The Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) convened a meeting of the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). The proceedings were held on March 18, 2003 at the Hilton Crystal City Hotel in Arlington, Virginia. The following individuals were present to contribute to the discussion.
ACCLPP
Members Dr. Carla Campbell, Chair Dr. William Banner, Jr. Dr. Helen Binns Ms. Anne Guthrie-Wengrovitz Dr. Birt Harvey Dr. Richard Hoffman Dr. Tracey Lynn Dr. Sergio Piomelli Dr. Kimberly Thompson Dr. Routt Reigart II (AAP) Dr. Walter Rogan (NIH) Mr. Robert Roscoe (NIOSH)
Designated
Federal Official
Ex-Officio/Liaison Members |
CDC
Representatives Ms. Bonnie Dyck Mr. Ellis Goldman Ms. Crystal Gresham Ms. Janet Henry Ms. Nicki Kilpatrick Dr. David Mannino Dr. Tom Matte Dr. Pamela Meyer Mr. Timothy Morta Mr. Kent Taylor
Presenters and Guests |
Ms. Bonnie Dyck of LPPB reported that HHS established a goal for CDC to eliminate childhood lead poisoning as a major public health problem in the United States by 2010. The Lead Contamination Act of 1998 authorized the HHS Secretary through CDC to award grants to state and local health agencies for comprehensive programs. These initiatives are designed to screen infants and children for elevated blood lead levels (EBLLs); ensure lead poisoned infants and children are given referrals for medical and environmental interventions; provide education about childhood lead poisoning; and implement core public health functions, including policy development, program assessment and quality assurance.
CDC grantees are required to create screening policies or guidelines; develop surveillance systems at state or jurisdiction levels to assess the prevalence of childhood lead poisoning; monitor the effectiveness of programs; and review trends of local screening rates. The National Childhood Lead Poisoning Prevention Program (NCLPPP) will be reauthorized in 2005, but its funding mechanism was changed in 2000 from grants to cooperative agreements. This mechanism allows CDC to establish more collaborative relationships with states and local jurisdictions. NCLPPP currently funds 43 states, nine cities and eight counties.
Childhood lead poisoning surveillance programs at national and state levels; public and professional health education and communication activities; and CLPPP quality assurance projects are developed and implemented. Partnerships are built and linked with state CLPPPs, community-based organizations and federal agencies to prevent and control lead hazards in high-risk areas. Scientific studies are performed on blood, environmental lead, laboratory technologies, handheld analyzers and dust wipe analyzers. Epidemiological research is conducted as well. Policy statements and guidance documents are developed. Financial support is provided through cooperative agreements and supplemental funding.
Technical assistance and consultation are offered to state and local
CLPPPs. Support is provided for primary prevention activities,
laboratory capacity, new technologies and quality control initiatives.
Several state grantees are performing surveillance studies to examine
screening rates among children enrolled in Medicaid and the Women,
Infants and Children (WIC) program. Collaborative efforts are
undertaken with managed care organizations (MCOs), interdepartmental
projects and interagency activities on an ongoing basis. Healthy
Homes, surveillance studies and other special projects are conducted.
Childhood lead poisoning prevention education activities are designed
and implemented.
In FY’03, CDC will allocate ~$31 million to fund 43 states, local
programs, territories and federally recognized Indian tribes. Of these
grantees, five will be local jurisdictions with the largest number of
children who are at risk for lead exposure. The major requirements
outlined in the FY’03 program announcement are the development of
childhood lead poisoning elimination plans, targeted screening
approaches, surveillance systems, case management guidelines,
strategic partnerships, protective policies, primary prevention
projects and evaluation plans. Grantees will also be required to
coordinate activities with agencies involved in lead hazard reduction
programs.
At a minimum, state grantees will be required to develop, implement
and evaluate statewide screening plans; adopt ACCLPP’s case management
guidelines; and design statewide elimination plans to determine the
amount of screening needed to meet the federal definition of <1% of
lead poisoned children . FY’03 funding will be allocated on July 1,
2003; grantees will be given one year from that time to meet the
minimum requirements. LPPB established several priorities in the FY’03
program announcement. Funding will be provided to state and local
CLPPPs. Guidance and technical assistance will be given for CLPPPs to
define populations of children at risk for lead poisoning, assess
prevalence rates within jurisdictions, identify lead poisoning
sources, and link resources that can be used to develop lead-safe
environments for children.
