Improving Care to Address Maternal and Child Lead Exposure

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, finding children exposed to lead, rethinking the approach to families, meeting them where they are with impressive results.

DR. ALEXANDER BILLIOUX:
Lead exposure does often break down by socioeconomic status. Communities of color in Louisiana are more at risk for lead exposure than white communities. That takes a different political nature as well. It becomes an issue of health advocacy, and about another aspect of institutional racism.

DR. TRINA EVANS-WILLIAMS:
There are still some barriers about lead and some people still think lead is a situation of the past, but our data shows us that it is still prevalent right here in our state and prevalent in America because we have so many old homes.

ANALISA PEARSON:
The huge deficits that it can cause for children academically and health-wise—you know, the need for better mental health, especially in rural areas, is huge, and lead can really contribute to behavioral health and mental health problems as well as school readiness. I mean, those are other pieces that we can't lose sight of even though we have a pandemic that, you know, it just has long-term, high-cost outcomes.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: public health teams looking for lead in the soil, the water, and old homes; trying new ways to reach families; teaching parents how to eliminate the risks while treating kids for exposure.

Over the years, lead has disappeared from gasoline, paint, and other consumer products, but is it out of our lives? Despite decades-old laws banning lead's use, mothers and children living in older and rural communities continue to deal with a poison that is debilitating and sometimes deadly.

Our experts today are waging a war on lead. Dr. Alexander Billioux is the assistant secretary of health for the Louisiana department of health. Dr. Trina Evans-Williams is the state program coordinator for the department's healthy homes and childhood lead prevention program. Analisa Pearson leads the Title V child and adolescent health programs for the Iowa department of health.

First, Dr. Alexander Billioux, Louisiana's assistant secretary of health.

BILLIOUX:

We don't know of any safe level of lead in children's blood. And just given the amount of lead that is in the environment and sometimes even in drinking water, paints, things like that when lead was used in a lot of industrial settings for many years, lead exposure is a significant problem made even more complicated by the fact that we just don't know how big a problem because it's not been the focus of much of our surveillance systems.

JOHNSON:
Lead was everywhere. It was an ingredient or a component of all kinds of things from paint to plumbing.

Have we gotten those things out of our system or are they still out there?

BILLIOUX:
Yeah, no, there's been lot of helpful legislation that's actually really limited where lead can be used now in industrial settings—so, you know, you're not going to find lead in your paint anymore, gasoline is all unleaded at this point, really few places where lead is actually getting introduced.

There is still a lot of pipes, especially in places with older infrastructure, still have lead pipes. That is a perennial risk of exposure, depending on corrosion and things like that.

But much of the lead exposure that both adults and children get is from historical sources. It's still, you know—in your neighborhood, the paint might have broken down and now it's in fine dust, even in top soil, like in a place like New Orleans.

JOHNSON:
So, it is something that you would probably see more in an older neighborhood or an older community then?

BILLIOUX:
Yeah, that's true. So, certainly old homes, regardless of socioeconomic status of those neighborhoods, might have a lot more—if not lead paint, maybe the lead paint has been removed—certainly lead dust in the environment because the paint and things like that did, over time, break down and add to what's in the soil and the environment. So, certainly older infrastructure is associated with lead.

JOHNSON:
You started by talking about children. Are they the ones most at risk?

BILLIOUX:
Yeah. There's certainly a risk to lead poisoning in adults. It mostly causes a blood problem and the exposure has to be relatively high. And mostly what we see is adults who are in industrial settings, where they're particularly exposed to lead, are at the highest risk.

So, what we mostly focus on with lead is children. They have the greatest risk because one of the effects lead can have is actually long-term effects on the developing brain, producing challenges with education, behavior, and even potentially leading to poor outcomes and poor opportunities down the road.

JOHNSON:
Do they pick it up after they're born? Or can they get it while they're still inside the mother's womb?

BILLIOUX:
By and large, the exposure we are worried about in children is after they're born.

