Lead Exposure and Prevention Advisory Committee (LEPAC) Inaugural Meeting

Agenda - April 29, 2020

9:00 am: Welcome, Introductions, and Announcements Perri Ruckart, MPH, Designated Federal Official, NCEH/ATSDR; Patrick N. Breysse, PhD, CIH, Director, NCEH/ATSDR; Matthew Ammon, Chair, LEPAC and Director, HUD Office of Healthy Homes and Lead Hazard Control

9:30 am: Charge/Purpose (Chair)

9:45 am: New member orientation (SBI) Demetria (Dee) Gardner, CDC Strategic Business Initiatives (SBI) Unit

10:00 am: Key Federal Programs and Federal Lead Action Plan Sharunda Buchanan, PhD, MS, Director, NCEH/ATSDR Office of Priority Projects and Innovation

10:30 am: CDC's Role in Lead Poisoning Prevention and Lessons Learned Perri Ruckart, MPH, Team Lead/Health Scientist, Lead Poisoning Prevention and Environmental Health Tracking Branch

11:00 am: Break

11:15 am: Committee member discussion on morning presentations

12:00 pm: Lunch

12:30 pm: Methods and Results of a Community Guide Environmental Scan and Scoping Review of Lead Interventions Jeff Reynolds, MPH, CDC Community Guide Office

1:15 pm: Committee member discussion on Community Guide presentation

1:45 pm: Public comment

2:00 pm: Break

2:15 pm: Facilitated discussion of effective services and best practices regarding lead screening and the prevention of lead poisoning

3:15 pm: Facilitated discussion of research gaps and additional research needs

4:15 pm: Wrap up and discuss topics for next meeting (Chair)

4:30 pm: Adjourn

Summary and action items

Meeting date and time: April 29, 2020 from 9:00 AM EST to 4:30 PM EST

Meeting location: remote participation through virtual Zoom webinar meeting. Approximately 137 people attended the meeting or a portion of the meeting.

Meeting attendance (in alphabetical order)

• Matthew Ammon, LEPAC Chair; Director, Office of Lead Hazard Control and Healthy Homes, U.S. Department of Housing and Urban Development (HUD)
• Tammy Barnhill-Proctor; Acting Director, Office of Early Learning, Office of Elementary and Secondary Education, U.S. Department of Education
• Patrick Breysse; Director, National Center for Environmental Health (NCEH)/Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Disease Control and Prevention (CDC)
• Jeanne Briskin; Director, Office of Children's Health Protection, U.S. Environmental Protection Agency (EPA)
• Sharunda Buchannan; Director, Office of Priority Projects and Innovation, NCEH/ATSDR, CDC
• Wallace Chambers; Deputy Director, Environmental Public Health, Cuyahoga County Board of Health
• Tiffany DeFoe; Director, Office of Chemical Hazards-Metals, Occupational Safety & Health Administration (OSHA), U.S. Department of Labor
• Michael Focazio; Program Coordinator, Environmental Health Mission Area, U.S. Geological Survey (USGS)
• Demetria Gardner; Senior Committee Management Specialist, Federal Advisory Committee Act Program, Strategic Business Initiatives Unit, Office of the Chief Operating Officer, CDC
• Nathan Graber; Pediatrician, St. Peter's Pediatrics, St. Peter's Health Partner Medical Associates
• Karla Johnson; Administrator, Healthy Homes Environmental Consumer Management and Senior Care Department, Marion County Public Health Department
• Donna Johnson-Bailey; Senior Nutrition Advisor, Office of Policy Support, Food and Nutrition Service, U.S. Department of Agriculture
• CDR Monica Leonard; Acting Branch Chief, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH, CDC
• Erika Marquez; Assistant Professor, School of Public Health, University of Nevada at Las Vegas
• Howard Mielke; Professor, Department of Pharmacology, Tulane University School of Medicine
• Anshu Mohllajee; Research Scientist III, Childhood Lead Poisoning Prevention Branch, California Department of Public Health
• Celeste Philip; Deputy Director for Non-Infectious Diseases, CDC
• Jeffery Reynolds; Health Scientist, Contractor, Cherokee Nation Assurance (CNA), LLC, Community Guide Office, Office of the Associate Director for Policy and Strategy, CDC
• Perri Ruckart, Designated Federal Officer (DFO); Lead Health Scientist, Program Development, Communications, and Evaluation Team, Lead Poisoning Prevention and Surveillance Branch (proposed), NCEH, CDC
• Jill Ryer-Powder; Principal Health Scientist, Environmental Health Decisions
• Jana Telfer; Strategic Projects Officer, NCEH/ATSDR, CDC