Regional training workshops will be held on the new case management
guidelines developed by ACCLPP for CLPPPs to ensure appropriate
medical and environmental case management is provided to children with
EBLLs. Ms. Patricia McLaine, an ACCLPP liaison representative, will
lead these sessions. Community-based support for lead poisoning
prevention efforts will be encouraged. Statewide surveillance systems
will be enhanced through capacity building initiatives. Collaborative
efforts will be undertaken with several partners to educate health
care providers, MCOs, insurers, real estate brokers, parents and the
general public about childhood lead poisoning. During CDC’s strategic
planning meeting in December 2002, several key recommendations
emerged: The National Electronic Disease Surveillance System (NEDSS)
should be supported within states. Primary prevention activities
should be improved by tracking and monitoring housing with data
collected by the U.S. Department of Housing and Urban Development
(HUD). Advocacy for Healthy Homes projects and lead-safe housing
should be strengthened. Private and federal resources should be
maximized to allocate more funding to states and local jurisdictions.
Media advocacy training should be provided to state and local CLPPPs.
A forum for lead poisoning researchers should be convened each year. A
Blue Ribbon Committee of lead poisoning prevention experts should be
established to travel to states and local jurisdictions to build
programmatic capacity. Consideration should be given to adding a
question on housing conditions to the U.S. Census.
Dr. Michael Weitzman, the Workgroup Chair, explained that the
workgroup was formed because previous guidance indicated adverse
health effects might occur at BLLs <10 µg/dL. The workgroup was
charged with reviewing existing evidence to confirm or refute these
guidelines. Dr. Weitzman, in conjunction with the ACCLPP Chair and CDC
staff members, selected the following workgroup members: Drs. David
Bellinger, Birt Harvey, Betsy Lozoff, Patrick Parsons, David Savitz,
Joel Schwartz and Kimberly Thompson. The diverse membership represents
a wealth of experience in lead, laboratory issues, pediatrics and
epidemiology. Over the past year, the workgroup has held one
face-to-face meeting and convened more than six conference calls.
The workgroup considered several issues that play a role in causal
inferences, including biologic plausibility, blood lead tracking, age
trends and potential confounders from social or physical environments.
These factors may include iron status, maternal prenatal smoking,
postnatal environmental tobacco smoke (ETS) and mouthing behavior. In
reviewing both epidemiologic studies and animal data, the workgroup
noted several key issues that will need to be addressed. First, animal
studies are problematic because the process to make inferences across
species is difficult and methodologies to expose animals and children
are different.
Second, data are lacking on whether a critical period of vulnerability
exists during a particular point in a child’s life. The literature
does not clarify whether the most essential component in a child’s
development is a peak BLL or duration of exposure to lead. Third,
mouthing behavior was evaluated in previous studies, but is not being
actively investigated. The lack of current data will significantly
increase the difficulty in making this assessment. Fourth, blood lead
measurements, accuracy and precision may not be reliable due to
variability among laboratories. Fifth, the quality of neurobehavioral
assessments is questionable because several different tests have been
used to date.
The workgroup reviewed a published paper that relied on NHANES data to
show an association between BLLs of children >6 years of age and
achievement test outcomes. The workgroup is uncertain whether
concurrent or earlier BLLs acted as a predictor of decreased IQ
points, but upcoming longitudinal studies are expected to explain the
importance of blood lead tracking and age trends. The workgroup
originally decided to limit its review to peer-reviewed papers of
substantial numbers of children with BLLs <10 µg/dL. These data would
also contain published results that assessed the relationship between
BLLs and outcomes at levels <10 µg/dL. However, the workgroup soon
learned that only a small amount of studies meet these criteria
because children with BLLs <10 µg/dL are a relatively recent
phenomenon.