Again, children spend their time much lower to the ground than we do. So, if there's things like dust that has lead, you know, dirt outside.

Paint chips in the house were a big concern, especially because lead has a slightly sweet taste. The Romans used to use lead in their food to add a sweet flavor to it. And so, children will just eat the paint chips back when it had lead because it would have that sweet flavor.

So, exposure usually is happening after the fact for kids.

JOHNSON:
I remember that, as a kindergartner myself, in the winter the paint would come off the radiators in the school classrooms and kids would flock to that. I never ate the paint—I couldn't fathom eating something that wasn't food, even at five years old—but a lot of kids did.

BILLIOUX:
Right, and it probably starts with—I mean, what we do enjoy is peeling things off of things and breaking things up. And so, you can see how it leads to that. And even if it's not directly ingested, then, again, those fine particles are then broken down, they're dust on the floor, and kids are not always the best at washing their hands before they eat.

And by and large, those small exposures are probably not what is going to cause problems for a child. But if there's lead paint or lead dust in a home or around the soil around their home, you're talking about daily exposures that build up over time and do have significant impacts on cognition and on behavior.

JOHNSON:
Or water flowing through old lead pipes?

BILLIOUX:
Or water flowing through old lead pipes.

And usually what we find, as in the case in Flint, is really it's—as we now try to upgrade our infrastructure, we find that pipes that have lead but were essentially stabilized because the acid-base level going through those pipes was well-regulated for a long time, weren't really causing a problem.

But we make some sort of change to water treatment or we start getting water from a different source and the balance, then, of the acid-base in that water changes, and suddenly you start to get corrosion and leeching of lead in those old pipes.

JOHNSON:
How serious of a problem is lead exposure there in Louisiana?

BILLIOUX:
Well, you know, we think it's a pretty serious problem. The challenge that we have is we don't know how serious it is because measures that we've tried to take to really get a good sense of, you know, how many children actually have lead exposure have been challenged.

For instance, you know, children have to have a lead test and lead tests are covered by insurance in the state of Louisiana. We still see very, very low uptake of those tests, both by the primary care providers—the pediatricians recommending those—and by parents requesting them.

And so, part of our concern, from a public health standpoint, is you've got to start with understanding the scope of the problem. We know that there's a lot of lead in the environment. We know that there's lead in our pipes—we have very aging infrastructure here in Louisiana. And so, we think that there's probably more lead exposure than we can actually identify.

Where we're challenged is in getting the data about what kind of blood lead levels are we seeing in our children.

JOHNSON:
Have you tried to develop any strategy around getting more parents to have their kids tested?

BILLIOUX:
We've actually tried, and continue to pursue, a sort of multifaceted strategy.

So, as I noted, there's a lot of different actors involved. There's the parents as key, you know, people concerned about child welfare. We are really trying to work with families to help them understand more about what lead exposure is, how it impacts their children, and encouraging them to advocate for themselves and their children to really get those lead tests.

We also work with providers directly, encouraging them to do the lead testing, encouraging them to then really engage with families and have a similar discussion to the one that we're having directly.

And, as I noted, working with insurance companies, as well—they can be a major driver of provider behavior. And so, setting quality metrics around lead testing early in life is a way to really sort of partner with providers to make sure that they're also being rewarded and they're getting reinforced messages from their payers that lead testing is really critical.

JOHNSON:
Are you finding cooperation from those jurisdictions, given how much it could cost to go in and replace a system?

BILLIOUX:
So, by and large, I think you've really hit on the problem, Robert, with that question.

You know, there's a lot of emphasis and eagerness—in our state, at least—around testing, and especially testing water. I think water has really—after Flint, Michigan—captured the imagination and people throughout the country had concerns. And so, there's a lot of interest in testing in schools, testing water systems, testing for lead in various different water systems.

What we don't see, though, is financial support for the remediation, for what we're going to do when we find the lead.