Public comment

Held from 1:45-2:00 pm. Commenters included Dr. Michael Kosnett, Associate Adjunct Professor at the Colorado School of Public Health and the Division of Environmental and Occupational Health, and Perry Gottesfeld, MPH, Executive Director of Occupational Knowledge International.

Common themes

Primary and secondary prevention; blood lead reference value (BLRV); environmental lead (soil and air); lead poisoning prevention at the local/community level; messaging (including to parents/families/caretakers); occupational/take home lead exposure; evaluating best practices

Identified research gaps

Evaluate existing programs and current interventions; identify best practices; review existing funding structures and identify resources that have most impact; cost-benefit analysis (CBA); BLRV; verify existing lead hazard models; lifelong effects of lead exposure; culturally-specific sources; sources of exposure: aviation gasoline; lead in bullets; occupations; lead hazard control ordinances; systematic method for collecting and processing blood lead testing

Meeting notes

Charge and purpose

• The LEPAC is charged with
  • Reviewing the federal programs and services available to individuals and communities exposed to lead;
  • Reviewing current research on lead exposure to identify additional research needs; reviewing and identifying best practices or the need for best practices, regarding lead screening and the prevention of lead poisoning;
  • Identifying effective services, including services relating to healthcare, education, and nutrition for individuals and communities affected by lead exposure and lead poisoning; and,
  • Undertaking any other review or activities that the U.S. Department of Health and Human Services (HHS) Secretary determines to be appropriate.
• An annual report of the LEPAC accomplishments will be submitted to the HHS Secretary and various Congressional committees.
• Some of the underlying work mentioned in the charge has already been completed, as part of the Federal Lead Action Plan.

Primary prevention and secondary prevention

• NCEH leadership requested that the LEPAC members present thoughts on lead elimination and how to shift society towards eliminating lead hazards from our environment.
• Primary and secondary prevention need to be used together. The aspirational goal is to move away from using children's blood lead levels (BLLs) to monitor environmental exposures and move towards lead elimination, primary prevention, and identification of specific sources.
  • However, BLL surveillance is important to continue for monitoring progress and discovering emerging sources.
  • LEPAC members suggested funding should support putting point-of-care testing machines in primary care doctors' offices and improving the accuracy for point-of-care testing.
• Lead poisoning prevention requires a multifactorial approach. CDC recommends targeted testing, but not all children in high-risk areas and populations are being tested. Universal testing would provide powerful data to help identify risk and pinpoint interventions for targeted efforts.
• LEPAC members suggested that CDC strongly influences the way lead testing, surveillance, and case management are done across the nation.
• LEPAC members suggested that CDC should consider if there are better alternatives to measure lead exposure, perhaps by measuring bone lead.
• There is great value in having a systematic method for state and local governments to collect and process BLLs because it helps ultimately inform environmental standards.
• LEPAC members suggested that CDC should evaluate the effectiveness and associated costs of interventions, such as looking at local laws that focus on primary prevention.
• It is important to determine what interventions are effective in lowering BLLs in high-risk communities and if there are novel approaches that are less expensive or complicated that could be at least as or more effective than traditional, heavily regimented approaches.
• Concern was expressed about increasing the workload for local public health departments without increasing resources.
• LEPAC should document successful state lead prevention and mitigation efforts to provide best practices, particularly in higher-risk communities.
• LEPAC should consider how it can encourage programs or facilitators of interventions to publish their work.
• LEPAC members suggested that CDC should find a way to easily and widely share information about culturally specific sources.
• LEPAC should consider changes in the healthcare structure which have affected surveillance and strategic partnerships.
  • For example, shifts to managed care systems have changed relationships between Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and healthcare.
• Although there is support for focusing more on primary prevention, questions arose on how to balance blood lead surveillance versus environmental surveillance to move towards primary prevention.
• Expenses related to blood lead surveillance could reduce resources available for environmental surveillance.
• The Community Guide scoping review on lead interventions could be used to develop a research agenda and inform funding sources.

