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Ohio Healthy Homes Network’s Spring Forum – June 18, 2019

Update on Lead in Paint, Drinking Water and Food Issues Nationally and Around the Country. Ohio Healthy Homes Network’s Spring Forum – June 18, 2019. Tom Neltner, CHMM, HHS Chemicals Policy Director Environmental Defense Fund tneltner@edf.org. What we’ll cover.

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Ohio Healthy Homes Network’s Spring Forum – June 18, 2019

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  1. Update on Lead in Paint, Drinking Water and Food Issues Nationally and Around the Country Ohio Healthy Homes Network’s Spring Forum – June 18, 2019 Tom Neltner, CHMM, HHS Chemicals Policy Director Environmental Defense Fund tneltner@edf.org

  2. What we’ll cover • Trends and relative source contribution • Finding the right balance • RWJF/Pew policy solutions • Recent actions at federal level • Lead in paint • Lead in drinking water • Lead in food • Other sources of lead

  3. Healthy People 2020 Objective is mean of 1.6 µg/dL

  4. Latest on blood lead trends

  5. Sources of exposure for infants contaminated by lead contaminated by lead Zartarian et al. 2017. Lead Exposure: A Multimedia Modeling Analysis to Guide Public Health Decision-Making. Envir Health Persp

  6. Sources of exposure for toddlers contaminated by lead contaminated by lead Zartarian et al. 2017. Lead Exposure: A Multimedia Modeling Analysis to Guide Public Health Decision-Making. Envir Health Persp

  7. Finding the right balance • Between paint, water, food, and other sources • Between testing, prevention, and remediation • Between federal, state, and local policy • Between public and private sectors

  8. RWJF/Pew Policy Solutions Report

  9. Pew/ RWJF Report: 10 Policies • Preventing all lead exposure would save $84 billion per annual cohort of children • $18.5 billion to federal government • $9.6 billion to states • Paint prevention policies recommended: • Remove lead paint hazards from low-income housing built before 1960 and other places children spend time. • Increase enforcement of the federal renovation, repair, and painting rule.

  10. Pew/ RWJF Report: 10 Policies • Non-paint prevention policies recommended: • Reduce lead in drinking water in homes built before 1986 and other places children frequent. • Reduce lead in food and consumer products. • Reduce air lead emissions. • Clean up contaminated soil. • Poisoning responses recommended: • Improve blood lead testing among children at high risk of exposure and find and remediate the sources of their exposure. • Ensure access to developmental and neuropsychological assessments and appropriate high-quality programs for children with elevated blood lead levels.

  11. Pew/ RWJF Report: 10 Policies • Data and research recommended: • Improve public access to local data. • Fill gaps in research to better target state and local prevention and response efforts.

  12. Recent Actions at Federal Level

  13. Target Housing and Suites • In May 2017, Congress expanded definition of target housing to include zero bedroom dwelling if child younger than six is living there.

  14. Elevated Blood Lead Level in Young Children • Centers for Disease Control and Prevention’s (CDC) National Center for Environmental Health (NCEH) • Converted from “Level of Concern” to “Reference Level” in 2012 • Serves as Elevated Blood Lead Level (EBLL) • Set at level that 97.5% of young children (< 72 months) are below level – 5 μg/dL • Reassess every four years • Current reassessment is 3 years overdue – Likely to drop to 3.5 μg/dL

  15. Maximum Allowed Daily Limit for Lead in Food • Food and Drug Administration’s (FDA) Center for Food Safety and Nutrition (CFSAN) • Switched “Provisional Total Tolerable Intake Level” (PTTIL) set in 1993 to “Interim Reference Level” in October 2018 • Units are micrograms per day (μg/day) • Serves as “Maximum Daily Intake for Lead” • Children – Lowered from 6 μg/day to 3 μg/day • Adults – Lowered from 25 μg/day to 12.5 μg/day • Expected to track CDC Reference Level • FDA estimated children’s dietary exposure to lead in May 2018 – 2.2 million children exceeded interim reference level • FDA also banned lead acetate hair dyes in October 2018

  16. Action Level for Lead in Drinking Water • Environmental Protection Agency’s (EPA) Office of Water • Public Water Systems • Technology-based drinking water standard - Lead and Copper Rule (LCR) • Based on effectiveness of corrosion control and not health • Lead Action Level – 90th Percentile of First Draw Overnight Samples < 15 ppb • Anticipates proposing revision to LCR in February 2019 and finalizing in 2020 • Schools and Child Care Facilities • In October 2018, eliminated 20 ppb action level and let state, community or user define it

  17. Lead-based Paint Hazard Levels • In pre-1978 Residential and Child-Occupied Facilities • Environmental Protection Agency’s (EPA) Office of Chemical Safety and Pollution Prevention (OCSPP) proposed rule in July 2018 • Deteriorated Lead-based Paint – 5000 ppm in pre-1978 paint v. 90 ppb in new paint • Floor Dust – 40 μg/ft2 on floor proposed drop to 10 μg/ft2 (but not clearance) • Window Sill Dust – 250 μg/ft2 on floor proposed drop to 100 μg/ft2 • Bare Soil – 400 ppm in children’s play area and 1,200 ppm in rest of yard