And so, I do think that schools get a little anxious because it could be quite expensive if you're talking about changing all of the piping versus just changing some fixtures, to understand what they're on the hook for. And that's true, I think, for almost any remediation across the state. When we start talking about soil—I mean, these are not easy things or cheap things to manage.

But we try to emphasize that just, you know, putting our heads in the sand is not going to be the right way for us to manage this.

JOHNSON:
Have you come up with any cost-effective ways to deal with the problem to mitigate the threat?

BILLIOUX:
So, we do think that, for instance, when it comes to water, one of the most cost-effective things we can do is just maintain the right level of acid-base in the water, do frequent testing so that we have early indications where there's a problem.

Again, trying to ensure that anything that's built going forward really is being built in a way that it's not going to add to a lead problem.

JOHNSON:
You have so many issues on your plate. People in other states who do the same work as you, right in there with you.

How do you raise the level of interest in this topic when you're battling a pandemic, for example?

BILLIOUX:
Yeah, well, it's certainly tough right now in the era of COVID for anything other than COVID to get airtime. I will say, though, I do think COVID has exposed an issue with health equity—certainly in states like Louisiana where we see a disproportionate impact of COVID, both cases and deaths, in communities of color—and the approach that we've taken in the office of public health is to highlight it. I mean, we've been in this space trying to advocate for health equity and undoing racism for quite some time.

This is an opportunity to note not just COVID—there are other impacts on health that are related to health equity and disproportionately affecting our communities of color and of lower socioeconomic status, lead being one of them.

JOHNSON:
On this topic, then, what is the call to action in public health? What should be the top priority for trying to at least get a handle on this issue?

BILLIOUX:
I think, like so many things in public health right now, we have a real opportunity to partner with our healthcare systems to really get better information about what is going on with lead exposure in our children.

And so, I think there's a lot that we will need to do in mitigation, but I think the first thing we need to do is work with healthcare providers to really get a good scope of the problem.

We need consistent, early, and essentially universal lead testing, certainly in a state like Louisiana where we know that exposure is so broad. We need that basis so that we can speak to political leadership, communities, everybody from a basis of fact about the size and scope of the problem. And then, I think that that will help things like identifying sources and mitigating them.

If we do just lean into mitigation right now—we're just, you know, testing water as what we're going to do for lead—think we'll never really get where we need to go and miss what is the potential impact that we're having on our children.

JOHNSON:
Working with a group of clinics, following an evaluation of gaps in data, Louisiana developed a pilot program with help from the state's WIC nutrition program for women, infants, and children. Dr. Trina Evans-Williams starts there.

EVANS-WILLIAMS:
What we did is we had a pilot project in the WIC clinics that we did probably about three years ago. And, in that pilot, we had nine clinics that were on board with us, and we're very thankful for our leadership that supported that.

And so, we were able to initially test over 2000 kids with that pilot. So, we said, "Let's go in that pilot, dig a little deep, and create an innovative strategy."

And so, we went and looked at the clinics that were low testers and we approached them. And one of the clinics said that they would want to join forces with us with the AMCHP-MCH COIN initiative to get them started back up again. And so, by us having multiple resources available and, you know, providing coordinated systems of care, they were able to get on board.

And they also had a very strong community presence. They have a community action network of multiple key players, children's service providers. And so, we train them about the importance of lead. So, that entire community was very supportive of our initiatives.

We're really excited because, with the COIN, our initial goal was to test 450 children within that pilot project. It was an 18-month project, and we were able to actually triple that and test 1,586 kids.

So, we think looking at where we are, letting the data lead us, and then going in and creating innovative, workable strategies with a coordinated approach to those strategies and getting key players together—it actually ends in a very successful story.

JOHNSON:
The pilot is over, correct?

EVANS-WILLIAMS:
Yes.

JOHNSON:
What came of it?

You have those results—did you continue that work with the clinics or are you doing something different as a result of what you learned there?

What's happening now?

EVANS-WILLIAMS:
Well, now—because of COVID, as we all know—a lot of the clinics, unfortunately, right now have decreased their services because of COVID. But if the world was without COVID right now, they would still be up and running and functioning and continuing the actual testing.