Based on this finding, the workgroup revised its approach to include
studies of postnatal lead exposure and intelligence with a minimum of
10 children with BLLs <10 µg/dL. Under the new criteria, the data will
assess BLLs by atomic absorption, spectrometry and anodic stripping
voltammetry and will also evaluate health outcomes beyond
neurocognition and behavior, including nerve conduction, hearing,
height and onset of adolescence. The workgroup has discussed the
possibility of conducting a meta-regression analysis to explore
threshold and other causal inferences. Differences in the slope of the
relationship between IQ and BLLs at <10 µg/dL and >10 µg/dL are being
considered as well. Variations in methodologies, study designs,
outcome measures and study samples to pool data are being noted.
Dr. Meehan mentioned that LPPB made a
commitment to ACCLPP to closely collaborate with appropriate partners to
ensure the Medicaid targeted screening recommendations are reviewed,
seriously considered and implemented. After ACCLPP submitted the
guidelines to the HHS Secretary in September 2002, CDC and the Centers
for Medicare and Medicaid Services (CMS) formed a workgroup to review
the recommendations, formulate a strategy and develop an implementation
plan. Both agencies are in complete agreement that states should be
allowed to target populations for screening to improve screening rates
among Medicaid children so long as data support this effort.
To date, the interagency workgroup has held three telephone conferences
and one internal meeting. CDC and CMS will continue to collaborate to
develop an approach that is effective for both agencies. The
implementation strategy will be refined, presented to the HHS Operation
Divisions and eventually forwarded to the HHS Secretary. CDC and CMS do
not have a written proposal or recommendations to share with ACCLPP at
this time, but the agencies hope to present a formal process at the next
meeting in October 2003. Mr. Rick Fenton of CMS confirmed that the
agencies are making strong efforts to finalize a strategy to implement
ACCLPP’s recommendations.
Dr. Harvey raised the possibility of CDC recommending that states
conduct epidemiologic studies to identify Medicaid children who should
and should not be screened. To assist in the decision-making process,
CDC could provide a strong epidemiologic basis or background data to
states requesting waivers. States could then use this information to
develop screening plans and appropriately target children within the
Medicaid population. Dr. Meehan conveyed that in the FY’03 cooperative
agreements, LPPB will emphasize targeted screening for Medicaid
children. This effort will be consistent with the overall objective for
states to obtain the best information and use data as effectively as
possible. LPPB is closely collaborating with states to improve analyses
of available housing, census and screening data.
Efforts are also being made for states to develop screening and
elimination strategies that are based on solid data. This type of
logical approach will eliminate the need to screen every child and
direct resources to areas with the greatest need. Dr. Banner disagreed
with Dr. Harvey’s suggestion because epidemiologic studies will overlook
at-risk children in Oklahoma and other rural states. These types of data
will most likely conclude that EBLLs are not a problem. A focused
screening strategy should be developed to identify children with diffuse
health problems in rural areas. Dr. Meehan agreed with this
recommendation because a large number of providers in Oklahoma and other
rural states ignore the mandatory universal screening requirement due to
the small number of children who present with EBLLs.
Dr. Campbell advised the interagency workgroup to thoroughly review
ACCLPP’s report to the HHS Secretary while developing the implementation
strategy. The document outlined data needs for Medicaid targeted
screening in great detail. With this approach, CDC and CMS will be less
likely to duplicate the excellent product developed by ACCLPP. Ms.
Guthrie-Wengrovitz followed up on this comment by volunteering the
Medicaid Screening Workgroup to assist the agencies in developing the
strategic plan. The workgroup could also recommend field personnel who
can clarify issues the interagency workgroup is currently considering.
Dr. Piomelli agreed with ACCLPP’s approach to screen Medicaid children,
but he underscored the importance of including other poor children who
are excluded from this population. For example, many immigrants may not
have sufficient education or English speaking skills to apply for
Medicaid.