BLRV

• NCEH leadership requested guidance on the proposed BLRV, specifically on how it should be established and how it should be used.
• Several members suggested that the BLRV is an appropriate discussion for a subcommittee or work group.
• Issues surrounding adopting a lower reference value include measuring lower levels of lead with precision and accuracy, costs, associations between the reference value and other lead regulations across the federal government, and burden placed on states.
• LEPAC needs to consider if tying the reference value to the 5th percentile of the National Health and Nutrition Examination Survey (NHANES) blood lead distribution in children is appropriate and what should happen if that value increases.
• Lowering the reference value to 3.5 µg/dL becomes less practical because practitioners using LeadCare II products may not consider 3.5 µg/dL an elevated BLL due to the accuracy of the tests.
• Practicality is important when considering what BLL to recommend as an action level and how recommendations will be implemented at the local level since many states will adapt their practices based on CDC recommendations.
• LEPAC should consider what changes would be expected when moving from 5 to 3.5 ug/dL, such as changes with confirmatory, follow-up blood testing and the recommended schedule for obtaining the confirmatory venous sample.
  • If a venous blood test is ordered for a child, it is less likely to get done than a point-of-care test at the clinic.
  • One of the issues with venous blood testing is laboratories report results with incomplete information.
• LEPAC members suggested that CDC should consider looking at how the BLRV is used in communities with the highest prevalence of elevated BLLs, how these communities define BLLs over time, and how their BLLs compare with NHANES data.
• It would be helpful to understand how well the reference value has been adopted by states. It could be a challenge for states to implement a very low BLRV if exposure is occurring in people's homes.
• It is easier to identify a particular source of exposure when the environmental investigation levels are higher, but this becomes more difficult with lower BLLs.
• LEPAC members suggested considering if it is more impactful to only manage children with the highest BLLs or the entire population with elevated BLLs.
• LEPAC should communicate what the reference value means to various audiences including policy makers and provide a cost-benefit analyses based on the reference value.
• There are concerns over how the BLRV is interpreted in practice, specifically what is the purpose and use of the reference value as an action level and/or as a tool for monitoring effectiveness of interventions.
• Parents believe that no action is needed when their child's BLL is lower than the BLRV currently set at 5 ug/dL. There is concern that if the BLRV is lowered, part of the lead poisoning prevention audience will be lost.
• LEPAC members suggested that CDC should clarify messaging to make it clear that 5 µg/dL is simply a reference value versus a safe lead level in the blood. Additionally, it is important to develop a standard/target for remediation levels.

Environmental lead levels

• Physicians should have access to questionnaires that address potential exposures to advise families.
• There is a gap in literature on interventions in childcare centers and air lead levels.
• Although lead-based paint is a major lead hazard, leaded gasoline also caused a legacy of lead in urban areas. Primary prevention must include air, water, and soil.
  • Seasonality needs to be considered.
• There are unevenly distributed soil lead levels and standards across the nation. LEPAC could work with states and EPA to create a conservative and health-based lead standard for soil.
• Accurate maps of soil lead levels across cities could be used during remediation and abatement.
• EPA is assessing the relationship between BLLs and soil lead levels to help evaluate soil lead cleanup level options.
• LEPAC should consider the best way to connect with communities with lead in their air/soil/water and ensure they have surveillance programs in place.
• LEPAC should address leaded aviation gas (avgas) and lead in bullets, as lead bullets are available in the US.
• USGS has data sets that could be helpful in identifying environmental exposure sources.
• Verifying models (e.g. IEUBK) to make sure that the parameters entered in the model are valid in finding a target blood lead level is a big research gap.
• There is a research gap about the effects of short- and long-term lead exposure throughout a person's life cycle. It could help us better understand exposure pathways and relative source contributions.