Our approach is to build off of this model within the top three regions in the state that have the highest amount of children that are exposed to lead. And so, those are: Region One, which is the Southern Corridor, which is Orleans, greater New Orleans area; Region Six, which is the central part of the state; and Region Eight, which is the Northeast Corridor.

So, our plan is to, eventually, expand this pilot within those regions that have the greatest need, the greatest exposure of children that have been lead poisoned.

JOHNSON:
Why do you think that model worked so well?

EVANS-WILLIAMS:
I think the model really worked so well because we were able to break it down in multiple components.

When we utilized and learned how to do the PDSA—which they taught us, which is the plan for every strategy. To actually do it at a small level, then to study what you learned from the strategy, and then act on the strategy. So, that's the PDSA, and from doing that, we were able to dissect the strategy one action at a time.

And so, we were able to see within that one clinic, that one barrier we were able to overcome was we needed to find out when were the peak times that the parents actually came to the WIC clinic. And so, one series of our PDSA was to actually detect highest volume of testing time. And so, we were able to see that when we looked at it from a monthly perspective, the beginning of the month and the end of the month was the peak high-volume times.

And then, we did another PDSA and digged a little deeper. We said, "Okay, now let's look within that actual month." And we saw that days of the week were also very important. So, Tuesdays and Thursdays were high peak volume days.

And so, by us being able to really do an in-depth data analysis and utilizing those innovative strategies, we were able to create a very successful workable solution.

JOHNSON:
Pregnant women are another audience that you are concerned about.

How are you reaching out to them on this issue?

EVANS-WILLIAMS:
Well, the WIC clinic is such a wonderful place because it is a wonderful avenue where we can reach out to pregnant moms—first-time pregnant moms or moms who, you know, have had their second, third, or fourth baby. And so, we're able to really tap in and engage with that population. We do parent trainings.

So, in addition to actually dissecting that time, then we said, "Okay, let's maximize on this and really look at how we can have a collective impact."

So, we have regional outreach specialists that are assigned to those areas that have the greatest needs, the areas that have the children that have the highest amount of lead exposure.

And so, the Region One outreach specialist, we asked her and positioned her to go to the clinic and train the moms—the first time moms, the newly pregnant moms, the moms who are on their second or third child—and really teach them about the dangers of childhood lead poisoning and ways that they can be engaged and prevent exposure within their own home environments or occupational safety measures that they can also add.

So, we made sure that she educated the parents, and then word of mouth—parents talked to other parents. And so, we had two group of moms talking to each other about what they had learned and getting that buy-in and trust for them. Then, they became advocates of what we were trying to do. And then, we started seeing the actual testing rates increase.

In addition to testing the parents, it's important to use a holistic approach. We also tested the staff, everybody that's there, that's at the clinic, all of the staff—not only the clinical staff that's doing the testing, but the administrative staff as well. We wanted buy-in for the entire clinic that this is an issue that we can actually work together and create a very possible solution.

And so, I think, on using the public health model, working to engage key partners is always very important.

JOHNSON:
We talk a lot about the threat of lead exposure to children, but adults are also at risk if they're in the wrong environment.

EVANS-WILLIAMS:
Absolutely, and that is one of the positive things about the actual parent trainings that we had, because we've had women and men, mothers and fathers, that are in there. And they were very enlightened by the work that they were doing in there.

I will always remember one of the dads that came up to us after we had a robust educational awareness campaign and lead testing day. And he said, "I work in an environment that's full of lead." And he said that he wishes, you know, his organization would have trained him more on the effects of lead on his child. And so, we taught him how to, you know, create safety measures and make sure that, you know, he removes his work clothes at work, put them in their own sealed bag, wash them separately from the child's clothing, and really work hard to prevent exposure.

That's a success story. He was very pleased that we were able to educate him, and then he followed through on it on his own. So, he's also become an advocate for childhood lead poisoning prevention.