Ms. Nikki Kilpatrick of LPPB
reported that ACCLPP submitted a letter to the HHS Secretary
emphasizing the importance of educating health care providers and
parents of immigrants, refugees and internationally adopted children
about potential lead hazards. The letter also underscored the need to
screen these populations for lead poisoning. LPPB has taken the
following actions to date in response to the letter. The U.S.
Department of State (DOS) and Office of Consular Affairs were
contacted to devise an effective mechanism to disseminate information
to parents who enter the country with young children. LPPB is
requesting assistance from ACCLPP in identifying points of contact for
these agencies.
In the interim, LPPB will distribute the parent letter ACCLPP
developed and other materials to consulate offices throughout the
country and foreign medical physicians who administer tests to
incoming children. These providers are certified by CDC and may serve
as a tool to more broadly circulate the ACCLPP parent letter. LPPB
also needs assistance in identifying a partner in the Immigration and
Naturalization Services. The agency was relocated in the Office of
Homeland Security and its focus on immigrant health issues may have
changed with the reorganization.
In contacting the DOS Bureau of Refugee and Migration Services, LPPB
learned that refugees entering the United States are assigned to one
of ten voluntary agencies. These organizations assist with the
reception, placement and community orientation of refugees; testing
and other health issues are covered in these sessions. LPPB also
learned that ~66% of states have a refugee coordinator who establishes
guidelines for refugee health issues. The president of an organization
representing state coordinators was contacted to assist in
disseminating the ACCLPP parent letter. The Joint Council on
International Children’s Services was contacted as well. This
organization establishes guidelines for state-regulated international
adoptions and also collects and distributes information to
international adoption clinics, federal agencies and child welfare
service bureaus.
The web sites of 19 international adoption clinics in the United
States were reviewed. All of these resources emphasize the need to
conduct lead screening of children adopted from certain countries. For
children of refugees and immigrants, ACCLPP’s recommendations will be
reinforced to health care providers and nurse practitioners. To
further communicate the guidelines, LPPB will tailor ACCLPP’s parent
letter to specific target audiences and distribute the document to
state and local health departments, federal agencies, non-profit
organizations and grantees. The CDC Yellow Book is targeted to
travelers and a section on international adoptions and lead poisoning
was incorporated into the 2003-2004 edition.
The next steps in this project will be for LPPB to distribute
explanatory letters and parent letters to various organizations.
Information about the impact of lead poisoning on refugee, immigrant,
and internationally adopted children will also be posted on the LPPB
web site. Information about ACCLPP has now been added to the CDC web
site and can be accessed at www.cdc.gov/nceh/lead/ACCLPP/acclpp_main.htm.
The roster, charter, workgroups, recommendations, meeting minutes and
upcoming meeting schedules are outlined on the new web page.
Dr. Campbell commended LPPB on its diligent efforts in making contacts
and disseminating ACCLPP’s parent letter. Dr. Piomelli reiterated that
children of illegal immigrants have the highest proportion of lead
poisoning, but have been excluded from screening activities. Dr. Binns
advised LPPB to contact Federally Qualified Health Centers since these
agencies provide care to illegal and uninsured immigrants. Dr. Jacobs
added that HUD and the Department of Justice issued policy guidance
making Lead Hazard Control Grant Program services accessible to
illegal immigrants. Dr. Banner committed to providing Ms. Kilpatrick
with a list of emergency physicians since emergency departments serve
as the only source of care for many Hispanic immigrants. Guidance to
these providers should emphasize the importance of screening this
population of children, particularly new arrivals to the United
States.
Dr. David Mannino of CDC
explained that tobacco smoke contains >4,000 different substances,
including combustion products, particulate matter, pollutants, lead,
cadmium and other metals. Several critical factors are considered when
smoke exposure is measured in individuals, such as the volume of space
in which smoke is dispersed, ventilation and removal of pollutants.
These components then follow a pathway of concentration of smoke in an
air space, exposure of persons breathing in the air space, individual
breathing rates, airway geometry, dose, individual capacity to
metabolize or eliminate smoke, biologically effective dose, and health
effects. Age, presence of underlying disease and other susceptibility
factors play a role in the pathway from ETS exposure to health
effects.
