WELCOME

1. WELCOME Ellen Bloom, MPH Health Educator Indiana State Department of Health Indiana Lead and Healthy Homes Program

2. LEAD RULE410 IAC 29 Indiana State Dept of Health Indiana Lead and Healthy Homes Program (ILHHP) http://www.in.gov/isdh/19124.htm REPORTING, MONITORING, AND PREVENTIVE PROCEDURES FOR LEAD POISONING

3. Overview of Statutory Background

4. From a Statute . . . Statutes aka Public Laws, Codes, Acts • Come from Indiana Legislature and start as Bills • Statutes may grant a State Agency the power to adopt rules • Senate Bill 538 (passed by the General Assembly)  Public Law 135-2005 (signed by the Governor)  IC 16-41-39.4 Indiana Code 16-41-39.4 • Granted ISDH statutory authority to adopt rules for case management of a child with lead poisoning – Title 410 • http://www.in.gov/legislative/ic/code/ • Health – Title 16

5. To a Rule Rules aka Administrative Codes, Regulations • Promulgated by State Agencies based on authority granted by the Legislature in a statute • Have the force and effect of law Indiana Administrative Code (Rule by ISDH) Rule 410 IAC 29-2-1: “Local health officers shall ensure the provision of case management to all children under seven (7) years of age in their jurisdiction.” • http://www.in.gov/legislative/iac/

6. LHD Authority and Responsibility Rule 410 IAC 29-4-1 Simply restates this already existent power to inspect: • Local health officers may enter upon and inspect private property, at proper times (think “reasonable”) after due notice (owner and residents), in regard to the possible presence, source, and cause of lead poisoning and lead hazards. • Local health officers may order what is reasonable and necessary to prevent lead poisoning or remediate lead hazards. • Remediation shall be followed by a clearance examination.

7. LHD Enforcement Powers Issue an Order to Abate* (IC 16-20-1-25) • Specify conditions in writing • Name shortest reasonable time for abatement • Enforceable by injunction in local court by county attorney • Eliminating an unlawful condition – not necessarily abatement as defined in lead hazard control laws Dwelling Unfit for Human Habitation (IC 16-41-20-1) (1) – Want of repair and/or (4) – Unsanitary conditions • Order to Vacate in 5-15 days (IC 16-41-20-4) • Declare a Public Nuisance (IC 16-41-20-6) • Order repair (IC 16-41-20-7) • Serve on tenant and owner

8. LHD Enforcement Powers Nuisance Law (IC 32-30-6) • (6-6) Whatever is injurious to health • (6-7) County OR City attorney may bring a civil action to abate or enjoin a nuisance Other tools: Municipal Laws, County Ordinances, Local Building Codes, IKE Model Code • Build relationships with County/City Attorneys and Local Judges

9. Alternate Option Local Health Departments may submit cases to Attorney General by providing the following documentation: • Risk assessment; • Statement about children living in home OR lead poisoned children who used to live in the home; • Copy of notice provided to property owner requesting lead hazard remediation within reasonable time period; • Referral letter stating that a property owner has failed to take steps to remediate; And • Authorization for the AG to take action on behalf of the LHD.

10. Overview of Case Management

11. Who is our target population? At-risk Child(410 IAC 29-1-2)is one who: • lives in or regularly visits a house or other structure built before 1978 • has a sibling or playmate who has been lead poisoned • has frequent contact with an adult who works in an industry or has a hobby that uses lead • is an immigrant, refugee, or has recently lived abroad • is a member of a minority group • is a Medicaid recipient • uses medicines or cosmetics containing lead • lives in a geographic area that increases the child’s probability of exposure to lead

12. The Team Approach The case management team (in ideal cases) includes: • Case manager • Child’s caregiver • Health educator • Nutritionist • Environmentalist • Child’s primary care provider

13. Definitions Case management -the process of providing, overseeing, and coordinating lead poisoning services (410 IAC 29-1-4). Case manager - a person authorized by a health department and trained by the ISDH to perform case management protocols (410 IAC 29-1-5). • Case managers must be trained within 6 months of hire

14. Case Management (410 IAC 29-2-1) Child case management includes: • Outreach and identification of EBLL children • Service planning and resource identification • Service implementation and coordination • Retesting • Monitoring of child case management service delivery, program advocacy, and program evaluation

15. One step further Effective case management includes: • Ongoing communication with the caregivers and other providers. • A cooperative approach to solving any problems that may arise. • Eliminate lead hazards in the child’s environment. • Efforts to decrease the child’s BLL.

16. Where Do We Begin? • Timeframe for action varies according to the child’s blood lead level A case manager should schedule an appointment with the child’s caregiver as soon as possible after being assigned the case. • Higher levels require a quicker response Where feasible, priority should be given to children with the highest BLLs and those less than two (2) years of age. • Highest levels treated as medical emergencies See case management chart (rainbow chart)

17. What is a Confirmed EBLL? • An elevated blood lead level is confirmed in the following situations: • The initial test was a venous test • The initial test was a capillary test, and was followed by a venous (preferred) or a capillary test within the recommended time frames (see rainbow chart)

18. Action levels defined ….for confirmed blood lead levels between zero (0) and nine and nine-tenths (9.9) g/dL…. • Notify primary medical provider within 10 working days of receipt of test results by the local health officer. • Provide educational materials to the parents or family of the child regarding prevention of lead poisoning. • Any additional actions the local health officer believes will assist the family in preventing the child’s blood lead level from increasing.

