Childcare Provider Education: Regulations and Policies Lead and Beyond Conference April 16, 2010

1. Childcare Provider Education:Regulations and PoliciesLead and Beyond ConferenceApril 16, 2010 Mary E. Coogan, Esq. Association for Children of NJ mcoogan@acnj.org

2. Mary CooganConflict of interest statement • As required: • I do not have a financial interest or affiliation with any interests concerning any material I will discuss in my presentation. • I am not going to discuss any non-FDA approved or investigational drugs or medical devices.

3. Testing of Children for Lead • Testing of Child Care Centers • Why are we talking about this? • Childhood lead poisoning is still a major public health problem in NJ

4. What is Lead? • Lead is a bluish-gray, soft metallic element used in many household and industrial items from batteries to fine crystal. • Although lead is no longer used in most products, remnants still remain in many homes. • People are exposed to lead poisoning today by swallowing tainted dust or dirt, ingesting lead polluted air, and drinking contaminated water.

5. Sources of Lead Exposure • Lead-based paints and lead-contaminated dust in older homes is the most common source. • Paint: Lead was used in house paint until it was banned in 1978.  Dust and chips can be generated whenever it deteriorates or is scraped or sanded. • Soil: Lead was widely used in gasoline until 1974, when a gradual regulated phase out began. • Lead is still found in high concentrations in the soil surrounding high traffic routes.  • Lead can also be found in the soil surrounding buildings or structures painted with lead-based paint.

6. Sources of Lead Exposure • Drinking Water:  may contain lead through plumbing fixtures. As a result of corrosion, lead and other metals from the pipes dissolve into the water.  • With private wells, lead can get into drinking water from well parts made of lead. • Nearby industrial waste facility or municipal landfill can contaminate water.

7. Sources of Lead Exposure • Certain occupations might result in lead exposure: • Battery manufactures, Auto mechanics • Metal smelters & lead-reclamation plants • Miners, Glass manufactures, Painters • Plastic manufactures, Printers • Ceramic or crystal ware manufactures • Lead abatement workers, Steel welders or cutters • Hobbies: Oil painting, Stained glass, Pottery making, Refinishing furniture, Hunting or fishing equipment, Lead soldering • Other areas of exposure: Folk remedies; Lead-based cosmetics, Antique furniture and toys

8. Young Children More Susceptible to being Poisoned • Children under age 6 are at particular risk: • The brain and other organs are developing • Their central nervous systems are not fully developed • Young children absorb lead more easily and retain lead to greater extent than adults making them particularly susceptible to damage from lead • Children absorb up to 50 percent of the amount of lead ingested • Adults absorb only about 10-29 percent • Lead poisoning has no obvious symptoms, and frequently goes unrecognized

9. Impact of Lead • Even minuscule amounts of lead can result in the impairment of cognitive functioning • Center for Disease Control and Prevention (CDC) consider any child with a blood lead level equal or greater than 5 micrograms of lead per deciliter of whole blood (µg/dL) to be suffering from childhood lead poisoning and in need of corrective follow-up treatment • Blood lead levels between 2 and 10 μg/dL have been found to cause persistent cognitive damage

10. Impact of Lead • At the earliest stages of nervous system development, lead burdened youngsters can be damaged intellectually • Learning disabilities • Hyperactivity • Reductions in IQ • If not diagnosed and treated quickly, the damage can be permanent

11. Impact of Lead • Muscular dysfunction • Failure to thrive • Slowed growth • Weakness and weight loss • Hearing problems • Convulsions • Coma, death

12. Lead Poisoning • Lead replaces the calcium and/or iron in the hemoglobin. • Lead can be stored in tissue and bones for several years and may reach a toxic level later in life. • A person considered to be “lead poisoned” when blood levels are above 20 µg/dL • proposed regulations to require case management and environmental intervention at lower levels

13. Screening is only way to Protect Children from Lead Poisoning • Pursuant to federal law, Medicaid-enrolled children must be screened at 12 and again at 24 months, or between 36 and 72 months if the child failed to receive a screen at either 12 or 24 months. • The NJ Lead Poisoning Abatement and Control Act (LPACA, 1996), requires local boards of health to work with medical professionals to provide all children with lead screening pursuant to the same time table set forth in the Medicaid Act.

14. Case Management Services • The LPACA mandates that local health departments, under the supervision of Department of Health and Senior Sercices (DHSS), provide case management services and environmental hazard assessments to • children with Blood lead levels (BLLs) over 20 µg/dL and • children with persistent BLLs of between 15 and 19 µg/dL

15. New Jersey Regulations • State regulations direct the health care provider to: • Screen every child around one year of age and again around age two. • Screen any child between three and six years of age who has never been tested. • Complete an annual risk assessment on each child between six months and six years of age. More frequent screening tests are required if the child is found to be at high risk for lead exposure. • Report the screening results to the parent or guardian. • Provide risk reduction education to the parent or guardian. • Parents may decline, in writing, to have their child tested for any reason.

16. Corrective Treatment • Under both federal and state law, children who are lead-burdened are legally entitled to corrective treatment. The type of corrective treatment depends upon each child’s blood lead level. • When the blood lead test result is 10 ug/dL or higher, the health care provider must give the report to the parent or guardian in writing and provide medical evaluation, treatment and follow-up in accordance with accepted medical guidelines. Children should receive follow-up testing and their families are to be provided with lead education and, if necessary, social service referrals. • HMOs must provide case management services for children with levels between 10 and 19.