Local policies and community practice

• Approaches to lead hazard control and eliminating risk need to be focused locally and interventions that are shown to be effective should be translated to the local level.
• To address lead poisoning, LEPAC should help strengthen local policies to address lead hazards and ensure consistency and regular enforcement.
  • For example, by working upstream to develop local policies or nuisance laws.
  • The benefits or harms of current lead hazard control ordinances is an identified research gap, specifically with a focus on if these ordinances positively or negatively impact the community and cause landlords to leave an area.
• Although a lot of lead interventions are local, oftentimes research is not done or supported at the local level. It would be useful to reach out to community organizations to identify additional interventions for review.
  • Successful local interventions should be scaled up.
• LEPAC should consider what could be done to combine existing federal and state programs, policies, and funding structures to fund local pilot demonstrations.
  • The research on local ordinances in Rochester, New York is a successful example of research being used to implement policy.
• LEPAC should identify what tools the federal government can provide to communities and how CDC can involve states in a dialogue to learn about best practices/what people are doing besides through their cooperative agreement.
• Discussion is needed about how LEPAC can support strengthening linkages between states, laboratories, and Medicaid offices.
• LEPAC should look at how CDC recommendations influence the relationship in health systems, particularly in state policy.
• LEPAC needs to be intentional about aligning guidelines and regulatory expectations and balancing this in a way that the state and local communities can implement practices that allow them to identify local risk factors and mitigation strategies.
• LEPAC should focus on research areas that can drive policy decisions and resources such as using a cost-benefit effectiveness approach.
• Research should be done on mitigating outcomes of lead exposure through early intervention services.

Messaging

• Messaging around lead poisoning prevention could be improved by reminding the nation that lead poisoning is a concern for everyone.
• Parents are an important audience. Communication/messaging could be improved by involving parents and personal stories.
• There is a void of information about what parents can expect during life stages for children older than age 6, as well as adulthood.
• Federal agencies need to streamline and coordinate messaging so that state and local communities receive a consistent message.
• LEPAC has an opportunity to rebrand messaging around lead poisoning prevention and guidelines, including the BLRV. The messaging around the BLRV is important because it is a starting point for many different evaluations and actions.
• Messaging could be a tool to help define the best science available and for translation.
• LEPAC can use messaging to support the importance of lead testing early in life.
• The clinical relevance of an elevated BLL is difficult to understand and communicate what that number means to parents.
• Including return on investment in messaging will encourage proactiveness, which is important to communicate the value of preventing lead exposure and the impacts of lead exposure.

Occupational/take-home exposure

• Members requested clarity on if LEPAC's focus is only childhood lead poisoning prevention or if adults are a concern as well.
  • NCEH leadership responded that the focus is on both child and adult lead poisoning and exposures.
• A recent National Institute of Occupational Safety and Health (NIOSH) presentation discussed using adult BLL surveillance data to target interventions at the workplace. Integrating information from screenings and site visits to build on existing referral programs between regional OSHA, the federal government, Adult Blood Lead Epidemiology and Surveillance (ABLES), and state health departments is needed.
• OSHA is working on an advance notice of proposed rulemaking focused on the issue of BLLs to trigger medical removal and return to work.
• More research is needed on occupational/take-home interventions, including stronger regulation, particularly for addressing the gap about hygiene and personal protective equipment (PPE) requirements in addition to interventions in the home to reduce take-home exposures.
• OSHA requires that standards to address a significant risk be technologically and economically feasible.

Public comment

• Kosnett emphasized that LEPAC is directed to address the health hazards of lead exposure in adults as well as children and called on the committee to include occupational lead exposure. He urged LEPAC to establish a subcommittee on occupational lead exposure.
• Gottesfeld commented on 1) updating the CDC BLRV, 2) improving blood lead testing technology to improve limits of detection and limits of quantification of point-of-care devices, 3) addressing inconsistent standard for soil and dust, 4) no noticeable action on occupational exposures since the 1970s and, 5) banning lead paint and lead in plastics.

Meeting wrap up

• Next steps include identifying topics for workgroups and forming committees. Possible topics for workgroups include the BLRV; exposures: take home, soil, aviation gas; and messaging (to include parents/families/caregivers as an audience).
• The time frame for the next meeting is Fall 2020.

Meeting resources

• Transcript