Data on ventilation adjusted by age and weight show that children are
disproportionately more exposed to air pollutants than adults. To
measure smoke exposure, questionnaires, measurements of air pollutants
and biomarkers can be used. Cotinine is a metabolized product of
nicotine and is the best and most frequently used biomarker of tobacco
smoke exposure. Cotinine has a half-life in blood of 15-40 hours and
can be measured in serum, urine, saliva and hair; 80% of nicotine is
metabolized to cotinine. Lead was a focus of CDC’s study due to its
presence in processed tobacco and tobacco smoke. Lead also has a
relatively long half-life of 30-200 days in blood. NHANES data show
that a comparison of reported and measured smoke exposure is
problematic, but conclusions have been made from research conducted to
date.
Lead levels in ambient air and tobacco have been decreasing over time.
The lead level in each cigarette is 1-5 µg/g; 1%-8% passes into smoke.
Lead levels in ambient air were 22 ng/m3 in homes where smoking was
allowed. Gastrointestinal absorption of lead is 50% in children versus
10%-15% in adults; pulmonary absorption of lead is >50% in children
compared to 30%-50% in adults. The objective of CDC’s study was to
determine whether smoke exposure was related to EBLLs. The analysis
was limited to a subset of 5,592 children 4-16 years of age with
available serum cotinine levels reported in NHANES data. BLLs were
measured with standard methods and a limit of detection of 1 µg/dL.
Reported exposure to ETS was defined as the total number of cigarettes
smoked in the child’s household per day. No ETS exposure was defined
as no persons in the household smoked. Any ETS exposure was defined as
at least one individual in the household smoked. Cotinine levels were
measured with atmospheric pressure ionization tandem mass spectrometry
and a limit of detection of 0.050 ng/mL. Covariates included in the
analysis were race/ethnicity, region of country, socioeconomic status
and demographics, i.e., parental education level, poverty level, age
of housing, gender, family size, number of persons and rooms in the
household, and age of child. Analytic methods included weights to
reflect national estimates; SAS and SUDAAN software; predictors of
BLLs >10 µg/dL; and regression models to examine the relationship
between smoke exposure and BLLs.
Children in the study were divided into a high exposure group of >20
cigarettes daily; a medium exposure group of 1-19 cigarettes daily;
and a low exposure group of no daily cigarettes. The majority of
children in the study were white and lived in housing built after
1973. The data showed the following results: ~15%-20% of children with
the highest measured cotinine levels had no reported smoke exposure;
~35% of children had reported smoke exposure in the home. As expected,
children with higher cotinine levels had significantly higher BLLs
than children with no exposure. Higher BLLs were also found among
children who were black, younger, poorer, resided in older or smaller
homes, lived in Northeastern states and had parents with lower
education levels.
Of all study participants, 4% had BLLs >10 µg/dL. This subset
primarily resided in Northeastern and Midwestern states. The cohort
was also stratified into three age groups of 4-6 years, 7-11 years and
12-16 years. Children who admitted to actively smoking and those with
cotinine levels >15 were excluded from the study. The strongest effect
of EBLLs was seen in the youngest age group and among black children.
No white children with low cotinine levels had EBLLs. Based on
uni-variate and multi-variate models, children with high exposure to
tobacco smoke had 60% and 40%, respectively, higher BLLs than those
with low-level exposure. Multi-variate models showed an odds ratio of
20 for BLLs >10 µg/dL among the 4-6 year age group; the odds ratio
decreased in older children. Overall, the study was unable to
definitively address several important issues:
The study concluded that children with recent ETS exposure as
defined by cotinine levels have increased BLLs. Lead may be a useful
biomarker of smoke exposure, but more research needs to be conducted.
Dr. Mannino announced that the paper is currently in press in
Epidemiology and is expected to be published by September 2003.
Dr. Banner emphasized the need to focus on other illicit substances
that are smoked in the environment and cause second-hand exposure. For
example, children are presenting with positive screens of
methamphetamine, cocaine and other substances that may be caused by
dust on surfaces or passive inhalation. Dr. Jacobs asked if housing
ventilation systems were examined in the study. Dr. Mannino replied
that this factor was not analyzed due to the lack of solid data.
