 0.86 (0.74, 0.99)

Secondary 111 874 985 1.83 (1.52, 2.20)

None 1,175 17,875 19,050

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