  18. Federal Lead Action Plan • Presidents Task Force on Environmental Health Risks and Safety Risks to Children released Lead Action Plan in December 2018

  19. Other Potential Changes • OSHA Limits – General Industry and Construction • Unchanged since 1992 • Permissible Exposure Limit (PEL) is 50 μg/m3 over 8 hours – same as NIOSH • Action level is 30 μg/m3 over 8 hours • Hazard Levels for Public and Commercial Buildings • EPA committed in 2010 to developing hazard standard as required by law • Development still underway but no proposal planned • Paint for Non-Residential Uses

  20. Lead in Adult Cardiovascular Disease

  21. Elevated Blood Lead Level in Adults • CDC’s National Institute for Occupational Safety and Health (NIOSH) • Lowered EBLL from 10 μg/dL set in 2009 to 5 μg/dL in 2015 • Used in Adult Blood Lead Epidemiology and Surveillance (ABLES) • “Based on data from 37 reporting states, ABLES established the 2010 baseline rate for Healthy People 2020 objective to reduce adult lead exposure. This 2010 baseline rate for BLLs ≥10 µg/dL is 26.4 adults per 100,000 employed adults.”

  22. CDC NIOSH Reference Blood Lead Levels

  23. Mortality and Lead – March 2018 Study • Low-level lead exposure and mortality in US adults: a population-based cohort study • Published in Lancet by Lanphear, Rauch, Auinger, Allen, and Harnung at http://dx.doi.org/10.1016/ S2468-2667(18)30025-2 • Aimed to quantify relative contribution of environmental lead exposure to: • All-cause mortality • Cardiovascular disease mortality • Ischemic heart disease mortality • Study population • Nationally representative sample of adults aged 20 years or older who were enrolled in the Third National Health and Nutrition Examination Survey (NHANES-III) between 1988 and 1994 and followed up to Dec 31, 2011. • Individuals were linked with the National Death Index.

  24. Lead is a recognized risk factor for cardiovascular disease • In experimental studies, chronic exposure to lead caused hypertension and enhanced the development of atherosclerosis by: • inactivating nitric oxide, • increasing formation of hydrogen peroxide, • inhibiting endothelial repair, • impairing angiogenesis, and • promoting thrombosis. • In human beings, higher concentrations of lead in blood have been associated with: • hypertension, • electrocardiographic abnormalities, • peripheral arterial disease, • left-ventricular hypertrophy, and • cardiovascular disease mortality.

  25. Results • 14,289 adults studied. • Geometric mean concentration of lead in blood was 2.71 μg/dL • 3,632 (20%) had a concentration of lead in blood of at least 5 μg/dL • During median follow-up of 19.3 years, 4,422 people died • 1,801 (38%) from cardiovascular disease • 988 (22%) from ischaemic heart disease. • Increase in the concentration of lead in blood from 1.0 μg/dL to 6.7 μg/dL was associated with” • All-cause mortality (hazard ratio 1.37, 95% CI 1.17–1.60); • Cardiovascular disease mortality (1.70, 1.30–2.22); and • Ischemic heart disease mortality (2·08, 1·52–2·85). • The population attributable fraction was equivalent to 412,000 annual deaths: • 256,000 deaths a year from cardiovascular disease • 185,000 deaths a year from ischemic heart disease.

  26. Limitations • Relied on baseline measures of exposure to predict death over the subsequent two decades. • “Some measures (eg, concentration of lead in blood) might be more stable than other risk factors (eg, diet). Lead that is circulating in whole blood of adults is an indicator of both past and ongoing exposures. Serial measures of concentrations of lead in blood or bone, which are better indicators of cumulative exposure than one concentration of lead in blood, would have strengthened this study; indeed, our reliance on one measurement for concentration of lead in blood might underestimate the contribution of lead exposure to mortality.” • Relied on death certificates for the underlying cause of death, but they are imperfect. • Not able to adjust for air pollutants or arsenic, both of which are risk factors for cardiovascular disease mortality. • Cannot exclude residual confounding that might result in an overestimation of the effect of concentrations of lead in blood, particularly from socioeconomic and occupational factors that were either not measured or measured inadequately.

  27. Lead in Water

  28. EPA: https://www.epa.gov/ground-water-and-drinking-water/infographic-lead-drinking-water

  29. Lead service line components Lead Service Line Replacement Collaborative: https://www.lslr-collaborative.org/

  30. Lead in plumbing materials Legislative history • In 1986, Congress amended the Safe Drinking Water Act to limit lead in plumbing • Banned pipe, plumbing and fixtures not “lead-free,” defined as less than 8% • Banned solder and flux not “lead-free,” defined as less than 0.2% • In 2011, Congress passed Reduction of Lead in Drinking Water Act, strengthening limits used in brass fixtures and fittings – effective 2014, limited to 0.25%. How big is the problem today? • Estimated 6.1 million homes served by lead service lines (LSLs) • Millions of older buildings with lead solder and fixtures across the U.S.