However, size of home was included as a confounder and is the best
surrogate of housing ventilation system. To further address this
issue, CDC has collected data on apartment buildings to determine
exposure outcomes when residents share air spaces.
Dr. Rogan asked if data are available on the amount of lead in air
produced by smokers. He raised the possibility of CDC also examining
children’s exposure to lead from food handled by smokers. Dr. Mannino
responded that data indicate as much as 300 ng/m3 of lead is in air.
Dr. Matte noted that the relationship between age of housing and BLLs
was more significant in the group with higher cotinine levels than
children with lower cotinine levels. He also pointed out that the
effect of cotinine on average BLLs was greater in children who lived
in older housing than those who lived in newer homes. Dr. Mannino
agreed with these observations because the data showed that ETS
enhanced older housing, poverty and other traditional risk factors for
lead exposure. Mr. Goldman questioned whether the study examined the
relationship between diet and smoking since unhealthy eating habits
create a higher uptake of lead.
Dr. Mannino mentioned that this factor was not included in the study.
However, he acknowledged that diets tended to be poorer among families
with more passive smoke exposure than those with no ETS. The
relationship between diet and smoking is explored in-depth in another
CDC paper that will soon be published in Nicotine and Tobacco.
Overall, the data did not demonstrate that diet is a major factor in
the correlation between ETS exposure and EBLLs. Dr. Weitzman raised
the possibility of reviewing earlier NHANES data when BLLs and
cotinine levels were higher. Dr. Harvey asked if data have been
collected on the relationship between cotinine levels and postnatal IQ
in children. Dr. Weitzman replied that one study estimated a loss of
4.5 IQ points for every 10 cigarettes the mother smoked. Dr. Banner
indicated that the Primary Prevention Workgroup should consider
focusing on the reduction of ETS exposure in terms of lead.
Dr. Campbell reported that the
workgroup was formed 16 months ago and is now presenting the seventh
draft of the primary prevention document to ACCLPP for review and
comment. The workgroup plans to submit the document to a medical
editor for further refinements. The current draft reflects general
recommendations made by ACCLPP during previous meetings: rewrite the
document with a stronger focus; incorporate additional references;
clarify the target audience; include more data on enforcement
strategies and incentives; ensure the terminology is consistent
throughout the document; and provide information about other sources
of lead for children, but maintain the focus on housing.
The workgroup is recommending that the document be issued as a
standalone publication. A shorter journal article targeted to
pediatricians, family practitioners, public health professionals,
housing personnel and other specific audiences should also be released
to compliment the main document. To more widely publicize primary
prevention and obtain endorsement beyond HHS, ACCLPP has been invited
to present the document at the next meeting of the Interagency Federal
Task Force on Lead Poisoning Prevention in May 2003. Dr. Campbell and
Ms. Amy Murphy, the workgroup chair, will most likely represent ACCLPP
at the meeting.
Another activity to advance the workgroup’s efforts is Building Blocks
for Primary Prevention: Protecting Children from Lead-Based Paint
Hazards. CDC has allocated funding to the Alliance to End Childhood
Lead Poisoning to implement the project. The purpose of the initiative
is to cite examples of primary prevention strategies that have been
implemented and make these models available to jurisdictions
throughout the country. The Alliance is tentatively scheduled to make
a presentation on the project during the ACCLPP meeting in October
2003. A summary of the project and Alliance’s paper on Making
Lead-Safe Housing the Central Focus of Strategic Plans to Eliminate
Childhood Lead Poisoning are collectively appended to the minutes as
Attachment 1.
In an effort to move toward consensus of the primary prevention
document, Dr. Campbell asked ACCLPP to make specific and concrete
comments. She reminded the members that the primary target audience is
health environmental and housing professionals at state and local
levels. A shorter document was also distributed that serves as a
preface. She conveyed that the workgroup is discussing the possibility
of developing a glossary to clarify terms. Dr. Campbell mentioned that
a workgroup meeting is scheduled on the following day for further
editing of the document. Comments made during the discussion by ACCLPP
members are outlined below.