17. Corrective Treatment • Children with blood lead levels over 20 µg/dL are to be reported to DHSS which must provide with appropriate medical treatment, case management and an investigation to determine the source of the lead. • For all children with a confirmed BLL of 20 or higher, local boards of health are to provide an environmental investigation to determine the source of the lead poisoning, and case management services, including the follow-up activities necessary to ensure that medical, environmental and education interventions are delivered in a timely, safe and coordinated manner. • children with blood lead levels over 40 µg/dL receive an environmental investigation within 48 hours

18. Pending Regulations • DHSS’s Proposed Readoption with Amendments of N.J.A.C.8:51 Childhood Lead Poisoning: State Sanitary Code Chapter XIII (published in the December 21, 2009 Register) reduces the capillary blood level necessary to classify a child as being lead burdened or poisoned, thus eligible for case management services and more proactive action.

19. Proposed Changes to Regulations • N.J.A.C. 8:51-2.3 will require a confirmation of blood lead tests when a screening sample produces a blood lead level of 10 µg/dL which is lower than prior standard of 20 µg/dL. • N.J.A.C. 8:51-2.4 reduces the blood lead level that requires intervention by the department of health in treating lead burdened children from the previous level of 20 µg/dL to 15 µg/dL. The local board of health will now provide case management for child and family when a child has a blood lead level of 15 or greater or two consecutive test results between 10 and 14 µg/dL.

20. Proposed Changes to Regulations • N.J.A.C. 8:51-3.1 and 3.2 require reporting between the local board of health and DHSS of actions taken on behalf of a child with a blood lead level of 10 µg/dL or greater rather that the previous level of 20 µg/dL. • N.J.A.C. 8:51-4 reduces the blood level that requires the local Board of Health to conduct an environmental intervention for lead burdened children from20 µg/dL to 15 µg/dLor children who had two consecutive test results between 10 and 14 µg/dL rather than the previous levels of between 15 and 19 µg/dL.

21. 2000 Pilot Project • Focused on two of the identified barriers to ensureing that all children screened: • (1) parental unawareness of the dangers of childhood lead poisoning and the need for lead testing; and • (2) provider refusal to perform on-site lead blood screens and provider persistence in referring children to off-site laboratories for lead tests

22. Parental Unawareness • The child care community was asked to help deliver the message • If a trusted child care provider tells parents about the dangers of lead and the importance of screening, parents may be more inclined to get their children tested.

23. Provider Issues • All doctors in the pilot areas were asked to screen children in their offices using a venous, capillary or the less intrusive filter paper method of testing • Filter paper testing involves the doctor taking two drops of blood from a child’s finger, places them on a piece of filter paper and sends the filter paper to a laboratory for analysis

24. Lead Related Regulations for Child Care Centers • The center shall be free from lead paint hazards. • The center shall comply with the lead paint inspection requirements, which means that a lead paint inspection of all painted surfaces of the center is conducted by a Lead Inspector/Risk Assessor, who is certified by the New Jersey Department of Community Affairs (DCA) and employed by either a public health agency or a lead evaluation contractor certified by DCA, as specified in N.J.A.C. 5:17. UNLESS

25. The center is located in a building constructed after 1978; • The center submits documentation to the Bureau of Licensing of a previous lead paint inspection conducted by a Lead Inspector/Risk Assessor, who is certified and employed as specified in regulation indicating the center is free of lead-based paint hazards; or • The center submits documentation to the Bureau of Licensing and the local department of health of: • (1) A lead paint inspection and risk assessment conducted by a Lead Inspector/Risk Assessor, who is certified and employed as specified in regulation within the previous 12 months indicating the presence of lead; and • (2) A lead paint risk management plan currently in progress at the center.

26. If lead is present • If the lead paint inspection indicates the presence of lead, there must be a lead paint risk assessment done by a certified Lead Inspector/Risk Assessor • The center shall submit documentation of the risk assessment results to the Bureau of Licensing and the local department of health

27. If Assessment Shows Lead Hazard The center shall: • Ensure that all lead hazards are remediated pursuant to N.J.A.C. 5:17 and 5:23 by a certified Lead Abatement Contractor; • Submit a certificate of lead abatement pursuant to NJAC 10:122-5.2 documenting that remediation has been completed to the Bureau of Licensing and the local department of health; and • Inform the parents of all enrolled children that a lead paint hazard has been found at the center and will be or has been remediated, as applicable.

28. If any area of the center is renovated or damaged after a lead paint risk assessment has been conducted, the center shall: • Ensure that an additional risk assessment is conducted by a certified Lead Inspector/Risk Assessor; and • Submit the results of the additional risk assessment to the Bureau and the local department of health.

29. The center shall follow the recommendations of the local department of health for enclosure, removal or other appropriate action to abate lead hazards, and shall permit the local department of health to conduct follow-up inspections to ensure compliance with State statutes governing lead paint hazards.

30. If a previous lead paint inspection indicates the presence of lead, or a lead paint risk management plan is in progress at the center, the center shall: • Ensure that a lead paint risk assessment is conducted by a certified Lead Inspector/Risk Assessor upon renewal of the center’s license; and • Submit the results of the risk assessment to the Bureau of Licensing and the local department of health.