JOHNSON:
Speaking of workplaces, I think that's an opportunity to find out what you're doing as it relates to lead abatement—getting the lead out of buildings, getting it out of the dirt, and the soil, and various places.

How is that program playing out in Louisiana?

EVANS-WILLIAMS:
We were the first in the state to be active with the HUD component, and, so, that's another part of the services that we provide.

And so, what we do is we have 17 parishes that have those elevated numbers of children that are poisoned, and we want to make sure that we're going where the greatest need is. Also, those parishes just have a huge amount of old homes built before 1978, and a lot of those homes are full of lead.

So, we provide full environment investigations, or they're called LIRAs—lead investigation risk assessments—within the homes of every identified child that has been poisoned by lead. We go in and we do that for the family.

Then from that, we sit down, have a meeting with the parents or the owners of the building, with the risk assessor and our staff, and talk about solutions.

And we go into the home and do a very robust lead abatement project where we look at all the sources of lead from the environmental assessment that has been done. It teaches us where the lead is. A lot of times the lead is in the lead-based paint within the home—it's on the doors, it's on the window seals, multiple places. And so, we were able to go in and to remove those sources of lead within that home, and it's no cost to the family.

We also provide temporary relocation for the family if they don't have another family's home that they can go to. We provide that as well as food vouchers for the family while they're out of their home and while we're going in doing the lead abatement work.

As of today, we've done 35 houses that are lead-safe and that those families and those children in those houses can grow up with the healthy start that does not include lead poisoning.

JOHNSON:
What is the ultimate goal? How much of a reduction in lead exposure cases in Louisiana do you hope to make over the course of the next year, five years?

What's the final objective here?

EVANS-WILLIAMS:
The final objective is to increase lead testing, work with our providers, and be able to continue to create innovative strategies so that we can look at what works, look at how we could improve what works, and then take that model and position that successful model within the communities that have the greatest needs, which are those areas where there's high numbers of children exposed to lead, those areas where there may be a very low testing rate, where we wanna encourage the providers to test all children for lead.

And then, when we bring it all the way down to the individual child, that's 35 houses that we were able to abate, that's 35 families that we were able to impact, and that's 35 children—and more, because a lot of these children have siblings—that can have a healthy start free from childhood lead poisoning. And I think if we keep building off of that, we want to provide that for all children in this state.

JOHNSON:
Nearly four out of five one-year-olds in Iowa are tested for lead, but the numbers drop for two and three-year-olds to about 42% and 13%, respectively.

Iowa's Analisa Pearson heads the state's team that worked with doctors and clinics on a plan to boost testing for babies and toddlers.

PEARSON:
So, we worked with physicians, really looking at sort of the immunization model that our colleagues in immunizations have developed where we want to have no missed opportunity.

So, if the kid's coming in for a sick visit or a well visit, that we test them or make sure that they've been tested for lead, that we present it as the standard of care, "So, today for this visit, we're going to do an unclothed exam, we're going to take a blood lead test, we're going to give these immunizations." And so, not putting it as something like, "Well, would you like your child to be tested for lead?" It's just an expected—that's what we do. And, of course, if parents have questions or concerns, we address those, but just letting families know that that is an important part of why they're there that day.

And then, if there is no record, we just go ahead and do a test. So, a lot of times physicians or healthcare providers ask, "Well, is your child part of WIC, have they had a lead test," and the parents can be confused. If they had their hemoglobin tested, they may think it was a lead test. So, if you don't have that in the clinical record or the family doesn't have an actual record, then go ahead and test.

JOHNSON:
What was the result of the pilot?

PEARSON:
So, we saw really great results with that pilot. So, we did a three-month pilot back in September, October, and November. One of our clinics during that same period in 2018 tested 25% of the children who came in for a visit during that time for lead. And in 2019, 85% of the kids were tested—or it was assured that they had had a lead test, there was a Lead test in the record. Another site went from 57% in 2018 to 77% in 2019. And then we had one clinic that was already doing quite a bit around lead and had already made it an incentive to their healthcare providers to make sure that was testing. So, they were already testing in the mid-eighties, but they were still able to make an increase into the mid-nineties, like almost 95% of all of the kids during that three month period had a test.