Several follow-up comments were made in response to the above
suggestions. Dr. Jacobs clarified that the document is an attempt to
encourage local health and housing agencies to prevent exposures and
exposure pathways in housing. This effort is consistent with the 1992
Congressional definition of a lead-based paint hazard as deteriorated
paint and contaminated dust and soil. The primary prevention document
offers guidance to local health and housing agencies to make housing
safe, conduct follow-up of children and intervene before exposures
occur. Several members requested that Dr. Jacobs’s comments be
formalized and included in the introduction of the document.
Dr. Meehan explained the process to finalize the document. After
ACCLPP formally approves a draft, LPPB staff and contract editors will
further refine the document into a professional and high-quality
product. Before additional progress can be made, however, ACCLPP must
now agree on the target audience and the publication venue. For
example, CDC’s Reports and Recommendations (R&Rs) are standalone
documents published in the MMWR. R&Rs are longer than regular MMWR
articles and are broadly disseminated to clinicians through web-based
subscriptions. The primary prevention document can also be issued as a
journal article or standalone publication outside of the MMWR.
Dr. Meehan mentioned that resolution of these issues will dictate
whether public health jargon or laymen’s terms would be more
appropriate. ACCLPP authorized the workgroup to define a time-line to
finalize the document and circulate a draft to CLPPPs for preliminary
review and comment. Agreement was reached to place the document for a
formal vote by ACCLPP during the October 2003 meeting. Dr. Jacobs
indicated that the primary prevention document may need to be
distributed before the next meeting, particularly if CLPPPS will use
the guidelines as reference materials for the July 1, 2003 cooperative
agreement.
Dr. Meehan returned to one of the recommendations and expressed
concern with ACCLPP formally requesting that CLPPPs shift from
screening to primary prevention. CDC would be more comfortable with
ACCLPP emphasizing the critical role of primary prevention in a
comprehensive public health program that includes screening, case
management and other important components. He explained that CDC is
mandated by legislation to fund screening programs. Dr. Campbell
clarified that the document recommends primary prevention strategies
be prioritized since secondary prevention efforts have traditionally
failed in detecting children with lead exposures and toxicities.
However, the guidelines do not ask programs to abandon secondary
prevention.
For example, continued case management of children with EBLLs is
suggested. The document further recommends that resources and staff be
redirected as the focus shifts from secondary to primary prevention.
Several members returned to the proposed time-line to finalize the
primary prevention document. Concern was expressed due to the
three-month delay between the July 1, 2003 program announcement and
ACCLPP’s formal vote on the draft in October 2003. Dr. Campbell asked
members to consider the possibility of approving the document by
e-mail, regular mail or conference call. To expedite the approval
process, Dr. Harvey suggested that only major changes be circulated to
the voting members. ACCLPP passed several consensus recommendations to
address issues raised during the deliberations.
Ms. Guthrie-Wengrovitz placed the following motion on the floor for a
vote. CLPPPs should serve as the primary target audience of the
document. Health agencies, community groups and other partners of
CLPPPs that will be needed to implement the primary prevention
recommendations should serve as the secondary target audience. The
focus of the document should remain on housing-based primary
prevention interventions. Ms. Guthrie-Wengrovitz accepted Dr.
Campbell’s amendment of the motion to also include local and state
health departments as a primary target audience, particularly agencies
without a CLPPP. The motion was seconded by Dr. Binns and unanimously
approved with no further discussion.
Dr. Lynn placed the following motion on the floor for a vote. The
primary prevention document should be issued as detailed standalone
guidelines that can be tailored to a shorter and more concise journal
article in the future. The motion was seconded by Dr. Binns and
unanimously approved with no further discussion.
Dr. Banner placed the following motion on the floor for a vote. The
motion was for conditional approval of the present draft of the PPWG
document. The revised primary prevention draft should be distributed
to voting members via e-mail for further approval after further
editing by the workgroup, LPPB staff and contract editors. ACCLPP
should be provided an opportunity to review and approve the final
draft. The motion was seconded by Dr. Binns and unanimously approved
with no further discussion. Dr. Meehan confirmed that all drafts will
continue to be circulated to ACCLPP ex officio and liaison
representatives for review and comment. He asked non-workgroup members
to submit additional comments on the document in writing to Mr. Morta.