19. 10-14.9 µg/dL… • Begin case management services within 10 working days • Notify the primary medical provider within 5 working days • Arrange testing of children under 7 years old in the home • Conduct an initial home visit • Initiate an environmental inspection • Provide written notice to property owner • Ensure coordination of long-term services and retesting

20. 15-19.9 µg/dL… • Begin case management services within 5 working days • Notify the primary medical provider within 5 working days • Arrange testing of children under 7 years old in the home • Conduct an initial home visit • Initiate an environmental inspection • Provide written notice to property owner • Ensure coordination of long-term services and retesting

21. 20- 44.9 µg/dL… • Begin case management services within 5 working days • Notify the primary medical provider immediately • Arrange testing of children under 7 years old in the home • Conduct an initial home visit • Initiate an environmental inspection • Provide written notice to property owner • Ensure coordination of long-term services and retesting

22. 45 – 69.9 µg/dL… • Begin case management services within 24 hours • Notify the primary medical provider immediately • Arrange testing of children under 7 years old in the home • Conduct an initial home visit • Initiate an environmental inspection within 2 working days if the structure was built before 1978 • Provide written notice to property owner • Ensure coordination of chelation therapy, long-term services and retesting

23. 70 µg/dL or greater… • Begin case management services within 24 hours • Notify the primary medical provider immediately • Initiate a home visit and environmental inspection within 24 hours for pre-1978 dwellings • Treat child’s condition as a medical emergency • Admit child to hospital for chelation therapy • Obtain venous blood test 1 month after completion of therapy • Arrange testing of children under 7 years old in the home • Provide written notice to property owner • Ensure coordination of long-term services and retesting

24. Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6) • Notify child’s primary medical provider • Assist in setting appointment, if necessary • Visit child’s residence (and other sites where the child spends significant amounts of time) • Provide educational materials to parents and caregivers • Assess factors that may impact the child’s BLL (including sources of lead, nutrition, access to services, family interaction and caregiver understanding)

25. Remember. . . • It is VERY important that EBLL history be included as part of the permanent medical problem list on a child’s medical chart! • Why? • Family may change providers • Alerts schools of the need to provide more intensive monitoring of the child

26. Conduct home visit to include: • Medical, developmental, behavioral history • Lead education, including medical effects and environmental sources • A determination of potential household exposures • Evaluated risk for other family members, including pregnant women • Nutrition assessment or referral • Developmental assessment or referral • Referral to other social services as appropriate

27. Referral Examples • First Steps • WIC • Early Head Start/Head Start • Parents as Teachers • YMCA programs • FSSA (Medicaid, Food Stamps, TANF) • Other local agencies

28. Initial Home Visit From Receipt Of BLL Test Result BLL (µg/dL)Time frame for home visit 10 – 14.9 Within 10 working days 15 – 19.9 Within 5 working days 20 – 44.9 Within 5 working days 45 – 69.9 Within 24 hours >70 Immediately

29. How Do I Notify Child’s Guardian? • Attempt to visit child’s primary residence • Telephone call to child’s parent/guardian What if the caregiver does not have a telephone, nor are they at home to receive initial notification and education? • Leave information at door • Mail (certified) letter to parent or guardian

30. Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6) • Implement child case management services • Develop a written plan for intervention The plan is based on the needs assessment determined through communication with primary healthcare provider, environmental investigation, home visits (including developmental and social evaluations), and parental involvement.

31. How to Create a Written Plan • Work with the caregiver • Identify priorities • Short-term goals • Exposure reduction • Caregiver education • Referrals • Followup for siblings or pregnant women in the home

32. How to Create a Written Plan • Work with the caregiver • Long-term goals • Housing remediation • Enforcement actions • Developmental and early intervention followup • Ensure the plan is relevant to the family’s needs and contains realistic goals

33. How Long is a Child in Case Management? Roberts, J. R., Reigart, J. R., Ebeling, M., Hulsey, T. C. (2001) Time required for blood lead levels to decline in nonchelated children. Journal of Toxicology, Clinical Toxicology, 39, 153-160.

34. Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6) • Provide an environmental inspection* to include(410 IAC 29-1-14): • Risk assessment of child’s primary and secondary addresses • Environmental investigation *Although environmental services may be provided by the case manager, environmental inspector, or other program staff; the case manager is responsible for ensuring that a child receives services in a timely fashion!

35. Environmental Inspectionfrom Receipt of BLL Test Result CEBLL (µg/dL)Time frame for environmental inspection: *10 – 14.9 Within 10 working days 15 – 19.9 Within 5 working days 20 – 44.9 Within 5 working days 45 – 69.9 Within 2 working days >70 Within 24 hours * For CEBLL child at or above ten, with a pre-1978 primary or secondary residence, case management must include an Environmental Inspection.

36. Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6) • Provide written notice, including risk assessment, to property owner of lead hazards present and required remediation options (per 410 IAC 29-1-22). • Ensure retesting (per 410 IAC 29-1-21). • Arrange testing for other children under age seven at same residence.

37. Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6) • Provide continuing child case management services until case closure • Coordinate the activities of the case management team • Evaluate compliance and success of the plan • Ensure that needed care is provided • Follow up on referrals or other problems identified during the child’s care

38. Case Closure (410 IAC 29-2-2) • “Case complete” • The child has at least 2 consecutive confirmed tests less than 10 μg/dL in a six (6) month period, AND • environmental lead hazards have been remediated and passed a dust clearance test, …AND… • Referrals have been made for long term medical, developmental, environmental and follow-up. …OR…

39. Case Closure continued • “Administratively closed” • the child moves to another state (referral) • the child moves to another county in Indiana (referral) • child reaches his or her seventh birthday (referral) • case management is blocked for religious or legal reasons • death of the child • the child can no longer be located (5 attempts – next slide)

40. “Administratively Closed” Five attempts to locate the child: • At least one telephone call to parent or guardian • At least one letter to parent or guardian • Certified letter to parent or guardian • Home visit attempt to last known residence …AND… • Any repeat (2nd attempt) of the above - shows due diligence

41. State Responsibilities • Oversight for county case management activities • Notify counties via EBLL Manifest • Provide guidance, support, and resources to local health departments, parents of lead poisoned children, physicians, health clinics and general public

42. Environmental Inspection(410 IAC 29-1-14) The local health officer shall enter upon and inspect private property of the primary and secondary addresses occupied by all lead poisoned children (CEBLL), if the structure was built before 1978, to include: • Risk Assessment(410 IAC 29-1-22) • Identifies specific lead hazards from structural sources of exposure • Includes more information such as and history of dwelling, occupancy by children under age 6, visual inspection, limited environmental sampling • Environmental Investigation(410 IAC 29-1-15) • Presentation of results of the nonstructural sources of lead hazards identified, including recommendations for reducing or eliminating exposure

43. Risk Assessment(410 IAC 29-1-22) • Conducted by a trained, licensed risk assessor, according to “documented methodologies” established by law (326 IAC 23-4-2). • Report given to the family and the owner (if the family does not own the home) including range of recommendations to mitigate identified lead hazards within 5 business days. • Written notice of the required remediation options to be completed within 180 days. A clearance examination is conducted to establish the efficacy of remediation. • Education of the family and owner on lead hazards in the home and temporary and permanent measures to protect children from further poisoning.

44. “Documented Methodologies” • Visual examination, underlying causes • Exterior testing of deteriorated paint • Soil testing of bare soil • Interior testing of deteriorated paint • Water samples when called for • Dust samples and testing

45. Local Health Officer may…order what is reasonable and necessary (410 IAC 29-4-1) • Risk Assessment Report • Remediation = actions that constitute either: • Abatement • “Lead-free home” • 2. Interim control of a lead hazard (326 IAC 23) • “Lead-safe home”

46. Lead Hazard Example Lead based paint deteriorated on a window sill Remediation Options*: • Remove and replace entire window with aluminum, vinyl, or wood painted with lead free paint. • Wet sand sill to bare wood, repaint with non-lead based paint. • Remove loose paint and repaint. * All of these must be done using lead safe work practices.

47. Lead Safe Work Practices(IC 13-17-14-12) • Find the causes of the problem • Prioritize work • Separate work and occupied spaces • Isolate high dust areas • Wet dust/sand, low temp heat guns • Correct causes of the problem (friction, impact, or substrate deterioration) • Dispose of waste safely • Educate occupants about risks from lead based paint

48. Remediation shall be followed by dust clearance examination(410 IAC 29-4-1) • Licensed clearance examiner or risk assessor • Required for all remediation • Visual examination of the area • Dust sample testing for lead

49. Risk Assessor Training • Environmental Management Institute (EMI) in Indianapolis • ILHHP maintains waiting list for the training • Scholarships available for LHD staff • Within the limits of the ILHHP budget, ISDH will cover the cost of the training classes. LHDs will have to pay for the travel expenses.

50. Resources • 247 licensed risk assessors in Indiana. • About half of them are private environmental. • Price generally between $400 and $700. • 31 LHDs have licensed risk assessors on staff*, many have more than one. *LHD counties with licensed risk assessors: Allen, Bartholomew, Boone, Dearborn, Decatur, Delaware, Elkhart, Fayette, Floyd, Grant, Hamilton, Hancock, Hendricks, Howard, Jackson, La Porte, Lake, Lawrence, Madison, Marion, Marshall, Miami, Monroe, Morgan, St Joseph, Tippecanoe, Vanderburgh, Vigo, Wayne, Wells, Whitley