JOHNSON:
Are you doing this now across the state?

PEARSON:
Yeah. So, we're looking now with the start in October will be the start of the new performance measures. And so, we'll be looking at ways that we can replicate those results and sort of work with local provider associations here in Iowa, like the Iowa Academy of Pediatrics, and family physicians, and the mid-level providers, and try to get them to understand that they can make some small changes to have a real big impact on this.

JOHNSON:
Are there other collaborations that are part of your strategy?

PEARSON:
So, we work very closely with our Medicaid here in Iowa—Iowa Medicaid Enterprise.

We also work very closely with the childhood lead poisoning prevention program here at the department, as I mentioned. And through that, we get a nightly feed from Medicaid of all newly enrolled children in Medicaid, as well as updates of screens or, you know, tests, well visits, sick visits, all that information, those paid claims data coming to us. And we also get a weekly feed from the HHLPSS database, which is the CDC's lead database that our childhood lead poisoning prevention program uses.

So, we get that information so that our contractors then, as they see families, can help do care coordination. So, we see that your child does not have a lead test, you've just newly been enrolled in Medicaid, so we can help coordinate that on the local level.

So, those are some of the really important partnerships that we have.

JOHNSON:
So many challenges right now facing public health because of the pandemic. Has it affected this program and your ability to get kids tested and treated?

PEARSON:
Yeah, So, families are not doing their well visits like they would during non-pandemic time. So, that affects not only immunizations but lead, so we've definitely seen a decrease in that here in Iowa and probably all over the country.

A lot of times, Title V will provide services alongside WIC. And so, people think that WIC does lead testing, which they don't, that's not part of the federal program. But people are used to getting tested at WIC. And that doesn't matter to us, you know, if families think that they were tested by WIC, it doesn't matter.

But what does matter is that, right now, most of our WIC programs, at least here in Iowa, are doing their visits through telehealth or telephone. And so, to make sure that families have access to nutrition and the foods that they need, they're not making them come in. And so, if they're not coming in, we can't do a lead test, we can't do immunizations.

JOHNSON:
No opportunity to do that sort of work in the field?

PEARSON:
Yeah. So, it becomes even more important that we don't miss the opportunities, whether that's in some sort of public health study and, if they do come in for an immunization, that we make sure we check their lead. Or, if they do go into the clinic and see a healthcare provider, that we also check for that lead because they're just not going as many places. So, when we do have them, we need to make sure that we're vigilant about that testing.

JOHNSON:
What's the best argument from your perspective for a state or territory to make lead exposure a priority, especially now?

PEARSON:
The huge deficits that it can cause for children academically and health-wise. You know, the need for better mental health, especially in rural areas, is huge, and lead can really contribute to behavioral health and mental health problems, as well as school readiness. I mean, those are other pieces that we can't lose sight of even though we have a pandemic. That, you know, it just has long-term, high-cost outcomes for kids if they have lead poisoning.

And lead poisoning—the only way you're going to find it is through that blood lead test. Most of the symptoms are subtle and mimic other things. So, a child acting out in class, having night terrors—they just mimic so many other things and can mimic typical toddler behavior. You know, a child who is throwing temper tantrums, you just think they are being a toddler. You're not thinking, "Oh, I wonder if they have a high lead."

So, it's kind of insidious in that way that it's hard to pick it out.

JOHNSON:
At the same time, if you catch it, you can do something about it.

PEARSON:
Right.

So, we can work nutritionally with the family, we can, you know, do developmental monitoring and developmental screening and get them into early access programs and really help them along the way if we know what the problem is and we can get the lead out of their system, as well as providing education and health supports that they need.

JOHNSON:
You can find links to relevant resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.