  31. Lead service lines across the country WA ME MT ND MI VT OR MN NH ID WI SD MA NY CT MI WY RI IA PA NJ NE NV OH DE IN UT IL MD CO WV MO CA VA DC KS KY NC Estimated 6.1 million LSLs across the country TN OK AZ NM SC AR AL GA MS TX LA AK 50,000 – 99,999 100,000 – 400,000 FL >400,000 LSLs <50,000 HI PR AWWA presentation, CEHN webinar; Cornwell et al., 2016. National Survey of Lead Service Line Occurrence. Journal of American Water Works Association

  32. Importance of corrosion control Lead pipe with corrosion control Lead pipe Corroded steel pipe Picture Source: Georgia Health News

  33. Analogies between paint and pipes Differences • Disclosure on sale or rental for paint • Health-based “hazard” standard for paint • Funding for low income residents on paint • Standards for contractors disturbing paint • Broad consumer access to paint sampling tools Similarities • Toxic legacy of old decisions • Shared responsibility between owner and renter • Windows and lead pipes both hard to manage • Estimates but no inventory • Eliminating exposure not realistic

  34. 1991 Lead and Copper Rule (LCR)Requirements for public water systems • Tap sampling to assess performance • 90th percentile of all samples collected from distribution system must be below 15 ppb Lead Action Level (LAL) • Corrosion control • Required for large utilities • Small utilities must do it if exceeds LAL • Lead service line replacement • If improved corrosion control does not meet LAL, replace 7% of lead service lines annually • Public education • Resident who took sample • General public (e.g., CCR) • Exceedances 15 ppb is not based on health LCR excludes an estimated 40-45 million people with private wells

  35. Long-term program to replace lead service lines Replace without regard to sampling Milestones of 15% every 3 years but lower at end Establish a health-based “Household Action Level” Level high enough to give formula fed infant an elevated blood level Notify local health department and resident More varied and frequent sampling Open up to consumer requests Don’t backslide on existing testing NDWAC recommendations to EPA

  36. Schools and child care • About 100,000 public schools and 500,000 child care facilities not required to test/report under LCR • Child care as a priority • EDF pilot project • 11 centers in IL, MI, MS, OH • Report coming out June 25 • Most vulnerable children • Additional challenges compared to school setting • New Jersey is one of 6 states requiring testing

  37. Reducing lead levels in the homeIdentify and remove lead sources Have the water tested by the local drinking water provider or a certified lab Figure out if there is a lead service line Ask local drinking water provider for service line records Inspect for the presence of an LSL • If installing new plumbing materials, ensure they are NSF/ANSI 61-G & 372 certified

  38. Reducing lead levels in the homeRoutine strategies to minimize lead • Only use cold tap water for drinking, cooking and making baby formula and baby cereal • Flush cold water taps before drinking (even 5 seconds helps, if no LSL) • Routinely wash faucet aerators, soaking in vinegar • Use a filter rated for lead (e.g., NSF/ANSI Standard 53) and regularly replace cartridges • Remember that boiling tap water will not remove lead

  39. Identifying LSLs in the home https://www.epa.gov/il/advice-chicago-residents-about-lead-drinking-water Check out NPR’s interactive tool: https://apps.npr.org/find-lead-pipes-in-your-home/en/#intro

  40. EDF’s proposed health-based benchmark for individual action How health professionals can use the health-based benchmark: • Step 1: Always consider paint • Step 2: Determine whether the home has an LSL • Step 3: Understand the sample method and results • Step 4: Provide basic educational materials to help residents reduce lead in drinking water

  41. What do water utilities say you can do? • Offering information on children’s blood lead levels.  • Intervening with residents to reduce risk to vulnerable populations. • Providing a bridge to health care professionals. • Supporting proposals to funders, elected officials and other community leaders. • Advising on best practices to reduce the risks posed by lead​. Serving as the trusted voice on public health to the community Partnering to Protect Children’s Health: Webinar David LaFrance, CEO of American Water Works Association. Slide from Children’s Environmental Health Network Webinar, “Partnering to Protect Children’s Health: LSL Replacement,” 6/28/18.

  42. What does EDF recommend? • Develop proactive plans towards LSL replacement with the goal of full replacement in 20 years. • Follow best practices: Fully replace pipes following AWWA post-replacement flushing protocol. • “In 20 years, we shouldn’t still be drinking water out of lead straws.” • Make LSL replacement at child care facilities a priority. • Encourage transparency of LSL location information (e.g., mapping inventories). • Keep up to date on what other communities are doing! AWWA C810-17 Replacement and Flushing of Lead Service Lines

  43. Cincinnati’s lead service line map https://www.cincinnati-oh.gov/water/lead-information/lead-service-line-map/lead-service-line-map-faqs/

  44. 12 states with proactive LSL policies https://www.edf.org/health/state-efforts-support-lsl-replacement

  45. Our goal is to accelerate voluntary LSL replacement in communities across the United States.

  46. Tom Neltner Chemicals Policy Director tneltner@edf.org 202-572-3263

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