Dr. Campbell reported that two ACCLPP workgroups are in the implementation phase, while two others are actively developing guidance. She reviewed a summary of five topics which remained from an ACCLPP prioritization process that occurred in February 2001. The two highest topics, primary prevention and review of the evidence for effects at BLLs <10 µg/dL, have already been incorporated into workgroups. Bearing this history in mind, topics that should serve as focus areas in the future should now be considered by ACCLPP and LPPB. Voting members will be asked to formally select priority issues either during the October 2003 or March 2004 meeting. ACCLPP members’ preliminary suggestions are outlined below.
Dr. Meehan followed up on some of the proposed priority topics.
First, LPPB will continue to closely collaborate and consult with the
CDC International Emergency and Refugee Health Branch and outside
agencies to address issues related to refugees. However, LPPB’s
funding and appropriations are limited to domestic lead poisoning
prevention programs. Second, LPPB has allocated resources and received
additional funds from HUD to focus on Healthy Homes. Efforts are
currently being made to educate CLPPPs about the importance of this
initiative.
Drs. Campbell and Lynn noted that refugees, immigrants, pregnant women
from certain foreign countries, and international adoptees entering
the United States have the largest burden of EBLLs in most states.
ACCLPP’s efforts in international lead issues would be to issue
guidance to states from this perspective rather than address EBLLs
among children overseas. To assist in this area, Dr. Meyer confirmed
that CDC is interested in including data on country of origin in the
new lead component of NEDSS.
The agenda and action items raised during the meeting were reviewed and are outlined below.
Agenda Items
- Presentation from CDC’s international divisions with responsibility for quarantine and immigrant screening prior to U.S. entry. The overview should cover health screening issues along the U.S.-Mexico Border; gaps in current surveillance data; and areas where ACCLPP’s screening recommendations could make the most significant impact to CDC.
- Presentation on lead exposures and screening issues related to pregnancy.
- Presentation by Dr. Ian von Lindern or the Agency for Toxic Substances and Disease Registry on the significant contribution of lead at Superfund sites.
- Presentation by Boston and Chicago programs on best practices and lessons learned from developing and implementing lead elimination plans.
- Overview by Dr. Brown, the new LPPB Chief.
Action Items
- Provide ACCLPP with copies of slides presented by Ms. Dyck and Dr. Meyer.
- Provide ACCLPP with LPPB’s surveillance summary and hard copies of the Second National Report on Human Exposure to Environmental Chemicals when available.
- Provide ACCLPP with an electronic version of CDC’s study on the relationship between ETS and BLLs after the paper is published.
- Provide ACCLPP with hard copies of handouts and other meeting materials at least one week prior to meetings.
- Circulate action items to ACCLPP that will require a consensus vote prior to meetings. This approach may assist in ensuring a quorum is maintained throughout the duration of the proceedings.
Dr. Borrazzo noted that in the ACCLPP charter scheduled for renewal in 2003, ex officios will be granted voting rights. As a result, votes by ex officios will represent agency positions rather than individual perspectives. This role may complicate the voting process for some ACCLPP agenda items. Dr. Meehan confirmed that this issue will be clarified by the CDC Office of General Counsel and Committee Management Office prior to the next meeting. He agreed with Dr. Borrazzo that a large number of ex officios may feel uncomfortable representing their respective agencies on certain topics and abstain from voting.
The
Chair opened the floor for public comments; no attendees responded.
Closing Session
Dr. Campbell encouraged the members to submit detailed information
for additional agenda items to be considered for the next meeting.
Suggestions should be sent via e-mail to Dr. Campbell with a copy to
Dr. Meehan no later than August 2003. The next ACCLPP meeting will be
held on October 14-15, 2003 in Atlanta, Georgia. LPPB will poll
members via e-mail to determine dates for the 2004 meetings.